[Senate Hearing 110-133]
[From the U.S. Government Publishing Office]


                                                         S. Hrg.110-133
 
                 DOD/VA COLLABORATION AND COOPERATION 
                   TO MEET THE HEALTH CARE NEEDS OF 
                        RETURNING SERVICEMEMBERS 
=======================================================================
                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 27, 2007

                               __________

       Printed for the use of the Committee on Veterans' Affairs


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
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                     COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Larry E. Craig, Idaho, Ranking 
    Virginia                             Member
Patty Murray, Washington             Arlen Specter, Pennsylvania
Barack Obama, Illinois               Richard M. Burr, North Carolina
Bernard Sanders, (I) Vermont         Johnny Isakson, Georgia
Sherrod Brown, Ohio                  Lindsey O. Graham, South Carolina
Jim Webb, Virginia                   Kay Bailey Hutchison, Texas
Jon Tester, Montana                  John Ensign, Nevada
                    William E. Brew, Staff Director
                 Lupe Wissel, Republican Staff Director



















                            C O N T E N T S

                              ----------                              

                             March 27, 2007
                                SENATORS

                                                                   Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........     1
Murray, Hon. Patty, U.S. Senator from Washington.................     2
Craig, Hon. Larry E., Ranking Member, U.S. Senator from Idaho....     4
Rockefeller, Hon. John D., IV, U.S. Senator from West Virginia...     6
Isakson, Hon. Johnny, U.S. Senator from Georgia..................     7
Obama, Hon. Barack, U.S. Senator from Illinois...................     8
Tester, Hon. Jon, U.S. Senator from Montana......................    10
Burr, Hon. Richard, U.S. Senator from North Carolina.............    11

                               WITNESSES

Duckworth, Major Ladda Tammy (Ret.), Director, Illinois 
  Department 
  of Veterans Affairs............................................    12
    Prepared statement...........................................    15
Pruden, Jonathan D., Veteran, Operation Iraqi Freedom Veteran....    16
    Prepared statement...........................................    18
    Response to written questions submitted by Hon. John D. 
      Rockefeller IV.............................................    21
Mettie, Denise, Representing the Wounded Warrior Project, and 
  Mother of Army Spc. Evan Mettie................................    22
    Prepared statement...........................................    25
Gans, Bruce M., M.D., Executive Vice President and Chief Medical 
  Officer, Kessler Institute for Rehabilitation, New Jersey......    27
    Prepared statement...........................................    29
    Response to written questions submitted by Hon. John D. 
      Rockefeller IV.............................................    31
      Attachment, National Institute for Disability and 
      Rehabilitation
        Research (NIDRR):
        Model systems for Burn Rehabilitation....................    32
        Model systems for Traumatic Brain Injury Rehabilitation..    34
        Model systems for Spinal Cord Injury Rehabilitation......    38
        List of Rehabilitation Research and Training Centers.....    44
        List of Rehabilitation Engineering Research Centers......    55
      Attachment, List of National Center for Medical 
      Rehabilitation Research (NCMRR) projects...................    64
Kussman, Michael J., M.D., Executive-in-Charge, Veterans Health 
  Administration, Department of Veterans Affairs.................    97
    Prepared statement...........................................    99
    Response to written questions submitted by:
      Hon. Daniel K. Akaka.......................................   101
      Hon. John D. Rockefeller IV................................   111
      Hon. Bernard Sanders.......................................   113
      Hon. Johnny Isakson........................................   115
Embrey, Ellen P., Deputy Assistant Secretary, Health Affairs/
  Force Health Protection and Readiness, Department of Defense...   115
    Prepared statement...........................................   117
    Response to written questions submitted by:
      Hon. Daniel K. Akaka.......................................   124
      Hon. Patty Murray..........................................   125
      Hon. Bernard Sanders.......................................   128
      Hon. Johnny Isakson........................................   128

                                APPENDIX

Response to written questions submitted to BVA from March 7, 2007 
  hearing on resources and TBI...................................   137
Summary of the VA/DOD seamless transition study conducted by:
    Government Accountability Office.............................   138
    VA Office of Inspector General...............................   138


 DOD/VA COLLABORATION AND COOPERATION TO MEET THE HEALTH CARE NEEDS OF 
                        RETURNING SERVICEMEMBERS

                              ----------                              


                        TUESDAY, MARCH 27, 2007

                               U.S. Senate,
                    Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:32 a.m., in 
Room SR-418, Russell Senate Office Building, Hon. Daniel K. 
Akaka, Chairman of the Committee, presiding.
    Present: Senators Akaka, Rockefeller, Murray, Obama, Brown, 
Tester, Craig, Burr, and Isakson.

     OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 
                    U.S. SENATOR FROM HAWAII

    Chairman Akaka. The Committee on Veterans' Affairs will 
come to order in this hearing on DOD/VA Collaboration and 
Cooperation to Meet the Health Care Needs of Returning 
Servicemembers. Good morning and aloha.
    This is the Committee's second hearing in our series on 
seamless transition. The focus today is on how DOD and VA are 
working to meet the health care needs of those transitioning 
from service, especially those who have sustained serious 
trauma. There have been many hearings about Walter Reed since 
the story first broke about conditions there. This is not such 
a hearing. And yet, at one level, it is.
    The servicemembers who were staying in Building 18 at 
Walter Reed were in medical hold, awaiting a decision on their 
future. Many would soon be separated from the military and 
become veterans, and that is exactly what we are talking about 
today: how those leaving the service after being injured make 
the transition 
to VA.
    With regard to the medical hold process, I realize that DOD 
must have time to make an informed decision on an injured 
servicemember's future. However, as soon as it seems likely 
that an individual will be unable to return to service, DOD 
must work with VA to ensure that the servicemember gets the 
care he or she needs and that the actual transfer is carried 
out effectively.
    There is much talk about seamless transition, but it is far 
from clear that the talk is matched by effective action. This 
is not a new issue, but it seems that now more than ever, when 
the demand is so great, we find that there is more talk than 
action.
    We have entered the fifth year of this war. I cannot help 
but wonder why so many things are still being planned, still 
being discussed. Why is it that DOD and VA still cannot make 
the handoff of wounded servicemembers more effectively? Why do 
budgets still not reflect that caring for veterans is part of 
the cost of war?
    Another key element in easing the transition is making sure 
that servicemembers and their families have someone at both DOD 
and VA to whom they can turn and who has responsibility for 
making sure that they are getting the care and services they 
need. The Committee needs to know where DOD and VA stand on 
this.
    I remain resolute. For those seriously injured to transfer 
from DOD to VA without undue disruption to the wounded 
servicemember simply must happen.
    We have two panels of witnesses today. The first includes a 
number of witnesses who, unfortunately are living every day 
with the impact of serious traumas. I have asked Dr. Kussman 
and Ms. Embrey to hear the testimony of the first panel so that 
when they come forward, they will be able to address issues 
raised by the first panel.
    In closing, I note that each Senator will be provided 
summaries from the IG and GAO on their respective work on 
seamless transition, and a copy of these summaries will be in 
the record of today's hearing. As you will see, many 
suggestions have been made already to VA and DOD on this issue.
    Now, I would like to yield to another leader of this 
Committee and of our side of the Senate, Senator Murray, for 
her opening statement.

                STATEMENT OF HON. PATTY MURRAY, 
                  U.S. SENATOR FROM WASHINGTON

    Senator Murray. Well, thank you very much, Mr. Chairman, 
for holding this really important hearing, and I really want to 
thank all of our witnesses who have come here today to join us, 
especially for your sacrifices and for coming here today to 
speak out. You are helping us get to the truth about what 
veterans are really facing and helping us change the system for 
the better for everyone else.
    I also want to extend a special welcome to Denise Mettie. 
She is from Selah, Washington, and her son, Evan, who is 
receiving treatment for traumatic brain injury. I visited 
Denise and Evan at Bethesda Naval Station last February, a 
little more than a year ago, and since then he has faced not 
just medical problems but a bureaucratic system that has thrown 
up obstacles in his path toward recovery. Denise has been a 
tremendous advocate for her son. She had to quit her job so she 
could fight for Evan in a system that is failing for too many 
of our wounded veterans today.
    Denise, our country owes you and your son an apology. Your 
son fought a war for our country. You should not have had to 
fight every day to give him the care that he deserves. You and 
Evan deserve a lot better, and so do a lot of our men and women 
who have served us, and that is why your testimony, all of 
yours, is so important today, to help us hold the VA and the 
Pentagon accountable so that servicemembers never fall through 
the cracks and are never denied vital information and are never 
left in limbo when they need our help. And we have got a long 
way to go because what happened to Evan is really not an 
isolated case at all.
    Mr. Chairman, one of my biggest frustrations is that we 
have been unable, so far, to get all the facts we need to solve 
the problems. We hear stories of serious problems from veterans 
and their families, but then when we have tried to get answers 
from the Administration, we have run into a brick wall. We 
cannot get full answers on the number of servicemembers who are 
treated for TBI. We cannot get accurate projections on how many 
veterans will need inpatient mental health care. We cannot even 
get accurate information on the number of amputations. In fact, 
I am now hearing that the Administration is not counting as 
amputees veterans who lose a finger or a toe. That minimizes 
the scope of the problem, and it hides the true cost of this 
war.
    War is expensive, and if we do not face the full cost of 
the war, including caring for our veterans, we will never be 
able to have the resources and the right policies to be able to 
help families like Evan's and the other ones that we'll hear 
about today. We need the truth so we can have the right budget 
and the right policies. But if the Administration keeps hiding 
the ball, we will never be able to get this right for those who 
sacrifice for us. I really thank the witnesses for helping us 
today to get to the facts so we can solve this problem.
    Now, Mr. Chairman, I have to say that I have about had it 
with the Administration officials who keep assuring us that 
everything is taken care of. Two years ago, the VA told us 
everything was fine when it was, in fact, facing a $3 billion 
deficit. We are going to hear from two officials from the VA 
and the Pentagon on the next panel, and I want them to know--I 
know you have tough jobs, and I know you work very hard, but we 
are going to judge you by the results you get for our veterans, 
and we are going to hold you accountable for those results.
    Two months ago, as the Chairman said, we had a similar 
hearing on this Committee. Officials from the VA and the 
Pentagon told us about all the progress they were making. They 
were improving communication; they were setting up seamless 
transition programs. Everything was on track. Well, a month 
later we discovered that things were not fine when the Walter 
Reed story broke.
    It is easy to whitewash a moldy wall. It is a lot harder to 
make sure that our veterans are taken care of every step of the 
way. That is the challenge that we now face as a country, and 
that is why we are going to hold people accountable for the 
results, not just creating a new box in an organizational 
chart, but what the results are that we are getting for our 
servicemembers and our families. Are they getting benefits in a 
timely way? Are they getting fair disability ratings? Are they 
being screened and treated for both PTSD and TBI? Are they 
getting the best care? Are their medical records where they 
need to be? And are their families being informed? Because let 
me tell you, you can make adjustments to a bureaucracy decade 
after decade, but the real results are whether the men and 
women who have served us so well are telling us that things are 
changed for the better, and that is what we are going to be 
looking for.
    You know, I have to say that a lot of this misery could 
have been avoided. Many of us saw the warning signs years ago. 
We saw the VA was not planning for the full cost of this war, 
we saw that it was not using realistic projections, and we saw 
an overwhelmed and underfunded VA not getting itself on wartime 
footing.
    Well, we are not going to wait now for the President to fix 
the problem. We are facing the costs of this war, and we are 
putting the money where it is needed.
    Mr. Chairman, as you know, right now on the floor of the 
Senate is our supplemental bill. It includes $50 million to 
build new polytrauma centers, $100 million for mental health 
care, $201 million to treat recent veterans so they do not have 
to wait in waiting lines that delays their care, $30 million 
for research on the best prosthetics for our amputees, $870 
million to fix problems that we have uncovered at VA facilities 
across this country now, and $46 million to finally hire new 
claims processors so our veterans do not have to wait for years 
for their benefits.
    Those are the costs of war, and these families know it all 
too well. As a Nation, we have to pay for them, so we need to 
be honest about what it is going to take so that we can get it 
right and give our veterans, servicemembers, and their families 
the care and support they deserve.
    Mr. Chairman, as you know, I am managing the supplemental 
on the floor. I hope to stay for quite a bit of this hearing, 
but I want you to know when I leave, my staff will be here to 
get your testimony. I will have some more questions that I will 
probably submit for the second panel as well. But we want you 
to know we want to get this right. Your help in being here is 
our path to get there, and we all very much appreciate your 
testimony today.
    Thank you.
    Chairman Akaka. Thank you, Senator Murray.
    I need to step away briefly, and I want to hand the gavel 
over to Senator Murray, and I shall return.
    Madam Chairman, the hearing is yours.
    Senator Murray [presiding]. Senator Craig, for your opening 
statement.

         STATEMENT OF LARRY E. CRAIG, RANKING MEMBER, 
                    U.S. SENATOR FROM IDAHO

    Senator Craig. Thank you very much, Chairmen, Chairman and 
Madam Chairman. I want to thank you all for our distinguished 
panelists who are here today testifying on a critical and 
important issue.
    Those of you on the first panel in particular have traveled 
great distances, and I look forward to this hearing and your 
firsthand experiences in leaving the battlefield and 
transitioning back into civilian life. Ms. Duckworth, again, 
welcome to this Committee. This is not your first appearance 
here, and let me congratulate you on your new position. The 
veterans in Illinois will be served well with you at the helm, 
and so we look forward to your leadership in that capacity.
    I also look forward to hearing from our second panel 
because of their managerial experiences operating the 
transition process. We have all been concerned by recent news 
accounts suggesting that our returning servicemen and women are 
not experiencing optimum care at our Nation's military and 
veterans' hospitals. Like many Members of this Committee, I too 
have received complaints from some constituents who suggest 
that wait times are too long or quality of care is too poor. I 
have also received numerous reactions that it is the very best 
that could possibly be received.
    However, this Committee also knows of the recognition VA 
has received for quality and consumer services over the past 
few years. We know the VA has led the University of Michigan's 
consumer satisfaction survey for the seventh year in a row. We 
also know that Time magazine's cover story of how VA became the 
best health care in America also boasts of the quality of VA 
care. In fact, all of you here today have included in your 
written testimony very positive accounts of your experience at 
both military treatment facilities and VA hospitals.
    So some of us on this Committee are left to wonder why it 
often sounds like two different VAs are being discussed in the 
news, or you just heard the opening testimony, as the Ranking 
Democratic Member of the Committee, two stories being told here 
through two very different sets of glasses.
    I for one believe the answer lies in a simple reality. 
Medical care is very personal to all of us, including our 
veterans, and one person's positive experience may be another 
person's negative experience. I know the VA is the system of 
choice for millions of our veterans. I say ``system of choice'' 
because I know that over 3 million veterans have other options 
for health care, such as Medicare and TRICARE and private 
insurance, but they still choose VA.
    Unfortunately, a lot of our most deserving veterans, those 
with service-connected disabilities, do not have the power to 
choose to go somewhere else. VA is their only avenue to full 
health care.
    There are the veterans who choose to be able to say loud 
and clear, ``I earned the right to be cared for by this 
Nation.'' At the same time, I think they should also have the 
power to say, ``If you do not treat me right or if someone else 
can provide me with a better medical service, I will go 
elsewhere.'' And I have introduced legislation that would 
provide our service-connected disabled veterans with that 
power.
    I am not sure nor am I confident that the solution that you 
have just heard from Senator Murray of pouring billions and 
billions more dollars at the current system is the best 
solution. When I introduced the legislation I am talking about, 
I said that in many ways the bill was about my confidence in 
the VA health care system. If veterans have the ability to 
choose and they choose to stay right where they are in the VA 
system, well, then, we have learned something about this 
system, because right now there is no internal polling or 
``voting with one's feet'' because the option simply does not 
exist. But I also said that if the veterans leave in droves, 
then we have learned something else that is awfully important.
    Mr. Chairman, our hearing today is a follow-up on January's 
hearing of seamless transition and a series of hearings that I 
held with your cooperation two years ago as Chairman on these 
very important issues. In fact, this is hearing number four or 
five on the issue of seamless transition. We have identified 
specific treatment challenges and the need for early 
intervention for mental health care and outreach to those still 
in need of family therapy services. As I said in January, I do 
have concern that DOD's efforts to take care of its own 
disabled personnel are complicating efforts by DOD and VA to 
coordinate care and benefits. I am hopeful that the President's 
new Interagency Task Force on Returning Global War on Terror 
Heroes will help us determine what changes, legislation or 
otherwise, are needed to make us meet these challenges as they 
relate to our young veterans of today.
    I also hope this hearing will shed some light on true 
personal struggles that some of our military families are 
facing today. Nothing is more important to this Committee than 
ensuring that our servicemembers return to civilian life, that 
they receive the very best possible care and services, and I 
acknowledge all of you here today and look forward to your 
testimony.
    Thank you, Madam Chairman.
    Senator Murray. Thank you, Senator Craig.
    We will recognize each one of our Senators for an opening 
statement before we go to our panelists in seniority order. 
Senator Rockefeller, you are next.

           STATEMENT OF HON. JOHN D. ROCKEFELLER IV, 
                U.S. SENATOR FROM WEST VIRGINIA

    Senator Rockefeller. Thank you, Madam Chairman. I will be 
very brief.
    Actually, I think this is the first day in quite a few 
months that all four of the Committees I am on meet, many of 
them at the same time, so I have to go off, too, but I will be 
here for a while.
    I think it is long past the time when we think of the 
warfighter and then we think of veterans who are physically 
wounded, mentally wounded. I think all is part of the cost of 
war. Veterans are as much a part of the cost of war as are 
Humvees, as are warfighters out there in the desert in 120 
degrees. There is no difference. I say directly to the Ranking 
Member that I do not think Senator Patty Murray, Chairman 
Murray was talking on two tracks. I think she was talking on 
one track. I think what she was saying is that veterans for the 
most part will say that the treatment they get from their 
doctors in VA hospitals, from their rehab people, from their 
counselors, from the professionals who work with them on a 
medical basis, day in and day out, is very good. I think the 
complaint comes about the Administration, and not in all VA 
hospitals, but I know in my own State, the case is so clear and 
it is so easy to pick out the difference between the two. Part 
of the reason is they are all in different VISNs, so, you know, 
they are going in all directions, and I regret that. But this 
is the cost of war. It is not some kind of special effort.
    Just going over the testimony, I really like the idea, Mr. 
Pruden, to offer rehabilitation in substance abuse to veterans 
who request it. I also think that Dr. Gans' testimony about 
using private rehabilitation centers may make good sense. I 
have discussed with the Ranking Member the idea that I know 
personally of hundreds of physicians, some of whom practice 
alternative medicine, which is a--when you walk into a Vet 
Center and there are five people standing there in gray suits, 
they look like they have come to audit the Vet Center. You ask 
them what they are doing there. They are there for PTSD 
treatment. And so there are so many. All of these people come 
back wounded particularly from this war, more so than any other 
war in terms of the psychology, the uranium additions to the 
IEDs, and all the rest of it, which are unremovable, agony for 
the rest of your life.
    So my thought, and I have discussed this with the Ranking 
Member, is that there are hundreds of specialists who have--
maybe they are orthopedic surgeons, there are all kinds of 
people-- discovered that there are other ways of helping. It is 
alternative medicine in a friendly sense, not alternative 
medicine in a strange sense. It is not invasive. It works. I 
have seen it work on PTSD with Gulf War I veterans. I have seen 
it work in a very short period of time. I think that the time 
has come for us to think about enlarging that capacity within 
the VA. Go to the private sector for some things, go to the 
private sector for some pro bono--everybody that I have talked 
to, it is all pro bono. We will go anywhere in the country. We 
will go to San Diego. We will go to Florida. We will go to West 
Virginia, anywhere you want. But we want to show that we can be 
helpful and, believe me, they can be. I just want to introduce 
that thought into this hearing because we are not throwing 
money at a problem. Chairman Murray bailed us out 2 years ago, 
and we are doing a little bit better this year. But this is not 
a fight between Republicans and Democrats. This is the 
treatment of veterans on the same par as we treat our 
warfighters, and maybe better.
    Thank you.
    Senator Murray. Thank you, Senator Rockefeller.
    Senator Isakson?

               STATEMENT OF HON. JOHNNY ISAKSON, 
                   U.S. SENATOR FROM GEORGIA

    Senator Isakson. Thank you very much, Senator Murray. I 
appreciate very much your calling this hearing, and I 
particularly want to welcome Jonathan Pruden, who we claim to 
be a Georgian. I know he is a North Carolinian, but he spent 2 
years at Fort Stewart, and that allows you permanent 
citizenship, as far as we are concerned. Captain, we appreciate 
your service to the country and your being here today.
    I also have to tell you that I sat on a mat at Walter Reed 
with Tammy Duckworth. She probably does not remember me, but I 
go out to Walter Reed whenever there is a wounded Georgia 
soldier there in rehabilitation. And there were a couple there 
that day, and I saw Tammy with that magnetic smile of hers, and 
her courageous recovery was taking place. So I sat on the mat 
with her for a while and talked to her about her experience, 
and I appreciate her service now to the VA--I guess in 
Illinois. Is that correct? Congratulations, Director. We are 
proud of you. And I want to apologize as I slip out for a 
minute. I am chairing with Senator Kennedy the card check 
hearing today, so we have got two extremely important hearings. 
I am going to have to bounce back and forth.
    For just a second, when we talk about the transition from 
DOD to Veterans and Veterans to DOD, I think it is really 
important for us to be focusing. And I do not disagree with any 
of the comments that I heard said by Senator Rockefeller. We 
want to see to it that the treatment of a veteran, active duty 
or a retired veteran, is the best that I can be. And to that 
end, although there has been a lot of negatives lately 
generated with the beginning of Building 18, we cannot forget 
the miracles that are done every day at Walter Reed and the 
hospitals around the country. I have a young man at Walter Reed 
now, Steven Pearson, whose father I called after I visited 
Steven to just tell him, ``Here is my number, if there is 
anything I can do while you are in Georgia and he is there 
recovering, let me know.'' And he said, ``Well, I will.'' And 
he said, ``One thing you can do is tell everybody. I stayed the 
first 10 days with my son at Walter Reed, and I have never seen 
a quality of care equal to that anywhere.'' So that is a good 
testimony from someone that is there receiving it today.
    Second, I want to mention and commend General Schoomaker, 
who is now at Walter Reed and was called upon to take that duty 
over. Before he came to Walter Reed, he was at the Eisenhower 
Medical Center in Georgia, in Augusta. And it has been a best-
kept secret about what he had done there. And I see you are 
nodding your head, Jonathan, so you may know what he has done 
there. But what he has done there is he decided that veterans' 
facility ought to be a facility that could seamlessly transfer 
active DOD soldiers into that facility, rehab them and turn 
them around so you would have utilization by both active DOD 
troops and the Veterans' Administration service provided.
    Dr. Hollings at that Augusta VA Medical Center is the head 
of that Center, and he and his employees have done a phenomenal 
job. They have a capacity of 30 at any one time. Walter Reed 
amputees are now being transferred directly to the VA medical 
center at Augusta for their immediate treatment. Since January 
of 2007, 431 soldiers, sailors, airmen, and Marines have 
received rehab services at the Augusta unit of the veterans 
medical center; 26 percent of them have been treated and have 
returned to active duty.
    So it is a great story about how collaboration and 
coordination and this idea of a seamless transition from 
Veterans to DOD and back again, if you will, can work.
    I appreciate very much Dr. Hollings at Augusta for the 
leadership that he is showing and all those employees. I am a 
big fan of General Schoomaker, and I think he is going to make 
a big difference in the lives of veterans everywhere because of 
the attention he will give. And I particularly, again, 
appreciate the service and commitment of Tammy Duckworth and 
Jonathan Pruden. Thank you both for being here today.
    Senator Murray. Thank you, Senator Isakson.
    Senator Obama?

                STATEMENT OF HON. BARACK OBAMA, 
                   U.S. SENATOR FROM ILLINOIS

    Senator Obama. Thank you, Madam Chairman, Ranking Member 
Craig.
    Let me start by saying I am so pleased to see Director 
Tammy Duckworth, who is a dear friend as well as a hero, and 
who is doing great work back in Illinois. It is nice to see you 
again. I thank all of the other panelists for their outstanding 
work on behalf of our veterans.
    I know this is the second hearing on seamless transition 
issues facing the Department of Veterans Affairs and Department 
of Defense during this session. I want to join my colleagues in 
recognizing that although Building 18 raised awareness in the 
general public, folks on this Committee I think have been 
concerned with how we are approaching these problems for quite 
some time. The question of how we care for our returning 
servicemembers and their families has gained greater 
significance given recent revelations. But what we know is that 
given the increasingly complex injuries resulting from fighting 
in Afghanistan and Iraq, it is clear that our current DOD and 
VA health and rehabilitation resource investments are 
inadequate.
    When it comes to providing the needed health care and 
support services to heal our wounded warriors, we owe them and 
their families the very best. Later today, I will be offering 
an amendment to the Iraq War supplemental to address many of 
these systematic problems uncovered at Walter Reed. The 
problems may affect DOD's military health care system, but also 
exacerbate many of the ongoing challenges to the VA's health 
system. And my amendment would boost the number of caseworkers 
and mental health counselors and make it far easier for our 
troops and family members to navigate the complex disability 
review process within DOD.
    I think all of us are in agreement that we need to make the 
DOD process less complex and better coordinated with the VA 
process. As Tammy has pointed out in her testimony, we need a 
more robust national engagement with our State VA programs as 
well.
    I look forward to working with the Chairman and this 
Committee as well as DOD, VA, and our private rehabilitation 
centers to ensure we are providing the health care and 
rehabilitation worthy of the sacrifices so many servicemembers 
and family members have made. And I just want to make one last 
point. I know that there was some back and forth with respect 
to the amount of money that is needed. Senator Craig, I do not 
think anybody disagrees with the notion that we should not be 
wasting money, and if we can find ways to do things that are 
more efficient and more cost-effective, they should be by all 
means pursued.
    But I do think it is important to note that for quite some 
time, at least since I have been on this Committee, the VA has 
underestimated both the amount of money and the amount of time 
required to get this right. I think DOD, when we start talking 
about creating what we would think would be relatively simple 
issues, such as setting up medical technology systems that 
allow military records to go from DOD to the VA, it seems like 
it keeps on stalling. And so on the one hand, I do not want to 
waste money. On the other hand, I do not want us to shortchange 
people who have made the extraordinary sacrifices on our 
behalf. I know you do not either. And I think it is important 
for us to recognize that, as Senator Rockefeller stated, this 
is part and parcel of the costs of going to war. And I am 
fearful that we have continually shortchanged the back-end 
costs that are involved.
    Thank you, Madam Chairman.
    Senator Murray. Thank you, Senator Obama.
    Senator Tester?

                 STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. Thank you, Madam Chairman. I appreciate the 
opportunity. Thank you, guests, for your testimony. I am going 
to make this quick. I do have some comments I want to make 
after the first panel. When I was elected to this position--and 
maybe it is because of this Committee--I thought the last thing 
that I would be doing is talking with veterans about problems 
within the medical care system for our veterans when they come 
home from the field of battle.
    That has not been the case. I have been going home every 
weekend, and about half of those weekends, I have been having 
hearings with veterans throughout the State of Montana. And I 
can tell you what I have been hearing is this: Once you get in 
the system, the care is excellent in the VA. But to quote one 
veteran, and I hear this over and over and over again--
``Sometimes it appears as if the VA is trying to outlive me''--
and not letting that person through the door. That is a huge 
problem. Veterans should not have to fight for their benefits. 
They should be granted those benefits for the service that they 
gave to this country.
    From a DOD perspective, I will just tell you that I have 
also heard that the care is very, very good, but the 
administrative runaround and red tape is almost unbearable. And 
for a lot of these folks that have been injured on the field, 
they do not have the ability to be their own advocates. Unless 
they have a wife or a father or a mother or a daughter or a son 
that is there to help them through this process, it becomes 
unbearable.
    Let me give you just one example. A fellow from Shelby, 
Montana, who is over at Walter Reed, they put him back together 
and did a heck of a job, and he would attest to that fact, too. 
Went in to get his medical records at Walter Reed. Couldn't get 
them. They pushed him to another person. That person pushed him 
to another person. That person pushed him to another person. 
That person pushed him to another person, who pushed him right 
back to the first person that he talked to, 4 hours later, 4\1/
2\ hours later. That is ridiculous, and it is not something 
that our military people should have to put up with. And that 
is the essence of what I like about this hearing, seamless 
transition between active military and the VA, and to put on 
something that Senator Obama talked about. The fact that the 
Department of Defense still has paper records, still has paper 
medical records, and you can use all the excuses of the courts 
or whatever, and the second panel may want to respond to this, 
it is ridiculous. This is 2007. It is not 1960 anymore. And the 
VA has made that transition--I applaud them for that--to 
electronic medical records. The DOD needs to do the same thing.
    Thank you, Madam Chairman.
    Senator Murray. Thank you, Senator Tester.
    Senator Burr, opening comments?

              STATEMENT OF HON. RICHARD M. BURR, 
                U.S. SENATOR FROM NORTH CAROLINA

    Senator Burr. Thank you, Madam Chairman, and to our 
witnesses, let me thank you for your willingness to come in and 
share your insight, your experience, and your stories.
    I think we all share the same feelings that we want to have 
a system that is perfect, and that should be our goal. And the 
reality is I hear about stories that Senator Tester said about 
an individual, and I hear Senator Obama talk about the transfer 
of medical data and health IT. I look outside the DOD world and 
the veterans' world and realize that the private system that we 
have got is deficient on everything that we are deficient in in 
these systems.
    So my concern is that our focus stay on how do we make the 
system better. How do we make sure that we are able to provide 
the level of care that our veterans deserve and that we set out 
in legislation to achieve? But also realize that things in 
health care happen in real time and that what we designed 2 
years ago has significant challenges today because of the 
change in the make-up of who walks in the door, the types of 
problems that they have, the demographic shift that happens in 
America as it relates to the VA.
    I happen to represent a State that is the number one choice 
of military retirees. I know in real time exactly what that 
does to a health care system, and the challenge to get ahead of 
the curve and to be able to offer and provide the level of 
health care that they deserve and that this Committee, in a 
bipartisan way, expects is challenging.
    I hope that all of you understand that we are attempting to 
get to the bottom of where our problems are and in a bipartisan 
way fix those problems. Our goal is to be perfect, but we will 
never reach it. But it is also to make sure that the stories of 
the runarounds, the stories of the lines, the stories of the 
inability to transfer medical data, that we fix these things. 
It is unacceptable. But it is also to realize that this is not 
just the VA health care system and the DOD health care system. 
We have got this bigger animal in America. It is Medicare and 
Medicaid and private pay, and they do not do these things very 
well either. And they have a tremendous influence on, in fact, 
these two systems that we are looking at today.
    My hope is that as Members attempt to wade through this to 
learn and to fix, we will also realize that we have got 
challenges on the private sector side that if, in fact, we do 
not fix those, we will find it impossible for the VA and for 
the DOD pieces to work as we expect them to work without those 
changes.
    So, once again, I thank our witnesses for being here. I 
thank the Chair for scheduling this. I look forward to hearing 
from the witnesses.
    Chairman Akaka [presiding]. I want to thank our Members for 
their opening statements, and I also want to thank Senator 
Murray for being the Chair.
    I welcome our first panel of witnesses. We have brought 
each of you here for your unique perspectives on VA and DOD and 
this kind of care, especially for serious traumas.
    First, I welcome back Tammy Duckworth. Since she testified 
in 2005, she has been named the Director of Veterans' Affairs 
for the State of Illinois. Director Duckworth has a firsthand 
perspective on Walter Reed, and she can also share what her 
office is doing to help veterans.
    Jonathan Pruden sustained serious injuries in Iraq. He, 
too, has firsthand knowledge about the various health care 
systems for returning servicemembers and veterans.
    I welcome as well Ms. Denise Mettie, whose son, Evan, 
sustained a very serious brain injury in Iraq last year. I 
understand that you are a wonderful advocate for your son.
    Finally, I have asked Dr. Bruce Gans from the renowned 
Kessler Institute for Rehabilitation to give us the perspective 
of a private provider dealing with the same sorts of injuries 
so many of our servicemembers are experiencing. Dr. Gans, as 
you summarize your testimony, it would be most helpful if you 
could build upon what the witnesses before you have said.
    I want to thank each of you for being here. Your full 
statements will appear in the record of the Committee, and I 
would like to first call on Director Duckworth for your 
statement.

  STATEMENT OF MAJOR LADDA TAMMY DUCKWORTH (RET.), DIRECTOR, 
            ILLINOIS DEPARTMENT OF VETERANS AFFAIRS

    Ms. Duckworth. Thank you, Mr. Chairman, Ranking Member 
Craig, Members. It is such a pleasure to be here today. Two 
years ago when I testified, I was still an inpatient at Walter 
Reed. I came here in my wheelchair, did not have my legs yet, 
and I want to tell you that I owe the medical personnel at 
Walter Reed my life. I owe them a debt of gratitude I can 
never, ever repay. And as we think about what is happening at 
Walter Reed, I hope people do remember that, that the personnel 
there are amazing.
    I would like to talk to you about three main things. First, 
I would like to talk about the state of readiness of the VA 
system and specific programs within the VA, such as the 
prosthetics program. I would also like to speak about 
information sharing between the DOD, the USDVA, and the need 
also to coordinate with the State VA agencies. And then I would 
like to make some recommendations on some testing that should 
be done universally across the Nation for all of our veterans 
coming home.
    Since I have entered the VA system, I must say that the 
transition from Walter Reed to Hines VA that I experienced was 
very, very easy for me. We have a wonderful lady at Walter 
Reed--her name is Brenda Foss--who is the VA coordinator there, 
and she had reached out to the local VA hospital from Walter 
Reed and had everything coordinated for me even before I left. 
I even got a tour of Hines VA Center from the OIF/OEF 
coordinator at Hines even before I checked into Hines itself. 
So that transition was quite smooth. They are certainly working 
with one another, and that went very well.
    Where I am experiencing problems is not the major clinics 
within Hines. It is with the prosthetics program. I do not know 
how it is across the Nation, but if I am talking to my 
comrades, my fellow wounded warriors, the prosthetics program 
within the VA is simply not ready to handle the high 
functioning level of the current war wounded that are coming 
home today. They are doing a wonderful job of taking care of 
our older veterans who are losing limbs to diabetes, who are 
ill, whose goal is to get a prosthetic device and be able to 
walk around their home and maybe make it out to the car. They 
are not ready for veterans who want to go rock climbing and 
running marathons. Many of the veterans coming out of Walter 
Reed want to join the Paralympics program. We are going to rock 
the Paralympics program at the next Olympics because we have so 
many of our young veterans entering that. We are going to 
really, I think, win a majority of those Gold Medals for the 
United States. But the VA system is simply not ready, and they 
do not have time to catch up. They simply do not have time to 
take some of those wonderful men and women who work in the 
prosthetics program and send them back for the year-long 
training that they need to work on the high-tech levels of 
prosthetics that we wear. If you do that, those prosthetists 
then are not available to take care of the veterans who are 
already in the system, and then you will be hurting and harming 
the veterans of previous wars who need access to the lower 
levels of prosthetic devices. Those of us who need carbon fiber 
running legs--and I am getting my scuba legs this week from 
Walter Reed. I have a prosthetist down in Florida who is making 
me a flying leg so I can get back in a cockpit again. We need 
to be able to access that level of care.
    So I was so pleased, Senator Craig, to hear you say that it 
would be wonderful for us to be able to go to outside sources. 
That is important. That is important because the VA simply does 
not have time to catch up when it comes to the prosthetics 
program.
    Once the war is over and the critical first 2 years of an 
amputee's life are behind us, then we have time to wait for a 
prosthetist to learn to fit us. But in the first 2 years, we 
simply do not have time, and that is why it is critical for 
those patients to be able to access the prosthetist that we 
need to access to get the care that we need.
    However, I do think that additional funds are needed for 
the VA system. It simply is underfunded, and the problems that 
we have with the VA right now come from the fact that while the 
personnel are excellent, they want to work hard, they want to 
do the best job for us, they cannot because they do not have 
the funding for it. And so that is why the supplemental, the 
additional spending, will really be a boon to the VA so that 
they can indeed do the job that they need to do.
    I would like to give you an example. My physical therapist 
at Hines wanted to come with me here this week to Walter Reed 
to coordinate and to learn to care for me better with my latest 
artificial limbs and simply was not able to because there is no 
funding for the plane ticket for him to come from Chicago here 
to Walter Reed to do that. That is not acceptable.
    I also would like to talk about information sharing. We 
need to make sure that there is adequate information being 
shared between DOD and USDVA. That is starting to happen. 
Secretary Nicholson introduced a new program in Florida where 
seven people participated, where soldiers voluntarily allowed 
the DOD to transfer their personal contact information to the 
local USDVA.
    There are a lot of State programs available that we cannot 
tell the wounded servicemembers that these programs exist 
unless we know that they are coming home to us. If they are 
part of the National Guard, we can reach out and touch them. 
But if they are coming home as a soldier, for example, serving 
with the 10th Mountain Division in New York, coming home to 
Illinois, I have no way of knowing that that individual soldier 
is coming home. And I have no way of telling him that here in 
Illinois, Governor Blagojevich has instituted a supplemental 
health care program, health insurance for veterans, or that he 
just recently signed a bill into law that gives all employers a 
$600 tax rebate next year on every OIF, OEF, and Persian Gulf 
War veteran that they hired in 2007. What a great thing to be 
able to write on your resume, that if you hire me, you get $600 
back on your taxes next year. But I cannot even tell those vets 
that because I do not even know that they have come home.
    So this seamless transition needs to happen down to the 
State agency level as well, and there is actually an 
organization of State Directors of Veterans Affairs, whom you 
addressed, Senator Akaka, just recently, who can help 
facilitate that so that we truly do work together, red States, 
blue States, Federal, local levels, to really do what we need 
to do for our veterans.
    I would also like to talk about some universal testing 
needs. We need to test universally all wounded veterans for 
PTSD, for traumatic brain injury, for hearing loss, and for 
vision loss. That is not being done uniformly across the VA 
system. Hines VA right now is testing for vision loss all of 
the patients that come through its traumatic brain injury unit, 
and it is finding that 60 percent of those patients in their 
polytrauma center at Hines have some form of functional vision 
loss. Vision loss will affect your scores on a traumatic brain 
injury test. Hines VA is the only VA hospital in the entire 
Nation that is testing for vision loss as a universal thing 
that is done for all polytrauma patients. That is very 
important because the veteran may be thinking that he is not 
understanding what is going on, maybe he has worse TBI than he 
really has, because he cannot read the test, he cannot pass 
some of the vision aspects of it. So that is important.
    I would like to finish by talking about the need for 
additional funding and coming back to that. One of the things 
that I have not heard people talk about are the Vietnam era 
veterans. We have been talking about this large influx of 
wounded warriors coming out of this war who are coming home, 
who are entering the VA system, and the fact that we need to 
take care of them. And this is where the additional spending is 
so critical.
    What people do not realize is that the Vietnam veterans 
have now reached an age, in their mid-60's, that they need 
additional medical care. They are reaching a point in their 
lives where they are accessing greater levels of medical care. 
In fact, in Illinois, the first Vietnam veterans have entered 
our nursing homes.
    Our VAs are now entering a stage where we talk about the 
sandwich generation of people who are taking care of their 
children and their parents at the same time. The VA is entering 
that stage within the next 5 to 10 years. We will have a large 
influx of Vietnam veterans in the next 5 to 10 years demanding 
greater access to VA health care at precisely the same time 
that you have all of the Iraq and Afghan vets coming in also 
accessing it. The VA simply is not ready.
    So I thank you for continuing to do this. It is such a 
pleasure to see you, Senator Akaka, as the Chairman of this 
Committee. You are one of us. You served, and we are so proud 
to be here. And, again, thank you so very much for having me 
here, and I know that Captain Pruden will have wonderful things 
to say as well.
    [The prepared statement of Major Duckworth follows:]
  Prepared Statement of Major Ladda Tammy Duckworth (Ret.), Director, 
                Illinois Department of Veterans Affairs
    Mr. Chairman, Members of the Committee. It is indeed a pleasure to 
be here to testify. I am honored to have the opportunity to follow up 
on my March 2005 testimony on the Seamless Transition from DOD to VA 
healthcare.
    When I last appeared before this Committee, I was newly injured and 
still an inpatient at Walter Reed Army Medical Center. The care that I 
received and continue to receive at Walter Reed is above the best. The 
personnel there are incredibly talented and dedicated. It is 
unfortunate that they are not given adequate resources to support our 
Wounded Warriors.
    Since my last appearance, I have undergone the transition from DOD 
to VA healthcare and have had an overall positive experience. However, 
compared to the experiences of other servicemembers, I know that mine 
is not uniform across the Nation. Even before I left Walter Reed, the 
USDVA representative had reached out to me and coordinated with the 
OIF/OEF coordinator at Hines VA Hospital. I had an early tour of the 
facility and met my future physicians. The one negative experience was 
the prosthetics department, which, while eager to meet my needs, was 
many decades behind in prosthetics technology. I now receive care at 
Hines but also continue to return to Walter Reed. The staff at Hines 
have been very helpful, and shown great initiative. For example, even 
though my physical therapist at Hines had not treated a high-
functioning amputee like myself before, he prepared for my treatment by 
reaching out and coordinating with my Physical Therapist at Walter 
Reed. Both therapists did this of their own initiative.
    I continue to return to Walter Reed for its prosthetics program. I 
also travel to a specialist in Florida for state-of-the-art care. 
Recently, Hines sent a prosthetist with me to Florida to learn about 
the high-tech artificial legs that I obtain from the private 
practitioner there. He was overwhelmed by the technology. The USDVA is 
absolutely not ready to treat amputee patients at the high tech levels 
set at Walter Reed. Much of the technology is expensive and most of the 
VA personnel are not trained on equipment that has been on the market 
for several years, let alone the state-of-the-art innovations that 
occur almost monthly in this field. I recommend that the VA expand its 
existing SHARE program that allows patients to access private 
prosthetic practitioners. There is simply not enough time for USDVA to 
catch up in the field in time to adequately serve the new amputees from 
OIF/OEF during these critical first 2 years following amputation. 
Perhaps after the end of the current wars in Iraq and Afghanistan, the 
VA will have time to advance its prosthetics program.
    In addition to medical treatment, Seamless Transition is also the 
passing from one administrative program to another. The Seamless 
Transition initiative needs to be expanded to each state's VA, and more 
importantly, local counties and municipalities. The current model for 
Seamless Transition focuses on transition from the DOD to the USDVA 
entities within the state. It is also important to involve each state's 
VA agency as there are many state programs that are unique to the 
state. For example, in Illinois we provide Veterans' Care, a health 
insurance plan for veterans. We also provide additional funds for 
accessibility modifications to disabled veterans' homes. New benefits 
are added at the state level more quickly than can be tracked by the 
USDVA. For example, as of January this year, Illinois gives up to a 
$600 rebate on employer's state taxes for each Persian Gulf War, OIF or 
OEF veteran, that they hire.
    One of the greatest difficulties for state VA agencies is the 
tracking of returning servicemembers who come home from active duty 
status. We at the states only find out about these individuals if they 
self-report to our agency. It appears that a significant difficulty 
with the Seamless Transition between DOD and USDVA is the sharing of 
servicemember's information. The DOD and USDVA are still negotiating a 
Memorandum of Agreement (MOA) for this process. Recently, the USDVA 
announced a new program that was pilot-tested in Florida called the 
Florida Seamless Transition Program. This program for sharing 
information between USDVA and state VA agencies is just now being 
expanded to other states. It basically allows wounded servicemembers at 
DOD medical facilities to voluntarily give permission to have their 
contact information forwarded to their home state's VA agency. Only 
seven servicemembers chose to participate, but this is an excellent 
start.
    A related aspect of information sharing between DOD, USDVA and 
state VA agencies is the technical aspect of data sharing. The USDVA 
and DOD each have their own excellent medical records keeping system. 
Unfortunately, most state agencies that operate health facilities such 
as long-term care facilities do not have electronic records keeping due 
to the prohibitive costs. At the very least, the USDVA and the DOD 
should be able to electronically share data so that the wounded 
servicemembers' medical records can simply be transmitted 
electronically once they enter the USDVA healthcare system. If there 
are issues of patient privacy, the records could be given to the 
servicemember on a CD-ROM, to be turned over at the patient's 
discretion once they begin seeing their USDVA healthcare provider.
    Any Seamless transition program must also include comprehensive 
screening for Traumatic Brain Injury (TBI), Post Traumatic Stress 
Disorder (PTSD) and vision loss by both the DOD and the USDVA Health 
Care systems. I know that efforts are underway to strengthen these 
assessments by both the DOD and the USDVA. However, there is no 
standard procedure in place to ensure that all war wounded are screened 
nationwide.
    Currently, there is an issue with TBI screenings. Some 
servicemembers who are not screened for TBI, are being identified as 
suffering only from PTSD. However, it is possible to have both PTSD and 
TBI or either condition alone. My concern is that servicemembers with 
TBI are not diagnosed and then return to civilian life without this 
medical condition noted on their records. The symptoms of TBI can 
result in inability to work or even aggression that results in 
homelessness and entry into the criminal justice system. At that time, 
these veterans are then often diagnosed as having PTSD and treated for 
PTSD even though the main injury is TBI. What is significant about this 
situation is that TBI and PTSD have many treatment methods that are the 
exact opposites.
    One additional screening criteria that is critical is testing for 
vision loss. At the Hines USDVA Hospital, all polytrauma patients are 
routinely screened for vision loss as soon as they enter the facility. 
The result of these screenings is that 60 percent of the polytrauma 
patients at Hines have been found to have some form of functional 
vision loss. Vision loss, an acute injury on its own terms, can also 
negatively affect how patients perform on tests for TBI, which are 
heavily reliant on vision. Hines is the only USDVA facility in the 
Nation that conducts routine screening of patients in its polytrauma 
centers. This is because it is the initiative of the excellent Blind 
Rehabilitation program at Hines.
    I would like to close by saying that I have had a surprisingly 
positive transition to the VA system. I also understand that this may 
not be the same across the board for all returning servicemembers. 
There are problems that can be resolved such as the establishment of 
standard screening criteria for major injuries such as TBI, PTSD and 
vision loss. I would also strongly urge this Committee to consider 
eliminating the 2-year window for free VA care for OIF/OEF veterans. 
This is a new time limit that will limit veterans' ability to access 
care for injuries such as PTSD, which may not become evident until over 
2 years after their service. We have more work ahead of us, but much of 
it can be resolved through information sharing, use of patient 
advocates, and a willingness to access private healthcare specialists.

    Chairman Akaka. Thank you so much for your testimony.
    And now Jonathan Pruden.

               STATEMENT OF JONATHAN D. PRUDEN, 
                OPERATION IRAQI FREEDOM VETERAN

    Mr. Pruden. Mr. Chairman, Members of the Committee, good 
morning. It is an honor to be here. I strongly agree with Major 
Duckworth's assessment of VA prosthetics and have experienced 
similar challenges in receiving adequate prosthetic care. I had 
my legs made at a private clinic down in Gainesville, Florida.
    Part of the problem here may be that VA care has 
predominantly become geriatric care, and this is only right 
given that most of the veterans are over the age of 50 right 
now. VA physicians and clinicians have become very good at 
diagnosing and treating chronic diseases associated with this 
aging population. However, they have little experience with 
blast injuries and young patients. At facilities I have been 
asked at least a dozen times if I lost my leg to diabetes or 
vascular disease. While re-establishing ADLs for an 80-year-old 
veteran is certainly an admirable goal, these young OIF/OEF 
veterans, as Major Duckworth said, want to go on and live 
fuller lives. They want to go run marathons and climb rocks, 
and they need a higher level of care.
    On July 1, 2003, I was wounded in Baghdad. Over the next 3 
years, I had 20 operations, including the amputation of my 
right leg. At Army, Navy, and VA hospitals, I encountered 
caring and competent individuals willing to go the extra mile 
to care for servicemembers and veterans.
    I understand that steps are being taken already to remedy a 
lot of the issues that we are discussing here today, but I also 
understand that a lot of times there is a substantive gap 
between policy change here and the effects on the ground for 
the guys implementing it.
    Our severely wounded men and women should receive the best 
medical care, regardless of the cost. One of my favorite 
soldiers, Corporal Robert Bartlet was critically wounded in 
Iraq on May 3, 2005. He lost his left eye; the bones and soft 
tissue on the left side of his face and his jaw were all blown 
away or pulverized; both his hands have nerve damage; he 
suffers from PTSD and has a mild TBI. He is about to go in for 
his 30th surgery on April 13th.
    Currently, Corporal Bartlet must go back and forth between 
Walter Reed and Johns Hopkins for separate dental and plastic 
surgery care because TRICARE will not authorize dental care at 
Johns Hopkins. This is inexcusable. He will have to endure an 
extra 8 months of surgeries because TRICARE will not allow his 
plastic surgeon and a dental surgeon to tag team and do two 
surgeries at once. The practice of tag teaming is very common. 
They did that on me a lot at Walter Reed. I would have 
vascular, ortho, and neuro all working on me at once, so 
instead of having three surgeries at separate times and having 
long recoveries, they piled it all into one. This reduces 
recovery times and risks associated with anesthesia and so 
forth. Military physicians caring for our severely wounded must 
be able to base their treatment decisions solely on what is 
best for the patient, not TRICARE authorizations.
    Rob is a very positive, inspiring individual who wants to 
get on with his life and his education. He should not be facing 
numerous extra surgeries and putting his life on hold for lack 
of a TRICARE authorization. He and other servicemembers like 
him have already sacrificed enough.
    We also must ensure that servicemembers have advocates who 
know the system and can help them and their families navigate 
the incredibly complex MEB/PEB process and the VA's benefits 
process. When I went to my local VA to apply for benefits when 
I was medically retired in December of 2005, I discovered that, 
despite what I had been told, an earlier application for a 
vehicle adaptive grant had been filed as my disability claim. 
My disability claim did not even include the amputation of my 
right leg. So I tried to stop the disability claim and find out 
what was going on. No one at the Gainesville VA or anyone I 
could talk to could get through to the regional office to stop 
the claim or, you know, add my amputated leg to my disability 
claim.
    Finally, I contacted someone up here in VA Central Office 
who contacted someone in benefits who contacted St. Pete, and 
then they called me. And it worked out in the end, but you 
should not have to work the system like that to make this 
happen. And a lot of these individuals do not have the 
wherewithal because of injuries and medications and so forth to 
do that, to work the system, or they do not have the contacts. 
You should not have to do that to get your benefits straight. 
This is something we really need to work on.
    For over 5 years, VA and DOD have been promising IT 
miracles that will connect military treatment facilities one to 
another, inside DOD, and DOD to the VA. I am wondering when it 
is all going to get fixed.
    Last summer, GAO reported that two VA polytrauma centers 
they visited could not access DOD electronic records. I have 
encountered this time and again. When I filled out a post-
deployment health assessment at Walter Reed, I thought that 
would be the one time I had to fill it out. I wound up filling 
that out five different times at five different medical 
facilities because never did another facility have a record of 
me filling out this post-deployment health assessment at any 
other facility. And to date, the VA still does not have a 
record of me having filled out this assessment, which is 
supposed to help screen for various health conditions.
    We can do better than this. I know a lot is being done. I 
appreciate what this Committee is trying to do, and I 
appreciate the very caring and competent people in the VA and 
DOD and the work that they are doing.
    Thank you all very much for having me here today.
    [The prepared statement of Mr. Pruden follows:]
               Prepared Statement of Jonathan D. Pruden, 
                    Operation Iraqi Freedom Veteran
    Mr. Chairman and Members of the Committee, good morning. It is an 
honor to be here today.
    On July 1, 2003, I was wounded in Baghdad. Over the next 3 years I 
had 20 operations, including the amputation of my right leg. At Army, 
Navy, and VA hospitals I encountered caring and competent individuals 
working diligently to help wounded servicemembers and veterans heal. 
There have been some obstacles along the way, but most of my care and 
the care of my wounded soldiers has been first rate. This is as it 
should be.
    Our men and women in uniform deserve nothing but the best care we 
can provide when they are wounded in the service of our Nation. 
Anything less is not acceptable. Although I will express a number of 
concerns about our current system of care, I think we all need to be 
very careful when pointing fingers. The vast majority of VA and DOD 
employees are extraordinary men and women, willing to go the extra mile 
to care for servicemembers and veterans. Individuals like Lieutenant 
Colonel Gajewski at Walter Reed, Jim Mayer in VA Outreach, and Karen 
Myers at the Gainesville VA have influenced my life and the lives of 
countless others in profoundly positive ways.
    As this Committee well knows, VA and DOD provide outstanding 
medical care and benefits to millions of servicemembers and veterans 
each year. The dedicated public servants who provide this care deserve 
our utmost respect. That being said, there are still areas that need 
improvement to ensure truly seamless care for our wounded warriors. I 
understand that steps are already being taken to remedy some of these 
issues but I also know that there can be quite a chasm between policy 
change and substantive changes ``on the ground.''
                         in need of an advocate
    I've found that soldiers will often ``suck it up'' and not complain 
about challenges they face or seek the help they need. At times they 
are stymied by an overly complex system that can be challenging to 
negotiate even without mental and physical obstacles created by their 
wounds or medications. The following cases are a few examples of issues 
faced by men I've worked with.

     I caught one of my men dragging his nerve damaged foot and 
asked him why he wasn't wearing a much needed Ankle-foot orthosis 
(AFO). He told me that the Sergeant at the orthopedics clinic didn't 
have one in his size.
     One if my old Scout's was seriously wounded and his entire 
squad was Killed in Action (KIA) or Wounded In Action (WIA). He denied 
having any PTSD and believed those who claimed to have it were faking. 
Meanwhile he was consuming ever greater quantities of alcohol and was 
having trouble controlling his anger.
     Another soldier; a bilateral amputee, was rendered 
unconscious for an undetermined amount of time by a blast that killed 
the driver of his vehicle and grievously wounded the other occupant. 
His mother reported he has great difficulty remembering things but he 
was not screened for a TBI in nearly 2 years by DOD. This is likely 
because his TBI symptoms were masked by symptoms of significant PTSD 
and substance abuse.

    There was no reason for these men to suffer. In each of cases 
resources were available and could have been used to help these men. 
Often problems arise, not because of a lack of resources, but a lack of 
information. These soldiers all needed more information and an advocate 
to ensure they received the services they needed.
                       not authorized by tricare
    Our severely wounded men and women should receive the best medical 
care regardless of the cost. One of my favorite soldiers, Corporal 
Robert Bartlet, was critically wounded in Iraq on May 3, 2005. He lost 
his left eye, the bones and soft tissue of the left side of his face 
were pulverized or blown away, both his hands have nerve and tissue 
damage, he suffers from PTSD, and a mild TBI. He is about to go in for 
his 30th surgery on April 13, 2007.
    Currently, Corporal Bartlet must go back and forth between Walter 
Reed and Johns Hopkins for separate dental and plastic surgery care. 
This is inexcusable.
    He will have to endure an extra year of surgeries and time away 
from his wife because TRICARE will not pay for dental care at Johns 
Hopkins that would allow his plastic surgeon and dental surgeons to 
``tag-team'' and do two surgeries at once. The practice of ``tag-
teaming'' is very common and prevents patients from having to endure 
extra surgeries, longer recoveries, and increased health risks 
associated with multiple surgeries.
    Walter Reed has the dental surgeon but not the plastic surgeons to 
work on Rob. So he will continue to endure, needless, extra surgeries 
as he bounces between Walter Reed and Johns Hopkins. Despite repeated 
requests, TRICARE will not allow him to receive dental care at Johns 
Hopkins.
    This is completely unacceptable. Military physicians caring for our 
severely wounded must be able to base their treatment decisions on what 
is best for the patient not on TRICARE authorizations. Rob is a very 
positive, inspiring individual who wants to get on with his life and 
his education. He should not be facing numerous extra surgeries, pain, 
and recoveries while his life is put on hold in order to save the 
government a few dollars.
    He and other soldiers in similar situations have already sacrificed 
enough.
                                the jec
    In recent Congressional committee hearings representatives 
repeatedly expressed great concern about the complex and confusing 
quagmire that the wounded must attempt to navigate as they transition 
from DOD to VA care. In light of these concerns it seems important that 
Congress consider the actions of the Joint Executive Council (JEC), the 
only significant entity that straddles the divide between DOD and the 
VA.
    Unfortunately this year, Congress will not be receiving its annual 
report on the JEC from the Government Accountability Office (GAO) as it 
has each March for the past 3 years. The 2003 NDAA required GAO to 
present an annual report on the JEC to Congress. According to Laurie 
Ekstrand, of GAO's healthcare team, ``GAO asked to have the annual 
reporting changed. Given the array of issues we have to cover it seems 
more reasonable to report on an as-needed basis and to have reporting 
about the JEC considered in relation to the relative importance of the 
rest of our requested workload.''
    The JEC provides its own annual report to Congress but they have a 
vested interest in highlighting the ``good news stories'' and 
minimizing the focus on areas in need of improvement. Allowing agencies 
to self report without the objective oversight provided by GAO reports 
may have contributed to the problems at Walter Reed. Army Leadership 
was so focused on all the good that was being done that they failed to 
look for, or acknowledge, the bad. In recent Congressional hearings 
General Schoomaker, the Army Chief of Staff, addressed the Army's 
propensity to believe its own good press about Walter Reed and 
acknowledged, ``we have been drinking our own bathwater.''
                           a complex process
    We must ensure that wounded servicemembers have advocates who know 
the system and can help them and their families navigate the incredibly 
complex MEB/PEB process and the VA benefits process. Secretary 
Nicholson's hiring of 100 patient advocates and 400 benefits personnel 
is a step in the right direction but much more needs to be done.
    The problems with the current system have been highlighted by the 
MED HOLD situation at Walter Reed. One of my old troops lived in 
Building 18 last year. Neither he nor the others I've been working with 
complained about their accommodations. Rather, they were frustrated by 
the way they were treated by NCOs, social workers, and administrators 
as they worked to recover and either get back to the line or get on 
with their lives. One soldier expressed this common sentiment bluntly; 
``They treat us like . . . 5 year olds!'' These frustrations are 
exacerbated by feelings of powerlessness and an overly complex MEB/PEB 
process especially among those suffering from TBI and/or PTSD. One 
soldier who was at WRAMC when I was injured in July of 2003 is still in 
MED HOLD 3 years and 8 months later.
                              va benefits
    When I went to my local VA to apply for benefits after I was 
medically retired in December of 2005 I discovered that, despite what I 
had been told, an earlier application for a vehicle adaptive grant had 
been submitted as my disability claim. The claim failed to include the 
amputation of my right leg! Try as I might, I, nor anyone at the VAMC 
could actually contact anyone in the regional claims office who could 
address my concerns. Fortunately, I knew a senior VA administrator in 
Washington, DC. He had one of the key leaders over VA benefits in VA 
Central Office call me. Through them I finally made contact with a 
manager in the regional claims office who was able to help correct the 
situation. Wounded servicemembers should not have to have to ``work the 
system'' to ensure their claims are properly handled.
                                va care
    At VA facilities I have been asked at least a dozen times if I lost 
my leg to diabetes/vascular disease. VA practitioners have become 
specialists in geriatrics and have very little experience with blast 
injuries and young patients. Currently, the majority of their patients 
are over 50, however these doctors are facing a new wave of veterans 
with different needs. While reestablishing Activities of Daily Living 
(ADLs) may be an acceptable goal for an 80-year-old veteran, OEF/OIF 
veterans typically want to return to the active lives they led before 
being wounded.

     Seriously wounded veterans should be assigned to the best/ 
most experienced Primary Care Managers (PCMs) available. Too often it 
seems the veterans who have been in the system a long time know who the 
best physicians are. This means that the ``best'' PCMs are perpetually 
``booked up'' by older veterans. Unfortunately, this leaves the newest 
veterans, who may have the most complex and challenging medical issues, 
under the care of the least experienced or desirable Nurse 
Practitioner.
     The VA should offer drug rehabilitation to combat veterans 
who received an Other Than Honorable discharge from the service for 
substance abuse.
          clear, accurate, and timely exchange of information
    The most significant challenges to a truly seamless transition for 
our wounded often result from poor communication. In September of 2002, 
a VA news release touted the development of ``a single, reliable, data 
source and a single point of integration between VA and DOD.'' Four and 
a half years later no such system exists for practitioners ``on the 
ground.'' Last summer GAO reported that the two VA Polytrauma centers 
they visited could still not access DOD electronic medical records. 
(GAO-06-794R Transition of Care for OEF and OIF Servicemembers GAO.)
    I have filled out the Post Deployment Health Assessment (PDHA) five 
separate times at Walter Reed Army Medical Center, Brooke Army Medical 
Center, Eisenhower Army Medical Center, Winn Army Community Hospital, 
and Portsmouth Naval Hospital. Never has a facility had a record of me 
filling out this form. The VA also has no record of me filling out a 
PDHA.
    I have requested, in writing, a record of my amputation at 
Portsmouth Naval Hospital from PNH, WRAMC, DOD, and the VA. The only 
evidence that I had an amputation is my lack of a leg a copy of my 
discharge paperwork from PNH.
    We can do better than this.
                               conclusion
    Recently, my cousin was severely injured in a helicopter crash in 
Afghanistan. I have been impressed by the level of care and support he 
and his family have received both medically and administratively. A 
great deal has changed since 2003. Over the past 3.5 years I've 
witnessesed an evolution in the depth and nature of the health and 
social services provided by DOD and the VA for the wounded returning 
from combat. These changes will ensure that my cousin and others 
wounded today will not face many of the issues faced by those wounded 
in 2003.
    Fourteen servicemembers on my cousin's helicopter came back to the 
United States on stretchers. Eight returned in flag draped caskets. 
These wounded, and the families of those who were killed, deserve the 
best this Nation has to offer. The work that you all are doing is, and 
will continue to be, critical to ensuring wounded servicemembers and 
Veterans of every generation receive the best care this Nation can 
offer.
    Thank you all for all that you are doing and thanks for having me 
here today.
                                 ______
                                 
 Response to Written Question Submitted by Hon. John D. Rockefeller IV 
        to Jonathan D. Pruden, Veteran, Operation Iraqi Freedom
    Question 1. I am interested in your suggestion about providing 
rehabilitation services to veterans on request for substance abuse. Can 
you explain more about why you think it is such a priority, and how you 
think your colleagues would react to such an offer? Do you think that 
some type of substance abuse screening would be important for veterans 
with PTSD or TBI diagnoses?
    Response. The extensive substance abuse that devastated so many 
lives in the wake of Vietnam should make us consider how we will care 
for those with similar issues after combat in Iraq and Afghanistan. 
Time and again I have witnessed soldiers slide into substance abuse 
after combat. Some ask for help, go through rehabilitation, and return 
to duty. Too many however, wind up being discharged when they ``come up 
hot'' during drug screens or for behavioral issues secondary to 
substance abuse. A large number of those discharged for substance abuse 
likely turned to drugs or alcohol to medicate psychological problems 
stemming from combat.
    After recent policy changes, the VA is now screening all OIF/OEF 
veterans for TBIs, PTSD, alcohol abuse, depression, and infectious 
diseases. However, there is not a separate screen for drug/substance 
abuse. The VA has world class substance abuse rehabilitation programs 
but the door to these programs is closed if a veteran left the service 
with an ``Other than Honorable'' or ``Dishonorable'' discharge.
    Those who believe that veterans who are not honorably discharged do 
not deserve any VA care should consider how rehabilitation may reduce 
the long term costs of substance abuse for family, community, society, 
and the government. I've spoken to several soldiers, VA employees, and 
friends about this matter and every person has supported this idea. 
Several expressed shock that the VA did not currently offer 
rehabilitation to those discharged for substance abuse.
    I am not proposing free healthcare for these veterans. However, it 
seems that we have an obligation to help these men and women when they 
show up at the VA wanting to ``get clean.'' Although DOD and the VA are 
taking proactive steps to address post-combat PTSD, TBI, and substance 
abuse they cannot change human nature nor the horrors of war. The 
entanglement of TBI, PTSD, depression, and substance abuse can make it 
difficult to determine what the roots of substance abuse may be. 
Veterans who were other than honorably discharged due to substance 
abuse may have turned to drugs and alcohol to cope with devastating 
combat experiences. They deserve our compassion, not disdain.

    Chairman Akaka. Thank you very much, Mr. Pruden.
    Denise Mettie?

 STATEMENT OF DENISE METTIE, REPRESENTING THE WOUNDED WARRIOR 
                    PROJECT, AND MOTHER OF 
                     ARMY SPC. EVAN METTIE

    Ms. Mettie. Mr. Chairman and Members of the Committee, my 
name is Denise Mettie, and I am representing my son, Retired 
Army Specialist Evan Mettie, who was injured in Iraq on January 
1, 2006, and the Wounded Warrior Project, a group that assists 
wounded servicemen from Iraq and Afghanistan.
    Let me start by giving you some details of Evan's initial 
injury and his subsequent treatment.
    Chairman Akaka. Would you please turn the microphone on?
    Ms. Mettie. But I want to whisper.
    [Laughter.]
    Ms. Mettie. Evan was injured while on a highway outside of 
Baji when his patrol stopped to investigate a car. When they 
challenged the driver, he blew himself up. We were told that 
Evan was initially reported as killed in action, but when a 
medic arrived 15 to 20 minutes later, she discovered he was 
still breathing. He was quickly evacuated to the nearest 
medical facility. In Balad, doctors performed a left-side 
craniectomy and removed shrapnel from his brain. Evan 
stabilized very well and was transferred to Landstuhl, Germany, 
the next day.
    Since I could not be there with him, I had the staff put 
the phone to his ear, told him we loved him, hang in there, we 
would be with him very soon. The nurse said that as soon as I 
started talking to him, she saw his heart rate go up. From that 
moment on, I knew he was there and God was with our son and was 
bringing him back to us.
    Evan arrived at Bethesda on January 3, 2006, just 3 days 
after the blast, and we arrived a day later--my husband and two 
teenage daughters. Evan spent the next 86 days in ICU at 
Bethesda. He endured fevers as high as 106, and his weight 
dropped from 190 to 99 pounds. We were told he would most 
likely remain in a vegetative state, not breathe or eat on his 
own, and be paralyzed on his right side.
    Before Evan came out of his coma, approximately 17 days 
after his injury, we were approached about his Medical Boards 
and the process that would initiate his retirement from the 
military. Not knowing or having the time at that time to figure 
out what was going on, I just said, ``Do what you have to do.''
    During the months of January and February, Evan moved his 
head from side to side, opened his right eye, and squeezed my 
fingers. When Evan's sister came back for a visit, his response 
was amazing. As soon as he heard her voice, he lifted his head 
and shoulders and raised his arms out like he was trying to sit 
up.
    On March 10th, it was like an awakening. Evan was really 
alert. He even watched a movie for 2 hours for the first time.
    By this time the doctors at Bethesda recommended that we 
return home so I could be closer to the family and return to a 
more normal life and Evan could go to the Seattle VA. We asked 
about rehab and were told he was not ready. At no point did 
anyone mention the possibility of going to one of the VA's 
polytrauma centers let alone private rehab.
    On March 26th, he was medevaced to the Seattle VA. That 
night when I kissed him goodnight and turned to leave, he 
raised his right hand and hit my arm for the first time. I just 
cried for joy. Frustratingly, Evan's records were sent with us 
in large packets, but somehow some had been misplaced. So for 
the next several days, I was filling the doctors in on his care 
that he had received for the previous 3 months.
    Four days after being there, the doctors told me that Evan 
was too healthy to be in ICU and that we needed to move him out 
as soon as possible. Since Evan was still on a ventilator, that 
meant he has one of four civilian skilled nursing facilities to 
choose from in the State of Washington.
    One of the VA doctors told me that Evan's brain injury was 
the most devastating that she had seen and hope for recovery 
was unlikely. Like all of the other times, I told her, ``We 
have seen Evan do amazing things. You have your prognosis and I 
have mine, and I am following mine.''
    Before being sent to the nursing facility, Evan was making 
significant progress. He ultimately went 24 hours breathing on 
his own. He was squeezing hands on command, smiling, tried to 
lift his left hand several times. He would give little modified 
``thumbs up'' when we asked him questions or asked him to do 
it, raised his head and would try to lift both hands at the 
same time.
    Because there was no interim place in the hospital to place 
him for a week or even two, to continue his vent weaning, he 
was transferred directly to a civilian skilled nursing 
facility, a SNF. This was undoubtedly the most horrendous 
experience we have ever endured. The medevac nurses were 
initially afraid to leave him because they feared for his 
safety. After 3 weeks of enduring continuous disregard to his 
care, his pain, and the fact that he could not speak for 
himself, the VA investigated and moved him back to the Seattle 
VA.
    I could not even begin to tell you how relieved I was. At 
that point I could just take a breath again.
    In May, however, because Evan's MEB had been stalled until 
we gained guardianship, he was still on active duty. His 
medical holding was changed to Fort Lewis. Due to this change, 
I was no longer able to get a per diem. I had quit my job with 
US Bank to be with him, and now all motel, food, and gas costs 
were at our expense.
    The people in Seattle treated Evan wonderfully, but he was 
the first OIF TBI to come through there, and there was no 
overall treatment plan. To this day, I am still unsure how Evan 
originally bypassed the entire polytrauma system that could 
have potentially provided such a plan. I even asked for 
referrals, but was told Palo Alto could not take him because he 
was not ready.
    At that point Evan's rehab program consisted of a 30-minute 
range of motion each morning, Monday through Friday. One to 
three times a week a physical therapist would come in and sit 
him upright on the side of his bed for approximately 30 
minutes. That was it.
    During this time I did my own research. I devised my own 
coma stimulation program, and I did his extra range-of-motion 
activities.
    Part of the problem lay with a test, an SSEP test that they 
took that measures the impulse activity throughout the nervous 
system. And when they did it, the testing resulted normal, up, 
through, behind his ears, the electrodes they had placed on top 
of his head did not pick up any electrical impulse activity in 
the cortex of his brain. In studying these tests, they can be 
inaccurate for a variety of reasons. When the rehab doctor met 
with me to tell me about this, I told her that it was wrong. I 
had seen him do too many things that he would not have been 
able to do if he did not have this impulse activity.
    On November 30th, almost a year after his initial injury, 
Evan finally made it to rehab at Palo Alto and soon started 
command responses again. Evan came in for a 30-day evaluation 
and was extended 2 more weeks. He occasionally could answer 
questions with raising his right hand, and he would move his 
head to the left and right, and they extended him for another 2 
weeks.
    In January, I was advised to take Evan home and put him in 
a skilled nursing facility until he reached the next level and 
that he could come back for more therapy. My question was: How 
can he reach the next level if he is not receiving 
rehabilitation therapy? They said they would send videos and 
written instructions for the staff at the nursing home to 
follow and I would be there to train them. After our experience 
with the previous facility, this scared the living daylights 
out of me. Evan was to heal himself before he could get further 
rehab.
    Unfortunately, by mid-February Evan's lack of responses was 
noticeable, and I could not figure out what was happening. On 
the 16th, I was told the team doctors thought it would be a 
good idea to transfer Evan to a VA long-term facility until he 
could be transferred elsewhere. I was livid. First, any moves 
are extremely hard on Evan, especially if it is just for a week 
or two. Second, since mid-January I had not seen a particular 
neuropsychologist with Evan. He was an integral part of his 
program. He had been seeing him for 3 to 4 weeks prior to this, 
and he was making continual progress. I requested a meeting to 
address my concerns, and the doctors agreed to check the 
records.
    On March 14th, I received an apology from the hospital 
director as it appeared that Evan's records were not accurate. 
They offered another evaluation and therapist for Evan, and in 
the meantime, I had requested second opinions from both Tampa 
VA and a private rehab facility called Casa Colina. 
Representatives from Tampa VA met with me and, without seeing 
Evan, told me since he is a year out in his injury they could 
not help us. I asked if further therapy would be beneficial and 
was told no.
    The ironic thing was earlier that day, I asked Evan if he 
was going to work with PT today. He raised his right hand for 
yes. Therapists came in and asked him questions about what hair 
color he liked on girls. Blondes? Right hand raised for yes. 
Brunettes? No response. Redheads? Right hand raised for yes. 
And this is from the kid who is not worth more therapy.
    A recent CT scan showed a buildup of fluid in Evan's brain. 
If it is causing the pressure, this could explain his 
regression. To date, Casa Colina has not responded to my 
inquiries, but the Rehabilitation Institute of Chicago is 
sending an evaluator. Although I do not know who will pay for 
this care should they accept him, RIC's answer will determine 
Evan's future. He will either progress with more rehab or go 
home to a local skilled nursing facility until our house is 
adapted. Then he will come home where, with my own prognosis, 
we will continue his rehab.
    This is our story, and I wish it were unique. But, 
unfortunately, many of the challenges we face are faced by 
other families also. If you take but a few things from this 
story, please let it be this: Traumatic brain-injured patients 
and families need time to adjust to the reality of their 
situations, and it is unfair to quickly begin the retirement 
process for individuals with such an unknown and unpredictable 
injury, especially when retirement limits care options. Give us 
time to get our feet under us and understand what we are 
dealing with.
    Traumatic brain-injured patients and families need options. 
I know that the VA is building their program, and I understand 
it continues to make progress. Still, there are many private 
hospitals which have many years of experience treating and 
rehabilitating patients like my son. It is unfair to deny us 
access to the same level of care that you would choose for your 
own children. At the same time, the VA must use these private 
facilities as the resources they are so that one day, hopefully 
soon, the VA will be the facility of choice.
    Thank you, and I look forward to your questions.
    [The prepared statement of Ms. Mettie follows:]
 Prepared Statement of Denise Mettie, Representing the Wounded Warrior 
              Project, and Mother of Army Spc. Evan Mettie
    Mr. Chairman, and Members of the Committee, my name is Denise 
Mettie, and I am representing my son, retired Army Spc. Evan Mettie who 
was injured in Iraq on January 1st, 2006 and the Wounded Warrior 
Project, a group that assists wounded servicemembers from Iraq and 
Afghanistan.
    Let me start by giving you some of the details of Evan's initial 
injury and subsequent treatment. Evan was injured while on a highway 
outside of Baji when his patrol stopped to investigate a car. When they 
challenged the driver, he blew himself up. We were told that Evan was 
initially reported as ``Killed in Action,'' but when a Medic arrived 
15-20 minutes later, she discovered he was still breathing. He was 
quickly evacuated to the nearest medical facility.
    In Balad, doctors performed a left side cranectomy and removed 
shrapnel from his brain. Evan stabilized very well and he was 
transferred to Landstuhl, Germany the next day. Since I could not be 
there with him, I had the staff put the phone up to his ear, I told him 
to hang on, we loved him and we would be with him soon. The nurse told 
me his heart rate went up as soon as I started speaking--I knew then 
the good Lord was watching my guy.
    Evan arrived at Bethesda on January 3, 2006, just 3 days after the 
blast that injured him, and we arrived a day later. Evan spent the next 
86 days in ICU at Bethesda. He endured fevers as high as 106, and his 
weight dropped from 190 to 99lbs. We were told he would most likely 
remain in a vegetative state, not breathe or eat on his own, and be 
paralyzed on his right side.
    Before Evan came out of his coma, and just 17 days after his 
injury, we were approached about his Medical Boards, the process that 
would initiate his retirement from the military. Not knowing or having 
the time to figure out what that meant, I said ``do what you have to 
do.''
    During the months of January and February, Evan moved his head from 
side to side, opened his right eye, and squeezed my fingers. When 
Evan's sister Kira arrived, and as soon as she started talking to him 
there was a huge response. He opened both eye's wide, lifted his head 
and shoulders up and outstretched his arms as if he were trying to sit 
up. On March 10th , it was like an ``awakening''--Evan was really 
alert, he even watched a 2-hour movie and smiled.
    By this time the doctor at Bethesda recommended that we return home 
so I could be closer to family, return to a more normal life and Evan 
could go to the Seattle VA. We asked about rehab and were told he 
wasn't ready. At no point did anyone mention the possibility of going 
to one of the VA's Polytrauma Centers let alone a private rehab 
facility.
    On March 26th, he was medivaced to the Seattle VA. That night when 
I kissed him goodnight and turned to leave, his right hand reached up 
and hit my arm. I cried for joy. Frustratingly, Evan's records had not 
arrived at Seattle with him, so for the next few days I was filling 
them in on his condition. They then told me Evan was too healthy to be 
in the ICU and we needed to get him out ASAP. That meant Evan had to go 
to a civilian Skilled Nursing Facility.
    One of the VA Doctors told me Evan's brain injury was one of the 
most devastating she had seen and hope for recovery was unlikely. Like 
all of the other times, I told her ``we've seen Evan do things no one 
else has and we have a strong Faith, so you can have your prognosis and 
I will have mine.''
    Before being sent to the Nursing Facility, Evan seemed to be making 
significant progress. He ultimately went 24 hours breathing on his own, 
squeezed his hand on command, smiled, lifted his left hand several 
times, gave a thumbs up sign, raised his head, and tried to lift both 
arms.
    Because there was no interim place in the hospital to place him for 
a week or two to continue his vent weaning, he was transferred directly 
to a civilian Skilled Nursing Facility (SNF). This was a horrendous 
experience due mostly to their inattention to Evan's needs, their 
disregard for his constant pain, and their blatant disrespect of a 
patient unable to speak for himself.
    After a month of this substandard care, the VA investigated, and 
Evan was transferred back to Seattle. Everyone there was wonderful, and 
he was treated with kindness and respect. I could finally breathe 
again.
    In May, however, because Evan's MEB had been stalled until we 
gained guardianship and he was still on active duty, his Medical 
holding was changed to Ft. Lewis. Due to this change I was no longer 
able to get a per diem. I had quit my job with US Bank to be with him, 
and now all motel, food and gas costs were at our own expense.
    The people in Seattle treated Evan wonderfully, but he was the 
first OIF TBI to come through there, and there was no overall treatment 
plan. To this day, I am still unsure how Evan originally bypassed the 
entire polytrauma system that could have potentially provided such a 
plan. I even asked for referrals but was told Palo Alto wouldn't take 
Evan because he was not ready.
    At that point, Evan's rehab program consisted of 30 minutes of 
Range of Motion each morning Monday thru Friday, and 1-3 times a week a 
physical therapist sits him upright on his bed. That was it. I 
dedicated my time to research, devising my own Coma Stimulation program 
and doing extra ROM activities.
    On November 30th, almost a year after his initial injury, Evan 
finally made it to rehab at Palo Alto and soon started command 
responses again. Evan came in for a 30-day evaluation and was extended 
2 more weeks. He occasionally could answer a few questions by raising 
his right hand for yes and was extended another 2 weeks.
    In January, I was advised to take Evan home and put him into a SNF 
until he reached ``the next level'' and then he could come back for 
more therapy. How could he reach the next level if he was receiving no 
rehabilitation therapy? They said they would send videos and written 
instructions for the staff at the nursing home to follow, and I would 
be there to train them. After our experience with the previous 
facility, this scared the living daylights out of me. Evan was to heal 
himself before he could get further rehab.
    Unfortunately, by mid-February Evan's lack of responses was 
noticeable, and I couldn't figure out what was happening. On the 16th, 
I was told the ``team'' doctors thought it would be a good idea to 
transfer Evan to a VA long term care facility until he could be 
transferred elsewhere. I was livid, first, because moves are very hard 
on Evan, especially for a week or two. Second, since mid January I had 
not seen a particular Neuro Psychologist with Evan, which was an 
integral part of his therapy. He had been seeing her 3-4 times a week 
prior to that and was making continual progress. I requested a meeting 
to address my concern and the doctors agreed to check the therapist's 
records.
    On March 14th, I received an apology from the Hospital Director, as 
it appeared that Evan's records were not accurate. They offered another 
evaluation and therapist for Evan, and in the meantime I had requested 
a second opinion from both the Tampa VA and a private rehab facility 
called Casa Colina. Representatives from the Tampa VA met with me, and 
without seeing Evan, told me since he's a year out in his injury they 
could not help us. I asked if further therapy would be beneficial and 
was told no. The ironic thing was that earlier that day, I asked Evan 
if he was going to work with PT today, he raised his right hand for 
yes. Therapists asked him questions about what hair color he liked on 
girls, blonde? Right hand raise, yes. Brunettes, no response. Redheads? 
Right hand raise, yes. This, from the kid who isn't worth more therapy.
    A recent CT scan shows a buildup of fluid in Evan's brain. If it is 
causing pressure, this could explain his regression. To date, Casa 
Colina has not responded to my inquiries, but the Rehabilitation 
Institute of Chicago (RIC) is sending an evaluator. Although I don't 
know who will pay for this care should they accept him, RIC's answer 
will determine Evan's future--he will either progress with more rehab 
or go home to a local Skilled Nursing Facility until our house is 
adapted. Then he will come home where with my own prognosis, we will 
continue his rehab.
    That is our story, and I wish it were unique. Unfortunately, many 
of the challenges we faced are being encountered by others in similar 
situations. If you take but a few things from this story, please let it 
be this:

     Traumatic Brain Injured patients and families need time to 
adjust to the reality of their situations, and it is unfair to quickly 
begin the retirement process for individuals with such an unknown and 
unpredictable injury, especially when retirement limits care options. 
Give us time to get our feet under us and understand what we are 
dealing with.
     Traumatic Brain Injured patients and families need 
options. I know that the VA is building their program, and I understand 
that it continues to make progress. Still there are many private 
hospitals which have many years of experience in treating and 
rehabilitating patients like my son. It is unfair to deny us access to 
the same level of care that you would choose for your children. At the 
same time the VA must use these private facilities as the resources 
they are, so that one day, hopefully soon, the VA will be the facility 
of choice.

    Thank you, and I look forward to your questions.

    Chairman Akaka. Thank you very much for your testimony.
    Dr. Gans?

STATEMENT OF BRUCE M. GANS, M.D., EXECUTIVE VICE PRESIDENT AND 
                CHIEF MEDICAL OFFICER, KESSLER 
            INSTITUTE FOR REHABILITATION, NEW JERSEY

    Dr. Gans. Thank you, Mr. Chairman, Members of the 
Committee. I am really moved by the testimony of the three 
panelists who have preceded me. It makes me remember that we 
are here about people and their families and the injuries and 
the concerns and the hope and the optimism and opportunity that 
they face. And I would like to share you the view from the 
private rehabilitation community, the things that we try to do, 
the things we would like to be able to do, and the capacity 
that we do represent that may be at least in part a way of 
helping with the current problem.
    We tried over 4 years ago as an institution to reach out to 
the DOD when we saw injured soldiers coming back without access 
to services. It was visible in the press at that time. We 
reached out to the VA. Many of our other organizations in the 
private rehabilitation community did so. Unfortunately, we 
could not find a way in. We could not find a way to offer our 
services. It was not about business. It was about care for 
people and the needs. We had the capacity. We wanted to provide 
the service. We continue to be frustrated in those regards as a 
field for a number of years.
    Let me tell you about the private rehabilitation community 
capacity in this country. Actually, World War II created much 
of what exists, and the VA itself was a leader in creating the 
rehabilitation capacity that became a very large part of what 
is available in the civilian community. Today there are more 
than 217 free-standing rehabilitation hospitals in this 
country, more than 1,000 rehabilitation units in acute-care 
hospitals, and many thousands of outpatient rehabilitation 
therapy centers. Many of those have very specialized programs 
for exactly the kinds of injuries and disabling conditions that 
our injured warriors are coming back with--amputations, 
traumatic brain injuries, spinal cord injuries, and many other 
disabling conditions. And we even have organized networks of 
research and clinical service that are capable of dealing with 
them that are even funded by the Federal Government. The 
National Institute on Disability and Rehabilitation Research 
funds currently 16 model systems in spinal cord injury and is 
re-funding right now 14 systems in traumatic brain injury. 
These are model systems that provide research, that 
collaborate, provide education services, and advance the state 
of the knowledge and the art of rehabilitation. And there is a 
smaller network of burn injury rehabilitation programs as well.
    I merely mention these to say that the civilian community 
has capacity for exactly the kinds of injuries that are being 
seen and has ways of identifying those programs that have true 
expertise and are uniquely qualified, and that I think is part 
of the key to how the civilian sector could be helpful to 
augment what the DOD and the VA systems currently have 
available to them.
    At the same time, it is ironic to think that the VA rehab 
capacity has sadly shrunk over the years in response to the 
changing needs of its members and service providers while the 
civilian community has grown and its capacity has been 
enriched. We now serve injured individuals in urban violence, 
people in motor vehicle accidents, older people with the same 
kinds of problems that the VA is experiencing, but we do have 
experience with trauma and all the range of services that are 
needed.
    What is needed is accessible, excellent quality care that 
is organized and where people need to have it accessible to 
them, not just the quality but also the location. The civilian 
sector is capable of augmenting and complementing the military 
and the VA systems if you will find a way to let us help so 
that we can do that.
    Last week, I had the privilege of meeting with Secretary 
Nicholson at his offices with several of his key staff members 
to talk about just this issue. We made, on behalf of the 
rehabilitation hospital facilities, a proposal that we could 
establish a coordinating council that would let the private 
sector coordinate and cooperate and plan together with both the 
military and the VA systems to identify mechanisms of 
identifying service centers of excellence that could be 
qualified for participation in serving our servicemembers, that 
could be located geographically where they are needed to 
complement the existing excellence of the VA facilities and the 
military systems, and could arrange for information exchange 
and even could organize a research effort so that the 
information that is learned about how the private sector and 
the publicly sponsored programs can work together can be 
enhanced so that the quality of care that we all want to 
provide can be made more effective, more efficient, cost even 
less, but do even a better job.
    I would like to mention one other problem that may seem 
irrelevant but is very germane. The rehabilitation capacity in 
the civilian sector is starting to fall apart in this country 
because of pressure from CMS, the Medicare program, that is 
forcing beds to close because of changing views as to where 
rehabilitation is appropriate. Over the last year alone, more 
than 8 percent of the Nation's rehabilitation beds have closed 
because of pressure from the 75 percent rule, which is a 
Medicare regulation, and we have only seen the tip of the 
iceberg. This is going to be a huge problem that may close as 
many as a third to half of the rehab beds and facilities in 
this country if it is not addressed.
    We are very grateful that Senators Nelson, Bunning, 
Stabenow, and Snowe have introduced S. 543, the Preserving 
Patient Access to Inpatient Rehabilitation Act of 2007, which 
will help stop this problem from continuing. We do not need the 
civilian sector to be disassembled the way the VA system was 
just at the time that we need it most. The civilian community 
wants to help, can make itself available, has services and 
resources to complement the VA, and we want to make that 
possible so that the kinds of stories that I just heard do not 
have to be replicated.
    Thank you for your attention.
    [The prepared statement of Dr. Gans follows:]
Prepared Statement of Bruce M. Gans, M.D., Executive Vice President and 
Chief Medical Officer, Kessler Institute for Rehabilitation, New Jersey
    Good morning, Senator Akaka and Members of the Committee. Thank you 
for inviting me today to share my experience and recommendations 
regarding cooperation among the DOD, the VA, and the civilian 
rehabilitation hospitals to provide for the medical rehabilitation 
needs of returning servicemembers.
    I am Dr. Bruce Gans, a physician who specializes in Physical 
Medicine and Rehabilitation (PM&R). I currently am the Executive Vice 
President and Chief Medical Officer of the Kessler Institute for 
Rehabilitation in New Jersey. I have been president of the Association 
for Academic Physiatrists (the society that serves medical school 
faculty members and departments), and the American Academy of PM&R, 
which represents approximately 8,000 physicians who specialize in PM&R. 
I currently serve as a Board member and officer of the American Medical 
Rehabilitation Providers Association (AMRPA), the national association 
that represents our Nation's rehabilitation hospitals and units. In the 
past, I have chaired medical school departments at Tufts University 
School of Medicine in Boston, and Wayne State University School of 
Medicine, in Detroit. I also served as President and CEO of the 
Rehabilitation Institute of Michigan in Detroit for 10 years.
    Kessler Institute for Rehabilitation is the largest medical 
rehabilitation hospital in the Nation. We operate specialized Centers 
of Excellence to treat patients with amputations, traumatic brain 
injuries, spinal cord injuries, strokes, and many other neurological 
and musculoskeletal diseases and injuries. We also offer more than 
fifty sites for outpatient rehabilitation services in New Jersey that 
provide services such as medical care, physical therapy, prosthetic 
fabrication and fitting, cognitive rehabilitation treatment, high 
technology wheelchairs and electronic assistive device fittings, and 
many other services.
    We are also a major medical rehabilitation education and research 
facility. We train physicians, therapists, psychologists, and others as 
to how to provide rehabilitation programs and services. We also host 
many research programs and projects to advance the knowledge and 
science of medical rehabilitation. Much of this research is funded by 
Federal grants from the National Institutes of Health (NIH), the 
National Institute for Disability and Rehabilitation Research (NIDRR), 
other Federal and state organizations, and private foundations.
    The reason I am speaking with you today is to share my experience 
regarding how in the past we tried, without success, to offer our 
medical rehabilitation services to returning military personnel, both 
active military and veterans. I will also share my views as to how the 
civilian medical rehabilitation provider community can help the DOD and 
VA health systems to provide the highest quality immediate and long-
term rehabilitation care to our wounded warriors at facilities that are 
close to their homes, while still being cost effective for our Nation.
       rehabilitation capacity in the civilian health care system
    Over the past 60 to 70 years, our Nation's civilian health care 
system has developed a rich capacity to provide sophisticated medical 
rehabilitation care through an array of several hundred free-standing 
rehabilitation hospitals, more than a thousand rehabilitation units of 
acute care hospitals, and thousands of outpatient therapy centers. Many 
of these facilities are capable of providing technically advanced care 
for patients with traumatic brain injuries, amputations, and all the 
other injuries being experienced by our servicemembers. This 
rehabilitation care is provided by multidisciplinary teams of 
physicians, nurses, therapists, neuropsychologists, and many other 
professionals in well organized and goal directed programs.
    Highly specialized expertise exists in some of these facilities to 
deal with the exact problems our servicemembers have. For example, 
there currently is a network of 14 Spinal Cord Injury Model Systems in 
a grant supported program funded by NIDRR that provides state-of-the-
art clinical care, as well as conducts cutting edge research to advance 
the effectiveness of medical rehabilitation. Similarly, there is a 
network of 16 Traumatic Brain Injury Model Systems, and a smaller 
network of Burn Rehabilitation Model Systems also funded by NIDRR. Each 
of these centers has been able to demonstrate objectively how they 
provide exceptional clinical care, as well as community outreach, 
education, and research.
    In addition to the centers that have received these grant 
designations, there are many other equally well-qualified 
rehabilitation programs in operation today that are serving patients 
with the same injuries. Consider that when the SCI Model System grant 
program was recently competed, more than 30 qualified organizations 
applied for the 14 awards that were eventually made.
    My point is that there is a rich care-giving capacity that already 
exists in our country that could be tapped to assist our servicemembers 
and their families. There is also an established basis for judging 
program quality, to determine which ones can meet rigorous standards of 
excellence.
            the private, dod and va sectors have not worked 
                        or planned together well
    About 4 years ago, when it became apparent that serious injuries 
were being incurred by growing numbers of our troops, we at Kessler 
tried to reach out to offer our services to the DOD and VA. We called, 
wrote, e-mailed, and in other ways tried to engage medical and 
administrative leaders in the Departments and individual facilities to 
offer our assistance. Unfortunately, at that time we were unable to 
find a receptive ear.
    One of the reasons we reached out to the VA in particular, is 
because we knew that over the last few years, much of the VA's clinical 
ability to deliver rehabilitation care in organized units had been 
taken out of service, presumably as a response to budget pressures and 
a belief that the demand for services was in decline as our veterans 
were aging and expiring.
    Sadly, in retrospect we can see that dismantling the VA 
rehabilitation capacity was an unfortunate choice. The need for 
physical medicine and rehabilitation has now grown dramatically. While 
I applaud the efforts of the DOD and the VA to create high quality 
treatment facilities such as the VA Polytrauma Centers, the current 
efforts fall far short of the immediate need for technically excellent, 
compassionate rehabilitation care that can be provided to all in need, 
in a timely manner, and close to home in the patient's local community.
    Having a limited number of centers that can only be accessed by 
people if they uproot themselves and their families to live in 
temporary housing of variable conditions, only adds insult to injury. 
Further, it still leaves patients and families at risk to eventually 
return to a home community with no accessible lifelong care capacity 
that they can utilize. It seems to me that this is unwise, unnecessary, 
and a breach of our moral responsibility to our servicemembers as a 
grateful Nation.
    In the era following World War II, when there were very few local 
rehabilitation care delivery options, it made sense to create a 
national network of veteran specific settings to provide care not 
otherwise available for our returning GIs. In fact, that early work of 
the VA is largely responsible for having trained physicians, supported 
important research, and allowed the civilian sector to build upon their 
experience to create our rehabilitation capacity today.
    Now, however, the situation is reversed. A large and qualified 
network of services does exist in the civilian sector, and a limited 
distribution of VA and DOD facilities exists. There is no need to 
recreate a ``separate but equal'' VA-housed network that will have to 
be available for the next 80 years to provide solely for the lifelong 
specialized needs of our injured servicemembers.
                     a recommended course of action
    The solution is obvious: establish a mechanism for qualified 
civilian rehabilitation hospitals to contract with the VA and DOD to 
provide high quality services to our injured, both now and for the long 
term. Services should include medical, pharmaceutical, therapy, 
psychological, social, Durable Medical Equipment, and especially case 
management support. Certainly, we should continue to utilize the 
capacity of the VA and DOD where it now exists. But we should not force 
people to leave their homes and support systems for many months. And we 
should not just drop them back into distant home communities without 
access to appropriate ongoing services that they will need indefinitely 
(for repairs and replacements for prostheses, ongoing cognitive 
rehabilitation therapies, continuing counseling for Post Traumatic 
Stress Disorder, or the treatment of other related conditions).
    Last week, I had the privilege to meet with Secretary Nicholson and 
several members of his senior staff, to discuss these matters. At that 
meeting, I recommended to them that a standing Coordinating Council 
between the DOD, the VA, and the private medical rehabilitation 
hospital community be established. This Council could work together to 
Develop standards to qualify appropriate provider organizations to 
serve servicemembers:
    (1) Target case management resources to oversee these 
servicemembers' unique needs;
    (2) Establish appropriate contracting and payment mechanisms; and
    (3) Provide ongoing monitoring of the programs it would create.
    In addition, there should be funds targeted to create a focused 
research program to understand how effective this collaboration will 
be, and how to improve upon it, based on outcomes of care and 
satisfaction of patients and their families.
                         another problem exists
    There is another current problem of enormous importance in the 
civilian rehabilitation community that is threatening the ongoing 
existence of the care delivery capacity I have just described. It 
centers on drastic cutbacks being imposed on the field by the Centers 
for Medicare and Medicaid Services (CMS) that are trying to balance 
budgets and constrain expenditures by denying access to needed 
rehabilitation services. Due to the regulation we know as the ``75 
percent Rule,'' more than 8 percent of the Nation's rehabilitation beds 
have been closed in just the last year. Those beds closed because of 
these pressures, and thousands more are expected to be forced to close 
as the regulatory pressures continue.
    We desperately need a rational plan for maintaining and nurturing 
an appropriate care giving capacity for medical rehabilitation. By 
stopping the further escalation of the pressures forcing bed and 
facility closures now, we will preserve the availability of services 
that can be of enormous help to our soldiers today, and sustain the 
availability of those services for their lifetimes. Senators Ben 
Nelson, Jim Bunning, Debbie Stabenow, Olympia Snowe, and colleagues 
have recently introduced S. 543, the ``Preserving Patient Access to 
Inpatient Rehabilitation Hospitals Act of 2007'' to address this 
critical problem.
    I urge that in addition to creating effective mechanisms to allow 
the cooperation of the DOD, the VA, and the private rehabilitation 
hospital community, you also support S. 543 to preserve the private-
public rehabilitation hospital resource so that our servicemembers may 
readily access it now and in the future.
    Thank you very much for giving me the opportunity to address the 
Committee. I would be happy to respond to any questions you might have.
                                 ______
                                 
Response to Written Questions Submitted by Hon. John D. Rockefeller IV 
  to Bruce M. Gans, M.D., Executive Vice President and Chief Medical 
       Officer, Kessler Institute for Rehabilitation, New Jersey
    Question 1. Can you provide a list and locations of the 
rehabilitation centers funded by NIH, and the National Institute for 
Disability and Rehabilitation Research (NIDRR), and if possible provide 
information on how such centers overlap with existing VA facilities to 
help highlight the potential to expand access and coverage?
    Response. Attached are listings from the Web site for the National 
Institute for Disability and Rehabilitation Research (http://
www.ed.gov/about/offices/list/osers/nidrr/index.html) that describe 
their current funded portfolio of Model Systems for Burn 
Rehabilitation, TBI Rehabilitation and SCI Rehabilitation. In addition, 
I am providing you with a list of its Rehabilitation Research and 
Training Centers and Rehabilitation Engineering Research Centers, which 
cover many highly relevant clinical areas.
    I have also included a project listing from the National Center for 
Medical Rehabilitation Research (NCMRR), which is a division of the 
National Institute for Child Health and Human Development (NICHD) at 
the National Institutes of Health (NIH). These projects are directly 
relevant to the TBI problem as well.
    Please note that this is only a representative sample of the 
locations in the civilian care delivery system where expertise exists 
that could be tapped to complement, supplement and enhance the current 
VA and DOD capabilities. Many of these civilian programs are located in 
larger urban areas, and are associated with universities and academic 
medical centers. As such, it is likely that a number will be proximate 
to existing VA or military facilities.
    In the case of the Kessler Institute for Rehabilitation, we are 
very near the East Orange VA (which has recently reached out to us to 
explore the potential for clinical collaboration), and also have active 
clinical research projects in cooperation with the Bronx VA in New 
York.
    Many of the civilian clinical programs operate extended networks of 
outreach themselves. For example, while Kessler Institute for 
Rehabilitation's primary TBI Center of Excellence is located on our 
West Orange, New Jersey campus (12 miles from Manhattan); we operate 
additional programs in northern New Jersey at our Saddle Brook campus, 
and also in western New Jersey at our Chester campus.
    It is also common for rehabilitation hospitals to operate 
outpatient therapy facilities and clinics. Kessler, for example, 
operates more than 50 rehabilitation centers throughout New Jersey. 
Many of our sites are capable of delivering specialized programs for 
patients who have completed inpatient programs in our Centers of 
Excellence. Thus, the private sector is very likely to represent an 
extensive distribution channel to reach smaller communities where no VA 
or military facilities exist.
    I am not familiar with all of the existing 1,266 VA facilities, nor 
their specific capabilities, but I suggest that taking stock of them 
would best be pursued by a Coordinating Council that included VA, DOD 
and civilian representation.

    [National Institute for Disability and Rehabilitation Research 
(NIDRR) rehabilitation model systems for Burn, TBI and SCI; list of 
NIDRR Rehabilitation Research and Training Centers; list of NIDRR 
Rehabilitation, Engineering Research Centers; and list of projects for 
the National Center for Medical Rehabilitation Research (NCMRR) 
follow:]

     model systems for burn rehabilitation funded by the national 
          institute for disability and rehabilitation research
UCHSC Burn Model System Data Coordination Center (BMS/DCC)
Dennis C. Lezotte, Ph.D., University of Colorado Health Sciences 
Center, Denver, CO; Project Number: 144; Start Date: October 1, 2002; 
Length: 60 months.

    Abstract: The BMS/DCC establishes a data management and analytical 
support facility for Burn Model Systems clinical and outcomes research 
projects.
    Objectives include: (1) to serve the clinical, research, and public 
communities to which it is responsible; (2) to serve the needs of good 
scientific procedure in multi-institutional outcomes research; and (3) 
to support the needs for patient safety and data confidentiality as 
required by Federal regulations when conducting collaborative clinical 
studies. The BMS Project is structured as a set of interacting, 
observational, randomized, and quasi-experimental clinical studies run 
at different centers that share the common purpose of acquiring and 
disseminating knowledge about burn injury care and rehabilitation. The 
project offers support in four important areas: project management, 
data management, analytical support, and dissemination. Support is 
provided in developing appropriate integrated systems to affect 
national data collection, project management, data coordination, 
technical support, collaborative clinical projects, scientific conduct, 
scientific publication, and effective dissemination. The UCHSC BMS/DCC 
continues to accumulate and integrate a central repository of data from 
the Model Systems to enhance their abilities to make sentinel 
statements and change the way burn injury rehabilitation is done. While 
the main function of the DCC is to integrate and manage these data, it 
also needs to be responsive to the technical and analytical needs of 
these individual clinical centers. In addition, the DCC provides and 
coordinates statistical support among the clinical and statistical 
groups from each Burn Center and is prepared to expand this support, 
adding several new protocols and/or clinical studies where appropriate.

Johns Hopkins University Burn Injury Rehabilitation Model System (JHU-
        BIRMS)
James A. Fauerbach, Ph.D., Johns Hopkins School of Medicine, Baltimore, 
MD; Project Number: 101; Start Date: October 1, 2002; Length: 60 
months.

    Abstract: This project tests interventions targeting three common 
postburn secondary complications affecting health and function: 
generalized deconditioning, muscle atrophy, and acute stress disorder. 
Testing the effectiveness of these interventions holds promise for 
improving the health and function of burn survivors as well as 
enhancing their options for workplace and community reintegration. The 
JHU-BIRMS includes several projects: (1) testing the efficacy of its 
augmented exercise program in rehabilitating people with generalized 
deconditioning, (2) testing the efficacy of enhanced cognitive-
behavioral therapy in treating individuals with acute stress disorder 
and preventing the development of chronic posttraumatic stress 
disorder, (3) developing a new measure that quantifies the degree of 
social stigmatization experienced by burn survivors and its impact on 
emotional adjustment and integration into the workplace and the 
community (this project involves the Phoenix Society, the largest 
foundation supporting burn survivors and their significant others), (4) 
a collaborative effort with the University of Washington on a workplace 
integration study identifying and quantifying those factors interfering 
with early and complete return to work, and (5) a collaborative study 
on health and function with the University of Texas.

North Texas Burn Rehabilitation Model System (NTBRMS)
Karen Kowalske, M.D., The University of Texas Southwestern Medical 
Center, Dallas, TX; Project Number: 143; Start Date: October 1, 2002; 
Length: 60 months.

    Abstract: This project conducts five research projects, two 
collaborative and three site-specific: (1) barriers to return-to-work 
following major burn injury; (2) long-term outcome following major burn 
injury; (3) outcome following deep, full-thickness hand burns; (4) the 
evolution over time of burn-associated neuropathy; and (5) the 
socioeconomic determinants of disability in individuals with burn 
injury. The North Texas Burn Rehabilitation Model System (NTBRMS) is a 
collaboration of Parkland Health and Hospital System (PHHS) and the 
University of Texas, Southwestern Medical Center (UTSW). Collaboration 
occurs on many levels at the NTBRMS. Clinical collaboration is the 
hallmark of the burn team, which includes individuals from several 
institutions who work together seamlessly, as well as collaboration 
with rural care providers through rural clinics and a biannual seminar. 
Research collaboration occurs locally with the surgeons and academic 
computing staff, and nationally with the other model systems.

Pediatric Burn Injury Rehabilitation Model System
David Herndon, M.D., University of Texas Medical Branch, Galveston, TX; 
Project Number: 102; Start Date: October 1, 2002; Length: 60 months.

    Abstract: This program conducts independent and multi-center 
projects focusing on evaluating and improving the rehabilitation 
provided to the burned child, striving to decrease disability and 
improve reintegration into society. The project continues longitudinal 
assessments of patients, expanding the database that includes measures 
of cardiopulmonary function, physical growth and maturation, bone 
density, range of motion, activities of daily living, scar formation, 
reconstructive needs, and measures of psychosocial adjustment. This 
data is used to identify areas that require improvement and provide 
functional outcome measures that can be used in the evaluation of 
treatment methods.
    Research activities include: (1) a multi-center project assessing 
the efficacy of the long-term administration of oxandrolone in the 
treatment of burn injury with endpoints of improved strength, lean body 
mass, bone density, and growth; (2) improving rehabilitative outcomes 
for children by instituting and evaluating major modifications to 
current treatment for children with large burns; (3) evaluating the use 
of pressure garments in controlling scar following burn injury; (4) a 
multi-center study evaluating the relationship between treatment, 
injury, patient characteristics, and patient outcome in those patients 
sustaining full thickness hand burns; and (5) evaluating acute stress 
disorder and posttraumatic stress disorder, including its occurrence, 
predictive elements, and efficacy of treatment.

University of Washington Burn Injury Rehabilitation Model System
Loren H. Engrav, M.D., University of Washington, Seattle, WA; Project 
Number: 103; Start Date: October 1, 2002; Length: 60 months.

    Abstract: This model system conducts five research projects: (1) A 
New Approach to the Etiology of Hypertrophic Scarring: develops an 
increased understanding of hypertrophic scarring. (2) Effect of Virtual 
Reality on Active Range-of-Motion During Physical Therapy: uses 
distraction via immersive virtual reality as an adjunctive non-
pharmacologic analgesic. This study tests the hypothesis that virtual 
reality allows patients to tolerate greater stretching during physical 
therapy compared to no distraction, and that in spite of achieving 
greater range-of-motion, patients still experience lower pain levels 
while in virtual reality. (3) Determination of Reasons for Distress in 
Burn-Injured Adults: identifies reasons behind a burn survivor's 
distress at various time-points after hospital discharge. (4) Barriers 
for Return to Work: identifies specific barriers to return to work for 
burn survivors. (5) Acute Stress Disorder Among Burn Survivors: 
evaluates the effectiveness of cognitive-behavioral therapy, relative 
to a non-directive, supportive therapy control group, and a national 
comparison sample in reducing the prevalence of posttraumatic stress 
disorder diagnosis and symptom severity. Projects 4 and 5 are 
collaborative. In addition, this project participates in the national 
database.

 model systems for traumatic brain injury rehabilitation funded by the 
     national institute for disability and rehabilitation research
UAB TBI Model System
Thomas A. Novack, Ph.D., University of Alabama/Birmingham, Birmingham, 
AL; Project Number: 151; Start Date: October 1, 2002; Length: 60 
months.

    Abstract: The University of Alabama at Birmingham (UAB) is 
maintaining and further developing a Traumatic Brain Injury Model 
System (TBIMS) that improves rehabilitation services and outcomes for 
persons with TBI. This project provides a multidisciplinary system of 
rehabilitation care specifically designed to meet the needs of 
individuals with TBI, and, as demonstrated over the past 4 years as a 
TBIMS, adequately enrolls subjects to complete research projects 
successfully. In addition to contributing data to the TBI National 
Database, the UAB TBIMS conducts two research projects: (1) an 
examination of the use of a serotonin agonist medication (sertraline) 
to lessen the incidence and severity of depression during the first 
year of recovery following TBI; (2) a study of the impact of a training 
program in problems solving for caregivers.

Northern California Traumatic Brain Injury Model System of Care
Tamara Bushnik, Ph.D., Santa Clara Valley Medical Center (SCVMC), San 
Jose, CA; Project Number: 159; Start Date: October 1, 2002; Length: 60 
months.

    Abstract: This project conducts two studies to better characterize 
the type and impact of fatigue on the TBI population: (1) a cross-
sectional study of people up to 10 years post-TBI and (2) a 
longitudinal study that focuses on the evolution of fatigue over the 
first 2 years post-injury. Both studies utilize standardized 
measurements of fatigue, as well as those for depression/affective 
disorders, sleep disturbance, activity scales, and measurements of 
hormone levels reflective of the health of the neuroendocrine system. 
Two additional studies characterize the impact of late posttraumatic 
seizures on recovery: (1) a study utilizing data already in the TBIMS 
National Database that compares the functional, vocational, and medical 
complication outcomes of those with and without late posttraumatic 
seizures; (2) a study in collaboration with Denver Hospital Medical 
Center that interviews individuals at both sites who participated in a 
previously funded NIDRR grant on seizure risk identification. This 
study further evaluates barriers to the environment, transportation, 
and challenges in control of their seizures.

The National Data and Statistical Center for the Traumatic Brain Injury 
        Model 
        Systems
Cynthia Harrison-Felix, Ph.D., Craig Hospital, Englewood, CO; Project 
Number: 1713; Start Date: October 1, 2006; Length: 60 months.

    Abstract: By implementing a comprehensive and innovative program of 
new data management technologies and operating procedures that emulate 
the best practices of clinical research organizations and data 
coordinating centers, the National Data and Statistical Center (NDSC) 
increases the rigor and efficiency of scientific efforts to 
longitudinally assess the experience of individuals with traumatic 
brain injury (TBI) and advances TBI rehabilitation. The TBIMS database 
and the NDSC introduce the following innovations: a state-of-the-art 
Web-based data management system; a computer-assisted interview system; 
a Standard Operating Procedures Manual; training through quarterly Web-
based conferences, as well as more frequent in-person conferences; 
comprehensive Data Collector certification; annual data monitoring 
visits to each center; analysis of ethnic/racial bias in participant 
recruitment and retention and collaboration with the NIDRR-funded 
Center for Capacity Building on Minorities with Disabilities Research; 
providing more comprehensive methodological as well as statistical 
consultation; continuation of the TBIMS survival study; a system for 
following participants from defunded centers; and the use of common 
procedures, technologies, and training among all Model System Data 
Centers.

The Rocky Mountain Regional Brain Injury System (RMRBIS)
Gale G. Whiteneck, Ph.D., Craig Hospital; Englewood, CO; Project 
Number: 152; Start Date: October 1, 2002; Length: 60 months.

    Abstract: The Rocky Mountain Regional Brain Injury System (RMRBIS) 
conducts three research projects: Study 1 examines the effects of 
Modafinil on fatigue and excessive sleepiness after TBI. Study 2 
assesses the effectiveness of a group therapy intervention for social 
pragmatic communication. Study 3 uses the unique database assets of 
Craig Hospital and investigates the environmental and clinical factors 
that influence outcome over a 40-year time frame to understand the 
process of living and aging with a TBI. In addition to clinical 
research and service, Craig Hospital, as the RMRBIS, documents an 
outstanding record of dissemination, for all customers including 
clinical consumers, community agencies and advocacy groups, other 
clinical service centers and systems, and professionals engaged in the 
treatment of persons with TBI.

The Spaulding/Partners TBI Model System at Harvard Medical School
Mel B. Glenn, M.D., Spaulding Rehabilitation Hospital, Boston, MA; 
Project Number: 153; Start Date: October 1, 2002; Length: 60 months.

    Abstract: The Spaulding TBI Model System (TBIMS) provides a 
comprehensive spectrum of care for people with TBI through the 
collaborative efforts of three hospitals that are part of Partners 
Health Care System, Inc., and four organizations that operate a variety 
of postacute rehabilitation programs. Research at the center includes 
development of functional neuroimaging as a tool to guide cognitive 
rehabilitation treatment for people with TBI, and use of functional 
magnetic resonance imaging (fMRI), with both a cross-sectional and 
longitudinal component. The cross-sectional component assesses regional 
brain activation during the memorization of word lists, both under 
undirected (spontaneous) conditions and following training and cueing 
to use a categorization strategy. The longitudinal component studies 
the ability of the fMRI findings to predict outcome among people with 
TBI who participate in community integration program with a cognitive 
rehabilitation focus.

Southeastern Michigan Traumatic Brain Injury System (SEMTBIS)
Robin A. Hanks, Ph.D., Wayne State University and Rehabilitation 
Institute of Michigan, Detroit, MI; Project Number: 155; Start Date: 
October 1, 2002; Length: 60 months.

    Abstract: The Southeastern Michigan Traumatic Brain Injury System 
(SEMTBIS) program conducts projects developed with the help of SEMTBIS 
consumers, as well as other members of the Detroit community. There are 
three principal studies during this grant cycle: (1) a peer-mentoring 
intervention: This study is a randomized controlled trial of a peer-
mentoring program for both survivors and their caregivers; (2) a 
dynamic system of survivor and significant-other well-being: This 
investigation studies 250 community-dwelling adults with TBI and their 
caregivers/significant others, exploring the relationship of survivor-
caregiver situations with survivor distress and family dysfunction. It 
also studies whether or not social support acts as a moderating 
influence upon the well-being of persons with TBI; (3) resumption of 
driving after brain injury: This study examines correlates of driving 
after brain injury: barriers, fitness to drive, and community rapport. 
Participatory action is a central component of project implementation, 
evaluation, and dissemination. SEMTBIS participates in clinical and 
systems analysis studies of the TBI Model Systems by collecting and 
contributing data to the uniform, standardized national database. 
Project findings for the studies described above are available at: 
TBINDC.org or http://tbindc.org/registry/
searchresults.php?searchparam=project/center/4.

Mayo Clinic Traumatic Brain Injury Model System
James F. Malec, Ph.D., Mayo Medical Center, Rochester, MN; Project 
Number: 149; Start Date: October 1, 2002; Length: 60 months.

    Abstract: This Traumatic Brain Injury Model System (TBIMS) focuses 
on three local research projects: (1) decisionmaking and outcomes of 
inpatient and outpatient rehabilitation pathways, (2) very-long-term 
(5-15+ years postinjury) process and outcome for people with TBI, 
identified through the Rochester Epidemiology Project, and (3) 
telehealth-based (Internet) cognitive rehabilitation. Telehealth is a 
potentially important innovation in this system's region, where 
distance limits access to medical and rehabilitation services and many 
consumers have limited access to health care, insurance, employment, 
and viable political representation. In addition to professional 
publications and presentations, continuing dissemination efforts 
include the Mayo Clinic TBIMS Web site, the TBI Hotline, the Messenger 
newsletter, contributions to the COMBI Web site and COMBI and TBIMS 
newsletters, and regular participation by Mayo Clinic TBIMS staff at 
all annual state brain injury association meetings in the extended 
five-state geographical region. During the next 5 years, the project 
plans to develop an advocacy training program to help people with TBI 
and their families and significant others in the region learn self-
advocacy skills. Members of the Mayo TBI Regional Advisory Council were 
proactively involved in developing this project.

Traumatic Brain Injury Model System of Mississippi (TBIMSM)
Mark Sherer, Ph.D., ABPP-Cn, Methodist Rehabilitation Center, Jackson, 
MS; Project Number: 154; Start Date: October 1, 2002; Length: 60 
months.

    Abstract: The TBI Model System of Mississippi (TBIMSM) is a 
collaborative project of Methodist Rehabilitation Center and the 
University of Mississippi Medical Center. This project involves three 
studies. The first study investigates two medications in a parallel 
group, double blind, placebo controlled, randomized assignment design. 
The drugs under investigation have differing neurotransmitter effects, 
although each drug has been reported to have therapeutic benefit. The 
target population for this study is persons with TBI who are in a state 
of posttraumatic confusional state (PCS). This is considered a state-
of-the-art approach to PCS given the severe lack of controlled research 
to measure medication usage in PCS. The second study develops and 
conducts a trial of an intervention to improve the therapeutic 
alliances between persons with TBI and family members and professional 
staff serving persons with TBI in a post-acute brain injury 
neurorehabilitation program (PABIR). The third research project 
investigates the use of transcranial magnetic stimulation (TMS) to 
improve the characterization of motor disorders after TBI. Current 
research suggests that improved use and better understanding of TMS 
technology will lead to new intervention trials to improve motor 
function after TBI.

JFK-Johnson Rehabilitation Institute TBI Model System
Keith D. Cicerone, Ph.D., JFK Johnson Rehabilitation Institute, Edison, 
NJ; Project Number: 157; Start Date: October 1, 2002; Length: 60 
months.

    Abstract: This project implements and evaluates innovative 
rehabilitation interventions that address the spectrum of severity and 
needs of persons with TBI. The first research study investigates the 
relationship between neurobehavioral (i.e., standardized rating scale) 
and neurophysiologic (i.e., functional MRI data) indices of brain 
function in persons with traumatic minimally conscious state (MCS). The 
second study addresses current clinical and methodological concerns 
over the effectiveness of cognitive rehabilitation on cognitive 
functioning, community integration and social participation, return to 
school and work, and quality of life after traumatic brain injury. The 
third study uses qualitative inquiry to describe the quality of life 
after TBI from the perspective of persons at various stages after their 
injuries. These findings are triangulated with quantitative indices of 
community integration and satisfaction with functioning, which should 
provide a richer and more authentic understanding of what it takes to 
live a fulfilling life after traumatic brain injury.

New York Traumatic Brain Injury Model System (NYTBIMS)
Wayne A. Gordon, Ph.D., Mount Sinai School of Medicine, New York, NY; 
Project Number: 145; Start Date: October 1, 2002; Length: 60 months.

    Abstract: This project advances the understanding of TBI and its 
consequences and improves rehabilitation outcomes. The research 
projects focus on depression and fatigue, impairments that limit 
participation in community and vocational activities: Treatment of 
Post-TBI Depression is a randomized clinical trial to examine the 
efficacy of sertraline (Zoloft) in the treatment of depression and 
anxiety after traumatic brain injury. Study of Post-TBI Fatigue and its 
Treatment investigates the components, consequences, and correlates of 
post-TBI fatigue, and in a randomized clinical trial, evaluates the 
benefits of modafinil (Provigil) to treat fatigue in individuals with 
TBI.

Carolinas Traumatic Brain Injury Rehabilitation and Research System 
        (CTBIRRS)
Flora M. Hammond, M.D., Charlotte Mecklenburg Hospital Authority, 
Charlotte, NC; Project Number: 158; Start Date: October 1, 2002; 
Length: 60 months.

    Abstract: This project investigates posttraumatic irritability, its 
relationship to the caregiver as a component of the environment, the 
reaction to amantadine hydrochloride, and the nature of the problem as 
experienced by those in the community. The mission of CTBIRRS is to 
improve care and outcomes for survivors of TBI through medical 
treatments, services, research, and dissemination to expand and enhance 
services throughout their lifetime. The system begins with prevention 
and emergency medical services and extends through intensive care, 
acute care, and comprehensive medical rehabilitation to long-term 
follow-up, community reintegration, and vocational rehabilitation.

Ohio Regional TBI Model System
John D. Corrigan, Ph.D., Ohio Valley Center for Brain Injury Prevention 
and Rehabilitation, Columbus, OH; Project Number: 147; Start Date: 
October 1, 2002; Length: 60 months.

    Abstract: This model system includes two local research projects on 
substance abuse and persons with TBI. Study 1 is a randomized clinical 
trial testing interventions to promote retention in substance abuse 
treatment. This study employs intervention strategies found effective 
for clients with TBI when first engaging with a treatment program. 
Study 2 tests the concurrent validity of an instrument that documents 
the extent of a person's prior history of TBI objectively. This 
instrument is intended for research on TBI as a mediating factor in 
substance abuse treatment. This model system utilizes innovative 
community integration programs: Team Brain Injury (follow-up case 
management), the TBI Network (substance abuse treatment), and Community 
Capacity Building (education and advocacy operated in conjunction with 
the Brain Injury Association of Ohio).

The Moss Traumatic Brain Injury Model System
Tessa Hart, Ph.D., Albert Einstein Healthcare Network, Philadelphia, 
PA; Project Number: 148; Start Date: October 1, 2002; Length: 60 
months.

    Abstract: This project provides cutting-edge care for persons with 
TBI, conducts research on treatment of TBI in three key areas, and 
disseminates new knowledge to consumer and professional audiences, 
using an extensive collaborative network. Seven Trauma Centers and two 
nationally renowned rehabilitation facilities, MossRehab and Magee 
Rehabilitation, collaborate in the clinical component of the Moss 
Traumatic Brain Injury Model System. The Moss Rehabilitation Research 
Institute administers the research component, which includes 
collaborative longitudinal data collection, as well as three local 
research projects on: (1) the use of assistive technology for cognitive 
and behavioral disabilities, (2) validation of an observational rating 
scale of attention dysfunction in a psychostimulant treatment trial, 
and (3) use of botulinum toxin for treating severe spasticity caused by 
TBI. The Moss TBIMS emphasizes consumer involvement in clinical program 
improvement, research design, and dissemination via collaboration with 
the Brain Injury Association of Pennsylvania and other consumers.

University of Pittsburgh Brain Injury Model System (UPBI)
Ross D. Zafonte, D.O., University of Pittsburgh, Pittsburgh, PA; 
Project Number: 146; Start Date: October 1, 2002; Length: 60 months.

    Abstract: The research focus of the University of Pittsburgh Brain 
Injury Model System is on innovation in rehabilitation technology for 
persons with TBI. The project evaluates the impact of selected 
innovations in technology on service delivery, functional outcome, and 
as a therapeutic intervention. It addresses the shortcoming in 
wheelchair design for persons with brain injury by evaluating a unique, 
personalized powered mobility system. Collaboration with the Robotics 
Institute at Carnegie Mellon University allows researchers to perform a 
randomized trial evaluating the efficacy of virtual reality and 
robotics for persons with TBI. Finally, the project uses intelligent 
navigation technology to implement and evaluate a Web-based virtual 
case manager support structure for persons with TBI and their families.

North Texas Traumatic Brain Injury Model System (NT-TBIMS)
Ramon R. Diaz-Arrastia, M.D., Ph.D., The University of Texas 
Southwestern Medical Center, Dallas, TX; Project Number: 160; Start 
Date: October 1, 2002; Length: 60 months.

    Abstract: The North Texas Traumatic Brain Injury Model System (NT-
TBIMS) provides a comprehensive continuum of care for TBI patients from 
the time of arrival at the emergency department through the intensive 
care unit, inpatient and outpatient rehabilitation, and long-term 
follow-up after community integration. Additionally, the NT-TBIMS 
conducts two research projects aimed at obtaining predictive 
information regarding outcome after TBI, which is important to the goal 
of developing novel therapies and tailoring these therapies to 
individual patients: (1) to determine whether the inheritance of 
particular alleles in certain candidate genes is associated with a 
greater risk of poor outcome after TBI; and (2) to determine whether 
Diffusion Tensor Magnetic Resonance Imaging, a novel imaging technique, 
is a more reliable indicator of Diffuse Axonal Injury than standard 
structural MRI.

Virginia Commonwealth Traumatic Brain Injury Model System
Jeffrey S. Kreutzer, Ph.D., Virginia Commonwealth University, Richmond, 
VA; Project Number: 156; Start Date: October 1, 2002; Length: 60 
months.

    Abstract: This project, utilizing rigorous scientific methods, 
examines the benefits of intervention during the acute and post-acute 
periods after brain injury. TBIMS and other researchers have primarily 
focused on delineating outcomes. Until recently, concerns about 
survivors' emotional well-being and adjustment to injury received scant 
attention. Yet, recent studies have identified a high prevalence of 
depression, with many survivors reporting feelings of hopelessness, 
diminished self-esteem, and social isolation. Brain injury also affects 
the family system; family members commonly describe emotional distress, 
lack of respite, financial stress, and lack of community support. 
Projects in three major research areas focus predominantly on 
survivors. One study examines pharmacological approaches to the 
treatment of depression, while another examines a structured approach 
to the treatment of acute cognitive and neurobehavioral problems. 
Examining the benefits of intervention programs for family members is 
the third major research area.

University of Washington Traumatic Brain Injury Model System
Kathleen R. Bell, M.D., University of Washington, Seattle, WA; Project 
Number: 150; Start Date: October 1, 2002; Length: 60 months.

    Abstract: This program conducts research relevant to TBI, enhances 
services to consumers, and furthers the National Database and 
intersystem collaboration. The program's three research projects are: 
(1) a randomized controlled intervention study examining the effect of 
exercise on depression after TBI. This low-cost, community intervention 
seeks to combat depression and emotional distress in persons with 
stable TBI by employing exercise as a positive approach to improved 
emotional and physical functioning and socialization. (2) An 
examination of the characteristics of TBI survivors who are able to 
return to employment and hold jobs that are stable and complex in 
nature, utilizing both the UW TBI longitudinal database and the Model 
System database. (3) An examination of the impact of the Medicare 
prospective payment system for inpatient rehabilitation on TBI 
survivors receiving access to acute rehabilitation efforts. The program 
also contributes to the National 
Database.

      model systems for spinal cord injury rehabilitation funded 
  by the national institute for disability and rehabilitation research
UAB Model Spinal Cord Injury Care System
Amie B. Jackson, M.D., University of Alabama/Birmingham, Birmingham, 
AL; Project Number: 1649; Start Date: October 1, 2006; Length: 60 
months.

    Abstract: The University of Alabama at Birmingham provides 
rehabilitation services specifically designed to meet the special needs 
of individuals with spinal cord injury (SCI) through its 
multidisciplinary, comprehensive Spinal Cord Injury Care System (UAB-
SCICS). The UAB-SCICS spans the clinical continuum from emergency 
services through rehabilitation and community re-entry. The System's 
research includes one collaborative research module and two in-house 
research projects, all of which ultimately aim at improving the health 
and function of its constituents. The collaborative research module 
involves the validation of an outcome measure for functional recovery. 
One in-house research project involves the assessment of the predictive 
value of key parts of the neurological exam for return of bladder 
function; the second is an investigation of the effect of nicotine on 
different types of SCI pain. The project continues to benefit from the 
active involvement of persons with SCI in the design and execution of 
the proposed activities. Project results are disseminated via a variety 
of accessible formats and venues for both professionals and persons 
with SCI and their families. A detailed plan of operation ensures 
timely completion of project goals and tasks. Finally, an evaluation 
plan has been designed to assess the quality and timeliness of project 
outcomes and dissemination, as well as short and long term impacts of 
project activities. Activities of the UAB-SCICS reflect an active 
partnership both within the components of UAB's health system and 
between UAB, the Lakeshore Foundation, and the Birmingham VA Medical 
Center. The project continues as a participant in data collection 
activities for the National Spinal Cord Injury Statistical Center.

Regional Spinal Cord Injury Care System of Southern California
Robert L. Waters, M.D.; Rod Adkins, Ph.D., Los Amigos Research and 
Education Institute, Inc. (LAREI), Downey, CA; Project Number: 1029; 
Start Date: September 1, 2000; Length: 72 months.

    Abstract: The Regional Spinal Cord Injury Care System of Southern 
California's primary mission is to collect initial and follow-up data 
on persons who have sustained spinal cord injuries and submit it to the 
national statistics database at the University of Alabama at 
Birmingham. Another component of the project focuses on literacy in 
individuals with SCI. Also, the project identifies, evaluates, and 
eliminates environmental barriers, particularly cultural and social 
barriers, to enable people with SCI to reintegrate fully into their 
community, and thus improve their lives. The project has been designed 
to meet the needs of the approximately 75 percent minority and 
underserved populations that comprise its clientele, and has samples 
sufficient for achieving adequate statistical power in the relevant 
designs and producing meaningful research. Finally, the System 
contributes new and useful information to the current collection of SCI 
literature. This project contributes to the national statistics 
database at the University of Alabama at Birmingham.

The Rocky Mountain Regional Spinal Injury System
Daniel P. Lammertse, M.D.; Susan Charlifue, Ph.D., Craig Hospital, 
Englewood, CO; Project Number: 1652; Start Date: October 1, 2006; 
Length: 60 months.

    Abstract: The Rocky Mountain Regional Spinal Injury System (RMRSIS) 
goals are to: (1) implement a program of research focusing on the 
immediate and long-term health, function, and community integration and 
participation of people with SCI; (2) improve its existing lifetime 
system of care for people with SCI; and (3) continue exemplary 
participation in the National SCI Database. A site-specific study 
determines if high vs. low tidal volumes are more effective in 
achieving ventilator weaning for individuals with high level 
tetraplegia, using a randomized clinical trial design. A collaborative 
research module study involves the development of a reliable, valid 
measurement tool to assess community participation. RMRSIS was first 
designated as a Regional Model System in 1974. The system includes two 
Level I trauma centers with specialized acute neurotrauma care 
facilities (St. Anthony Hospital and Swedish Medical Center) and the 
rehabilitation and lifetime follow-up services of Craig Hospital.

National Capital Spinal Cord Injury Model System
Suzanne L. Groah, M.D., National Rehabilitation Hospital/MedStar 
Research Institute, Washington, DC; Project Number: 1657; Start Date: 
October 1, 2006; Length: 60 months.

    Abstract: The National Capital Spinal Cord Injury Model System 
(NCSCIMS) serves Washington, DC and the Nation. By focusing on the 
frequent and costly complication of pressure ulcers (PU), the NCSCIMS 
leverages two unique strengths: an existing Rehabilitation Research and 
Training Center on SCI that focuses on reduction of secondary 
conditions, and the population of Washington, DC, which is 
predominantly composed of underserved individuals. The Center includes 
two site-specific and one modular project and describes a system of 
care that meets SCIMS priorities: Site Specific Project 1 is a 
Practice-Based Evidence (PBE) project specifically focused on PU 
prevention for all individuals with SCI and/or disease (SCUD) during 
the acute and rehabilitative phases of care (to evolve to the community 
in later phases). The PBE approach allows a detailed examination of the 
effects of methods, modalities, and therapies utilized in 
rehabilitation to prevent PUs, which are often based on evidence-based 
medicine, but in reality may not be extrapolated to the broader 
population with SCUD. In this project, researchers aim to utilize a PBE 
approach to augment evidence based practice while addressing a critical 
secondary complication for individuals with SCI. Site Specific Project 
2 is an SCI Navigator pilot project that combines elements of Peer 
Mentoring and Patient Navigation to decrease the occurrence of PUs once 
the individual has returned to the community. In this project, an SCI 
Navigator assists people with newly acquired SCI in the transition from 
inpatient rehabilitation to the community, within the framework of an, 
at times, dysfunctional healthcare system. The NCSCIMS works with the 
Model System at the University of Pittsburgh to explore Assistive 
Technology for Mobility (ATM). In this project, researchers investigate 
the degree to which inadequate wheelchair technology is the factor 
preventing people with SCI from doing more, work to understand the 
impact of changes in wheelchair reimbursement, and fully explore the 
issue of disparity in ATM prescription.

Georgia Regional Spinal Cord Injury Care System
David F. Apple, Jr., M.D., Shepherd Center, Inc., Atlanta, GA; Project 
Number: 1659; Start Date: October 1, 2006; Length: 60 months.

    Abstract: The Georgia Regional Spinal Cord Injury Care System 
admits approximately 200 individuals annually with acute onset 
paralysis secondary to spinal cord injury, and collects post-discharge 
data on 600 individuals each year. Its patient population comes 
primarily from Georgia, the rest of the Southeast, and the Eastern 
Seaboard. The continuum of care begins at injury and continues through 
transport, assessment, acute care, rehabilitation, emotional 
adjustment, community reintegration, and lifetime follow-up. The 
project continues a long record of comprehensive and timely collection 
of data on subjects who meet the inclusion criteria in three 
categories: inpatient hospitalization; longitudinal collection at 1, 5, 
10, 15, 20, and 25 years post-injury; and registry. In addition to 
continued model system research, the project conducts two site specific 
research projects: (1) Psychological Status During Inpatient 
Rehabilitation and One Year After Onset: Stress, Coping, and 
Expectation Hope for Recovery; (2) Development and Validation of a 
Clinical Measure of Wheelchair Seat Cushion Degradation. The project 
also manages a collaborative data collection research module entitled 
Impact of SCI on Labor Market Participation.

Midwest Regional Spinal Cord Injury Care System (MRSCIS)
David Chen, M.D., Rehabilitation Institute of Chicago, Chicago, IL; 
Project Number: 1658; Start Date: October 1, 2006; Length: 60 months.

    Abstract: The Spinal Cord Injury Rehabilitation Program at the 
Rehabilitation Institute of Chicago and the Acute Spinal Cord Injury 
Program at Northwestern Memorial Hospital demonstrate the ongoing 
comprehensive, multidisciplinary services that are provided to 
individuals with SCI which allow them to optimize their rehabilitation 
outcomes and enhance their ability to return to productive, independent 
living in the community. In order to contribute to the improvement of 
outcomes for persons with SCI, the System conducts two site-specific 
research projects: (1) Development of Low-Cost Devices to Increase 
Delivery of Intensive Treadmill Training, and (2) Disparities in Access 
to and Outcomes of Rehabilitation Care for Medicare and Medicaid 
Beneficiaries with Spinal Cord Injury. In addition, the project 
includes collaboration on one research project, Assistive Technology 
for Mobility (ATM) Module. MRSCICS has the capacity to enroll 140 
individuals from culturally diverse backgrounds with new spinal cord 
injuries annually into the Spinal Cord Injury Model Systems database, 
and collect follow-up data on individuals enrolled between 1973 and 
2000.

The New England Regional Spinal Cord Injury Center
Steve Williams, M.D., Boston University Medical Center Hospital, 
Boston, MA; Project Number: 1656; Start Date: October 1, 2006; Length: 
60 months.

    Abstract: The New England Regional Spinal Cord Injury Center 
(NERSCIC), based at Boston Medical Center (BMC), continues to forge new 
pathways in the care and quality of life of people with traumatic 
spinal cord injury (SCI). Additionally, NERSCIC maintains a research 
partnership with Boston's Spaulding Rehabilitation Hospital, Northeast 
Rehabilitation Hospital in Salem, NH, and Gaylord Hospital in 
Wallingford, CT. NERSCIC conducts innovative research projects to 
improve health and long-term functioning of patients with SCI through a 
site-specific project, Computer Adaptive Testing (CAT) for SCI, and a 
collaborative module, Telehealth for Health. NERSCIC's site-specific 
research project involves designing an improved outcome instrument in 
SCI research using traditional outcome assessment technology that 
presents difficult choices between comprehensive breadth and precision 
versus acceptable administration time and respondent burden. To solve 
this dilemma, this project applies contemporary measurement methods 
(CATS) to initiate a major transformation in the outcome assessment 
technology used to assess activity limitation frequently monitored in 
SCI research. Once the SCI-CAT has been developed using data collected 
from a major field study, the project conducts a demonstration of the 
SCI-CAT to evaluate its respondent burden, acceptability to patients 
and clinicians, as well as its breadth, precision, sensitivity to 
change, and validity with inpatients and outpatients with SCI who are 
receiving care from NERSCIC. Comparisons are made between the FIM and 
SCI-CAT over a 6-month follow-up period. The goal of the collaborative 
research project, Telehealth for Health, is the development and 
evaluation of an automated, telephone-based screening, referral, and 
behavioral intervention system with the long-term objective of 
promoting health and function by preventing and decreasing the severity 
of important secondary conditions among individuals with acute SCI, 
namely pressure ulcers, depression, and substance abuse.

University of Michigan Model Spinal Cord Injury Care System
Denise G. Tate, Ph.D., University of Michigan, Ann Arbor, MI; Project 
Number: 1653; Start Date: October 1, 2006; Length: 60 months.

    Abstract: The overall purpose of this project is to provide 
comprehensive rehabilitation and community participation services and 
to generate new knowledge through research, development, and 
demonstration designed to improve outcomes for persons with spinal cord 
injury (SCI). A site-specific research study is conducted in 
partnership with faculty from the University of Michigan Depression 
Center, Department of Psychiatry, and the Molecular and Behavioral 
Neurosciences Institute. This study is a randomized clinical trial 
study designed to evaluate the efficacy of a pharmacological agent, 
Duloxetine (Cymbalta'), as a preventive agent for reducing 
depression among persons with SCI. This clinical trial addresses a 
major need in the field as there are no randomized clinical trials 
currently available on the effectiveness of antidepressants in persons 
with SCI. In this study, the drug's effects on pain are also assessed. 
An outcome of this study is the formulation of recommendations for 
antidepressant medication use in SCI and implications for clinical 
practice guidelines. The project continues to operate an efficient data 
collection system, facilitating research and contributions to the 
National SCI Database.

Missouri Model Spinal Cord Injury System
Laura H. Schopp, Ph.D., ABPP, University of Missouri/Columbia, 
Columbia, MO; Project Number: 1019; Start Date: October 1, 2000; 
Length: 72 months.

    Abstract: The Missouri Model Spinal Cord Injury System (MOMSCIS) is 
committed to developing, implementing, and evaluating innovative 
research promoting independent living and community integration among 
persons with spinal cord impairment. The study focuses on the effect of 
a consumer-directed personal assistance services training intervention 
on consumer satisfaction, independent living, and community 
integration. The study develops, implements and evaluates the in-person 
Individualized Management of Personal Assistant/Consumer Teams (IMPACT) 
workshop. Workshop participants receive information on preventing and 
treating secondary medical conditions, including pressure sores, 
urinary tract infections, bowel and bladder management, autonomic 
dysreflexia, pain management, chronic fatigue, and thermoregulation, 
and information on relationship issues, such as hiring and firing, 
communication styles and strategies, assertiveness, and team building. 
Study objectives are: (1) to determine the effect of the IMPACT 
workshop on consumer satisfaction, the incidence of secondary 
conditions, activity, and participation (as defined by the ICF); (2) to 
determine the effect of the IMPACT workshop on personal assistants' job 
satisfaction, job stress and attrition; and (3) to provide online 
resources to the disability community, including an online personal 
assistant training manual for consumers and assistants, and an online 
resources database. Activity and participation are measured by the 
PARTicipation Survey for persons with Mobility Limitations (PARTS/M).

Northern New Jersey Spinal Cord Injury System
David S. Tulsky, Ph.D., Kessler Medical Rehabilitation Research and 
Education Corporation (KMRREC), West Orange, NJ; Project Number: 1651; 
Start Date: October 1, 2006; Length: 60 months.

    Abstract: The Northern New Jersey Spinal Cord Injury System 
(NNJSCIS) provides a comprehensive continuum of state-of-the-art care 
for persons with spinal cord injury (SCI) and their significant others 
from time of injury through long-term follow-up in the community and 
conducts spinal cord research, including clinical research and the 
analysis of standardized data. NNJSCIS conducts both a site-specific 
research study and a collaborative module. These studies contribute to 
evidence-based rehabilitation interventions and clinical and practice 
guidelines that improve the lives of individuals with SCI and consist 
of the following: An innovative rehabilitation intervention utilizing 
technology to prevent respiratory disease in persons with SCI, now the 
leading cause of death and the third leading cause of hospitalizations 
in this population; a collaborative module that adapts, develops, and 
validates an innovative and promising outcome system for use in SCI 
intervention research; and the NNJSCIS coordinates with the NIDRR-
funded Model Systems Knowledge Translation Center to provide scientific 
results and information for dissemination to clinical and consumer 
audiences. This project is a cooperative effort of the Kessler Medical 
Rehabilitation Research and Education Corporation (KMRREC), the Kessler 
Institute for Rehabilitation (KIR), the University of Medicine and 
Dentistry of New Jersey-The New Jersey Medical School (UMDNJ-NJMS), and 
UMDNJ-University Hospital.

Mount Sinai Spinal Cord Injury Model System
Kristian T. Ragnarsson, M.D., Mount Sinai School of Medicine, New York, 
NY; Project Number: 1655; Start Date: October 1, 2006; Length: 60 
months.

    Abstract: The research program of Mount Sinai Spinal Cord Injury 
Model System (MS-SCI-MS) is designed to advance the understanding of 
spinal cord injury (SCI) and its consequences, and to develop better 
methods of treatment of secondary conditions of SCI, especially pain. 
The purpose of this project is to: (1) demonstrate and evaluate a 
multidisciplinary system of rehabilitation care for persons with SCI in 
the New York City metropolitan area, including innovative programs for 
community integration; (2) contribute longitudinal data to the SCI 
National Database of the Model Systems program; (3) systematically 
collect and analyze extensive information on chronic pain after SCI. 
The site-specific project studies modified-release formulation of 
morphine sulfate for neuropathic pain after spinal cord injury through 
a randomized, double-blind crossover trial of modified-release morphine 
and placebo for patients with uncontrolled neuropathic pain of three 
types.

Northeast Ohio Regional Spinal Cord Injury System
Gregory A. Nemunaitis, M.D., MetroHealth System, Cleveland, OH; Project 
Number: 1662; Start Date: October 1, 2006; Length: 60 months.

    Abstract: The Northeast Ohio Regional Spinal Cord Injury System 
(NORSCIS) at MetroHealth Rehabilitation Institute of Ohio in 
collaboration with Case Western Reserve University and the Cleveland 
FES Center conducts research to further develop the effectiveness of an 
innovative Model Spinal Cord Injury Care System and to demonstrate how 
the application of advanced assistive technology can benefit persons 
with disabilities. NORSCIS offers a world-class multi-disciplinary 
system of spinal cord injury care and a 40-year tradition of 
excellence. Efficiency and effectiveness of care (and research 
potential) are enhanced as all components of the continuum of care 
(from trauma/emergency care to acute medical/surgical treatment to 
inpatient rehabilitation to outpatient rehabilitation and community 
support services) are on one campus. A site-specific project studies 
advances in functional electrical stimulation (FES) technology to 
document improvements in function, health, and wellness. An innovative 
focus on trunk muscle stimulation targets specific clinical problems, 
including seated stability and mobility, reachable workspace, and 
pulmonary function. A collaborative research project with UPMC-SCI, is 
directed at testing and collecting the data needed to understand the 
impact of coverage changes and to fully explore the issue of disparity 
in assistive technology for mobility prescription. A collaborative 
project with Craig Hospital involves the development of a reliable, 
valid measurement tool to assess community participation. The goal of 
these hypothesis-driven research and demonstration projects is to 
develop and measure the effectiveness of new intervention strategies at 
both the individual patient level and overall systems of care for 
persons with spinal cord injury.

Regional Spinal Cord Injury Center of the Delaware Valley
Ralph Marino, M.D., Thomas Jefferson University, Philadelphia, PA; 
Project Number: 1660; Start Date: October 1, 2006; Length: 60 months.

    Abstract: The Regional Spinal Cord Injury Center of the Delaware 
Valley (RSCICDV) provides and evaluates a comprehensive program of 
coordinated patient care, education, and research activities for 
individuals who have sustained a traumatic spinal cord injury (SCI). 
Clinical activities are directed at promoting evidence based practice 
to improve outcomes and reduce medical complications in persons with 
SCI. Research activities are designed to develop and validate upper and 
lower extremity outcome measures for use in clinical trials. 
Specifically, RSCICDV: (1) contributes to the National Database by 
enrolling an estimated 50 new subjects per year into the database and 
by collecting follow-up data on previously enrolled subjects; (2) 
conducts an onsite research project whose focus is to develop and 
validate the Capabilities of Arm and Hand in Tetraplegia (CAHT), an 
objective test of arm and hand functional capabilities needed to 
conduct clinical trials for neurological recovery in SCI; (3) 
participates in a collaborative module on evaluating an automated phone 
follow-up system for people with SCI; (4) participates in a 
collaborative module on validation of an outcome measure for motor 
recovery in incomplete SCI; and (5) develops educational resources for 
patients, healthcare providers 
and researchers.

University of Pittsburgh Model Center on Spinal Cord Injury
Michael L. Boninger, M.D., University of Pittsburgh, Pittsburgh, PA; 
Project Number: 1650; Start Date: October 1, 2006; Length: 60 months.

    Abstract: The UPMC-SCI continues its research focus on assistive 
technology (AT) for mobility. Pilot data collected during the previous 
funding cycle highlighted disparity in wheelchair prescription. 
Individuals from minority groups and people with low socioeconomic 
status received less and lower quality equipment. So that interventions 
can be developed, the project continues and expands this research to 
delve into the reasons for disparity. In addition, it investigates the 
impact of recent Centers for Medicare and Medicaid Services (CMS) 
changes for AT reimbursement. These changes will likely have a critical 
impact on the AT provided to individuals with spinal cord injury (SCI). 
Finally, the project develops a tool to determine how far, how fast, 
and when people travel in their wheelchairs. This data is related to 
the types of wheelchairs used, to the number of wheelchair failures, 
and to measures of participation. From these findings, researchers 
determine how the wheelchair prescribed impacts participation, and if 
greater use leads to greater failures. This data can be used to push 
for improvements in manufacturing and changes in coverage. UPMC-SCI 
also conducts a randomized, controlled trial to determine if following 
the Consortium of Spinal Cord Injury Medicine Guidelines on Upper Limb 
Preservation leads to decreased pain. These guidelines are applied to 
acutely injured patients who are followed for the first 6 months after 
injury. Validation of the guidelines' effectiveness helps assure that 
they become the standard of care across the country. SCI care at the 
University of Pittsburgh is provided in a multidisciplinary manner with 
a high level of communication among the constituent services. The 
project has fully implemented a system of continuity of treatment that 
begins with the emergency response at the scene of injury and continues 
with comprehensive treatment and rehabilitation from medical/surgical 
to acute stage rehabilitation through utilization of assistive 
technology services and vocational rehabilitation. The research and 
Model of Care set forth in this proposal will have a significant impact 
on the lives of individuals with SCI, leading to greater participation 
and employment. UPMC-SCI continues to enroll and collect long term 
follow up data on SCI subjects for the National Spinal Cord Injury 
Statistical Center.

Texas Model Spinal Cord Injury System
Daniel Graves, Ph.D.; William Donovan, M.D., The Institute for 
Rehabilitation and Research (TIRR), Houston, TX; Project Number: 1661; 
Start Date: October 1, 2006; Length: 60 months.

    Abstract: The Texas Model Spinal Cord Injury System (TMSCIS) 
provides services along the entire continuum of care from emergency 
medical service to long-term follow-up and management of secondary 
conditions. The TMSCIS includes a site-specific research project that 
is designed to provide high level evidence of the efficacy of a novel 
treatment to prevent bladder complications. The project is a 
randomized, double blind placebo, controlled parallel groups 
investigation of the effects of Botulinum toxin A treatment of detrusor 
external sphincter dyssynergia (DESD) during early spinal cord injury. 
Many patients with SCI develop neurogenic bladder dysfunction 
associated with detrusor hyperreflexia and DESD that can lead to long-
term complications in up to 50 percent of patients. These complications 
include hydronephrosis, vesicoureteral reflux, nephrolithiasis, sepsis, 
renal insufficiency or failure, and even death. This investigation is 
intended to determine if the prevention of DESD in the early phase of 
recovery can prevent some of these complications. In addition, the 
TMSCIS includes a module designed to develop an outcome measure of 
trunk and postural control to be utilized in activity-based therapy 
programs like locomotor training. The outcomes of large scale clinical 
trials of locomotor training highlight the need for outcome measures 
that are designed to capture changes brought about by translational 
research that may not have been necessary for more traditional therapy 
programs. This scale development project incorporates item response 
theory methods as well as reliability and validity investigations in a 
minimum of four model systems.

VCU Model Spinal Cord Injury Center
William O. McKinley, M.D.; David X. Cifu, M.D., Virginia Commonwealth 
University, Richmond, VA; Project Number: 1020; Start Date: October 1, 
2000; Length: 72 months.

    Abstract: This project develops and implements a Model Spinal Cord 
Injury System at Virginia Commonwealth University/Medical College of 
Virginia (VCU/MCV), that has a concentrated emphasis on employment. 
Researchers within this Model Systems systematically monitor and assess 
the impact of interventions, advancing technology, and policy changes 
on employment following SCI. In addition to contributing to the 
National Statistical Database at the University of Alabama at 
Birmingham, the VCU SCI Model System has three research studies. These 
studies involve the direct utilization of the SCI National Database, a 
major employment policy study across 18 states, and also an evaluation 
of technology training on employment of outcome. Involvement of SCI 
mentors in training new vocational mentors with SCI is also an 
important aspect of the project. By looking at the issues associated 
with employment for persons with SCI, this project complements other 
resources in place within VCU/MCV, including the RRTC on Workplace 
Supports, long-term relationships with the Virginia Department of 
Rehabilitation Services, and existing SCI Model Systems delivery of 
care. A significant number of persons with disabilities are involved as 
project staff as well as on an Advisory Board. A close relationship 
with the Mid-Atlantic Paralyzed Veterans Association (PVA) enhances 
training, dissemination, and other outreach activities.

Northwest Regional Spinal Cord Injury System
Charles H. Bombardier, Ph.D., University of Washington, Seattle, WA; 
Project Number: 1654; Start Date: October 1, 2006; Length: 60 months.

    Abstract: The University of Washington's Northwest Regional Spinal 
Cord Injury System (NWRSCIS) serves a critical mass of patients with 
SCI and has all the necessary disciplines to provide state-of-the-art 
medical, surgical, and rehabilitation care. One site-specific project 
is a randomized controlled intervention study evaluating the effect of 
proactive, structured, telephone-based counseling and care management 
on rehospitalization rate and quality of life during the first year 
after discharge from acute rehabilitation. This study builds upon 
successful experiences with telephone counseling for both people with 
traumatic brain injury and multiple sclerosis. This research is 
particularly important because the lifestyle changes and health care 
behaviors required for successful living after SCI are tremendously 
challenging, rates of rehospitalization are high, and many people 
(especially in rural regions) lack ready access to knowledgeable 
advice, behavior change support, and specialty care sufficient to 
maintain their health. A modular project studies the natural history of 
major depression under conditions of usual care during the first year 
after SCI. This project establishes reliable and valid means of 
screening and diagnosing major depression soon after SCI. It examines 
the impact of depression on rehabilitation efficiency and compares the 
effect of standard treatment to clinical practice guideline level care 
of depression. This study describes depression treatment preferences 
among people with SCI and lays the foundation for a multi-site clinical 
trial. This project contributes to the national statistics database at 
the University of 
Alabama at Birmingham.

rehabilitation research and training centers of the national institute 
               for disability and rehabilitation research
Rehabilitation Research and Training Center on Measuring Rehabilitation 
        Outcomes and Effectiveness
Allen W. Heinemann, Ph.D., Feinberg School of Medicine, Chicago, IL; 
Project Number: 1463; Start Date: December 1, 2004; Length: 60 months.

    Abstract: The purpose of this RRTC is to provide national 
leadership on the functional assessment, outcomes, and health policy 
issues facing the medical rehabilitation community and the diverse 
consumers it seeks to serve. The Center conducts research; hosts forums 
for discussion; publishes in rehabilitation, health policy, and 
consumer literature; trains researchers in rehabilitation-focused 
health services research; and disseminates information to diverse 
consumer, provider, and academic audiences. The RRTC's research seeks 
to (1) enable comparison of functional status measures across post-
acute settings so information can be provided to consumers and other 
rehabilitation stakeholders about the outcomes and effectiveness of 
various post-acute care settings; (2) develop an innovative measure of 
community participation in a meaningful, reliable, and valid manner in 
order to better describe the long-term outcomes of rehabilitation 
services; (3) increase the efficiency of outcome data collection so 
more resources can be directed to patient care; (4) examine how format 
and presentation style influences patient understanding of 
rehabilitation quality outcome indicators in order to provide 
information in ways that are helpful for consumers when selecting 
rehabilitation services. The project uses recent developments in item 
response theory and computer adaptive testing and stakeholder input in 
test development, outcomes reporting, and quality indicator reporting. 
The expected outcomes are a rational basis for provision of 
rehabilitation services post-acute care settings, increased efficiency 
of data collection, a better measure of community participation, and 
outcome reporting that is responsive to stakeholder needs. 
Dissemination activities include post-graduate and post-doctoral 
training opportunities, conferences, and a Web site that provides 
information on measurement of rehabilitation outcomes across the 
continuum of post-acute settings.

Rehabilitation Research and Training Center on Policies Affecting 
        Families of 
        Children with Disabilities
H.R. Turnbull, L.L.M.; Ann Turnbull, Ed.D., University of Kansas; 
Lawrence, KS; Project Number: 110; Start Date: November 1, 2003; 
Length: 60 months.

    Abstract: This center conducts eight research projects on the 
effects of the policies of governments, systems, networks, and agencies 
on the family quality of life and community integration (FQOL/FCI) of 
families who have children with developmental disabilities and 
emotional-behavioral disabilities or both. Researchers identify four 
target populations: families, providers, policy-leaders, and networks 
(all at the Federal, state, and local levels). Three policy challenges 
are prisms through which the effects of policy on families can be 
understood: early intervention, alternative schools, and consumer 
control of funding. For each policy challenge, researchers inquire into 
whether the applicable Federal and state policies and practices, and 
the applicable network policies, advance FQOL/FCI; whether the policies 
across education, social services, and health care are mutually 
consistent with each other and advance FQOL/FCI; and whether the 
practices of agencies in those systems advance FQOL/FCI. The center's 
analytical framework holds that the core concepts shape policies, 
policies shape services, policies and services should be coordinated 
and delivered through partnerships. Enhanced FQOL/FCI occurs when there 
is coherence among core concepts, coordinated policies delivered 
through partnerships, and coordinated services delivered through 
partnerships; and influencing factors must invariably be taken into 
account.

Rehabilitation Research and Training Center on Demographics and 
        Statistics
Andrew J. Houtenville, Ph.D., Cornell University, Ithaca, NY; Project 
Number: 269; Start Date: December 1, 2003; Length: 60 months.

    Abstract: The RRTC on Demographics and Statistics (Cornell 
StatsRRTC) bridges the divide between the sources of disability data 
and the users of disability statistics. The project conducts research 
exploring the reliability of existing data sources and collection 
methods, and studies the potential to improve current and future data 
collection efforts. In addition, the project utilizes existing data 
sources to provide a comprehensive and reliable set of statistics, and 
increase access to and understanding of how statistics can be used 
effectively to support decision making. Cornell StatsRRTC works with 
key organizations to determine their needs and helps them maximize the 
use of disability statistics in their ongoing efforts to improve the 
lives of people with disabilities and their families. As members of the 
Cornell StatsRRTC, the American Association of People with 
Disabilities, the Center for an Accessible Society, and InfoUse provide 
vital expertise and resources needed to reach the users of disability 
data and statistics. The Cornell StatsRRTC includes researchers from 
Cornell University, Mathematica Policy Research, the Urban Institute, 
and the Institute for Matching People and Technology, all of which 
bring extensive expertise in working with and creating sources of 
disability data.

University of Illinois at Chicago National Research and Training Center 
        on 
        Psychiatric Disability
Judith A. Cook, Ph.D., University of Illinois at Chicago, Chicago, IL; 
Project Number: 1559; Start Date: October 1, 2005; Length: 60 months.

    Abstract: The University of Illinois at Chicago National Research 
and Training Center on Psychiatric Disability (UIC-NRTC) promotes 
access to effective consumer-centered and community-based practices for 
adults with serious mental illness. The Center is conducting five 
rigorous research projects to enhance the state of evidence-based 
practice (EBP) in this field: A randomized controlled trial (RCT) study 
of Wellness Recovery Action Planning (WRAP) to gather evidence 
regarding its effectiveness; an RCT to evaluate the effectiveness of 
BRIDGES, a 10-week peer-led education course designed to provide mental 
health consumers with basic education about the etiology and treatment 
of mental illness, self-help skills, and recovery principles; an RCT of 
peer support services delivered by Georgia's Certified Peer Specialists 
(CPS) at consumer-run Peer Support Centers in order to determine the 
outcomes of service recipients; a self-directed care program in which 
adults with serious mental illnesses are given control of financial 
resources to self-direct their own recovery; and a project using data 
from 12 clinical trials studies of consumer-operated service programs 
to create a national data repository to promote research and develop 
scholarship in this area. The Center also conducts state-of-the-art 
training, dissemination, and technical assistance projects designed to 
enhance the leadership skills of people with psychiatric disabilities, 
and evaluate a self-advocacy skills training program delivered to 
clients of a large psychosocial rehabilitation agency. Additional 
projects evaluate self-advocacy skills training programs and implement 
training programs to prepare consumer leaders in the State of 
California to take part in systems change in their local communities. 
UIC-NRTC is embarking on an academic curriculum transformation project 
starting at UIC in the medical, social, and behavioral sciences to 
incorporate principles of recovery and EBP for people with psychiatric 
disabilities. The UIC-NRTC is designing and administering a no-cost 
online certification program, providing comprehensive introduction of 
knowledge required by peer providers. Additionally, the UIC-NRTC is 
providing training and developing projects and tools to assist 
individuals in recovery to gain the skills necessary for community 
integration through enhancing the research capacity of three federally 
funded consumer-run Technical Assistance Centers. Finally, the UIC-NRTC 
is offering an annual series of online workshops; Web-based continuing 
education courses; and a state of science national conference (2008) 
focusing on EBP, research implementation, consumer-centered systems, 
workforce development, and other emerging trends.

Rehabilitation Research and Training Center on Improving Vocational 
        Rehabilitation Services for Individuals Who Are Deaf or Hard of 
        Hearing
Douglas Watson, Ph.D., University of Arkansas, Little Rock, AR; Project 
Number: 263; Start Date: October 1, 2001; Length: 60 months.

    Abstract: This program conducts coordinated research and training 
to enhance the rehabilitation outcomes of persons who are deaf or hard 
of hearing who are served by VR and related employment programs. When 
appropriate, the unique needs of specific subgroups within this diverse 
and heterogeneous population are investigated. The ultimate goal of 
these efforts is to improve the capacity of the VR system and related 
programs to address the career preparation, entry, maintenance, and 
advancement, as well as the community living needs, of the target 
population. Research activities include: investigating the impact of 
changes in Federal employment and rehabilitation legislation and policy 
on the delivery of services to the target population; investigating the 
impact of business practices that contribute to accessible work and 
workplace supports to enhance the employment of the target population; 
and identifying, developing, and assessing rehabilitation-related 
innovations that enhance employment and community living outcomes of 
the target population.

Rehabilitation Research and Training Center on Disability in Rural 
        Communities
Tom Seekins, Ph.D., University of Montana, Missoula, MT; Project 
Number: 265; Start Date: December 1, 2002; Length: 60 months.

    Abstract: The research conducted by this project improves the 
employment status of people with disabilities in the rural U.S., 
enhances their ability to live independently, and advances the science 
of rural disability studies. Four core areas comprise eleven research 
projects in rural employment and economic development; rural health and 
disability; rural community transportation and independent living; and 
rural policy foundations. Projects include: (1) develop scientific 
methods to measure how rural environments influence an individual's 
community participation; (2) collaborate with very small rural 
businesses to employ people with disabilities; (3) improve rural 
transportation options; and (4) create programs to prevent or improve 
secondary conditions. Other projects explore ways for new partners, 
including faith-based organizations, to be involved in improving rural 
services. A training program disseminates research findings, trains 
students, and sparks the creative engagement of policymakers and social 
advocates. The innovative STATE (Same-Time Availability to Everyone) 
policy requires that the project provide standard print publications to 
the general public only when at least two alternative formats are also 
available to individuals with disabilities.

Rehabilitation Research and Training Center on Employment Policy and 
        Individuals with Disabilities
Susanne Bruyere, Ph.D.; Richard Burkhauser, Ph.D.; David Stapleton, 
Ph.D., Cornell University, Ithaca, NY; Project Number: 1466; Start 
Date: December 1, 2004; Length: 60 months.

    Abstract: The ultimate goal of the Employment Policy Rehabilitation 
Research and Training Center (EP-RRTC) is to increase the employment 
and economic self-sufficiency of people with disabilities and improve 
the quality of their lives. The immediate purpose is to contribute to 
the success of the transition from caretaker policies to economic self-
sufficiency policies. Specific goals and objectives are: completion of 
new research activities that will generate knowledge about the effects 
of past disability policy and other factors on economic self-
sufficiency, the impact of current and future initiatives designed to 
promote economic self-sufficiency, and/or the likely success of new 
policy options; completion of 20 publishable papers and companion 
policy briefs; training of consumers via 12 or more Washington-based 
Disability Policy Forums; training of 5 graduate students; a third-year 
conference; a conference volume; and technical assistance to consumers 
on policy research and evaluation methods and data. Short-term project 
outcomes include: annual interpretation of updated employment rate 
trends; a synthesis and critique of many relevant evaluation efforts; 
three or more significant policy options and ideas for next steps; 
reviews of three or more significant policy or program successes; 
detailed information on interactions between numerous programs and 
policies, and how they discourage employment; estimates of impacts of 
two public policies on employment and earnings for state VR clients; 
estimates of the impact of the ADA on both employer provision of 
accommodations and job retention after disability onset; estimates of 
the return to higher education for those with profound hearing loss; 
and two additional analyses of the role that human capital plays in 
determining economic self-sufficiency for adults with disabilities. 
Intermediate outcomes include use of this information in the policy 
improvement effort, and long-term outcomes include policy changes that 
increase the economic self-sufficiency of people with disabilities.

Rehabilitation Research and Training Center on Improving Employment 
        Outcomes
John O'Neill, Ph.D., Hunter College of CUNY, New York, NY; Project 
Number: 1469; Start Date: October 1, 2004; Length: 60 months.

    Abstract: This Employment Service Systems Research and Training 
Center develops, enhances, and utilizes partnerships to improve the 
quality of employment services, opportunities, and outcomes for people 
with disabilities. Five research projects have been designed to meet 
this goal and examine partnerships across public agencies, between not 
for-profit and public agencies, and between rehabilitation agencies and 
businesses. The Consortia for Employment Success (CES) creates and 
evaluates fully integrated disability service provider networks in 
three local communities. The CES increases access for people with 
disabilities to both effective, comprehensive placement services, and a 
well-managed and centralized employer network that will increase 
employment and career advancement opportunities for persons with 
disabilities. The Workplace Socialization Model (WPS) supplements the 
CES Model by focusing on job enhancement and retention. The WPS aims to 
extend the job tenure of employees with a disability and other positive 
work outcomes including the employee's job satisfaction, organizational 
commitment, and level of work culture competency, as well as the 
employer's satisfaction with the employee's job performance. 
Identification of ``Good Practices'' Within Vocational Rehabilitation 
is designed to identify a variety of good practices currently being 
used in the State-Federal VR system across the U.S. that facilitate 
consumer access to services and enhance employment outcomes. Designing 
and Testing Comprehensive Employment Practice and Policy Initiatives 
within a Vocational Rehabilitation State Agency develops and tests a 
model that leads to enhanced employment outcomes. The model includes 
the ``human capital'' characteristics of persons with disabilities as 
well as what vocational rehabilitation delivery systems add to these 
human capital factors to improve outcomes. A Study of Disability 
Navigators in One-Stops collects data on Workforce Investment Act 
regions in which Navigators operate and compares levels of customer 
satisfaction and employment outcomes between regions that use 
Navigators and regions that have no such positions.

Rehabilitation Research and Training Center on Substance Abuse, 
        Disability, and Employment
Dennis C. Moore, Ed.D., Wright State University, Kettering, OH; Project 
Number: 1465; Start Date: December 1, 2004; Length: 60 months.

    Abstract: This RRTC builds on previous findings to positively 
impact persons with disabilities who also experience substance use 
disorders, as well as the service providers upon whom they depend. The 
highly integrated program of research addresses the following goals and 
objectives: (1) Promote widespread use of substance use disorder 
screening among persons with disabilities who utilize disability-
related employment services. This is accomplished by developing and 
validating a new substance abuse screener called the ``SASSI-VR''. 
Following two stages of development and validation, the SASSI-VR is 
evaluated in three vocational rehabilitation (VR) programs on a 
statewide basis. (2) Conduct a randomized clinical trial of a model of 
supported employment, Individualized Placement and Support (IPS), to 
test its efficacy among persons with traumatic brain injury or other 
severe disabilities that also have a substance use disorder. The two 
trial sites are affiliated with rehabilitation programs in the Wright 
State and Ohio State medical schools. Utilization of the IPS model with 
the study populations holds tremendous potential or impacting services 
delivery for consumers who experience very low rates of employment. (3) 
Research policy and practices relative to their impact on VR services 
for persons with a disability and coexisting substance abuse. Serving 
as a critical complement to Rl, the roles of policies, statutes, 
guidelines, and VR service delivery practices will be investigated 
within the larger community of public agencies. (4) Investigate factors 
that specifically contribute to unsuccessful case closure among 
consumers of VR services. This component studies recent VR unsuccessful 
closures and their counselors, and the study has particular sensitivity 
to the role of ``hidden'' substance abuse among unsuccessful closures.

Rehabilitation Research and Training Center on Workplace Supports and 
        Job 
        Retention
Paul Wehman, Ph.D., Virginia Commonwealth University, Richmond, VA; 
Project Number: 1467; Start Date: November 1, 2004; Length: 60 months.

    Abstract: The purpose of the RRTC on Workplace Supports and Job 
Retention is to study those supports which are most effective in the 
workplace for assisting persons with disabilities to maintain 
employment and advance their careers. Research includes two long-term 
prospective randomized experimental control research projects: (1) 
determining the efficacy of public/private partnerships, and (2) 
determining the efficacy of business mentoring and career based 
interventions with college students with disabilities. The RRTC is 
partnered with Manpower, Inc., several community rehabilitation 
programs, and the VCU Business Roundtable. Additional projects look at 
disability management practices, extended employment supports, job 
discrimination in employment retention, benefits planning and 
assistance, and workplace supports. These studies are done in 
conjunction with Equal Employment Opportunity Commission, the Society 
of Human Resource Professionals, and the U.S. Chamber of Commerce.

Aging-Related Changes in Impairment for Persons Living with Physical 
        Disabilities
Bryan J. Kemp, Ph.D., Los Amigos Research & Education Institute, Inc., 
Downey, CA; Project Number: 266; Start Date: August 1, 2003; Length: 60 
months.

    Abstract: This project is a combined effort of Rancho Los Amigos 
National Rehabilitation Center and the University of California at 
Irvine, with other collaborators including the Center for Disability in 
the Health Professions at Western University and two Rehabilitation 
Engineering Research Centers. This project evolves from the fact that 
persons who have a disability are now living into middle age and late 
life in ever-increasing numbers. However, many of these people appear 
to be experiencing premature age-related changes in health and 
functioning. The project tests a model for improved understanding of 
these problems and interventions to help alleviate them. Persons who 
are experiencing these kinds of problems and their families are 
included in all center projects. The training, dissemination, and 
technical assistance activities include clinical training of current 
and future health providers, current and future researchers, persons 
with disabilities, their families, and policymakers. Both traditional 
methods of one-on-one and group training as well as technology-based 
distance training techniques are used to reach national audiences and 
underserved populations.

Rehabilitation Research and Training Center in Neuromuscular Diseases 
        (RRTC/NMD)
Craig McDonald, M.D., University of California, Davis, Davis, CA; 
Project Number: 273; Start Date: December 1, 2003; Length: 60 months.

    Abstract: The purpose of the Rehabilitation Research and Training 
Center in Neuromuscular Diseases (RRTC/NMD) is to enhance the health, 
function, and quality of lives of persons with neuromuscular diseases 
(NMD). The goals of this project are to: (1) develop a program for 
multicenter rehabilitation research in NMD through the Cooperative 
International Neuromuscular Research Group (CINRG); (2) conduct 
research that continues to address rehabilitation needs, particularly 
related to exercise, nutrition, pain, secondary conditions, and the 
quality of life of individuals with neuromuscular diseases; (3) develop 
and evaluate new or emerging technologies and interventions that 
provide the information needed to improve employment, community 
integration, and quality of life outcomes for this population of 
individuals with disabilities; (4) develop and evaluate appropriate 
health promotion and wellness programs that enhance the ability of 
individuals with neuromuscular disease to be physically active and 
participate in recreational activities; and (5) conduct a comprehensive 
program of training, dissemination, utilization, and technical 
assistance activities that are well-anchored in the research program 
and address the needs 
of stakeholders.

Rehabilitation Research and Training Center on Spinal Cord Injury: 
        Promoting Health and Preventing Complications through Exercise
Suzanne L. Groah, M.D., National Rehabilitation Hospital/MedStar 
Research Institute, Washington, DC; Project Number: 270; Start Date: 
December 1, 2003; Length: 60 months.

    Abstract: This project systematically and comprehensively addresses 
the role and impact of physical activity in the prevention of secondary 
conditions in people with spinal cord injury (SCI). Initially, the 
project establishes critical, yet-undefined physiological responses to 
exercise in SCI and comprehensively examines cardiovascular disease 
risk in individuals with SCI applying accepted guidelines used in the 
able-bodied population. The project develops exercise formats 
specifically designed according to severity of SCI and chronicity of 
SCI to address the prevention of and knowledge regarding osteoporosis 
and other secondary conditions. In addition, the project determines 
whether regular exercise is related to fewer secondary conditions. 
These research findings feed into four training activities that include 
a peer mentoring program for newly injured people with SCI, a consumer-
driven education curriculum for physical therapy and medical students, 
a state-of-science and training conference, and the development of a 
virtual resource network on exercise and prevention. The RRTC is a 
collaborative effort of clinical and disability researchers, SCI 
consumer organizations, and independent living advocates. The RRTC 
maintains a Live Journal site at http://rrtc-sci.livejournal.com/ 
and a Webcast on Exercise and Physical Activity for Persons with SCI 
at http://nrhfoundry.medstar.net/mediasite/viewer/?cid=d8381286-2ad2-
4fed-922c-31464b0cc049.

RRTC on Technology Promoting Integration for Stroke Survivors: 
        Overcoming 
        Social Barriers
Elliot J. Roth, M.D., Rehabilitation Institute Research Corporation, 
Chicago, IL; Project Number: 275; Start Date: October 1, 2003; Length: 
60 months.

    Abstract: This project develops and evaluates a sequence of robotic 
training and assistive devices that are designed with the idea of 
promoting efficient function in the workplace or at home, and with the 
further intent that they form a basis for the development of 
appropriate technologies to allow people with disabilities ready access 
to existing facilities in the community. At each stage the project 
engages engineering students as a means to provide intensive effort for 
development of novel designs, but also to provide valuable 
opportunities for training students in the themes related to recovery 
of function and community integration of people with disabilities. 
Other projects at this center include: the use of emotionally 
expressive and narrative writing to facilitate coping and adaptation 
after stroke; computerized training for conversational scripts that 
facilitate access to the community and workforce; and a consumer-
directed, dynamic assessment methodology for evaluating community 
living and work participation environments and technologies for use by 
people who have had a stroke. In addition to these projects, the RRTC 
develops and evaluates a comprehensive plan for training directed to 
stroke survivors and their families, students, researchers, clinicians, 
and service providers. These approaches are implemented through a 
variety of mechanisms, including continuing education courses, Web-
based presentations, and intensive training in our research facilities.

Missouri Arthritis Rehabilitation Research and Training Center (MARRTC)
Jerry C. Parker, Ph.D., University of Missouri, Columbia, MO; Project 
Number: 274; Start Date: October 1, 2003; Length: 60 months.

    Abstract: The purpose of the Missouri Arthritis Rehabilitation 
Research and Training Center (MARRTC) is to provide leadership at the 
national level in support of three key objectives: to reduce pain and 
disability, to improve physical fitness and quality of life, and to 
promote independent living and community integration for persons with 
arthritis of all ages in the United States. State-of-the-science 
rehabilitation research addresses the needs of persons with arthritis 
in the following areas: (1) home and community-based self-management 
programs, (2) benefits of exercise and physical fitness, and (3) 
technologies available to the broad populations of persons with 
arthritis in the environments where they live, learn, work, and play. 
The MARRTC conducts training and capacity-building programs for 
critical stakeholders within the arthritis disability arena, including 
consumers, family members, service providers, and policymakers. 
Additionally, the MARRTC provides technical assistance for persons with 
arthritis and other stakeholders in order to promote utilization of 
arthritis-related, disability research. The MARRTC also provides 
widespread dissemination of informational materials to persons with 
disabilities, their representatives, service providers, and other 
target audiences (e.g., editors 
and reporters).

Rehabilitation Research and Training Center on Traumatic Brain Injury 
        Interventions
Wayne A. Gordon, Ph.D., Mount Sinai School of Medicine, New York, NY; 
Project Number: 1464; Start Date: October 1, 2004; Length: 60 months.

    Abstract: The research program includes two randomized clinical 
trials (RCTs) and two projects supportive of better everyday 
interventions and better research: Research Study 1 (R1) is an RCT of a 
treatment for depression: cognitive behavioral therapy, adapted to 
address the unique cognitive and behavioral challenges of people with 
TBI that often pose barriers to treating depression, a major factor in 
reducing post-TBI quality of life, is compared to supportive therapy. 
In R2, a second RCT, a standard day treatment program is compared to a 
similar program (Executive Plus), augmented with modules to improve 
executive functioning and attention training. R3, Support for Evidence-
Based Practice, evaluates all published research on post-TBI 
interventions and assessment of outcomes; it serves as a national 
resource for disseminating the results. It also implements three 
participatory action research-based analyses of high priority areas, 
including meta-analyses if appropriate. In addressing improved outcome 
measurement, R4 focuses on the PART instrument, a measure of 
participation currently being tested within eight TBI Model Systems. R4 
focuses on creating a subjective approach to serve as a complement to 
the PART's current focus on objective assessment. A major focus of the 
RRTC is placed on capacity building of clinical and research 
professionals to address the need for better day-to-day interventions 
in the lives of people with TBI. Often their medical needs are misread, 
their brain injury goes unidentified, and they find services and 
accommodations inappropriate. Capacity building focuses on students 
early in their educational career--to help shape career choice and 
points of view; graduate and post-graduate students; and practicing 
``gate keepers'' in the community, primarily psychologists and 
physicians.

Rehabilitation Research and Training Center on Health and Wellness in 
        Long Term Disability
Gloria Krahn, Ph.D., M.P.H., Oregon Health and Science University, 
Portland, OR; Project Number: 1459; Start Date: October 1, 2004; 
Length: 60 months.

    Abstract: The vision of the RRTC is to contribute to the reduction 
of health disparities for person with disabilities through an 
integrated program of research, training, technical assistance, and 
dissemination. The Center has three inter-related strands of work to 
address its three intended outcomes/goals: (1) identify strategies to 
overcome barriers that impede access to routine healthcare for 
individuals with disabilities; (2) identify interventions in areas such 
as exercise, nutrition, pain management, or complementary and 
alternative therapies that promote health and wellness and minimize the 
occurrence of secondary conditions for persons with disabilities; and 
(3) develop improved status measurement tool(s) to assess health and 
well-being of individuals with disabilities regardless of functional 
ability. In order to achieve these outcomes, the RRTC conducts a 
coordinated program of research and training activities using a logic 
model framework. RRTC projects summarize and validate existing research 
findings on barriers to health care access as well as rigorously test 
and compare new strategies to overcoming identified barriers. The RRTC 
also examines and evaluates the practices of exemplary generic and 
specialized health promotion programs for people with disabilities in 
order to create an evidence-based set of evaluation and planning 
criteria. In addition, the RRTC organizes and uses panels to assess 
current health status measurement tools and develops or refines 
measures to more accurately reflect the health and well-being of people 
living with disabilities. Throughout these activities the RRTC 
disseminates informational materials and provide technical assistance 
to individuals with disabilities, their representatives, providers, and 
other interested parties.

Multiple Sclerosis Rehabilitation Research and Training Center
George H. Kraft, M.D., University of Washington, Seattle, WA; Project 
Number: 109; Start Date: October 1, 2003; Length: 60 months.

    Abstract: This center conducts rehabilitation research that: (1) 
Develops new interventions and practices in the areas of disease 
suppression, strength enhancement, preserving employment, depression 
management, and pain control; (2) collects data from an extensive 
survey and explores complex interactions among multiple variables, 
models factors that predict differing levels of participation by people 
with MS, and proposes points of intervention that modify changes in 
function; and (3) facilitates enhanced participation through training, 
technical assistance, and dissemination through professional meetings, 
publications, and a State-of-the-Science conference. In addition, a 
Web-based knowledgebase provides technical assistance to individuals 
with MS and healthcare providers with respect to caregiver issues, 
financial and insurance planning, self-sufficiency and coping, and 
assistive technology.

Rehabilitation Research and Training Center on Personal Assistance 
        Services
Charlene Harrington, Ph.D., R.N., University of California, San 
Francisco, San Francisco, CA; Project Number: 267; Start Date: July 1, 
2003; Length: 60 months.

    Abstract: This project provides research, training, dissemination, 
and technical assistance on issues of personal assistance services 
(PAS) in the United States. Center projects focus on: (1) the 
relationship between formal and informal PAS and caregiving support, 
and the role of AT in complementing PAS; (2) policies and programs, 
barriers, and new models for PAS in the home and community; (3) 
workforce development, recruitment, retention, and benefits; and (4) 
workplace PAS models that eliminate barriers to formal and informal PAS 
and AT at work. The Center is based at the University of California, 
San Francisco, and includes the Topeka Independent Living Resource 
Center, InfoUse, the Paraprofessional Healthcare Institute, the 
Institute for the Future of Aging Services, as well as faculty members 
at the University of Maryland, Baltimore County Policy Sciences 
Graduate Program, the West Virginia University Job Accommodation 
Network, and the University of Michigan's Institute of Gerontology and 
the Department Health Management and Policy. A Blue Ribbon Advisory 
Committee of PAS users, disability advocates, business leaders, 
independent living center leaders, and academics provide guidance to 
the project.

Rehabilitation Research and Training Center for Children's Mental 
        Health
Robert Friedman, Ph.D., University of South Florida, Tampa, FL; Project 
Number: 1454; Start Date: October 1, 2004; Length: 60 months.

    Abstract: The Research and Training Center Children's Mental Health 
conducts an integrated set of research projects designed, in the short 
run, to enhance knowledge about effective implementation of systems of 
care, and, in the long run, to make it possible for children with 
serious emotional disturbances to live, learn, work, and thrive in 
their own communities. The Center has developed a theory of factors 
that contribute to effective implementation; within that theory is a 
strong emphasis on the importance of understanding from a systemic 
perspective the interrelationship between the different factors, and 
their relationship to the community culture and context in which a 
service delivery system exists. The Center has a set of six 
interconnected research projects that use both quantitative and 
qualitative methods, and are holistic in their focus, to further test 
and develop its theory. The Center translates new knowledge from 
research into change in policy and practice through a targeted program 
of training, consultation, technical assistance, publication, and 
dissemination. To support these efforts, the Center maintains 
dissemination partnerships with a range of organizations committed to 
help present research findings in formats well-suited for key audiences 
of state and local policymakers, family organizations, researchers, and 
representatives of related service sectors.

Rehabilitation Research and Training Center on Aging with Developmental 

        Disabilities
Tamar Heller, Ph.D., University of Illinois at Chicago, Chicago, IL; 
Project Number: 276; Start Date: October 1, 2003; Length: 60 months.

    Abstract: The mission of the RRTCADD is to have a sustained 
beneficial impact on the health and community inclusion of adults with 
intellectual and developmental disabilities (I/DD) as they age through 
a coordinated set of research, training, and dissemination activities. 
Major goals are: (1) improving health and function of adults with I/DD, 
(2) enhancing caregiving supports and transition planning among older 
caregivers and other family members, and (3) promoting aging and 
disability friendly environments that enable adults with I/DD to 
participate in community life. Each goal is addressed through 
coordinated and complementary sets of activities within the core areas. 
Projects promoting health and functioning include: examination of age-
related changes, epidemiological surveys, research on health care 
utilization, and development of community-based health promotion 
interventions. To enhance caregiving supports and transition planning, 
RRTCADD research includes epidemiological surveys on family demographic 
and health characteristics, including families of minority backgrounds 
and families of persons with dual diagnoses of I/DD and psychiatric 
impairments; sibling roles and interventions in transition planning; 
and consumer direction in family support. Projects examining aging and 
disability-friendly environments include research to identify features 
of communities and residences that hinder and assist community 
integration as people with I/DD age, state policies regarding nursing 
home use, and dementia care in family homes and other community 
residences. Training and dissemination activities involve 
collaborations with national provider, professional, and consumer 
organizations to enhance skills and to promote progressive 
interventions and policies.

Rehabilitation Research and Training Center on Full Participation in 
        Independent Living
Glen W. White, Ph.D., The University of Kansas, Lawrence, KS; Project 
Number: 107; Start Date: January 1, 2001; Length: 60 months.

    Abstract: Through research, training, and dissemination, this 
project makes available person-environment strategies that enable full 
participation in society by persons with disabilities from diverse 
cultures, varying socioeconomic strata, and emerging disability 
populations. This mission is implemented through multiple research and 
training activities that are influenced by independent living (IL) 
philosophy and values; for example, participatory action research is 
emphasized, in which consumers take an active role throughout the 
research process. The RRTC develops, tests, and uses measurement tools 
to investigate the interactional relationship between personal and 
environmental factors and their effects on full participation in IL by 
the designated populations. Based on the project's Analytical Research 
Framework, the four core areas of intervention development and testing 
include: (1) increasing the knowledge base about the emerging universe 
of disability, (2) community participation and wellness, (3) cultural 
IL accommodations, and (4) personal and systems advocacy.

Rehabilitation Research and Training Center on Measurement and 
        Interdependence in Community Living RRTC/MICL
Glen W. White, Ph.D., The University of Kansas, Lawrence, KS; Project 
Number: 1721; Start Date: October 1, 2006; Length: 60 months.

    Abstract: The goal of the Research and Training Center on 
Measurement and Interdependence in Community Living (RRTC/MICL) is to 
increase the independence and participation of people with disabilities 
in their communities through the development and implementation of 
scientifically sound, theoretically driven, and evidence-based 
interventions. RRTC/MICL researchers accomplish this through six core 
projects. Two research projects, one on community participation and a 
second on economic utility, involve development of theory-driven 
measurement tools. The remaining four projects include the application 
of these measurement tools as part of their methods and procedures. Two 
of these projects are interventions and two develop model assessments. 
The first assessment project uses secondary analysis to develop and 
implement a model for assessing the economic utility and health-related 
outcomes of participants enrolled in Home and Community-Based Service 
(HCBS) waivers. The second assessment project evaluates the effects of 
different independent living advocacy-service models to determine the 
comparative effectiveness of different models in increasing community 
participation. The first intervention project examines the 
effectiveness of personal assistance services and enhanced training to 
increase consumer participation in the community. Finally, the second 
intervention project is a multisite study that examines the effects of 
a consumer-led grassroots approach in identifying and removing barriers 
to increase community participation. Together, these projects represent 
a comprehensive, integrated, and robust set of activities that 
recognize that ``disability'' is an interaction between the 
characteristics of an individual and his or her environment.

Opening Doors for Children with Disabilities and Special Health Care 
        Needs
Judith S. Palfrey, M.D., Children's Hospital, Boston, MA; Project 
Number: 1643; Start Date: October 1, 2005; Length: 60 months.

    Abstract: This rehabilitation research and training center (RRTC) 
on children with disabilities who have special health care needs (CYDS) 
tests the effectiveness of two intensive interventions, integrated 
transition planning and community participation in recreation and 
fitness, and demonstrates the viability of a screening tool to promote 
access to services and supports for traditionally underserved 
communities. Research activities include two intervention projects that 
use randomized controlled designs to improve the educational and 
recreational activities of CYDS and a demonstration project to improve 
the early identification of CYDS from traditionally underserved 
communities. Research Study 1 investigates the use of a regional 
interagency team that integrates innovative practices in education, 
social services, and medical support for transition aged students. 
Research Study 2 builds off of innovative practices in recreation and 
volunteer training to examine a model that integrates CYDS into 
community recreation activities. Research Study 3 models the 
integration of a reliable screening mechanism into the flow of activity 
at a busy, urban neighborhood health center. The RRTC is a 
collaboration of the Massachusetts Consortium for Children with Special 
Health Care Needs, the Parent Advocacy Coalition for Educational Rights 
(PACER), and six Multicultural Community Based Organizations that serve 
traditionally underrepresented communities. RRTC staff and 
collaborators include nationally and internationally known experts in 
pediatrics, nursing, public policy, education, family advocacy, 
rehabilitation, and community organizing.

Rehabilitation Research and Training Center Recovery and Recovery 
        Oriented 
        Psychiatric Rehabilitation for Persons with Long Term Mental 
        Illness
Marianne Farkas, Sc.D.; E. Sally Rogers, Sc.D., Boston University, 
Boston, MA; Project Number: 1453; Start Date: November 1, 2004; Length: 
60 months.

    Abstract: This project focuses on the concepts and dimension of 
recovery and the various factors that inhibit and facilitate recovery 
from long-term mental illness by a comprehensive and meritorious set of 
research projects and training, technical assistance, and dissemination 
activities. The research and the training, dissemination, and technical 
assistance programs are organized into the following three programmatic 
areas of investigation and development: concepts and dimensions of 
recovery; factors enhancing recovery, and factors inhibiting recovery. 
The research projects are designed to have an impact on the field at 
multiple levels, including the personnel level as well as the program 
and system levels. Research projects use a participatory research 
process with significant input from consumers and other stakeholders, 
and culminate in dissemination, training, or technical assistance 
activities to maximize the input of the research program. The Training, 
Dissemination, and Technical Assistance (TDTA) projects are designed to 
provide exposure, experience, and expertise levels of knowledge 
transfer. The TDTA program produces new technologies in recovery and 
psychiatric rehabilitation, as well as increases the likelihood that 
researchers, service providers, and others use the cumulative knowledge 
developed by the RRTC. The RRTC is tied together by its programmatic 
focus on three specific core areas, strengthened by the use of 
appropriate research strategies, and assisted by a vigorous program of 
training, technical assistance, and dissemination activities designed 
to maximize the impact of the RRTC at all levels in the field of 
psychiatric rehabilitation.

Research and Training Center on Community Living (RTC/CL)
Charlie Lakin, Ph.D., University of Minnesota, Minneapolis, MN; Project 
Number: 271; Start Date: October 1, 2003; Length: 60 months.

    Abstract: The Center conducts research, training, technical 
assistance, and dissemination to enhance inclusion and self-
determination of citizens with intellectual and developmental 
disabilities (ID/DD). The research program has six outcome areas: 
policy studies, data base supports for full participation, self-
determination and consumer-control, workforce development, and quality 
assessment and improvement systems. The research program within the 
priority areas includes: (1) research syntheses of the state of 
knowledge and practice; (2) secondary analyses of high quality, 
topically relevant national and state data sets; (3) case studies of 
best practices; (4) evaluation of demonstration efforts to improve 
policy and practice; (5) survey and interview studies of critical 
issues; and (6) group process studies with key constituencies. An 
integrated intramural training program addresses the development of 
skilled disability researchers and community service professionals. 
Outreach training programs provide training and technical assistance to 
agencies and individuals providing support to people with ID/DD, 
including members of their families. The College of Direct Support 
provides online interactive multimedia training to thousands of direct 
support professionals across the U.S. Outreach programs include 
conferences and workshops for a wide variety of national, regional, and 
state audiences, a state-of-the-art conference, annual ``Reinventing 
Quality'' conference, and intensive technical assistance with community 
organizations, including advocacy and self-advocacy organizations. The 
Center disseminates practical information to targeted audiences through 
its internal publication program that includes: IMPACT, Policy Research 
Brief, DD Data Brief, and Frontline Initiative. It maintains high 
standards for scholarly productivity and publication through books, 
journal articles and technical reports. About 18,000 people visit 
Center Web sites each month for access to view publications or other 
information on best practices in person-centered services 
(``QualityMall.org''), national statistics on services and 
expenditures, the direct support workforce, and other contemporary 
topics.

Rehabilitation Research and Training Center for Community Integration 
        for Individuals with Disabilities, Strengthening Family and 
        Youth Participation in Child and Adolescent Mental Health 
        Services
Barbara Friesen, Ph.D., Portland State University, Portland, OR; 
Project Number: 1458; Start Date: October 1, 2004; Length: 60 months.

    Abstract: This project conducts research, training, and technical 
assistance activities to study and promote effective, community-based, 
culturally competent, family centered, individualized, and strength-
based services for children and youth with emotional or behavioral 
disorders and their families. Projects include: (1) ``Community 
Integration (CI) of Transition-Age Youth,'' designed to gain 
understanding of CI and related concepts from the perspectives of 
transition-age youth, young adults, and caregivers; (2) ``Transforming 
Futures: Research on Expanding the Career Aspirations of Youth with 
Mental and Emotional Disorders,'' explores transition experiences; (3) 
``Partnerships in Individualized Planning'' develops an intervention to 
increase youth and family member participation in the individualized 
service planning process, a conceptual framework for understanding 
recovery in children's mental health, and ways to reduce stigma; (4) 
``Work-Life Integration'' addresses CI for adult caregivers of children 
and youth with emotional disorders, specifically around maintaining 
employment. It is designed to influence human resource professionals' 
practice, and aims to reduce stigma and increase organizations' family 
friendliness; (5) ``Transforming Transitions to Kindergarten'' focuses 
on the preschool-kindergarten transition for young children with 
challenging behaviors. It develops and tests an intervention promoting 
children's successful school entry while empowering caregivers; (6) 
``Practice-Based Evidence: Building Effectiveness from the Ground Up,'' 
conducts a case study in partnership with a Native American youth 
organization and the National Indian Child Welfare Association, and 
addresses the need to study practices that are believed to be helpful, 
but for which little evidence exists.

Rehabilitation Research and Training Center Promoting Community 
        Integration of Individuals with Psychiatric Disabilities
Mark Salzer, Ph.D., University of Pennsylvania, Philadelphia, PA; 
Project Number: 268; Start Date: October 1, 2003; Length: 60 months.

    Abstract: The goal of this Center is to ensure that people with 
psychiatric disabilities not only move from institutional care to more 
integrated settings but also are free to choose to participate in a 
wide range of roles in their communities. The Center's 5-year mission 
focuses on three core areas: (1) Factors Associated with Community 
Integration develops a coherent conceptual framework for community 
integration and identifies key factors, intervention models, and 
appropriate instrumentation and research methodologies; (2) Policies 
Associated with Community Integration identifies, develops, and 
assesses the effectiveness of a range of public policies and system 
strategies promoting community integration and engage key stakeholders 
in learning about and utilizing the Center's findings; and (3) 
Intervention Supports that Assist Community Integration identifies, 
develops, and assesses the effectiveness of support service 
interventions promoting community integration, and provides training, 
technical assistance, and dissemination based on those initiatives to 
change behaviors and practices of key stakeholders. This Center 
capitalizes upon the longstanding history of collaboration among three 
Philadelphia-based central partners: The University of Pennsylvania, 
the peer-operated Mental Health Association of Southeastern 
Pennsylvania, and The Matrix Center at Horizon House, Inc.

Rehabilitation and Training Center on Community Integration of Persons 
        with TBI
Angelle M. Sander, Ph.D.; Margaret Struchen, Ph.D., The Institute for 
Rehabilitation and Research (TIRR), Houston, TX; Project Number: 272; 
Start Date: November 1, 2003; Length: 60 months.

    Abstract: The research program of this project includes: 
development and evaluation of a social network mentoring program; an 
investigation of racial/ethnic differences in acceptance of disability, 
community integration needs, barriers, and supports; a distance 
learning program to train family members in rural areas as 
paraprofessionals; assessment of employers' attitudes toward persons 
with TBI and a pilot educational intervention to reduce attitudinal 
barriers in the workplace; a randomized clinical trial to assess the 
effectiveness of a brief substance abuse intervention; a qualitative 
exploration of intimacy following TBI; and a study investigating the 
role of social communication abilities and environmental factors on 
social integration. Training projects include: a National Information, 
Educational Resources, Dissemination, and Technical Assistance Center 
for the Community Integration of Individuals with TBI; development of 
educational materials for increasing community awareness of TBI and 
reducing attitudinal barriers; adoption of a social action network 
program from disability studies for improving positive identity; 
partnering with artists in the community to implement a Center for 
Creative Expressions for Persons with TBI; training of community 
healthcare professionals in the community integration needs of persons 
with TBI; a rehabilitation fellowship in community integration of 
persons with TBI; and a state-of-the-science conference and book on 
community integration.

 rehabilitation engineering research centers of the national institute 
               for disability and rehabilitation research
RERC on Spinal Cord Injury: Keep Moving: Technologies to Enhance 
        Mobility and Function for Individuals with Spinal Cord Injury
Philip Requejo, Ph.D.; Robert Waters, M.D., Los Amigos Research and 
Education Institute, Inc. (LAREI), Downey, CA; Project Number: 483; 
Start Date: November 1, 2002; Length: 60 months.

    Abstract: This RERC improves the lives of individuals with SCI by 
promoting their health, safety, independence, and active engagement in 
daily activities. Activities include: (1) monitoring trends and 
evolving product concepts that represent future directions for 
technologies in SCI, (2) conducting research to advance the state of 
knowledge, (3) disseminating the information to the population, (4) 
developing and testing prototype devices that are useful and effective 
and transferring them to the marketplace, (5) advancing employment 
opportunities for individuals with SCI, and (6) developing ways to 
expand research capacity in the field of SCI. The R&D program is 
focused on a key issue for individuals with SCI, the need to maintain 
mobility for as long as possible in order to enhance independent 
function. A survey of the user population determines where areas of 
greatest need exist. An active Mobile Arm Support for adults allows 
those with limited arm function greater independence. The shoulder-
preserving wheelchair, gait training robotic assist device, and 
adaptive exercise equipment are all specifically geared to preserve or 
enhance mobility in individuals with SCI. A project on optimized 
wheelchair suspension keeps people mobile by increasing comfort and 
reducing tissue loading.

Rehabilitation Engineering Research Center: Develop and Evaluate 
        Technology for Low Vision, Blindness, and Multi-Sensory Loss
John A. Brabyn, Ph.D., The Smith-Kettlewell Eye Research Institute, San 
Francisco, CA; Project Number: 1646; Start Date: August 1, 2006; 
Length: 60 months.

    Abstract: This Center conducts a program of research and 
development to enhance the independence of blind, visually impaired, 
and deaf-blind individuals. Research includes investigation of 
assessment methods to guide rehabilitation of infant cortical visual 
impairment; practical innovations in assessment and interventions for 
elders with visual impairments; and development of independent 
assessment guidelines for emerging visual prostheses. The Center also 
conducts research in access to graphical information for blind, 
visually impaired, and deaf-blind persons, developing tools for rapid 
screen overview, auditory and tactile graph presentation, image 
classification, and on-demand production of tactile street maps. To 
address signage and travel information, the project is investigating 
information interfaces for travelers who are blind or visually 
impaired, and innovative computer vision methods to find and read 
existing print signs and labels. To address the rising barriers to 
accessing visual displays and appliances for employment and daily 
living, there is a designer education campaign and development of a 
universal talking LCD/LED display reader, practical consumer tools, and 
jobsite adaptations for employees who are blind or visually impaired. 
Other projects include development of a new-generation robotic finger-
spelling hand for deaf-blind communication, and pilot investigations of 
difficulties in lipreading and sign language reading experienced by 
those with combined auditory and visual impairment.

Rehabilitation Engineering Research Center for the Advancement of 
        Cognitive 
        Technologies (RERC-ACT)
Cathy Bodine, University of Colorado, Denver, CO; Project Number: 1451; 
Start Date: November 1, 2004; Length: 60 months.

    Abstract: The goal of this RERC is to research, develop, evaluate, 
implement, and disseminate innovative technologies and approaches that 
will have a positive impact on the way in which individuals with 
significant cognitive disabilities function within their communities 
and workplace. The Center incorporates: (1) a consumer-driven model for 
identifying the most significant barriers to independent living and 
workforce; (2) an approach that is balanced and uses both well-
established and newly emerging technologies in its development 
projects; (3) a focus both on functional limitations and specific 
disabilities; and (4) mutually beneficial partnerships with private 
industry and public agencies. Research activities include: Needs, 
knowledge, barriers, and uses of AT by persons with cognitive 
disabilities; technology for remote family support for people with 
cognitive disabilities; influences on AT use, non-use, and partial, and 
inappropriate use by persons with traumatic brain injury; AT 
enhancement of written expression for children and adults; needs 
assessment for creating affordable, context-aware technologies; and 
technology to promote decisionmaking skills and self-determination for 
students with cognitive disabilities. Development activities include: 
Design, implementation, and deployment of context aware technologies 
for persons with cognitive disabilities residing in community living 
environments; development of HealthQuest, an Internet-based product 
that enables individuals with intellectual disabilities to become 
active participants in their own health care; XML repository of common 
tasks; batteryless micropower sensors for context aware technologies; 
perceptive animated interfaces for workforce training; and 
environmentally appropriate behavioral cues for individuals with TBI.

Rehabilitation Engineering Research Center on Hearing Enhancement
Matthew H. Bakke, Ph.D., Gallaudet University, Washington, DC; Project 
Number: 484; Start Date: October 1, 2003; Length: 60 months.

    Abstract: The mission of this RERC is to build and test components 
of a new, innovative model of aural rehabilitation tools, services, and 
training, in order to improve assessment and fitting of hearing 
technologies and to increase the availability, knowledge, and use of 
hearing enhancement devices and services. Component A: (1) develops and 
evaluates new methods for field evaluation and fitting of hearing aids; 
(2) develops and evaluates techniques to enhance auditory self-
monitoring; and (3) develops methods for predicting the speech-to-
interference ratio and intelligibility of speech for a hearing aid when 
used with a wireless telephone. Component B conducts a needs assessment 
survey of people who use hearing technologies and evaluates the use of 
Bluetooth technology as a means of improving and expanding wireless 
connection to a hearing aid. Component C investigates environmental 
factors affecting children's speech recognition abilities in classroom 
settings. Component D investigates the use of distortion product 
otoacoustic emission and reflectance for diagnosis of hearing loss and 
tinnitus; and creates and standardizes sets of synthesized nonsense 
syllables for use in hearing aid research. Component E develops a new, 
innovative model for the delivery of aural rehabilitation services to 
adults with hearing loss. In addition the RERC conducts a program of 
training and dissemination that will reach a diverse audience of 
people, both consumers 
and professionals.

Rehabilitation Engineering Research Center on Technology for Successful 
        Aging
William C. Mann, Ph.D., University of Florida, Gainesville, FL; Project 
Number: 475; Start Date: October 1, 2001; Length: 60 months.

    Abstract: The RERC-Tech-Aging conducts research, development, 
education, and information dissemination work on technology for 
successful aging. Projects of the RERC focus on the closely related 
areas of communications, home monitoring, and ``smart'' technologies. 
The technology driving the focus for this RERC is developing rapidly 
and requires an understanding of current and emerging technology areas, 
including wireless technology, computers, sensors, user interfaces, 
control devices, and networking. Successful integration of this 
technology into products and systems for older persons requires an 
understanding of their complex health, independence, and quality-of-
life issues. The RERC-Tech-Aging tests currently available home 
monitoring products and demonstrates their effectiveness in relation to 
independence, quality of life, and health related costs. The RERC-Tech-
Aging also identifies needs and barriers to home monitoring and 
communication technology, and addresses needs of special populations 
including rural-living, elders, and people aging with disability. The 
RERC-Tech-Aging brings together national expertise to meet this 
challenge, including major universities, industry leaders working in 
this area, major aging or aging-related organizations, major Federal 
agencies that relate to funding or services in this area, other NIDRR-
funded RERCs and RRTCs, and service-related organizations that assist 
in identifying study participants.

Rehabilitation Engineering Research Center for Wireless Technologies
Helena Mitchell, Ph.D., Georgia Institute of Technology, Atlanta, GA; 
Project Number: 1671; Start Date: October 1, 2006; Length: 60 months.

    Abstract: The Rehabilitation Engineering Research Center for 
Wireless Technologies' mission is to: (1) promote equitable access to 
and use of wireless technologies by persons with disabilities; and (2) 
encourage adoption of Universal Design in future generations of 
wireless technologies. To accomplish these aims, the RERC is organized 
into three main project sections: The Research Section is comprised of 
four research initiatives: Facilitating User Centered Research is 
designed to establish a research portal that communicates to industry 
the needs of people with disabilities for wireless technologies. 
Customer-driven Usability Assessment enhances the usability of future 
generations of cell phones and other wireless products by developing a 
methodology for assessing their usability by representative users with 
disabilities. Collaborative Policy Approaches to Promote Equitable 
Access develops, implements, and evaluates specific policy initiatives 
related to accessible wireless technologies and services. Advanced 
Auditory Interfaces develops, tests, and disseminates guidelines for 
the design of advanced auditory interfaces for cell phones and other 
handheld electronic devices. The Development Section includes four 
projects that promote equitable access to and use of wireless 
technologies by persons with disabilities through the development of 
prototype designs: Alternative Interfaces continues its work on the V2 
standards for universal remote consoles and Real-time Location-based 
Information Services expands on previous work on the RERC's personal 
captioning system by addressing the needs of patrons with vision or 
hearing impairments in three different venues--exhibit spaces, 
airports, and hospitals. Development of Wireless Emergency 
Communications and Ensuring Access to Emergency Assistance both focus 
on the area of wireless emergency communications for people with 
disabilities; developing wireless communication technology to be used 
by emergency personnel to contact individuals with disabilities, and by 
people with disabilities to signal the need for assistance. The 
Training and Dissemination Section promotes the synthesis of new 
knowledge into practice with the RERC's State of the Science conference 
and a number of initiatives designed to educate consumers, providers, 
and other professionals, including: university courses, an annual 
student design competition, conference tutorials and workshops, all 
geared toward access and usability of mobile wireless technologies.

Rehabilitation Engineering Research Center on Wheeled Mobility
Stephen H. Sprigle, Ph.D., Georgia Institute of Technology, Atlanta, 
GA; Project Number: 491; Start Date: November 1, 2003; Length: 60 
months.

    Abstract: The goal of this RERC is to undertake a major shift in 
the way wheeled mobility is conceptualized and understood, from the 
design of assistive devices that enable some individuals to perform 
some activities, to the design of a broad range of interventions that 
enable as many individuals as possible to actively engage and 
participate in everyday community life. Research activities include: 
(1) User Needs and Design Input uses participatory focus groups to 
identify needs of wheelchair users; (2) User Needs of Older Adults 
assesses the needs of older adults living at home and in other 
residential settings; (3) Effects of Environment and Mobility 
Technology on Participation and Activity measures the influences of 
environmental barriers and specialized wheelchair technology on 
participation and activity in everyday life; (4) Efficacy of Animation 
and Visualization Training uses computer simulation techniques to 
investigate their efficacy in improving mobility training; and (5) 
Clinical and Functional Implications of Seating Standards and 
Guidelines studies the relationship between standardized measures of 
cushion performance and actual impact on wheelchair users. Development 
efforts include: (1) development and marketing of new mobility devices 
in collaboration with industry design partners; (2) development of a 
wheelchair for frail elders that can be used in any residential 
environment; (3) interventions to overcome barriers to participation 
including guidelines and technologies to help wheelchair users overcome 
environmental and technological barriers; (4) development of animation 
and visualization training through computer simulations to improve 
training in transfers and outdoor mobility; and (5) development of 
valid wheelchair cushion test methods which enables clinicians to 
prescribe appropriate wheelchair cushions based on positioning and 
aload distribution.

Rehabilitation Engineering Research Center on Workplace Accommodations
Karen Milchus; Jon Sanford, Georgia Institute of Technology, Center for 
Assistive Technology & Environmental Access, Atlanta, GA; Project 
Number: 480; Start Date: November 1, 2002; Length: 60 months.

    Abstract: This RERC identifies, designs, and develops devices and 
systems to enhance the workplace productivity of people with 
disabilities. Universal design is a primary focus of the Center: making 
the design of products and environments usable by all workers to the 
greatest extent possible, without the need for adaptation or 
specialized design. The RERC's research projects evaluate existing 
workplace products and services and determine areas where further 
product development is needed. The Center also studies archival 
materials to identify factors that contribute to successful or 
unsuccessful outcomes, and analyzes policies and practices that may 
influence the nature and availability of workplace accommodations for 
persons with disabilities. The RERC's development activities focus on 
Remote Services and Universal Design in the Workplace. The Remote 
Services projects investigate ways that remote technologies such as 
videoconferencing and telework can be used to facilitate employment and 
provide technical support services to people with disabilities. The 
Universal Design projects work with manufacturers to develop new 
generations of universally designed and accessible products. Digital 
human modeling tools developed by the project provide visualizations of 
products or systems with human interaction and movement and reduce the 
need for preliminary physical prototypes. Products are developed for 
workers in office, manufacturing, retail/sales, service industry, and 
other environments. Finally, training, technical assistance, and 
dissemination activities on workplace accommodations and universal 
design promote the transfer of new knowledge into practice.

RERC on Rehabilitation Robotics and Telemanipulation: Machines 
        Assisting 
        Recovery from Stroke (MARS)
W. Zev Rymer, M.D., Ph.D., Rehabilitation Institute Research 
Corporation, Chicago, IL; Project Number: 481; Start Date: November 1, 
2002; Length: 60 months.

    Abstract: MARS-RERC focuses its research and development on 
restoring function in hemispheric stroke survivors. Five projects 
assess different approaches that have the potential to improve 
performance of the upper extremity, and one project attempts to restore 
gait and fluid locomotion to the lower extremities. These projects 
include: the ARM Guide, a robotic therapy for force training of the 
upper extremity in chronic hemiparetic stroke; Lokomat-Gait restoration 
in hemiparetic stroke patients using goal-directed, robotic-assisted 
treadmill training; Augmented Reality Robotic Rehabilitation, which is 
in the development of a robotic system with an augmented reality 
interface for rehabilitation retraining of arm function for brain-
injured individuals; Robotic Assisted Finger Extension, rehabilitation 
of finger extension in chronic hemiplegia; and T-WREX, a home-based 
telerehabilitation system for improving functional hand and arm 
movement recovery following stroke utilizing an anti-gravity orthosis 
and video games to track progress. In addition to these projects, MARS-
RERC's purpose is to train undergraduate engineering students, medical 
students, physician residents, graduate students in engineering and 
neuroscience, and allied health clinicians, including physical and 
occupational therapists in the area of rehabilitation robotics. The 
broad intent of MARS-RERC is to develop robotic devices or machines 
that assist the therapist in providing treatments that are rationally 
based, intensive, and long in duration. This project is a collaboration 
of the Rehabilitation Institute of Chicago (RIC), the Catholic 
University of America (CUA) and National Rehabilitation Hospital in 
Washington, DC, the University of Illinois at Chicago (UIC), and the 
University of California at Irvine (UCI).

Rehabilitation Engineering Research Center in Prosthetics and Orthotics
Steven A. Gard, Ph.D., Northwestern University, Chicago, IL; Project 
Number: 490; Start Date: October 1, 2003; Length: 60 months.

    Abstract: This Center conducts ten research projects, three of 
which are pilot studies. In the area of human locomotion the objectives 
are to conduct quantitative studies that include non-disabled gait, 
modeling of gait, roll-over shape influence on transtibial amputee 
gait, gait initiation, shock absorption studies, the role of the spine 
in walking, transfemoral socket design studies, and evaluation of 
stance-control orthotic knee joints. Pilot studies, where preliminary 
data is not available, are proposed on partial foot prosthesis/orthosis 
systems, on evaluation of Ankle Foot Orthoses and on the design of a 
Shape & Roll foot for children. Six developmental projects include a 
simple gait monitoring instrument (Direct Ultrasound Ranging System), a 
new prosthetic ankle joint that adapts to inclines, and a manual 
through which individuals in low-income countries can make their own 
artificial feet. In addition, two upper-limb prosthetics development 
projects are proposed that deal with reaching, manipulation, and 
grasping. Finally, an outcomes measurement tool is developed for 
prosthetics and orthotics (P&O) facilities in their reporting to the 
American Board of Certification. The vision for this RERC is to improve 
the quality of life for persons who use prostheses and orthoses through 
creative applications of science and engineering to the P&O field. The 
goal is to uncover new knowledge and understanding in P&O and to bring 
more quantification to the field, which will enable them to develop new 
concepts and devices to improve the quality, cost-effectiveness, and 
delivery of P&O fittings.

Rehabilitation Engineering Research Center on Recreational Technologies 
        and 
        Exercise Physiology Benefiting Persons with Disabilities (RERC 
        RecTech)
James H. Rimmer, Ph.D., University of Illinois at Chicago, Chicago, IL; 
Project Number: 479; Start Date: November 1, 2002; Length: 60 months.

    Abstract: This program researches access to recreational 
opportunities and physical endurance of people with disabilities, 
targeting four primary areas: (1) increased access to fitness and 
recreation environments; (2) interventions to increase physical 
activity and recreation participation; (3) adherence strategies to 
reduce physical activity relapse and dropout rates; and (4) randomized 
clinical trials to evaluate improvements in health and function. 
Research and development projects include: (1) a comprehensive needs 
assessment that involves ongoing assessment of consumer needs as they 
pertain to existing and emerging recreational and fitness technologies; 
(2) research on the use of information technology and a newly designed 
environmental accessibility instrument for facilitating access to 
recreational and fitness environments and promoting improved health and 
function; (3) research on the use of ``teleexercise'' technology for 
promoting participation and for monitoring intensity and physiological/
psychological outcomes of home-based exercise programs; (4) research 
and development of technology to create virtual exercise environments 
to promote greater adherence to exercise and thereby improved health 
and function; (5) development of technology to allow users adaptive 
control of exercise machines; (6) development of broadly applicable 
aftermarket accessory kits for adapting existing cardiovascular 
exercise equipment for use by people with disabilities and determining 
the efficacy of the new adaptations in improving fitness; and (7) 
development of an online RecTech solutions database of currently 
available recreational and fitness technologies to make available 
solutions more accessible to consumers. Two training projects promote 
capacity building for future recreation, fitness, exercise physiology, 
engineering, and rehabilitation professionals, and two additional 
training projects support professional development.

Rehabilitation Engineering Research Center on Technology Access for 
        Landmine 
        Survivors
Yeongchi Wu, M.D.; Kim Reisinger, Ph.D., Center for International 
Rehabilitation, Chicago, IL; Project Number: 487; Start Date: November 
1, 2003; Length: 60 months.

    Abstract: The Center strives to improve the quality and 
availability of amputee and rehabilitation services for landmine 
survivors by focusing on the development of ``appropriate technology,'' 
i.e., technology that is most suitable to the limited technical and 
human resources available in most mine-affected regions through the 
application of research methodologies, the development of mobility 
aids, and the creation of educational materials, all of which are 
designed specifically for mine-affected populations and disseminated 
through a network of rehabilitation service providers in mine-affected 
regions. Laboratory-based research projects investigate issues of 
importance relating to transtibial alignment, ischial containment 
socket trim lines as they relate to the gait of transfemoral amputees, 
and the evaluation of a non-toxic resin for the direct lamination of 
prosthetic sockets. Field-based research evaluates an anatomically 
based transtibial alignment methodology and a wheelchair prototype 
manufacturing and dissemination strategy. Development projects, many of 
which contain research components, can be classified into two areas: 
those that improve the service delivery through improved fabrication 
techniques, and those that develop appropriate prosthetic components 
and mobility aids. In order to promote the successful transfer of 
techniques and technologies that are developed, the RERC creates 
training materials that describe the manufacture, assembly, and use of 
the technique or devices developed under the research and development 
program. Additionally, because the current number of trained prosthetic 
technicians in developing countries is far from sufficient to 
adequately meet the needs of landmine survivors, the center produces 
education and training materials covering the basic science of 
prosthetics and orthotics. All materials are adapted to the specific 
languages, culture, and needs of the mine-affected regions served by 
the RERC and distributed through a blended distance learning network.

Rehabilitation Engineering Research Center on Wheelchair Transportation 
        Safety
Lawrence W. Schneider, Ph.D. (Michigan); Patricia Karg, Ph.D. 
(Pittsburgh); Gina Bertocci, Ph.D. (Louisville), University of 
Michigan, Ann Arbor, MI; Project Number: 1672; Start Date: November 1, 
2006; Length: 60 months.

    Abstract: Research conducted by the RERC on Wheelchair 
Transportation Safety (RERC WTS) advances the safety, usability, and 
independence of people who remain seated in their wheelchairs when 
traveling in motor vehicles. Research and development projects involve 
close collaboration with manufacturers, transit providers, vehicle 
modifiers, clinicians, and consumers to ensure quick translation of 
results into meaningful solutions that benefit travelers with mobility 
disabilities. Projects range from developing innovative solutions for 
forward-facing and rear-facing wheelchair passenger stations in large 
accessible transit vehicles, to investigating issues of school-bus 
transportation for children seated in WC-19 compliant and noncompliant 
wheelchairs, and to improving frontal- and rear-crash protection for 
occupants in private vehicles. Continuing research from previous 
grants, the RERC WTS extends the in-depth investigations of adverse 
events involving wheelchair-seated travelers, but also conducts a study 
of the transportation experience of wheelchair users in large public 
transit vehicles, including the process of entering and exiting the 
vehicle, accessing the wheelchair station, securing the wheelchair and 
restraining the occupant, and traveling to and from destinations. In 
addition to conducting research and development in six project areas, 
RERC WTS staff engages in information dissemination, training of future 
researchers, transferring innovative technology concepts to the 
marketplace, developing and revising voluntary industry standards, and 
convening the second State-of-the-Science Workshop on Wheelchair 
Transportation Safety. The RERC is a partnership of the University of 
Michigan Transportation Research Institute, the University of 
Pittsburgh, the University of Louisville, and the University of 
Colorado.

Rehabilitation Engineering Research Center on Children with Orthopedic 
        Disabilities
Richard A. Foulds, Ph.D., New Jersey Institute of Technology, Newark, 
NJ; Project Number: 1560; Start Date: November 1, 2005; Length: 60 
months.

    Abstract: The Rehabilitation Engineering Research Center on 
Technology for Children with Orthopedic Disabilities focuses on 
research and development assisting children to achieve their full 
potential as productive citizens. The work plan includes a roster of 
projects designed to enhance the physical skills of these children to 
be successful in learning, playing, and living independently. This 
project includes three research and three development projects, as well 
as training projects serving the needs of children, families, students, 
and professionals. Project selection is driven by the RERC on Children 
with Orthopedic Disabilities' vision of RERCs as a source of innovation 
and of new technologies designed to address the serious problems faced 
by children with disabilities. This project is a collaboration of New 
Jersey Institute of Technology, the Childrens' Specialized Hospital, 
and Rutgers University, bringing together two academic departments of 
biomedical engineering with the Nation's largest pediatric 
rehabilitation hospital.

Rehabilitation Engineering Research Center on Technology Transfer 
        (T2RERC)
Steve Bauer, Ph.D., State University of New York (SUNY) at Buffalo, 
Buffalo, NY; Project Number: 489; Start Date: October 1, 2003; Length: 
60 months.

    Abstract: The activities of this project transfer and commercialize 
new and improved assistive devices, conduct research to improve 
technology transfer practice, and support other stakeholders involved 
in the technology transfer process. Four research projects investigate 
innovative ways to facilitate and improve the process of technology 
transfer for all stakeholders: (1) Identify Innovative Technology 
Transfer Practices--draws critical success factors from examples of 
retrospective and prospective AT transfer case studies in various 
sectors; (2) Identify Innovative Technology Transfer Policies--traces 
the outputs and outcomes of Federal transfer programs supporting AT 
related projects and assesses their efficacy; (3) Facilitate AT 
Industry Innovation through Focused Market Research--provides a context 
for transfer opportunities involving the AT industry and for public 
policy decision making; and (4) Assess the Efficacy of Transferred 
Products--determines the extent to which products previously 
transferred through the T2RERC impact the functional capabilities of 
consumers. Four development projects increase the number and quality of 
successful transfers from RERC's and other sources: (1) Transfer 
Products through a Supply Push Approach--facilitates the movement of 
new or improved prototype inventions to the marketplace through 
licenses, sales, or entrepreneurial ventures; (2) Transfer Technologies 
through a Demand Pull Approach--validates technology needs within the 
AT industry and introduces advanced technology solutions to address 
those needs; (3) Improve the Accessibility of New Mainstream Products--
extends participatory research to integrate consumers' functional 
requirements into the design of new mainstream products; and (4) 
Facilitate RERC Transfer Activity Through Informatics--establishes a 
pilot informatics infrastructure and assesses its utility for 
increasing communication, collaboration, and transfers between RERC's.

Rehabilitation Engineering and Research Center (RERC) on Universal 
        Design and the Built Environment at Buffalo
Edward Steinfeld, Arch.D., State University of New York (SUNY) at 
Buffalo, Buffalo, NY; Project Number: 1561; Start Date: November 1, 
2005; Length: 60 months.

    Abstract: The RERC on Universal Design and the Built Environment is 
engaging the public and private sectors across four broad domains of 
the built environment: (1) community infrastructure, (2) public 
buildings, (3) housing, and (4) products. The RERC-UD generates 
strategically important research, development, education, and 
dissemination deliverables, to advance the fields of rehabilitation 
engineering and environmental design. The RERC-UD deliverables 
integrate universal design principles within the generally accepted 
models, methods, and metrics of design and engineering professionals in 
the building and manufacturing industries. Research projects document 
the efficacy of existing universally designed environments, and 
generate critical human factors data essential to resolving design and 
engineering problems. Development projects create evidence-based 
guidelines to implement universal design concepts within the tools of 
the design professions, and formulate methods to evaluate the usability 
of designs for people with mobility, sensory, and cognitive 
impairments. The usefulness of the guidelines and evaluation methods 
are demonstrated by applying them to the development of innovative 
products and environments with industry partners. Training activities 
emphasize online certificate programs in universal design for design 
professionals, builders, manufacturers, and consumer advocates; a Web 
portal and site for students and educators; and graduate programs that 
train researchers in advanced methods. Dissemination outputs include 
traditional refereed and trade publications, an extensive Web site with 
downloadable information products and design tools, model home 
demonstrations in local communities across the country, and outreach 
activities with professional, business, and standards development 
organizations. The RERC-UD's state-of-the-science conference includes 
stakeholders in a plan to elevate universal design to an integral 
component of the mainstream design and engineering disciplines.

Rehabilitation Engineering Research Center on Communication Enhancement
Frank DeRuyter, Ph.D., Duke University, Durham, NC; Project Number: 
488; Start Date: November 1, 2003; Length: 60 months.

    Abstract: The mission of this RERC is to assist people who use 
augmentative and alternative (AAC) technologies in achieving their 
goals across environments. The goals and objectives of the RERC are to 
advance and promote AAC technologies through the outputs and outcomes 
of research and development activities and to support individuals who 
use, manufacture, and recommend these technologies in ways they value. 
Research projects cover the following areas: (1) improving AAC 
technology to better support societal roles; (2) enhancing AAC access 
by reducing cognitive/linguistic load; and (3) enhancing AAC usability 
and performance. Projects address issues of literacy, telework, 
specialized vocabulary, contextual scenes and intelligent agents, 
improving interface performance, and monitoring and simulating 
communication performance. Development activities include: (1) 
technology and policy watch; (2) new interfaces; and (3) reducing the 
cognitive/linguistic burden on AAC users. Activities address monitoring 
emerging technologies, standards, and policies; technologies to 
supplement intelligibility of residual speech, dysarthric speech, and 
gesture recognition; brain interface; AAC WebCrawling; and enhancing 
the role of listeners in AAC interactions.

National Center for Accessible Public Transportation
Katharine Hunter-Zaworski, Ph.D., Oregon State University, Corvallis, 
OR; Project Number: 485; Start Date: October 1, 2003; Length: 60 
months.

    Abstract: This RERC addresses the need for improvements in the 
accessibility of public transportation. This center is both important 
and timely because of major changes in the travel industry, and the 
need to adapt to those changes in a way that provides safe and 
dignified travel for persons with disabilities. The transportation 
focus of this RERC is inter-city travel via air, rail, and bus. Air, 
rail, and over-the-road buses (OTRB) account for nearly all of the 
inter-city public transportation. Accessibility issues focus on persons 
with mobility, agility, and hearing disabilities and account for a 
large percentage of persons with disabilities. Two areas of research 
are addressed: (1) the biomechanics of wheelchair transfers in confined 
spaces; and (2) the perceptions, reactions, and attitudes of subjects 
toward existing and proposed accessibility solutions. The biomechanics 
studies include the use of a sophisticated eight-camera motion analysis 
system in conjunction with force plates to determine the motions and 
forces involved in dependent and independent transfers in confined 
spaces, such as an aircraft aisle. The survey-based study includes 
comprehensive surveys of groups that are directly involved with 
accessibility issues including travelers with disabilities, non-
travelers with disabilities, and employees of airlines and airports. 
Drawing on results of their research, the RERC focuses on four 
development topics: (1) vehicle boarding technologies; (2) real time 
passenger information and communications systems; (3) accessible 
lavatories; and (4) passenger assistance training tools and techniques. 
The accessible lavatory project has two main components; regulations 
and new designs for the next generation of aircarft.

Rehabilitation Engineering Research Center on Telerehabilitation
David M. Brienza, Ph.D., University of Pittsburgh, Pittsburgh, PA; 
Project Number: 1450; Start Date: December 1, 2004; Length: 60 months.

    Abstract: The vision of this RERC is to serve people with 
disabilities by researching and developing methods, systems, and 
technologies that support remote delivery of rehabilitation and home 
health care services for individuals who have limited local access to 
comprehensive medical rehabilitation outpatient and community-based 
services. Research and development activities include: (1) 
Telerehabilitation Infrastructure and Architecture: development of an 
informatics infrastructure and architecture that builds on existing 
programs and technologies of the University of Pittsburgh Medical 
Center's e-Health System, supports the RERC's research and development 
activities, meets HIPAA requirements, provides a test-bed for third 
party telerehabilitation applications, and can be used as a model for 
future telerehabilitation infrastructure; (2) Telerehabilitation 
Clinical Assessment Modeling: development of a conceptual model for 
matching consumers with telerehabilitation technology. The model is 
user-oriented and driven by consumer experiences regarding 
satisfaction, simplicity, and reimbursability of telerehabilitation; 
(3) Teleassessment for the Promotion of Communication Function in 
Children with Disabilities: development of a Web-based teleassessment 
infrastructure that links therapists and child participants, allowing 
therapeutic content to be adapted to the child's individual progress 
and abilities; (4) Remote Wheeled Mobility Assessment: determines if 
individuals with mobility impairments can obtain appropriate 
prescriptions for wheeled mobility devices through the use of a 
telerehabilitation system based upon information and telecommunications 
technologies; (5) Behavioral Monitoring and Job Coaching in Vocational 
Rehabilitation: researches technologies to conduct remote delivery of 
rehabilitation services to individuals who have limited access to 
rehabilitation services that are necessary to participate in and 
achieve education and employment outcomes in their community; and (6) 
Remote Accessibility Assessment of the Built Environment: determines 
the effectiveness of a remote accessibility assessment system in 
evaluating the built environment of wheeled mobility device users.


Rehabilitation Engineering Research Center on Wheelchair Transportation 
        Safety
Patricia Karg, University of Pittsburgh, Pittsburgh, PA; Project 
Number: 477; Start Date: November 1, 2001; Length: 60 months.

    Abstract: This RERC aims to improve the safety of wheelchair users 
who remain seated in their wheelchair while using public and private 
motor-vehicle transportation. RERC tasks investigate and develop new 
wheelchair tiedown and occupant restraint system technologies, 
including wheelchair-integrated restraints and universal docking 
concepts, that enable wheelchair users to secure and release their 
wheelchair independently and quickly, and use an effective occupant 
restraint system without the need for assistance. The RERC also 
researches the issues and factors involved in providing improved 
occupant protection to wheelchair-seated drivers and passengers in rear 
and side impacts, and uses a multifaceted approach, including in-depth 
investigations of real-world accidents, to investigate the incidence, 
severity, and causes of injuries to wheelchair-seated occupants in 
different sizes of vehicles and in different types of crashes and non-
impact incidents experienced during vehicle motion. In particular, this 
RERC explores the need for, and suitability of, using different levels 
of wheelchair securement and occupant restraint in larger public 
transit vehicles, with the goal of recommending and developing 
equipment and systems that provide for a safe ride and that are more 
compatible with the operational needs of the transit environment. The 
program includes a comprehensive research and development effort that 
involves consumers, manufacturers, students, clinicians, transport 
providers, and rehabilitation technology experts. The RERC also has 
active programs of information dissemination, training, and technology 
transfer using personnel, mechanisms, and facilities that have been 
previously established at the University of Pittsburgh/University of 
Michigan.

Rehabilitation Engineering Research Center on Accessible Medical 
        Instrumentation
Jack Winters, Ph.D.; Molly Follette Story, M.S. , Marquette University, 
Milwaukee, WI; Project Number: 482; Start Date: November 1, 2002; 
Length: 60 months.

    Abstract: The RERC on Accessible Medical Instrumentation: (1) 
increases knowledge of, access to, and utilization of healthcare 
instrumentation and services by individuals with disabilities; (2) 
increases awareness of and access to employment in the healthcare 
professions by individuals with disabilities; and (3) serves as a 
national center of excellence for this priority topic area. Specific 
research projects include: (1) needs analysis for people with 
disabilities as both recipients and providers of healthcare services, 
and for manufacturers of healthcare instrumentation; (2) usability 
analyses to determine what makes certain medical instrumentation either 
exemplary or problematic yet essential to healthcare service delivery; 
(3) accessibility and universal usability analysis to identify 
classification and measurement approaches that could be used to explore 
metrics for accessibility of medical instrumentation; and (4) policy 
analyses to explore how medical policies affect healthcare utilization 
and employment in the healthcare professions of persons with 
disabilities. Specific development projects include: (1) development of 
tools for usability and accessibility analysis; (2) development of 
modified and new accessible medical instrumentation; (3) monitoring of, 
and involvement in development of, emerging, accessible healthcare 
technologies; and (4) development of design guidelines for accessible 
medical instrumentation and model policies for healthcare service 
delivery.

Rehabilitation Engineering Research Center on Telecommunication Access
Gregg C. Vanderheiden, Ph.D. (Trace); Judy Harkins, Ph.D. (Gallaudet 
University), University of Wisconsin/Madison, Madison, WI; Project 
Number: 1435; Start Date: October 1, 2004; Length: 60 months.

    Abstract: The focus of this RERC is on advancing accessibility and 
usability in existing and emerging telecommunications products for 
people with all types of disabilities. Telecommunications accessibility 
is addressed along all three of its major dimensions: user interface, 
transmission (including digitization, compression, etc.), and modality 
translation services (relay services, gateways, etc.). Research and 
development projects cover three areas: (1) development of tools, 
techniques, and performance-based measures that can be used to evaluate 
current and evolving telecommunication strategies including visual 
communication and cognitive access; (2) solving the problems faced by 
individuals using hearing aids or cochlear implants with digital phones 
(including development of tools that users can employ to match 
appropriate hearing technologies with telecommunication technologies); 
and (3) improving access to emerging telecommunications for people with 
visual, hearing, physical, and cognitive disabilities' particularly 
digital and IP-based systems including emergency communication. The 
RERC looks at advances that have both short- and long-term outcomes 
related to assistive technologies (AT), interoperability, and universal 
design of telecommunications. In addition, the RERC provides technical 
assistance to government, industry, and consumers, training for 
industry, and education for new researchers in this field. The RERC is 
a collaboration of the Trace Center at the University of Wisconsin and 
the Technology Access Program at Gallaudet University.

Rehabilitation Engineering Research Center on Universal Interface and 
        Information Technology Access
Gregg C. Vanderheiden, Ph.D., University of Wisconsin/Madison, Madison, 
WI; Project Number: 486; Start Date: October 1, 2003; Length: 60 
months.

    Abstract: The focus of this RERC is on both access to information 
(e.g., content) in its various forms, as well as access to interfaces 
used within content and by electronic technologies in general. The 
research and development program is carefully designed to provide an 
interwoven set of projects that together advance accessibility and 
usability in a fashion that takes into account, and supports, the full 
range of access strategies used by manufacturers and people with 
disabilities. These strategies range from enhancing the design of 
mainstream products that can be used by individuals with different 
ability sets to enhancing the ability of users to deal with the 
information and interfaces as they encounter them. Key to these 
projects are the development of new models and approaches for 
characterization of the functional requirements of current and future 
interfaces, and a better understanding of the type, diversity, and 
similarity of functional limitations across etiologies and 
disabilities. Research activities include: model generation and initial 
pilot studies for the characterization of interface requirements 
(current and emerging) and cross-disability user abilities; abstract 
user interfaces and human interface sockets; emerging technologies and 
future research needs; and accessible real-time visual information 
presentation in meetings and virtual meetings. Development projects 
include: tools to facilitate the incorporation of cross-disability 
interface features in public information technologies; tools to 
facilitate AT-IT interoperability; server-based and ``virtual assistive 
technology''; and support for national and international standards and 
guidelines efforts.

 national center for medical rehabilitation research (ncmrr) projects 
                                  list

------------------------------------------------------------------------
             Project Number                        Description
------------------------------------------------------------------------
F31--Predoctoral Individual National
 Research Service Award:
1F31HD053986-01........................  COWAN, RACHEL E
                                         UNIVERSITY OF PITTSBURGH AT
                                          PITTSBURGH
                                         PREDOCTORAL FELLOWSHIPS FOR
                                          STUDENTS WITH DISABILITIES
                                         SHINOWARA, NANCY
5F31HD049319-02........................  AJIBOYE, ABIDEMI B
                                         NORTHWESTERN UNIVERSITY
                                         MINORITY PREDOCTORAL FELLOWSHIP
                                          PROGRAM
                                         QUATRANO, LOUIS A
5F31HD049326-02........................  JAGODNIK, KATHLEEN M
                                         CASE WESTERN RESERVE UNIVERSITY
                                         UPPER EXTREMITY CONTROL USING
                                          REINFORCEMENT LEARNING
                                         NITKIN, RALPH M
 
F32--Postdoctoral Individual National
 Research Service Award:
 
3F32HD047099-02S1......................  LOVERING, RICHARD M.
                                         UNIVERSITY OF MARYLAND BALT
                                          PROF SCHOOL
                                         THE ROLE OF CYTOKERATINS IN
                                          SKELETAL MUSCLE INJURY
                                         NITKIN, RALPH M
5F32HD049217-02........................  KLUZIK, JOANN
                                         KENNEDY KRIEGER RESEARCH
                                          INSTITUTE, INC.
                                         LEARNING POSTURAL DYNAMICS IN A
                                          NOVEL REACHING TASK
                                         QUATRANO, LOUIS A
 
K01--Research Scientist Development
 Award--Research & Training:
 
1K01HD049476-01A2......................  ZACKOWSKI, KATHLEEN
                                         KENNEDY KRIEGER RESEARCH
                                          INSTITUTE, INC.
                                         MECHANISMS OF LOCOMOTOR
                                          RECOVERY IN MULTIPLE SCLEROSIS
                                         SHINOWARA, NANCY
1K01HD049593-01A1......................  PURSER, JAMA L
                                         DUKE UNIVERSITY
                                         CANDIDATE GENES AND
                                          LONGITUDINAL DIABILITY
                                          PHENOTYPES
                                         NITKIN, RALPH M
1K01HD050369-01A1......................  MORTON, SUSANNE M
                                         UNIVERSITY OF MARYLAND BALT
                                          PROF SCHOOL
                                         EFFECT OF CONTRALATERAL LEG ON
                                          MOTOR OUTPUT POST STROKE
                                         ANSEL, BETH
1K01HD050582-01A1......................  REISMAN, DARCY S
                                         UNIVERSITY OF DELAWARE
                                         LOCOMOTOR ADAPTATIONS FOLLOWING
                                          STROKE
                                         NITKIN, RALPH M
5K01HD042057-06........................  AGUILAR, GUILLERMO
                                         UNIVERSITY OF CALIFORNIA
                                          RIVERSIDE
                                         PORT WINE STAIN TREATMENT FOR
                                          INFANTS AND YOUNG CHILDREN
                                         NITKIN, RALPH M
5K01HD042491-04........................  LUDEWIG, PAULA M
                                         UNIVERSITY OF MINNESOTA TWIN
                                          CITIES
                                         BIOMECHANICALLY BASED SHOULDER
                                          REHABILITATION STRATEGIES
                                         NITKIN, RALPH M
5K01HD043352-04........................  SALSICH, GRETCHEN B
                                         SAINT LOUIS UNIVERSITY
                                         PATELLOFEMORAL PAIN:
                                          TIBIOFEMORAL ROTATION
                                          IMPAIRMENTS
                                         NITKIN, RALPH M
5K01HD045293-03........................  MURPHY, SUSAN L
                                         UNIVERSITY OF MICHIGAN AT ANN
                                          ARBOR
                                         CLINICAL STRATEGIES TO REDUCE
                                          OSTEOARTHRITIS DISABILITY
                                         NITKIN, RALPH M
5K01HD046602-02........................  KALPAKJIAN, CLAIRE ZABELLE
                                         UNIVERSITY OF MICHIGAN AT ANN
                                          ARBOR
                                         MENOPAUSAL TRANSITION IN WOMEN
                                          WITH SPINAL CORD INJURY
                                         NITKIN, RALPH M
5K01HD046682-02........................  OSTIR, GLENN V
                                         UNIVERSITY OF TEXAS MEDICAL BR
                                          GALVESTON
                                         ASSESSING QUALITY OF LIFE FOR
                                          REHABILITATION PATIENTS
                                         QUATRANO, LOUIS A
5K01HD047148-02........................  QUANEY, BARBARA M
                                         UNIVERSITY OF KANSAS MEDICAL
                                          CENTER
                                         MOTOR PERFORMANCE AND CORTICAL
                                          CHANGES IN CHRONIC STROKE
                                         NITKIN, RALPH M
5K01HD047669-02........................  LANG, CATHERINE E
                                         WASHINGTON UNIVERSITY
                                         MECHANISMS UNDERLYING LOSS OF
                                          HAND FUNCTION AFTER STROKE
                                         ANSEL, BETH
5K01HD048437-02........................  EARHART, GAMMON M
                                         WASHINGTON UNIVERSITY
                                         PARKINSONIAN GAIT DISORDERS:
                                          MECHANISMS AND TREATMENT
                                         NITKIN, RALPH M
 
K02--Research Scientist Development
 Award--Research:
 
5K02HD044099-04........................  YEATES, KEITH O
                                         CHILDREN'S RESEARCH INSTITUTE
                                         OUTCOMES OF TRAUMATIC BRAIN
                                          INJURY IN CHILDREN
                                         QUATRANO, LOUIS A
5K02HD045354-03........................  HALEY, STEPHEN M
                                         BOSTON UNIVERSITY
                                         COMPUTER ADAPTIVE TESTING OF
                                          FUNCTIONAL STATUS
                                         QUATRANO, LOUIS A
7K02HD045354-04........................  HALEY, STEPHEN M
                                         BOSTON UNIVERSITY MEDICAL
                                          CAMPUS
                                         COMPUTER ADAPTIVE TESTING OF
                                          FUNCTIONAL STATUS
                                         QUATRANO, LOUIS A
 
K08--Clinical Investigator Award:
 
1K08HD049459-01A2......................  SNOW, LEANN
                                         UNIVERSITY OF MINNESOTA TWIN
                                          CITIES
                                         SKELETAL MUSCLE PLASTICITY POST-
                                          STROKE
                                         NITKIN, RALPH M
1K08HD049616-01A2......................  EVANS, MELISSA C
                                         VIRGINIA COMMONWEALTH
                                          UNIVERSITY
                                         ARTERIAL CELL SIGNALING IN
                                          VASODILATORY SHOCK.
                                         NICHOLSON, CAROL E
1K08HD051609-01A1......................  FAIRCHILD, KAREN D
                                         UNIVERSITY OF VIRGINIA
                                          CHARLOTTESVILLE
                                         HYPOTHERMIA ENHANCES
                                          INFLAMMATORY CYTOKINE
                                          EXPRESSION VIA NF-KAPPA B
                                         NICHOLSON, CAROL E
1K08HD052619-01........................  BURNS, ANTHONY S
                                         THOMAS JEFFERSON UNIVERSITY
                                         THE LOWER MOTOR NEURON & SPINAL
                                          CORD INJURY: IMPLICATIONS FOR
                                          REHABILITATION
                                         NITKIN, RALPH M
1K08HD052885-01........................  SHEW, STEPHEN BRIAN
                                         UNIVERSITY OF CALIFORNIA LOS
                                          ANGELES
                                         EFFECT OF CYSTEINE ON
                                          GLUTATHIONE PRODUCTION IN
                                          CRITICALLY ILL  NEONATES
                                         NITKIN, RALPH M
5K08HD044558-03........................  DE PLAEN, ISABELLE G
                                         CHILDREN'S MEMORIAL HOSPITAL
                                          (CHICAGO)
                                         MECHANISMS OF ACUTE BOWEL
                                          INJURY ROLE OF NF-KB
                                         NICHOLSON, CAROL E
 
K12--Physician Scientist Award
 (Program):
 
2K12HD001097-11........................  WHYTE, JOHN
                                         MOSS REHABILITATION HOSPITAL
                                         REHABILITATION MEDICINE
                                          SCIENTIST TRAINING (RMST)
                                          PROGRAM
                                         NITKIN, RALPH M
5K12HD047349-03........................  DEAN, JONATHAN MICHAEL
                                         UNIVERSITY OF UTAH
                                         PEDIATRIC CRITICAL CARE
                                          SCIENTIST DEVELOPMENT PROGRAM
                                         NICHOLSON, CAROL E
 
K23--Mentored Patient-Oriented
 Research Devel Award:
 
1K23HD049472-01A1......................  RAGHAVAN, PREETI
                                         MOUNT SINAI SCHOOL OF MEDICINE
                                          OF NYU
                                         INTERHEMISPHERIC TRANSFER OF
                                          GRASP CONTROL AFTER STROKE
                                         ANSEL, BETH
1K23HD049552-01A2......................  VARGUS-ADAMS, JILDA N
                                         CHILDREN'S HOSPITAL MED CTR
                                          (CINCINNATI)
                                         TOWARDS IMPROVED CLINICAL
                                          TRIALS IN CEREBRAL PALSY
                                         NICHOLSON, CAROL E
5K23HD041040-05........................  KEENAN, HEATHER T
                                         UNIVERSITY OF UTAH
                                         OUTCOMES OF TRAUMATIC BRAIN
                                          INJURY
                                         NICHOLSON, CAROL E
5K23HD042014-05........................  TRAUTNER, BARBARA W
                                         BAYLOR COLLEGE OF MEDICINE
                                         E. COLI FOR PREVENTION OF
                                          CATHETER UTI IN SCI PATIENTS
                                         NITKIN, RALPH M
5K23HD042128-04........................  LENGENFELDER, JEAN
                                         KESSLER MEDICAL REHAB RES &
                                          EDUC CORP
                                         USING FMRI TO IDENTIFY ENCODING
                                          DEFICITS IN TBI
                                         NITKIN, RALPH M
5K23HD042702-04........................  CHEN, CHRISTINE C
                                         NEW YORK UNIVERSITY
                                         MEASURING HAND FUNCTION--
                                          DEVELOPMENT OF OUTCOME MEASURE
                                         QUATRANO, LOUIS A
5K23HD043843-04........................  BERGER, RACHEL P
                                         CHILDREN'S HOSP PITTSBURGH/UPMC
                                          HLTH SYS
                                         USING BIOCHEMICAL MARKERS TO
                                          DETECT ABUSIVE HEAD TRAUMA
                                         NICHOLSON, CAROL E
5K23HD044425-04........................  SCHAECHTER, JUDITH DIANE
                                         MASSACHUSETTS GENERAL HOSPITAL
                                         FMRI AND TMS OF MOTOR RECOVERY
                                          AFTER HEMIPARETIC STROKE
                                         NITKIN, RALPH M
5K23HD044632-04........................  VAVILALA, MONICA S
                                         UNIVERSITY OF WASHINGTON
                                         HEMODYNAMICS AND OUTCOME IN
                                          PEDIATRIC BRAIN INJURY
                                         NICHOLSON, CAROL E
5K23HD046489-03........................  WATSON, R SCOTT
                                         UNIVERSITY OF PITTSBURGH AT
                                          PITTSBURGH
                                         CONSEQUENCES OF SURVIVING
                                          CRITICAL ILLNESS IN CHILDHOOLD
                                         NICHOLSON, CAROL E
5K23HD046690-02........................  WALZ, NICOLAY C
                                         CHILDREN'S HOSPITAL MED CTR
                                          (CINCINNATI)
                                         SOCIAL DEVELOPMENT FOLLOWING
                                          PRESCHOOL BRAIN INJURY
                                         NITKIN, RALPH M
5K23HD047634-03........................  MORRIS, MARILYN C
                                         COLUMBIA UNIVERSITY HEALTH
                                          SCIENCES
                                         EXCEPTION FROM INFORMED CONSENT
                                          IN PEDIATRICS
                                         NICHOLSON, CAROL E
5K23HD048637-02........................  MARINO, BRADLEY S
                                         CHILDREN'S HOSPITAL OF
                                          PHILADELPHIA
                                         TESTING THE PEDIATRIC CARDIAC
                                          QUALITY OF LIFE INVENTORY
                                         NICHOLSON, CAROL E
5K23HD048817-02........................  ZUPPA, ATHENA F
                                         CHILDREN'S HOSPITAL OF
                                          PHILADELPHIA
                                         IMPROVING DRUG DEVELOPMENT FOR
                                          THE CRITICALLY ILL CHILD
                                         NICHOLSON, CAROL E
 
K24--Midcareer Investigator Awd in
 Patient-Oriented Res:
 
5K24HD041504-04........................  STEVENSON, RICHARD D
                                         UNIVERSITY OF VIRGINIA
                                          CHARLOTTESVILLE
                                         GROWTH AND PHYSICAL MATURATION
                                          IN CEREBRAL PALSY
                                         NITKIN, RALPH M
5K24HD043819-03........................  CAMPAGNOLO, DENISE I
                                         ST. JOSEPH'S HOSPITAL AND
                                          MEDICAL CENTER
                                         HEALTH AND IMMUNITY FOLLOWING
                                          SPINAL CORD INJURY
                                         NITKIN, RALPH M
K25--Mentored Quantitative Research
 Career Development:
1K25HD048643-01A1......................  MONSON, KENNETH L
                                         UNIVERSITY OF CALIFORNIA SAN
                                          FRANCISCO
                                         VASCULAR MECHANOTRANSDUCTION IN
                                          TRAUMATIC BRAIN INJURY
                                         NICHOLSON, CAROL E
5K25HD043993-02........................  ERIM, ZEYNEP
                                         REHABILITATION INSTITUTE OF
                                          CHICAGO
                                         IMPAIRED MOTOR UNIT CONTROL IN
                                          BRAIN AND SPINAL INJURY
                                         NITKIN, RALPH M
5K25HD044720-04........................  PERREAULT, ERIC J
                                         NORTHWESTERN UNIVERSITY
                                         REFLEX CONTROL OF MULTI-JOINT
                                          MECHANICS FOLLOWING STROKE
                                         NITKIN, RALPH M
5K25HD047194-02........................  STERGIOU, NICK
                                         UNIVERSITY OF NEBRASKA OMAHA
                                         NONLINEAR ANALYSIS OF POSTURAL
                                          FUNCTION IN INFANTS
                                         NICHOLSON, CAROL E
 
P01--Research Program Projects:
 
5P01HD033988-10........................  JENSEN, MARK P
                                         UNIVERSITY OF WASHINGTON
                                         MANAGEMENT OF CHRONIC PAIN IN
                                          REHABILITATION MEDICINE
                                         QUATRANO, LOUIS A
 
R01--Research Project:
 
1R01AR052113-01A1......................  WEINSTEIN, STUART L
                                         UNIVERSITY OF IOWA
                                         BRACING IN ADOLESCENT
                                          IDIOPATHIC SCOLIOSIS (BRAIST)
                                         SHINOWARA, NANCY
1R01HD046570-01A2......................  MOSSBERG, KURT A
                                         UNIVERSITY OF TEXAS MEDICAL BR
                                          GALVESTON
                                         PHYSICAL WORK CAPACITY AFTER
                                          TRAUMATIC BRAIN INJURY
                                         ANSEL, BETH
1R01HD047242-01A2......................  MCALLISTER, THOMAS W
                                         DARTMOUTH COLLEGE
                                         RCT METHYLPHENIDATE & MEMORY/
                                          ATTENTION TRAINING IN TBI
                                         ANSEL, BETH
1R01HD047516-01A2......................  ISKANDAR, BERMANS
                                         UNIVERSITY OF WISCONSIN MADISON
                                         FOLIC ACID ENHANCES REPAIR
                                          MECHANISM IN THE ADULT CNS
                                         SHINOWARA, NANCY
1R01HD047709-01A2......................  VAN DILLEN, LINDA
                                         WASHINGTON UNIVERSITY
                                         CLASSIFICATION--DIRECTED
                                          TREATMENT OF LOW BACK PAIN
                                         SHINOWARA, NANCY
1R01HD047761-01A2......................  CHENG, MEI-FANG
                                         RUTGERS, THE STATE UNIV OF NJ-
                                          NEWARK
                                         BRAIN DAMAGE AND RECOVERY OF
                                          FUNCTION IN THE ADULT SYSTEM
                                         ANSEL, BETH
1R01HD048741-01A2......................  BASTIAN, AMY J.
                                         KENNEDY KRIEGER RESEARCH
                                          INSTITUTE, INC.
                                         HUMAN LOCOMOTOR PLASTICITY IN
                                          HEALTH AND DISEASE
                                         ANSEL, BETH
1R01HD048946-01A2......................  YEATES, KEITH
                                         CHILDREN'S RESEARCH INSTITUTE
                                         SOCIAL OUTCOMES IN PEDIATRIC
                                          TRAUMATIC BRAIN INJURY
                                         ANSEL, BETH
1R01HD049471-01A2......................  SUMAN, OSCAR E
                                         UNIVERSITY OF TEXAS MEDICAL BR
                                          GALVESTON
                                         EXERCISE AND QUALITY OF LIFE IN
                                          SEVERELY BURNED CHILDREN
                                         NICHOLSON, CAROL E
1R01HD049774-01A2......................  MULROY, SARA J
                                         LOS AMIGOS RESEARCH/EDUCATION
                                          INSTITUTE
                                         SHOULDER PAIN IN SCI: A
                                          LONGITUDINAL STUDY
                                         SHINOWARA, NANCY
1R01HD051844-01A1......................  PROTAS, ELIZABETH J
                                         UNIVERSITY OF TEXAS MEDICAL BR
                                          GALVESTON
                                         GAIT AND STEP TRAINING TO
                                          PREVENT FALLS IN PARKINSON'S
                                          DISEASE
                                         SHINOWARA, NANCY
1R01HD052127-01........................  CRISCO, JOSEPH J
                                         RHODE ISLAND HOSPITAL
                                          (PROVIDENCE, RI)
                                         3-D MULTI-ARTICULAR MODELS OF
                                          THE CARPUS
                                         SHINOWARA, NANCY
2R01HD032943-06A2......................  DILLER, LEONARD
                                         NEW YORK UNIVERSITY SCHOOL OF
                                          MEDICINE
                                         PROBLEM-SOLVING TREATMENT/ADULT/
                                          ACQUIRED BRAIN DAMAGE
                                         QUATRANO, LOUIS A
2R01HD037433-05A1......................  CAVANAGH, PETER R
                                         CLEVELAND CLINIC LERNER COL/MED-
                                          CWRU
                                         DESIGN CRITERIA FOR THERAPEUTIC
                                          FOOTWARE IN DIABETES
                                         QUATRANO, LOUIS A
2R01HD037985-05........................  SNYDER-MACKLER, LYNN
                                         UNIVERSITY OF DELAWARE
                                         DYNAMIC STABILITY OF THE ACL
                                          DEFICIENT KNEE
                                         SHINOWARA, NANCY
2R01HD040289-05A1......................  BASTIAN, AMY J
                                         KENNEDY KRIEGER RESEARCH
                                          INSTITUTE, INC.
                                         MECHANISMS AND REHABILITATION
                                          OF CEREBELLAR ATAXIA
                                         NITKIN, RALPH M
3R01HD034273-10S1......................  TAUB, EDWARD
                                         UNIVERSITY OF ALABAMA AT
                                          BIRMINGHAM
                                         A TREATMENT FOR EXCESS MOTOR
                                          DISABILITY IN THE AGED
                                         ANSEL, BETH
3R01HD045798-03S2......................  CHIARAVALLOTI, NANCY D.
                                         KESSLER MEDICAL REHAB RES &
                                          EDUC CORP
                                         IMPROVING LEARNING IN MS: A
                                          RANDOMIZED CLINICAL TRIAL
                                         QUATRANO, LOUIS A
3R01HD048628-01A1S1....................  FROEHLICH-GROBE, KATHERINE
                                         UNIVERSITY OF KANSAS MEDICAL
                                          CENTER
                                         A RANDOMIZED EXERCISE TRIAL FOR
                                          WHEELCHAIR USERS
                                         QUATRANO, LOUIS A
5R01AR048781-06........................  AGARWAL, SUDHA
                                         OHIO STATE UNIVERSITY
                                         EXERCISE DRIVEN MOLECULAR
                                          MECHANISMS OF JOINT REPAIR
                                         NITKIN, RALPH M
5R01EB001672-04........................  WEIR, RICHARD FERGUS FFRENCH
                                         NORTHWESTERN UNIVERSITY
                                         MULTIFUNCTION PROSTHESIS
                                          CONTROL USING IMPLANTED
                                          SENSORS
                                         SHINOWARA, NANCY
5R01HD030149-11........................  SIPSKI, MARCA L
                                         UNIVERSITY OF ALABAMA AT
                                          BIRMINGHAM
                                         EFFECTS OF SCI ON FEMALE SEXUAL
                                          RESPONSE
                                         SHINOWARA, NANCY
5R01HD031476-08........................  KAUFMAN, KENTON R.
                                         MAYO CLINIC COLL OF MEDICINE,
                                          ROCHESTER
                                         MICROSENSOR FOR INTRAMUSCULAR
                                          PRESSURE MEASUREMENT
                                         QUATRANO, LOUIS A
5R01HD032116-12........................  ALVAREZ-BUYLLA, ARTURO
                                         UNIVERSITY OF CALIFORNIA SAN
                                          FRANCISCO
                                         ORIGINS OF NEW NEURONS AND GLIA
                                          IN THE POSTNATAL BRAIN
                                         NITKIN, RALPH M
5R01HD034273-11........................  TAUB, EDWARD
                                         UNIVERSITY OF ALABAMA AT
                                          BIRMINGHAM
                                         A TREATMENT FOR EXCESS MOTOR
                                          DISABILITY IN THE AGED
                                         ANSEL, BETH
5R01HD035047-07........................  STUIFBERGEN, ALEXA K
                                         UNIVERSITY OF TEXAS AUSTIN
                                         HEALTH PROMOTION FOR WOMEN WITH
                                          FIBROMYALGIA
                                         QUATRANO, LOUIS A
5R01HD036019-13........................  FRIEDMAN, RHONDA B
                                         GEORGETOWN UNIVERSITY
                                         COGNITIVELY BASED TREATMENTS OF
                                          ACQUIRED DYSLEXIAS
                                         QUATRANO, LOUIS A
5R01HD036020-09........................  CHEN, XIANG YANG
                                         WADSWORTH CENTER
                                         SUPRASPINAL CONTROL OF SPINAL
                                          CORD PLASTICITY
                                         SHINOWARA, NANCY
5R01HD036895-07........................  MUELLER, MICHAEL J
                                         WASHINGTON UNIVERSITY
                                         VISUALIZING DIABETIC FEET TO
                                          OPTIMIZE ORTHOTIC FITTING
                                         QUATRANO, LOUIS A
5R01HD037661-05........................  RIVERA, PATRICIA A
                                         UNIVERSITY OF ALABAMA AT
                                          BIRMINGHAM
                                         PROBLEM-SOLVING FOR CAREGIVERS
                                          OF WOMEN W/ DISABILITIES
                                         QUATRANO, LOUIS A
5R01HD037880-07........................  COLLINS, JAMES J
                                         BOSTON UNIVERSITY
                                         NONLINEAR DYNAMICS AND ENHANCED
                                          SENSORIMOTOR FUNCTION
                                         ANSEL, BETH
5R01HD038107-06........................  KRUPP, LAUREN B
                                         STATE UNIVERSITY NEW YORK STONY
                                          BROOK
                                         INTERVENTIONS TO IMPROVE MEMORY
                                          IN PATIENTS WITH MS
                                         ANSEL, BETH
5R01HD038582-05........................  BUCHANAN, THOMAS S
                                         UNIVERSITY OF DELAWARE
                                         FES AND BIOMECHANICS: TREATING
                                          MOVEMENT DISORDERS
                                         QUATRANO, LOUIS A
5R01HD038878-06........................  LAWLOR, MARY C
                                         UNIVERSITY OF SOUTHERN
                                          CALIFORNIA
                                         BOUNDARY CROSSINGS: RE-
                                          SITUATING CULTURAL COMPETENCE
                                         QUATRANO, LOUIS A
5R01HD040692-04........................  TAUB, EDWARD
                                         UNIVERSITY OF ALABAMA AT
                                          BIRMINGHAM
                                         RANDOMIZED CONTROLLED TRIAL OF
                                          PEDIATRIC CI THERAPY
                                         NICHOLSON, CAROL E
5R01HD040909-04........................  HENRY, SHARON M
                                         UNIVERSITY OF VERMONT & ST
                                          AGRIC COLLEGE
                                         MECHANISMS OF SPECIFIC TRUNK
                                          EXERCISES IN LOW BACK PAIN
                                         SHINOWARA, NANCY
5R01HD041055-05........................  SNYDER-MACKLER, LYNN
                                         UNIVERSITY OF DELAWARE
                                         NMES FOR OLDER INDIVIDUALS
                                          AFTER TOTAL KNEE ARTHROPLASTY
                                         SHINOWARA, NANCY
5R01HD041487-05........................  FIELD-FOTE, EDELLE C.
                                         UNIVERSITY OF MIAMI-MEDICAL
                                          SCHOOL
                                         COMPARISON OF POST-SCI
                                          LOCOMOTOR TRAINING TECHNIQUES
                                         SHINOWARA, NANCY
5R01HD041490-04........................  BRIENZA, DAVID M.
                                         UNIVERSITY OF PITTSBURGH AT
                                          PITTSBURGH
                                         RCT ON PREVENTING PRESSURE
                                          ULCERS WITH SEAT CUSHIONS
                                         QUATRANO, LOUIS A
5R01HD042141-05........................  GARSHICK, ERIC HARVARD
                                         UNIVERSITY (MEDICAL SCHOOL)
                                         RESPIRATORY FUNCTION AND
                                          ILLNESS IN SPINAL CORD INJURY
                                         SHINOWARA, NANCY
5R01HD042385-05........................  LEVINE, BRIAN T
                                         ROTMAN RESEARCH INSTITUTE
                                         THE NEUROANATOMY OF COGNITION
                                          IN TRAUMATIC BRAIN INJURY
                                         NITKIN, RALPH M
5R01HD042527-05........................  CLARK, JANE E.
                                         UNIVERSITY OF MARYLAND COLLEGE
                                          PK CAMPUS
                                         ADAPTIVE SENSORIMOTOR CONTROL
                                          IN CHILDREN WITH DCD
                                         NICHOLSON, CAROL E
5R01HD042588-04........................  STINEMAN, MARGARET G
                                         UNIVERSITY OF PENNSYLVANIA
                                         DO AMPUTEES BENEFIT FROM
                                          REHABILITATION SERVICES?
                                         QUATRANO, LOUIS A
5R01HD042705-03........................  MARTIN, ANATOLE D
                                         UNIVERSITY OF FLORIDA
                                         RESPIRATORY MUSCLE TRAINING IN
                                          VENTILATOR DEPENDENT PTS.
                                         ANSEL, BETH
5R01HD042729-05........................  WADE, SHARI L
                                         CHILDREN'S HOSPITAL MED CTR
                                          (CINCINNATI)
                                         CHILD AND FAMILY SEQUELAE OF
                                          PRESCHOOL BRAIN INJURY
                                         QUATRANO, LOUIS A
5R01HD042838-05........................  JENSEN, MARK P
                                         UNIVERSITY OF WASHINGTON
                                         REHABILITATION OF SPINAL CORD
                                          INJURY-RELATED PAIN
                                         SHINOWARA, NANCY
5R01HD043137-04........................  KUIKEN, TODD A
                                         REHABILITATION INSTITUTE OF
                                          CHICAGO
                                         EMG PROPAGATION IN PLANAR
                                          MUSCLES FOR PROSTHESIS CONTROL
                                         QUATRANO, LOUIS A
5R01HD043249-03........................  LAZAR, RONALD M
                                         COLUMBIA UNIVERSITY HEALTH
                                          SCIENCES
                                         NEUROCHEMICAL CHALLENGE IN
                                          HUMAN STROKE RECOVERY
                                         ANSEL, BETH
5R01HD043323-04........................  MOHR, DAVID C
                                         NORTHERN CALIFORNIA INSTITUTE
                                          RES & EDUC
                                         A CONTROLLED TRIAL OF CBT FOR
                                          MS INFLAMMATION
                                         QUATRANO, LOUIS A
5R01HD043378-04........................  LYSACK, CATHERINE L
                                         WAYNE STATE UNIVERSITY
                                         COMMUNITY LIVING AFTER SPINAL
                                          CORD INJURY
                                         SHINOWARA, NANCY
5R01HD043499-05........................  LEWIS, CORA E
                                         UNIVERSITY OF ALABAMA AT
                                          BIRMINGHAM
                                         LAXITY AND MALALIGNMENT IN A
                                          LARGE COHORT STUDY OF OA
                                         SHINOWARA, NANCY
5R01HD043500-05........................  SHARMA, LEENA
                                         NORTHWESTERN UNIVERSITY
                                         LAXITY AND MALALIGNMENT IN A
                                          LARGE COHORT STUDY OF OA
                                         SHINOWARA, NANCY
5R01HD043501-05........................  TORNER, JAMES C
                                         UNIVERSITY OF IOWA
                                         LAXITY AND MALALIGMENT IN A
                                          LARGE COHORT STUDY OF OA
                                         SHINOWARA, NANCY
5R01HD043502-05........................  NEVITT, MICHAEL C
                                         UNIVERSITY OF CALIFORNIA SAN
                                          FRANCISCO
                                         LAXITY AND MALALIGNMENT IN A
                                          LARGE COHORT STUDY OF OA
                                         SHINOWARA, NANCY
5R01HD043770-04........................  SCHENKMAN, MARGARET L
                                         UNIVERSITY OF COLORADO DENVER/
                                          HSC AURORA
                                         EXERCISE, PHYSICAL FUNCTION,
                                          AND PARKINSON'S DISEASE
                                         SHINOWARA, NANCY
5R01HD043859-03........................  LEE, SAMUEL C
                                         UNIVERSITY OF DELAWARE
                                         STRENGTH TRAINING USING NMES
                                          FOR CHILDREN WITH CP
                                         NICHOLSON, CAROL E
5R01HD043943-03........................  DAROUICHE, RABIH O
                                         BAYLOR COLLEGE OF MEDICINE
                                         PREVENTION OF UTI IN PERSONS
                                          WITH SPINAL CORD INJURY
                                         SHINOWARA, NANCY
5R01HD043988-04........................  HAPP, MARY E
                                         UNIVERSITY OF PITTSBURGH AT
                                          PITTSBURGH
                                         IMPROVING COMMUNICATION WITH
                                          NONSPEAKING ICU PATIENTS
                                         ANSEL, BETH
5R01HD043991-04........................  SCHWARTZ, MYRNA F
                                         ALBERT EINSTEIN HEALTHCARE
                                          NETWORK
                                         AAC PROCESSING SUPPORT FOR
                                          SPOKEN LANGUAGE IN APHASIA
                                         ANSEL, BETH
5R01HD044295-04........................  ZHANG, LI-QUN
                                         REHABILITATION INSTITUTE OF
                                          CHICAGO
                                         NEUROMECHANICAL CHANGES CAUSED
                                          BY STROKE & STRETCHING
                                         ANSEL, BETH
5R01HD044444-02........................  AW, MARY C
                                         MCMASTER UNIVERSITY
                                         FAMILY-CENTRED FUNCTIONAL
                                          THERAPY FOR CEREBRAL PALSY
                                         NICHOLSON, CAROL E
5R01HD044772-04........................  WOLF, WILLIAM A
                                         UNIVERSITY OF ILLINOIS AT
                                          CHICAGO
                                         DRUG-ENHANCED REHABILITATION IN
                                          RECOVERY FROM STROKE
                                         NITKIN, RALPH M
5R01HD044775-04........................  PARENT, JACK M
                                         UNIVERSITY OF MICHIGAN AT ANN
                                          ARBOR
                                         AUGMENTATION OF NEUROGENESIS
                                          AND RECOVERY AFTER STROKE
                                         NITKIN, RALPH M
5R01HD044816-02........................  CHAE, JOHN
                                         CASE WESTERN RESERVE UNIVERSITY
                                         FES FOR FOOT-DROP IN
                                          HEMIPARESIS
                                         ANSEL, BETH
5R01HD044830-04........................  EDGERTON, V. REGGIE
                                         UNIVERSITY OF CALIFORNIA LOS
                                          ANGELES
                                         SEROTONERGIC FACILITATION &
                                          ROBOTICS IN SPINAL LEARNING
                                         NITKIN, RALPH M
5R01HD044831-04........................  HODGE, CHARLES J
                                         UPSTATE MEDICAL UNIVERSITY
                                         CORTICAL PLASTICITY: MECHANISMS
                                          AND MODULATION
                                         NITKIN, RALPH M
5R01HD045343-03........................  KREBS, HERMANO IGO
                                         MASSACHUSETTS INSTITUTE OF
                                          TECHNOLOGY
                                         THE EFFECT OF PROXIMAL AND
                                          DISTAL TRAINING ON STROKE REC
                                         QUATRANO, LOUIS A
5R01HD045364-03........................  DUHAIME, ANN-CHRISTINE
                                         DARTMOUTH COLLEGE
                                         TRAUMA TO IMMATURE BRAIN:
                                          RESPONSE REPAIR & TREATMENT
                                         NICHOLSON, CAROL E
5R01HD045412-03........................  DUNLOP, DOROTHY D
                                         NORTHWESTERN UNIVERSITY
                                         FUNCTIONAL LIMITATION,
                                          ARTHRITIS, DEPRESSION, & RACE
                                         QUATRANO, LOUIS A
5R01HD045512-03........................  THOMAS, JAMES S
                                         OHIO UNIVERSITY ATHENS
                                         PREDICTING RECURRENCE OF LOW
                                          BACK PAIN--STUDY #2 SHINOWARA,
                                          NANCY
5R01HD045639-03........................  STERNAD, DAGMAR
                                         PENNSYLVANIA STATE UNIVERSITY-
                                          UNIV PARK
                                         VARIABILITY AND STABILITY IN
                                          SKILL ACQUISITION
                                         SHINOWARA, NANCY
5R01HD045694-02........................  ALONSO, ESTELLA M
                                         CHILDREN'S MEMORIAL HOSPITAL
                                          (CHICAGO)
                                         FUNCTIONAL OUTCOMES IN
                                          PEDIATRIC LIVER
                                          TRANSPLANTATION
                                         NICHOLSON, CAROL E
5R01HD045751-02........................  LIGHT, KATHYE E
                                         UNIVERSITY OF FLORIDA
                                         EXAMINING PARAMETERS OF
                                          CONSTRAINT-INDUCED THERAPY
                                         ANSEL, BETH
5R01HD045798-03........................  CHIARAVALLOTI, NANCY D.
                                         KESSLER MEDICAL REHAB RES &
                                          EDUC CORP
                                         IMPROVING LEARNING IN MS: A
                                          RANDOMIZED CLINICAL TRIAL
                                         QUATRANO, LOUIS A
5R01HD045834-03........................  GREENDALE, GAIL A
                                         UNIVERSITY OF CALIFORNIA LOS
                                          ANGELES
                                         THE YOGA FOR HYPERKPHOSIS TRIAL
                                         ANSEL, BETH
5R01HD045968-02........................  CLARK, ROBERT S.
                                         UNIVERSITY OF PITTSBURGH AT
                                          PITTSBURGH
                                         GENDER-SPECIFIC TREATMENT OF
                                          PEDIATRIC CARDIAC ARREST
                                         NICHOLSON, CAROL E
5R01HD046442-02........................  ALEXANDER, MICHAEL P
                                         BETH ISRAEL DEACONESS MEDICAL
                                          CENTER
                                         COGNITION AND FUNCTIONAL
                                          RECOVERY AFTER CARDIAC ARREST
                                         ANSEL, BETH
5R01HD046700-02........................  KLINE, ANTHONY E
                                         UNIVERSITY OF PITTSBURGH AT
                                          PITTSBURGH
                                         NOVEL REHABILITATIVE APPROACHES
                                          FOR RECOVERY FROM TBI
                                         ANSEL, BETH
5R01HD046740-02........................  DOBKIN, BRUCE H
                                         UNIVERSITY OF CALIFORNIA LOS
                                          ANGELES
                                         FMRI PREDICTOR MODEL FOR STROKE
                                          LOCOMOTOR REHABILITATION
                                         QUATRANO, LOUIS A
5R01HD046774-03........................  MURRAY, WENDY M
                                         PALO ALTO INSTITUTE FOR RES &
                                          EDU, INC.
                                         BIOMECHANICAL MODELING OF
                                          TENDON TRANSFER IN TETRAPLEGIA
                                         QUATRANO, LOUIS A
5R01HD046814-03........................  DELP, SCOTT L
                                         STANFORD UNIVERSITY
                                         SIMULATION-BASED TREATMENT
                                          PLANNING FOR GAIT DISORDERS
                                         QUATRANO, LOUIS A
5R01HD046820-03........................  KAUTZ, STEVEN A
                                         UNIVERSITY OF FLORIDA
                                         INTERMUSCULAR COORDINATION OF
                                          HEMIPARETIC WALKING
                                         QUATRANO, LOUIS A
5R01HD046922-03........................  TING, LENA H
                                         GEORGIA INSTITUTE OF TECHNOLOGY
                                         NEUROMECHANICAL MODELING OF
                                          POSTURAL RESPONSES
                                         QUATRANO, LOUIS A
5R01HD047447-02........................  MOORE, JASON H.
                                         DARTMOUTH COLLEGE
                                         GENETICS BASIS OF TRAUMA
                                          RECOVERY
                                         NITKIN, RALPH M
5R01HD047569-02........................  DEWALD, JULIUS P
                                         NORTHWESTERN UNIVERSITY
                                         THE ROLE OF THE CORTEX IN
                                          DISCOORDINATION AFTER STROKE
                                         ANSEL, BETH
5R01HD048051-03........................  VANDENBORNE, KRISTA H
                                         UNIVERSITY OF FLORIDA
                                         MOLECULAR SIGNATURES OF MUSCLE
                                          REHABILITATION
                                         NITKIN, RALPH M
5R01HD048162-03........................  WAGNER, AMY K
                                         UNIVERSITY OF PITTSBURGH AT
                                          PITTSBURGH
                                         DOPAMINE GENETIC VARIANTS
                                          MODULATING RECOVERY AFTER TBI
                                         NITKIN, RALPH M
5R01HD048176-03........................  MCALLISTER, THOMAS
                                         DARTMOUTH COLLEGE
                                         ROLE OF CANDIDATE ALLELES IN
                                          COGNITIVE OUTCOME AFTER TBI
                                         NITKIN, RALPH M
5R01HD048179-03........................  DIAZ-ARRASTIA, RAMON R
                                         UNIVERSITY OF TEXAS SW MED CTR/
                                          DALLAS
                                         GENETIC FACTORS IN OUTCOME FROM
                                          TRAUMATIC BRAIN INJURY
                                         NITKIN, RALPH M
5R01HD048501-02........................  LIEBER, RICHARD L
                                         UNIVERSITY OF CALIFORNIA SAN
                                          DIEGO
                                         DIRECT DETERMINATION OF LOWER
                                          EXTREMITY OF MUSCLE DESIGN
                                         SHINOWARA, NANCY
5R01HD048628-02........................  FROEHLICH-GROBE, KATHERINE
                                         UNIVERSITY OF KANSAS LAWRENCE
                                         A RANDOMIZED EXERCISE TRIAL FOR
                                          WHEELCHAIR USERS
                                         QUATRANO, LOUIS A
5R01HD048781-02........................  AN, KAI-NAN
                                         MAYO CLINIC COLL OF MEDICINE,
                                          ROCHESTER
                                         BIOMECHANICS OF WHEELCHAIR
                                          PROPULSION
                                         SHINOWARA, NANCY
5R01HD048924-02........................  OSTRY, DAVID J
                                         MC GILL UNIVERSITY
                                         MOTOR CONTROL OF HUMAN ARM
                                          STIFFNESS
                                         NITKIN, RALPH M
5R01HD049773-02........................  ABBAS, JAMES J
                                         ARIZONA STATE UNIVERSITY
                                         ADAPTIVE ELECTRICAL STIMULATION
                                          FOR LOCOMOTOR RETRAINING
                                         SHINOWARA, NANCY
5R01HD049777-02........................  CHAE, JOHN
                                         CASE WESTERN RESERVE UNIVERSITY
                                         ELECTRICAL STIMULATION FOR
                                          UPPER LIMB RECOVERY IN STROKE
                                         ANSEL, BETH
5R01HD050385-02........................  DAHLQUIST, LYNNDA M
                                         UNIVERSITY OF MARYLAND BALT
                                          PROF SCHOOL
                                         VIRTUAL REALITY AND ACUTE PAIN
                                          MANAGEMENT FOR CHILDREN
                                         QUATRANO, LOUIS A
5R01HD052891-02........................  RIMMER, JAMES H
                                         UNIVERSITY OF ILLINOIS AT
                                          CHICAGO
                                         BUILDING HEALTH EMPOWERMENT
                                          ZONES FOR PEOPLE WITH
                                          DISABILITIES
                                         QUATRANO, LOUIS A
5R01NS050506-02........................  DUNCAN, PAMELA W.
                                         UNIVERSITY OF FLORIDA
                                         LOCOMOTOR EXPERIENCE APPLIED
                                          POST-STROKE (LEAPS)
                                         NITKIN, RALPH M
7R01EB001672-05........................  WEIR, RICHARD FERGUS FFRENCH
                                         REHABILITATION INSTITUTE OF
                                          CHICAGO
                                         MULTIFUNCTION PROSTHESIS
                                          CONTROL USING IMPLANTED
                                          SENSORS
                                         SHINOWARA, NANCY
 
R03--Small Research Grants:
 
1R03HD044534-01A2......................  CAURAUGH, JAMES H
                                         UNIVERSITY OF FLORIDA
                                         SUBACUTE STROKE RECOVERY:
                                          BIMANUAL COORDINATION TRAINING
                                         ANSEL, BETH
1R03HD049408-01A1......................  SAWAKI, LUMY
                                         WAKE FOREST UNIVERSITY, HEALTH
                                          SCIENCES
                                         DRIVING NEUROPLASTICITY WITH
                                          NERVE STIMULATION AND MODIFIED
                                          CIT
                                         NITKIN, RALPH M
1R03HD049735-01A1......................  BONINGER, MICHAEL L
                                         UNIVERSITY OF PITTSBURGH AT
                                          PITTSBURGH
                                         WHEELCHAIR PROPULSION TRAINING
                                         SHINOWARA, NANCY
1R03HD049885-01A1......................  CLENDANIEL, RICHARD A
                                         DUKE UNIVERSITY
                                         COMPENSATORY MECHANISMS
                                          FOLLOWING VESTIBULAR LOSS
                                         ANSEL, BETH
1R03HD050530-01A1......................  MODLESKY, CHRISTOPHER M
                                         UNIVERSITY OF DELAWARE
                                         VITAMIN K AND BONE IN CHILDREN
                                          WITH CEREBRAL PALSY
                                         NITKIN, RALPH M
1R03HD050532-01A1......................  SHARKEY, NEIL A
                                         PENNSYLVANIA STATE UNIVERSITY-
                                          UNIV PARK
                                         AN OBJECTIVE EVALUATION OF
                                          SEGMENTED FOOT MODELS
                                         SHINOWARA, NANCY
1R03HD051717-01A1......................  CHEN, YUYING
                                         UNIVERSITY OF ALABAMA AT
                                          BIRMINGHAM
                                         INTERVENTION ON WEIGHT CONTROL
                                          OF PERSONS:SPINAL INJURY
                                         QUATRANO, LOUIS A
1R03HD051825-01........................  KRAMER, ANDREW M
                                         UNIVERSITY OF COLORADO DENVER/
                                          HSC AURORA
                                         TWO-YEAR OUTCOMES OF OLDER
                                          PERSONS WITH STROKE
                                         ANSEL, BETH
1R03HD053135-01........................  HILLSTROM, HOWARD J
                                         HOSPITAL FOR SPECIAL SURGERY
                                         DEVELOPMENT OF A GEOMETRIC
                                          FOREFOOT MODEL: A TOOL FOR
                                          CLINICAL DECISION MAKING
                                         SHINOWARA, NANCY
1R03HD053163-01A1......................  BOYD, LARA A
                                         UNIVERSITY OF KANSAS MEDICAL
                                          CENTER
                                         COMPENSATORY BRAIN ACTIVATION
                                          AFTER STROKE
                                         NITKIN, RALPH M
5R03HD046930-02........................  STEFANATOS, GERRY A.
                                         ALBERT EINSTEIN HEALTHCARE
                                          NETWORK
                                         NEUROPHYSIOLOGICAL EFFECTS OF
                                          AMPHETAMINE APHASIA
                                         ANSEL, BETH
5R03HD048457-02........................  BOGNER, JENNIFER A
                                         OHIO STATE UNIVERSITY
                                         SELF-REGULATION IN CO-OCCURRING
                                          TBI AND SUBSTANCE ABUSE
                                         ANSEL, BETH
5R03HD048465-02........................  COOPER, RORY A
                                         UNIVERSITY OF PITTSBURGH AT
                                          PITTSBURGH
                                         ADVANCED 3D CONTROL TECHNIQUES
                                          FOR POWERED WHEELCHAIRS
                                         SHINOWARA, NANCY
5R03HD048481-02........................  JARIC, SLOBODAN
                                         UNIVERSITY OF DELAWARE
                                         HAND FUNCTION IN MULTIPLE
                                          SCLEROSIS
                                         QUATRANO, LOUIS A
5R03HD050591-02........................  SCHWEIGHOFER, NICOLAS
                                         UNIVERSITY OF SOUTHERN
                                          CALIFORNIA
                                         TASK PRACTICE SCHEDULES TO
                                          ENHANCE RECOVERY AFTER STROKE
                                         ANSEL, BETH
7R03HD053163-02........................  BOYD, LARA A
                                         UNIVERSITY OF BRITISH COLUMBIA
                                         COMPENSATORY BRAIN ACTIVATION
                                          AFTER STROKE
                                         NITKIN, RALPH M
 
R13--Conferences:
 
1R13HD048157-01A1......................  CREPEAU, ELIZABETH B
                                         MERICAN OCCUPATIONAL THERAPY
                                          ASSN
                                         HABITS AND REHABILITATION:
                                          PROMOTING PARTICIPATION
                                         QUATRANO, LOUIS A
1R13NS056636-01........................  GRIGGS, ROBERT C
                                         UNIVERSITY OF ROCHESTER
                                         NOVEL TREATMENT FOR MUSCLE
                                          DISEASE: FUELING THE PIPELINE
                                          AND FINDING THE PRODUCT
                                         SHINOWARA, NANCY
2R13DC006295-04........................  TOMPKINS, CONNIE A
                                         UNIVERSITY OF PITTSBURGH AT
                                          PITTSBURGH
                                         RESEARCH SYMPOSIUM IN CLINICAL
                                          APHASIOLOGY
                                         ANSEL, BETH
 
R21--Exploratory/Developmental Grants:
 
1R21HD046628-01A2......................  HEISS, DEBORAH G
                                         OHIO STATE UNIVERSITY
                                         EFFICACY OF THERAPEUTIC
                                          EXERCISE FOR RECURRENT BACK
                                          PAIN
                                         QUATRANO, LOUIS A
1R21HD047405-01A1......................  MATSUOKA, YOKY
                                         UNIVERSITY OF WASHINGTON
                                         ROBOTIC STROKE REHABILITATION
                                          USING PERCEPTUAL FEEDBACK
                                         ANSEL, BETH
1R21HD047756-01A2......................  WHITALL, JILL
                                         UNIVERSITY OF MARYLAND BALT
                                          PROF SCHOOL
                                         BILATERAL AND UNILATERAL
                                          TRAINING IN CHRONIC STROKE
                                         ANSEL, BETH
1R21HD049842-01A2......................  KIPKE, DARYL R
                                         UNIVERSITY OF MICHIGAN AT ANN
                                          ARBOR
                                         CORTICAL CONTROL USING MULTIPLE
                                          SIGNAL MODALITIES
                                         NITKIN, RALPH M
1R21HD050457-01A1......................  ARUIN, ALEXANDER S
                                         UNIVERSITY OF ILLINOIS AT
                                          CHICAGO
                                         COMPELLED BODY WEIGHT SHIFT
                                          THERAPY IN INDIVIDUALS WITH
                                          STROKE  RELATED
                                         SHINOWARA, NANCY
1R21HD050717-01A1......................  RIVIERE, CAMERON N
                                         CARNEGIE-MELLON UNIVERSITY
                                         NONLINEAR FILTERING OF ATHETOID
                                          MOVEMENT
                                         SHINOWARA, NANCY
1R21HD051861-01........................  CERMAK, SHARON
                                         BOSTON UNIVERSITY
                                         PHYSICAL ACTIVITY, FITNESS AND
                                          OBESITY IN CHILDREN WITH
                                          COORDINATION DISORDERS
                                         SHINOWARA, NANCY
1R21HD051988-01........................  SUGAR, THOMAS G
                                         ARIZONA STATE UNIVERSITY
                                         ROBOTIC SPRING ANKLE FOR GAIT
                                          ASSISTANCE
                                         SHINOWARA, NANCY
1R21HD052197-01A1......................  LEWIS, GWYN N
                                         REHABILITATION INSTITUTE OF
                                          CHICAGO
                                         THE UTILITY OF RTMS TO ENHANCE
                                          HAND FUNCTION IN STROKE
                                         NITKIN, RALPH M
1R21HD053669-01........................  ENGLISH, ARTHUR W
                                         EMORY UNIVERSITY
                                         PROTEOGLYCAN DEGRADATION AND
                                          FUNCTIONAL RECOVERY AFTER
                                          PERIPHERAL NERVE INJURY
                                         NITKIN, RALPH M
5R21HD045841-03........................  WARE, JOHN E
                                         UALITYMETRIC, INC.
                                         DYNAMIC ASSESSMENT OF PEDIATRIC
                                          HEALTH AND FUNCTIONING
                                         QUATRANO, LOUIS A
5R21HD045855-03........................  GRAY, DAVID B
                                         WASHINGTON UNIVERSITY
                                         REHABILITATION OUTCOMES,
                                          COMMUNITY PARTICIPATION AND
                                          ICF
                                         QUATRANO, LOUIS A
5R21HD045864-03........................  SATISH, USHA G
                                         UPSTATE MEDICAL UNIVERSITY
                                         SIMULATION BASED MAPPING OF
                                          DECISION MAKING IN CHILDREN
                                         QUATRANO, LOUIS A
5R21HD045869-03........................  VELOZO, CRAIG A
                                         UNIVERSITY OF FLORIDA
                                         DEVELOPING A COMPUTER ADAPTIVE
                                          TBI COGNITIVE MEASURE
                                         QUATRANO, LOUIS A
5R21HD045873-03........................  BONATO, PAOLO
                                         SPAULDING REHABILITATION
                                          HOSPITAL
                                         FIELD MEASURES OF FUNCTIONAL
                                          TASKS FOR CIT INTERVENTION
                                         QUATRANO, LOUIS A
5R21HD045881-03........................  STINEMAN, MARGARET G
                                         UNIVERSITY OF PENNSYLVANIA
                                         VIRTUAL RECOVERY SIMULATION
                                         QUATRANO, LOUIS A
5R21HD045882-03........................  YORKSTON, KATHRYN M
                                         UNIVERSITY OF WASHINGTON
                                         DEVELOPING A SCORE OF
                                          COMMUNICATIVE PARTICIPATION
                                         QUATRANO, LOUIS A
5R21HD045887-03........................  RILEY, BARTH B
                                         UNIVERSITY OF ILLINOIS AT
                                          CHICAGO
                                         A DYNAMIC DISABILITY SPECIFIC
                                          PHYSICAL ACTIVITY SCALE
                                         QUATRANO, LOUIS A
5R21HD046540-02........................  LEVY, CHARLES E
                                         UNIVERSITY OF FLORIDA
                                         THE IMPACT OF POWER-ASSIST
                                          WHEELCHAIR ON QOL
                                         QUATRANO, LOUIS A
5R21HD046844-02........................  MAKHSOUS, MOHSEN
                                         REHABILITATION INSTITUTE OF
                                          CHICAGO
                                         PRESSURE RELIEF SYSTEM FOR
                                          PREVENTING PRESSURE ULCERS
                                         QUATRANO, LOUIS A
5R21HD046876-02........................  HORNBY, T GEORGE
                                         REHABILITATION INSTITUTE OF
                                          CHICAGO
                                         PHYSICAL AND PHARMACOLOGICAL
                                          EFFECTS ON MOVEMENT IN SCI
                                         SHINOWARA, NANCY
5R21HD046903-02........................  SAPIENZA, CHRISTINE M
                                         UNIVERSITY OF FLORIDA
                                         EXPIRATORY MUSCLE TRAINING IN
                                          PATIENTS WITH PARKINSON'S
                                         SHINOWARA, NANCY
5R21HD046938-02........................  MOSES, PAMELA A
                                         UNIVERSITY OF CALIFORNIA SAN
                                          DIEGO
                                         WHITE MATTER DIFFUSION MRI IN
                                          CHILDREN WITH EARLY STROKE
                                         ANSEL, BETH
5R21HD047263-02........................  COHEN, LINDSEY L
                                         GEORGIA STATE UNIVERSITY
                                         AUTOMATED TRAINING FOR
                                          PEDIATRIC PAIN MANAGEMENT
                                         QUATRANO, LOUIS A
5R21HD047463-02........................  THOMAS, NEAL J
                                         PENNSYLVANIA STATE UNIV HERSHEY
                                          MED CTR
                                         SURFACTANT PROTEIN VARIANTS IN
                                          PEDIATRIC LUNG INJURY
                                         NICHOLSON, CAROL E
5R21HD047643-02........................  HERMANN, GERLINDA E
                                         LSU PENNINGTON BIOMEDICAL
                                          RESEARCH CTR
                                         THROMBIN AND CNS: GASTRIC
                                          DYSFUNCTION AFTER HEAD TRAUMA
                                         ANSEL, BETH
5R21HD047754-02........................  FRIED-OKEN, MELANIE
                                         OREGON HEALTH & SCIENCE
                                          UNIVERSITY
                                         AAC REHABILITATION FOR
                                          CONVERSATION IN DEMENTIA
                                         ANSEL, BETH
5R21HD048566-02........................  VALERO-CUEVAS, FRANCISCO J
                                         CORNELL UNIVERSITY ITHACA
                                         DEVELOPING A CLINICALLY USEFUL
                                          MEASURE OF DYNAMIC PINCH
                                         QUATRANO, LOUIS A
5R21HD048742-02........................  MORGAN, DON W
                                         MIDDLE TENNESSEE STATE
                                          UNIVERSITY
                                         UNDERWATER TREADMILL TRAINING
                                          IN SPASTIC DIPLEGIA
                                         SHINOWARA, NANCY
5R21HD048944-02........................  DAMIANO, DIANE L
                                         WASHINGTON UNIVERSITY
                                         EFFECTS OF MOTOR-ASSISTED
                                          CYCLING IN CEREBRAL PALSY
                                         SHINOWARA, NANCY
5R21HD048972-02........................  HASTINGS, MARY K
                                         WASHINGTON UNIVERSITY
                                         BOTULINUM TOXIN EFFECTS ON
                                          PLANTAR ULCER RECURRENCE
                                         QUATRANO, LOUIS A
5R21HD049019-03........................  WITTENBERG, GEORGE
                                         UNIVERSITY OF MARYLAND BALT
                                          PROF SCHOOL
                                         MOTOR-FUNCTIONAL NEUROANATOMY
                                          IN CEREBRAL PALSY
                                         NICHOLSON, CAROL E
5R21HD049020-02........................  GIORDANO, LOUIS A
                                         DUKE UNIVERSITY
                                         BEHAVIOR ANALYSIS OF CHRONIC
                                          LOW BACK PAIN
                                         QUATRANO, LOUIS A
5R21HD049135-02........................  CHASE, THERESA M
                                         CRAIG HOSPITAL
                                         MASSAGE TO REDUCE PAIN IN
                                          PEOPLE WITH SPINAL CORD INJURY
                                         SHINOWARA, NANCY
5R21HD049662-02........................  VAN DEN BOGERT, ANTONIE J
                                         CLEVELAND CLINIC LERNER COL/MED-
                                          CWRU
                                         INTELLIGENT CONTROL OF UPPER
                                          EXTREMITY NEURAL PROSTHESES
                                         QUATRANO, LOUIS A
5R21HD049832-02........................  VAVILALA, MONICA S
                                         CHILDREN'S HOSPITAL AND REG
                                          MEDICAL CTR
                                         CEREBRAL EDEMA IN PEDIATRIC
                                          DIABETIC KETOACIDOSIS
                                         NICHOLSON, CAROL E
5R21HD049883-02........................  LEWIS, GWYN N
                                         REHABILITATION INSTITUTE OF
                                          CHICAGO
                                         BILATERAL ACTIVATION IN UPPER-
                                          LIMB STROKE REHABILITATION
                                         ANSEL, BETH
5R21HD049893-02........................  WANG, JIONGJIONG
                                         UNIVERSITY OF PENNSYLVANIA
                                         HEMODYNAMIC NEUROIMAGING OF
                                          PEDIATRIC STROKE
                                         NICHOLSON, CAROL E
5R21HD050655-02........................  ODDSSON, LARS I E
                                         BOSTON UNIVERSITY
                                         TREATMENT OF MOTOR FUNCTION AND
                                          BALANCE- A NEW TOOL
                                         SHINOWARA, NANCY
5R21HD050707-02........................  MATHERN, GARY W
                                         UNIVERSITY OF CALIFORNIA LOS
                                          ANGELES
                                         CORTICAL PLASTICITY AFTER
                                          HEMISPHERECTOMY
                                         NITKIN, RALPH M
7R21HD046938-03........................  MOSES, PAMELA A
                                         SAN DIEGO STATE UNIVERSITY
                                         WHITE MATTER DIFFUSION MRI IN
                                          CHILDREN WITH EARLY STROKE
                                         ANSEL, BETH
 
R24--Resource-Related Research
 Projects:.
 
5R24HD050821-02........................  RYMER, WILLIAM Z
                                         REHABILITATION INSTITUTE OF
                                          CHICAGO
                                         ENGINEERING FOR NEUROLOGIC
                                          REHABILITATION
                                         NITKIN, RALPH M
5R24HD050836-02........................  WHYTE, JOHN
                                         ALBERT EINSTEIN HEALTHCARE
                                          NETWORK
                                         RESEARCH METHODS FOR COGNITIVE
                                          REHABILITATION
                                         NITKIN, RALPH M
5R24HD050837-02........................  LIEBER, RICHARD L
                                         UNIVERSITY OF CALIFORNIA SAN
                                          DIEGO
                                         NATIONAL CENTER FOR MUSCLE
                                          REHABILITATION RESEARCH
                                         NITKIN, RALPH M
5R24HD050838-02........................  SELZER, MICHAEL E
                                         UNIVERSITY OF PENNSYLVANIA
                                         CENTER FOR EXPERIMENTAL
                                          NEUROREHABILITATION TRAINING
                                         NITKIN, RALPH M
5R24HD050845-02........................  BREGMAN, BARBARA S
                                         GEORGETOWN UNIVERSITY
                                         NATIONAL CAPITAL AREA
                                          REHIBILIATION RESEARCH NETWORK
                                         NITKIN, RALPH M
5R24HD050846-02........................  HOFFMAN, ERIC P
                                         CHILDREN'S RESEARCH INSTITUTE
                                         INTEGRATED MOLECULAR CORE FOR
                                          REHABILITATION MEDICINE
                                         NITKIN, RALPH M
R34--Clinical Trial Planning Grant:
1R34HD050531-01A1......................  MOLER, FRANK W
                                         UNIVERSITY OF MICHIGAN AT ANN
                                          ARBOR
                                         PLANNING HYPOTHERMIA TRIAL FOR
                                          PEDIATRIC CARDIAC ARREST
                                         NICHOLSON, CAROL E
 
R37--Method to Extend Research in Time
 (MERIT) Award:
 
5R37HD031550-25........................  GOSHGARIAN, HARRY G
                                         WAYNE STATE UNIVERSITY
                                         FUNCTIONAL PLASTICITY IN THE
                                          MAMMALIAN SPINAL CORD
                                         NITKIN, RALPH M
5R37HD037100-08........................  OLNEY, JOHN W
                                         WASHINGTON UNIVERSITY
                                         ACUTE BRAIN INJURY, MECHANISMS
                                          AND CONSEQUENCES
                                         NITKIN, RALPH M
 
R41--Small Business Technology Transfer
 (STTR) Grants--Phase I:
 
1R41HD052318-01A1......................  HALEY, STEPHEN M
                                         CRECARE, LLC
                                         COMPUTER ADAPTIVE TESTING OF
                                          PEDIATRIC SELF-CARE AND SOCIAL
                                          FUNCTION
                                         QUATRANO, LOUIS A
5R41HD047726-02........................  BARBOUR, RANDALL LOCKE
                                         PHOTON MIGRATION TECHNOLOGIES
                                          CORP
                                         OPTICAL TOMOGRAPHY FOR
                                          DIAGNOSIS OF NEC
                                         NICHOLSON, CAROL E
5R41HD049224-02........................  RIMMER, JAMES H
                                         EXERSTRIDER PRODUCTS, INC.
                                         UNIVERSAL EXERCISE KITS FOR
                                          MANUAL WHEELCHAIR USERS
                                         SHINOWARA, NANCY
R42-- Small Business Technology
 Transfer (STTR) Grants--Phase II:
4R42HD051240-02........................  PESHKIN, MICHAEL A
                                         CHICAGO PT, LLC
                                         DEVICE FOR OVERGROUND GAIT/
                                          BALANCE TRAINING POST-STROKE
                                         SHINOWARA, NANCY
5R42HD043664-03........................  ZHANG, LI-QUN
                                         REHABTEK, LLC
                                         DEVELOPING AN INTELLIGENT &
                                          PORTABLE STRETCHING DEVICE
                                         SHINOWARA, NANCY
 
R43--Small Business Innovation Research
 Grants (SBIR)--Phase I:
 
1R43HD047493-01A2......................  PITKIN, MARK R
                                         POLY-ORTH INTERNATIONAL
                                         NEW IIZAROV TECHNIQUE FOR
                                          PEDIATRIC CRITICAL CARE
                                         NICHOLSON, CAROL E
1R43HD049211-01A1......................  GOLDIE, JAMES H
                                         INFOSCITEX CORPORATION
                                         ROBOTICALLY-AIDED HAND
                                          REHABILITATION
                                         QUATRANO, LOUIS A
1R43HD049960-01A1......................  THROPE, GEOFFREY B
                                         NDI MEDICAL, LLC
                                         NEUROSTIMULATION FOR ELBOW
                                          EXTENSION IN TETRAPLEGIA
                                         SHINOWARA, NANCY
1R43HD050006-01A1......................  HARTMAN, ERIC C
                                         CUSTOMKYNETICS, INC.
                                         STIMULATION-AUGMENTED EXERCISE
                                          AND NEUROMOTOR THERAPY
                                         SHINOWARA, NANCY
1R43HD051014-01A1......................  GREELEY, HAROLD P
                                         CREARE, INC.
                                         PHYSICAL ACTIVITY MONITOR
                                         QUATRANO, LOUIS A
1R43HD052310-01........................  SCHERER, MARCIA J
                                         INSTITUTE/MATCHING PERSON &
                                          TECHNOLOGY
                                         IMPROVING MATCH OF PERSON/
                                          ASSISTIVE COGNITIVE TECHNOLOGY
                                         QUATRANO, LOUIS A
1R43HD052311-01........................  RICHTER, W MARK
                                         MAX MOBILITY
                                         OPTIPUSH WHEELCHAIR TRAINING
                                          SYSTEM
                                         SHINOWARA, NANCY
1R43HD052313-01........................  VEATCH, BRADLEY D
                                         ADA TECHNOLOGIES, INC.
                                         A BIOACTUATOR-DRIVEN ANKLE
                                          DORSIFLEXOR UNIT
                                         QUATRANO, LOUIS A
1R43HD052327-01........................  TOWNSEND, WILLIAM T
                                         BARRETT TECHNOLOGY, INC.
                                         ADVANCED ROBOTIC DEVICE FOR THE
                                          SAFE REHABILITATION FOR STROKE
                                          AND BRAIN INJURY
                                         QUATRANO, LOUIS A
1R43HD053196-01........................  HERMES, MATTHEW E
                                         TURBO WHEELCHAIR COMPANY, INC.
                                         LIGHTWEIGHT, COMPLIANT MANUAL
                                          WHEELCHAIR HIGH-TONE CHILD
                                         SHINOWARA, NANCY
1R43HD053211-01........................  SCHAEFER, PHILIP R
                                         VORTANT TECHNOLOGIES, LLC
                                         A LIP READING CLICK DEVICE FOR
                                          DISABLED COMPUTER USERS
                                         SHINOWARA, NANCY
1R43HD054091-01........................  VEATCH, BRADLEY D
                                         ADA TECHNOLOGIES, INC.
                                         A LOW-COST UPPER-EXTREMITY
                                          PROSTHESIS FOR UNDER-SERVED
                                          POPULATIONS
                                         QUATRANO, LOUIS A
1R43HD054262-01........................  SELBIE, W. SCOTT
                                         C-MOTION, INC.
                                         ANALYTICAL TOOLS FOR OPTIMIZING
                                          NEUROREHABILITATION OF GAIT
                                         SHINOWARA, NANCY
1R43HD054313-01........................  EDELL, DAVID J
                                         INNERSEA TECHNOLOGY
                                         ULTRA-LOW-POWER WIRELESS
                                          IMPLANT STIMULATOR FOR
                                          PROSTHESIS SENSORY FEEDBACK
                                         QUATRANO, LOUIS A
1R43HD055110-01A1......................  FLYNN, LOUIS L
                                         LIGHTNING PACKS, LLC GENERATION
                                          OF ELECTRICITY BY NORMAL HUMAN
                                          MOVEMENT
                                         SHINOWARA, NANCY
5R43HD044271-02........................  GREEN, STEVE C
                                         GREEN TECHNOLOGIES, INC.
                                         A MANUAL STANDUP WHEELCHAIR
                                         QUATRANO, LOUIS A
5R43HD047071-02........................  AXELSON, PETER WILLIAM
                                         BENEFICIAL DESIGNS, INC.
                                         OPTIFIT WHEELCHAIR FITTING
                                          SYSTEM
                                         SHINOWARA, NANCY
5R43HD047086-02........................  GIUFFRIDA, JOSEPH P
                                         LEVELAND MEDICAL DEVICES, INC.
                                         ADAPATIVE WIRELESS COMPUTER
                                          MOUSE FOR MOVEMENT DISORDERS
                                         SHINOWARA, NANCY
5R43HD049251-02........................  MERZENICH, MICHAEL M
                                         POSIT SCIENCE CORPORATION
                                         BRAIN PLASTICITY BASED TRAINING
                                          FOR FOCAL DYSTONIA
                                         SHINOWARA, NANCY
5R43HD051061-02........................  RENSING, NOA M
                                         MICROOPTICAL ENGINEERING
                                          CORPORATION
                                         VISIONKEY+: ADVANCED EYE
                                          ACTIVATED KEYBOARD
                                         QUATRANO, LOUIS A
8R43HD054291-02........................  RIFKIN, JEROME R
                                         TENSEGRITY PROSTHETICS, INC.
                                         TENSEGRITY FOOT WITH
                                          COORDINATED JOINT MOTION
                                         SHINOWARA, NANCY
 
R44--Small Business Innovation Research
 Grants (SBIR)--Phase II:
 
1R44HD050047-01A1......................  TUEL, STEPHEN M
                                         PHASE V PHARMACEUTICALS, INC.
                                         TIZANIDINE FORMULATION FOR
                                          SPASTICITY WITH DYSPHAGIA
                                         QUATRANO, LOUIS A
1R44HD053176-01........................  JAKOBS, THOMAS
                                         INVOTEK, INC.
                                         RELIABLE/SAFE LASER POINTING-
                                          PEOPLE LOCKED-IN SYNDROME
                                         QUATRANO, LOUIS A
1R44HD054401-01........................  RICHTER, W MARK
                                         MAX MOBILITY
                                         ERGOCHAIR SMART MANUAL
                                          WHEELCHAIR
                                         SHINOWARA, NANCY
2R44HD037776-02A1......................  HAMILTON, PATRICK
                                         S.E.P., LTD
                                         AN AMBULATORY LORDOSIMETER FOR
                                          POSTURE CONTROL
                                         QUATRANO, LOUIS A
2R44HD040023-02A2......................  LOPRESTI, EDMUND F
                                         AT SCIENCES
                                         SMART WHEELCHAIR COMPONENT
                                          SYSTEM
                                         QUATRANO, LOUIS A
2R44HD042334-02........................  BENJAMIN, MALVERN J
                                         RHEOMEDIX, INC.
                                         PULMONARY AIRFLOW MONITOR IN
                                          TRACHEOSTOMIZED CHILDREN
                                         QUATRANO, LOUIS A
2R44HD046319-02........................  KLEDARAS, JOANNE B
                                         PRAXIS, INC.
                                         MONETARY EQUIVALENCE: READINESS
                                          INSTRUCTIONAL TRACK (PHASE II)
                                         QUATRANO, LOUIS A
2R44HD047044-02........................  JAKOBS, THOMAS
                                         INVOTEK, INC.
                                         SPEECH SUPPLEMENTED WORD
                                          PREDICTION PROGRAM
                                         QUATRANO, LOUIS A
2R44HD049205-02........................  KYLSTRA, BART
                                         DAEDALUS WINGS, INC.
                                         POWER PROPULSION ATTACHMENT FOR
                                          MANUAL WHEELCHAIRS
                                         SHINOWARA, NANCY
5R44HD033942-05........................  WYATT, CATHERINE
                                         MEALTIME PARTNERS, INC.
                                         ADD REGULATORY COMPLIANCE AND
                                          COST (REV A)
                                         QUATRANO, LOUIS A
5R44HD035793-06........................  MEGINNISS, STEVE M
                                         MAGIC WHEELS, INC.
                                         TWO-SPEED MANUAL WHEELCHAIR
                                          WHEEL
                                         QUATRANO, LOUIS A
5R44HD039962-03........................  BONINGER, RONALD M
                                         THREE RIVERS HOLDINGS, LLC
                                         DEVELOPMENT OF AN ERGONOMIC
                                          MANUAL WHEELCHAIR PUSHRIM
                                         QUATRANO, LOUIS A
5R44HD041805-03........................  KOENEMAN, JAMES B
                                         KINETIC MUSCLES, INC.
                                         CLINICAL ASSESSMENT OF A MASSED
                                          PRACTICE THERAPY DEVICE
                                         SHINOWARA, NANCY
5R44HD041820-04........................  HARTMAN, ERIC C
                                         CUSTOMKYNETICS, INC.
                                         ADAPTIVE STIMULATOR FOR
                                          EXERCISE AND REHABILITATION
                                         QUATRANO, LOUIS A
5R44HD042367-03........................  VAIDYANATHAN, RAVI
                                         THINK-A-MOVE, LTD
                                         AN EAR DEVICE ENABLING HANDS
                                          FREE WHEELCHAIR CONTROL
                                         QUATRANO, LOUIS A
5R44HD042892-03........................  IRVINE, BLAIR
                                         OREGON CENTER FOR APPLIED
                                          SCIENCE, INC.
                                         TRAINING PARENTS TO ADVOCATE
                                          FOR STUDENTS WITH TBI
                                         QUATRANO, LOUIS A
5R44HD043513-03........................  SEARS, HAROLD H
                                         MOTION CONTROL, INC.
                                         ELECTRIC HEAVY-DUTY WORK HAND
                                         QUATRANO, LOUIS A
5R44HD043516-03........................  GREEN, STEVE C
                                         GREEN TECHNOLOGIES, INC.
                                         A MODAL RECIPROCATING PUSHRIM
                                          DRIVE WHEELCHAIR
                                         QUATRANO, LOUIS A
5R44HD043567-03........................  KYLSTRA, BART
                                         DAEDALUS WINGS, INC.
                                         MANUAL WHEELCHAIR UTILIZING
                                          SINGLE LEVER FOR PROPULSION
                                         SHINOWARA, NANCY
5R44HD044288-03........................  BEHRMANN, GREGORY P
                                         EM PHOTONICS, INC.
                                         FIBER OPTICAL MICRO-SENSOR FOR
                                          MEASURING TENDON FORCES
                                         QUATRANO, LOUIS A
5R44HD047119-03........................  BOONE, DAVID A
                                         CYMA CORPORATION
                                         COMPUTERIZED PROSTHETIC
                                          ALIGNMENT SYSTEM (COMPAS)
                                         QUATRANO, LOUIS A
5R44HD049252-03........................  TUEL, STEPHEN M
                                         PHASE V PHARMACEUTICALS, INC.
                                         BACLOFEN FORMULATION FOR
                                          SPASTICITY WITH DYSPHAGIA
                                         QUATRANO, LOUIS A
5R44HD051157-03........................  GOODWIN, DIANNE M
                                         BLUE SKY DESIGN, INC.
                                         ACCESSIBLE MOUNTING AND
                                          POSITIONING TECHNOLOGY
                                         SHINOWARA, NANCY
 
T15--Continuing Education Training
 Program:
 
1T15HD050255-01A1......................  BLACKMAN, JAMES A
                                         UNIVERSITY OF VIRGINIA
                                          CHARLOTTESVILLE
                                         NIH GRANT PREP. WORKSHOPS FOR
                                          REHABILITATION RESEARCH
                                         NITKIN, RALPH M
 
T32--Institutional National Research
 Service Award:
 
1T32HD049303-01A1......................  FINEMAN, JEFFREY R
                                         UNIVERSITY OF CALIFORNIA SAN
                                          FRANCISCO
                                         RESEARCH TRAINING IN PEDIATRIC
                                          CRITICAL CARE MEDICINE
                                         NICHOLSON, CAROL E
1T32HD049350-01A1......................  LEVIN, HARVEY S
                                         BAYLOR COLLEGE OF MEDICINE
                                         MENTORED RESEARCH TRAINING IN
                                          REHABILITATION SCIENCE
                                         NITKIN, RALPH M
2T32HD007422-16........................  TATE, DENISE G
                                         UNIVERSITY OF MICHIGAN AT ANN
                                          ARBOR
                                         U MICHIGAN MED REHABILITATION
                                          RESEARCH TRAINING PROGRAM
                                         NITKIN, RALPH M
2T32HD007539-06........................  OTTENBACHER, KENNETH J
                                         UNIVERSITY OF TEXAS MEDICAL BR
                                          GALVESTON
                                         INTERDISCIPLINARY PREDOCTORAL
                                          REHABILITATION RESEARCH
                                          TRAINING
                                         NITKIN, RALPH M
2T32HD040686-06A1......................  KOCHANEK, PATRICK M
                                         UNIVERSITY OF PITTSBURGH AT
                                          PITTSBURGH
                                         PEDIATRIC NEUROINTENSIVE CARE
                                          AND RESUSCITATION RESEARCH
                                         NICHOLSON, CAROL E
5T32HD007414-14........................  JOHNSTON, MICHAEL V
                                         KENNEDY KRIEGER RESEARCH
                                          INSTITUTE, INC.
                                         RESEARCH TRAINING IN BRAIN
                                          INJURY REHABILITATION
                                         NITKIN, RALPH M
5T32HD007418-15........................  RYMER, WILLIAM Z
                                         NORTHWESTERN UNIVERSITY
                                         PATHOPHYSIOLOGY AND
                                          REHABILITATION OF NEURAL
                                          DYSFUNCTION
                                         NITKIN, RALPH M
5T32HD007425-15........................  SALCIDO, RICHARD
                                         UNIVERSITY OF PENNSYLVANIA
                                         RESEARCH TRAINING IN
                                          NEUROLOGICAL REHABILITATION
                                         NITKIN, RALPH M
5T32HD007434-14........................  MUELLER, MICHAEL J
                                         WASHINGTON UNIVERSITY
                                         DOCTORAL TRAINING PROGRAM IN
                                          MOVEMENT SCIENCE
                                         NITKIN, RALPH M
5T32HD007447-14........................  BASFORD, JEFFREY R
                                         MAYO CLINIC COLL OF MEDICINE,
                                          ROCHESTER
                                         MAYO REHABILITATION RESEARCH
                                          TRAINING CENTER
                                         NITKIN, RALPH M
5T32HD007459-13........................  BREGMAN, BARBARA S
                                         GEORGETOWN UNIVERSITY
                                         TRAINING IN RECOVERY OF
                                          FUNCTION AFTER CNS INJURY
                                         NITKIN, RALPH M
5T32HD007490-09........................  BINDER-MACLEOD, STUART A.
                                         UNIVERSITY OF DELAWARE
                                         PT/PHD PREDOCTORAL TRAINING
                                          PROGRAM
                                         NITKIN, RALPH M
5T32HD041899-04........................  RODGERS, MARY M
                                         UNIVERSITY OF MARYLAND BALT
                                          PROF SCHOOL
                                         ADVANCE REHABILITATION RESEARCH
                                          TRAINING PROJECT
                                         NITKIN, RALPH M
5T32HD043730-04........................  VANDENBORNE, KRISTA H
                                         UNIVERSITY OF FLORIDA
                                         TRAINING IN REHABILITATION AND
                                          NEUROMUSCULAR PLASTICITY
                                         NITKIN, RALPH M
 
U01--Research Project (Cooperative
 Agreements):
 
3U01AR052171-02S1......................  AMTMANN, DAGMAR
                                         UNIVERSITY OF WASHINGTON
                                         UW CENTER ON OUTCOMES RESEARCH
                                          IN REHABILITATION (RMI)
                                         QUATRANO, LOUIS A
5U01AR052171-03........................  AMTMANN, DAGMAR
                                         UNIVERSITY OF WASHINGTON
                                         UW CENTER ON OUTCOMES RESEARCH
                                          IN REHABILITATION(RMI)
                                         QUATRANO, LOUIS A
5U01HD042652-04........................  DIAZ-ARRASTIA, RAMON R
                                         UNIVERSITY OF TEXAS SW MED CTR/
                                          DALLAS
                                         TRAUMATIC BRAIN INJURY CLINICAL
                                          TRIALS NETWORK
                                         ANSEL, BETH
5U01HD042653-05........................  TEMKIN, NANCY R
                                         UNIVERSITY OF WASHINGTON
                                         TRAUMATIC BRAIN INJURY CLINICAL
                                          TRIALS NETWORK
                                         ANSEL, BETH
5U01HD042678-05........................  ZAFONTE, ROSS
                                         UNIVERSITY OF PITTSBURGH AT
                                          PITTSBURGH
                                         TRAUMATIC BRAIN INJURY CLINICAL
                                          TRIALS NETWORK
                                         ANSEL, BETH
5U01HD042686-04........................  TIMMONS, SHELLY D
                                         UNIVERSITY OF TENNESSEE HEALTH
                                          SCI CTR
                                         TRAUMATIC BRAIN INJURY CLINICAL
                                          TRIALS NETWORK
                                         ANSEL, BETH
5U01HD042687-05........................  NOVACK, THOMAS
                                         UNIVERSITY OF ALABAMA AT
                                          BIRMINGHAM
                                         TRAUMATIC BRAIN INJURY CLINICAL
                                          TRIALS NETWORK
                                         ANSEL, BETH
5U01HD042689-05........................  BULLOCK, M ROSS
                                         VIRGINIA COMMONWEALTH
                                          UNIVERSITY
                                         TRAUMATIC BRAIN INJURY CLINICAL
                                          TRIALS NETWORK
                                         ANSEL, BETH
5U01HD042736-04........................  EISENBERG, HOWARD M.
                                         UNIVERSITY OF MARYLAND BALT
                                          PROF SCHOOL
                                         TRAUMATIC BRAIN INJURY CLINICAL
                                          TRIALS NETWORK
                                         ANSEL, BETH
5U01HD042738-05........................  JALLO, JACK
                                         TEMPLE UNIVERSITY
                                         TRAUMATIC BRAIN INJURY CLINICAL
                                          TRIALS NETWORK
                                         ANSEL, BETH
5U01HD042823-05........................  RIEDEWALD, WILLIAM T
                                         COLUMBIA UNIVERSITY
                                         HEALTH SCIENCES
                                         TRAUMATIC BRAIN INJURY CLINICAL
                                          TRIALS NETWORK-DCC
                                         ANSEL, BETH
5U01HD049934-02........................  DEAN, JONATHAN MICHAEL
                                         UNIVERSITY OF UTAH
                                         CENTRAL DATA MANAGEMENT AND
                                          COORDINATING CENTER
                                         NICHOLSON, CAROL E
 
U10--Cooperative Clinical Research
 (Cooperative Agreements):
 
5U10HD049945-02........................  ZIMMERMAN, JERRY J
                                         CHILDREN'S HOSPITAL AND REG
                                          MEDICAL CTR
                                         1ST TIER DRUGS+THEOPHYLLINE IN
                                          PEDIATRIC SEVERE ASTHMA
                                         NICHOLSON, CAROL E
5U10HD049981-02........................  POLLACK, MURRAY M
                                         CHILDREN'S RESEARCH INSTITUTE
                                         ASSESSMENT AND PREDICTION OF
                                          FUNCTIONAL STATUS
                                         NICHOLSON, CAROL E
5U10HD049983-02........................  CARCILLO, JOSEPH A
                                         UNIVERSITY OF PITTSBURGH AT
                                          PITTSBURGH
                                         METOCLOPRAMIDE PREVENTS PICU
                                          NOSOCOMIAL INFECTION
                                         NICHOLSON, CAROL E
5U10HD050009-02........................  ANAND, KANWALJEET S
                                         ARKANSAS CHILDREN'S HOSPITAL
                                          RES INST
                                         PCCM NETWORK: REMEDIES FOR
                                          OPIOID TOLERANCE & WITHDRAWAL
                                         NICHOLSON, CAROL E
5U10HD050012-02........................  NEWTH, CHRISTOPHER J
                                         CHILDREN'S HOSPITAL LOS ANGELES
                                         PHYSIOLOGICALLY GUIDED
                                          VENTILATOR STRATEGIES IN
                                          CHILDREN
                                         NICHOLSON, CAROL E
5U10HD050096-02........................  MEERT, KATHLEEN L
                                         WAYNE STATE UNIVERSITY
                                         COLLABORATIVE PEDIATRIC
                                          CRITICAL CARE RESEARCH NETWORK
                                         NICHOLSON, CAROLE
 
U13--Conference (Cooperative
 Agreement):
 
5U13NS043180-05........................  SANGER, TERENCE D
                                         STANFORD UNIVERSITY
                                         NIH TASK FORCE ON CHILDHOOD
                                          MOTOR DISORDERS
                                         ANSEL, BETH
------------------------------------------------------------------------


    Question 2. What would be the key components for a successful 
collaboration with the VA?
    Response. I recommend creating an enduring administrative structure 
for ongoing collaboration. A Coordinating Council should be established 
and staffed by the VA, and include representation from the DOD and the 
organizations that represent the civilian rehabilitation hospitals and 
the specialty of Physical Medicine and Rehabilitation. At a minimum, 
the American Medical Rehabilitation Providers Association (AMRPA), the 
American Hospital Association (AHA), the Federation of American 
Hospitals (FAH), and the American Academy of Physical Medicine and 
Rehabilitation (AAPM&R) should be invited to participate. The charge to 
this Council should include the following:

     Work collaboratively to create a short-term and long-term 
sustainable plan for how to allow the civilian provider community to 
augment, strengthen, and complement the DOD and VA in providing medical 
rehabilitation services (both inpatient and outpatient) to current and 
former members of the armed services who qualify.
     Establish attributes and criteria to define rehabilitation 
service delivery capacity (both qualitatively and quantitatively) for 
specific disabling conditions, including, but not limited to:

       TBI
       SCI
       Amputation
       Burn
       Low Vision
       Hearing Impairment
       Post Traumatic Stress Disorder (PTSD)

     Determine the DOD, VA, and civilian care delivery settings 
that are capable of providing services that meet or exceed these 
criteria.
     Establish the relative locations of VA and civilian 
programs, with the hope of identifying locations where collaboration 
might be possible, and where the civilian sector could broaden access 
for servicemembers.
     Define which areas of the VA and DOD need enhancement 
through cooperating with civilian providers.
     Create or adopt a qualifying and contracting methodology 
to allow civilian providers to contract with the DOD and/or VA.
     Identify the appropriate payment methods and practices to 
utilize the civilian providers and provide adequate and timely 
reimbursement for the services they offer.
     Establish the research questions and activities needed to 
better understand the rehabilitation care delivery needs of these 
servicemembers, and how to improve the efficiency and effectiveness of 
the collaboration to achieving more successful outcomes.
     Oversee the implementation and operation of the 
collaboration and refine it over time as appropriate.

    Question 3. What difference in care and support do you anticipate 
in serving returning veterans, rather than the Institute's existing 
patients? Would your facilities have the expertise to also deal with 
TBI, PTSD, or other unique health and readjustment issues for returning 
veterans?
    Response. Kessler Institute for Rehabilitation currently provides 
comprehensive care and treatment for patients who are identical to 
those being injured in our country's service. Our multidisciplinary 
team includes:

     Physiatrists and Neurologists, who are expert at 
diagnosing and treating the behavioral, cognitive and medical problems 
these patients face.
     Neuropsychologists to assess, treat and support brain 
injured patients and their families.
     Rehabilitation Psychologists, who can assess and treat 
PTSD, substance abuse, adjustment to disability and the other common 
psychological problems associated with health catastrophes.
     Rehabilitation Nurses, who can manage wound care, provide 
bladder and bowel retraining, contribute to restoring function for real 
world application, and provide patient and family education.
     Physical Therapists, Occupational Therapists, Speech 
Language Pathologists and many other disciplines to effectively address 
the range of physical and functional problems individuals face, as well 
as goals to be achieved.
     Prosthetists and Orthotists to provide prostheses and 
orthoses, including C-legs and other state-of-the-art devices.
     Rehabilitation Technologists to provide sophisticated 
power wheelchairs, electronic environmental control systems, computer 
access and other high tech devices that are needed by the most severely 
injured and disabled.

    Our West Orange campus has the current capacity to care for 48 TBI 
inpatients and 48 SCI inpatients at any given time. Our outpatient 
programs include therapies by all the disciplines mentioned above, as 
well as a specialized Cognitive Rehabilitation Program that provides 
individually tailored, multidisciplinary care for patients with TBI 
scheduled a few times a week or as intensively as a day hospital, 
depending on needs and goals. We offer similar services at our Saddle 
Brook and Chester campuses as well.
    We operate two additional programs of special interest: a program 
for Severe Disorders of Consciousness (SDOC), and a dual-diagnosis 
program for patients with concomitant TBI and SCI. The SDOC program 
offers highly innovative and advanced evaluative and treatment services 
for the most severely brain injured patients. This program is having a 
remarkable impact on many or our patients. Our dual-diagnosis program 
is also capable of handling other combinations of disabling conditions, 
such as amputations that occur in addition to a TBI.
    In addition to the clinical services we offer, we serve as a major 
research and educational center for TBI, SCI and other rehabilitation 
conditions. For example, with our partners, the Kessler Medical 
Rehabilitation Research and Education Center (KMRREC) and UMDNJ-New 
Jersey Medical School, we are funded as an SCI Model System. We have 
been previously funded as a TBI Model System, and are currently 
reapplying for that award as well.
    These and other resources make the medical and rehabilitation care 
we would provide to injured servicemembers excellent, goal directed, 
and efficient. What would differ from our typical patient experience 
are the insurance, funding and administrative aspects of working with 
the VA or military under whatever contract mechanisms that would be 
developed. We do have experience in working with TRICARE already, so 
that would not be an issue.
    I suspect that all these matters would be favorably accommodated if 
there were an identified case manager from the VA or DOD, who would be 
actively engaged and involved with us in a way that would enable the 
economic and other administrative needs of the patients and their 
families to be dealt with efficiently and effectively.
    I am sure that the capabilities I described of Kessler Institute 
for Rehabilitation are also available at a number of other centers that 
have become specialized in managing the most complexly injured and 
disabled patients. From my conversations with the leadership of many 
rehabilitation programs, I am certain a strong enthusiasm exists to 
offer their capacity to enhance access to care by our servicemembers.

    Chairman Akaka. Thank you very much, Dr. Gans.
    I want to tell you that your testimonies have been 
excellent.
    Director Duckworth, you testified that the prosthetics 
service at Walter Reed is better than VA care, and, Dr. Gans, 
your Institute is consistently ranked as one of the top 
rehabilitation facilities in this country. I would like for 
both of you to comment. What do we need to do to make VA care 
the very best?
    Ms. Duckworth. Senator Akaka, I think for those programs 
that are already in existence in the VA, the polytrauma 
centers, the blind rehabilitation program, the spinal cord 
injury centers that are already state-of-the-art certainly 
maintain, but also give them more funds so that they can really 
reach out and do the job that they are trying to do.
    For those programs where the VA is behind, such as the 
prosthetics program, to try to help them catch up at this 
point, it is too late into the war; it is too late into the 
game. And you would negatively affect the new amputees who are 
within their first 2 years of amputation. Allow those new 
patients to go back to Walter Reed or to go to a civilian 
prosthetist. That way you also maintain the quality of care for 
the veterans already in the system. I cannot really speak as 
much about the rehabilitation programs, but I know that the 
rehab program, the spinal rehab, the blind rehab centers, and 
the polytrauma centers in the VA are certainly state-of-the-art 
and capable of doing the job.
    Chairman Akaka. Dr. Gans?
    Dr. Gans. I think coordination and cooperation is the key. 
Very happily, we had the opportunity to have a conversation 
with the New Jersey VA just last week regarding the traumatic 
brain injury patients and are now starting discussions about 
how we can be useful as a service delivery supplement to their 
resources and how we can cooperate. Many of the VAs are medical 
school facilities. They are training centers. We have all sorts 
of interactions between the civilian community and the VA. And 
we can build upon those strengths to provide educational 
programs, to provide resources, identify where the private 
sector has knowledge and expertise that could be tapped by the 
VA to help build and strengthen programs, where it simply does 
not make sense because the need is to transient, and to let the 
VA contract out with the private sector for specialized 
services. The high-tech kinds of prosthetic devices that are 
being discussed are really very high-end, very complicated, 
sophisticated devices. The military experience has dramatically 
expanded our knowledge and ability about how to use these 
devices in the civilian sector as well, and it is a small 
enough number in the size of the entire health care community 
that that kind of expertise really does need to be concentrated 
in centers of excellence that should be shared resources.
    Chairman Akaka. It seems as though VA is geared toward 
older patients. We are concerned that younger veterans may be 
having difficulties as a minority within the VA system.
    Mr. Pruden and Director Duckworth, have you seen 
improvement in the ability of VA health care providers to treat 
younger patients returning from Iraq and Afghanistan? And do 
you think that VA, on the whole, is now ready to manage this 
younger population? Mr. Pruden?
    Mr. Pruden. Sir, I believe that the VA is doing a lot and 
making a lot of steps toward that goal, but they are not there 
yet.
    I had an infection last spring due to a bacteria that I 
picked up in Iraq called acinetobacter, and when I came back in 
2003, there had not been very many cases of this at all in the 
United States, this particular strain. It has become very 
common now to see it in blast injuries coming back from Iraq 
and Afghanistan. Infectious Disease at Walter Reed is very 
familiar with this problem. But when I went to Infectious 
Disease at the local VA, they had no idea what I was talking 
about. So I brought them printouts from CDC and showed them 
what was going on. Long story short, I wound up coming back to 
Walter Reed and having treatment here for that, a regimen of 
antibiotics. But the Infectious Disease chief down there said, 
``If you had stayed here, we would have had to amputate your 
foot.'' That was my other leg, and I definitely wanted to keep 
that one.
    You know, they are not quite there yet. I think there is a 
lot of information that needs to be grasped, specifically with 
regards to diseases endemic to Central Asia and Iraq, where 
these guys are going to be picking up things, also with regards 
to the types of blast injuries and, again, TBI, PTSD, those 
kinds of things. They need to be more educated and prepared for 
us.
    Chairman Akaka. Thank you.
    Director?
    Ms. Duckworth. Mr. Chairman, I think in some programs the 
VA certainly has state-of-the-art capability, and I would like 
to cite again this spinal cord injury center in Hines and the 
blind rehab center. Those are, in fact, two places where Walter 
Reed sends its patients for rehabilitation, so those are 
certainly up there. Those other programs with information 
sharing such as learning about these bacteria--I also suffer. I 
think about 90 percent of us now have this bacteria. That is an 
easy information-sharing kind of thing. But other things, 
traumatic brain injury, some of these things, the high-tech 
prosthetics, we do not have the time to play catch-up, not when 
the care is needed now with the traumatic brain injury 
patients. As Mrs. Mettie was saying, you lose ground so quickly 
that you may never regain if they do not access that high-
quality care right away. And in those instances, I think a 
cooperative agreement between DOD, VA, and civilian 
practitioners, civilian providers, is critical because when you 
lose ground that early into your injury, you may never regain 
that ground back.
    Chairman Akaka. Thank you. My time in the first round has 
expired.
    Senator Craig?
    Senator Craig. Well, thank you very much, Mr. Chairman.
    I am a little overwhelmed with all of your testimony, and I 
say that in the positive sense, as someone who, in cooperation 
with this Chairman and he with me when I was Chairman, has 
spent a great deal of time attempting to make VA better, and we 
think we have.
    You are saying something that I began to recognize a year 
ago, and it resulted in the introduction of legislation, S. 
815, a few weeks ago. And I think, Tammy, you have said it 
well. There is no time to catch up. There is a huge private 
sector capability out there that is needed now, today. It was 
needed yesterday. And all of you are speaking to that.
    But here is our problem. I did not condemn. I simply 
offered some degree of observation as to what the Ranking 
Member here Patty Murray is doing. That is catch-up money. And 
it may not be well used today in a way that it should be used. 
And I do not say that in any condemnation of the VA at all.
    What we have is a wonderful health care delivery system 
within the VA, but you are speaking of its limitations. And yet 
every organization that is out there in support of it is also 
in defense of it. And when I offer a way for those who cannot 
get the public service, the VA service they need, a way to gain 
the private sector access, I am roundly criticized as someone 
who wants to tear down the current system or not adequately 
fund it. I think quite the opposite.
    Your response to an opportunity to have those who are 
eligible for VA health care to also have, if they are service-
connected disabled, access to selected and/or other private 
facilities, you have all given testimony to it at this moment. 
Your reaction to a piece of legislation that would qualify a 
veteran or an active servicemember for that kind of potential 
health care.
    Ms. Duckworth. Senator Craig, I certainly would support 
that; however, not at the expense of more funds going to the 
VA. I have to respectfully disagree with you that what Senator 
Murray is proposing is catch-up money. It is money that is 
badly needed in the system. At the same time as that funding, 
we also need access to private practices. As I mentioned 
earlier, we have a large generation of Vietnam veterans 
entering the system that we need to be ready to care for them 
as well. So we need both. The VA is already underfunded, and to 
take away those funds that they need to do their job so that 
they can support those state-of-the-art facilities--the blind 
rehab, the spinal cord, taking care of our older veterans--you 
know, it is not an either/or. We need both.
    Senator Craig. Well, you know, I appreciate that. Please go 
ahead, Jonathan.
    Mr. Pruden. Sir, I do not know if I have a good answer for 
you. I agree with Major Duckworth's statement that the VA needs 
more funds to adequately address the needs of veterans 
currently.
    I think great care has to be taken. Like you said, if they 
leave in droves, we will know something else. And I do not 
believe they will leave in droves, either, but if they do--or 
there is a significant number that leave, I guess my question 
is: What happens to VA if a significant number do choose the 
private practice? That would be a concern for me.
    Senator Craig. Yes, please.
    Ms. Mettie. An observation that I have made throughout this 
past year is for the acute care----
    Senator Craig. Just a moment. Mr. Chairman, do we know what 
the noise source is here?
    We are either under construction or destruction.
    [Laughter.]
    Senator Craig. Please continue, and hover close to that 
mike.
    Ms. Mettie. All right. Something I have noticed in the 
acute care is that if there could be an established place for 
these soldiers to go to in the beginning, instead of saying you 
have got to go to a nursing home, we do not know what progress 
they are going to make, and those first 6, 8 months, they make 
tremendous progress. My son had leaps and bounds in April and 
May. He was tapping his toe to music. He would raise his hand 
to anybody who walked in the room. We lost it all in May. 
Nobody knows why.
    So we look at that part and say we need more aggressive 
therapy in the beginning, but also, now that we are a year down 
the road, I look at Palo Alto and previously was told, well, we 
are filled, you cannot get in. Over half of the beds are empty 
because they do not have adequate staff. They do not have 
enough therapists to work with the patients. So how are we 
going to help all of these TBI-injured soldiers if they do not 
have the staff to work with them?
    Senator Craig. Well said. Thank you.
    Doctor Gans?
    Dr. Gans. Senator, as I mentioned earlier, the VA is a very 
important health care delivery system for those who use it, and 
it is also an important resource for medical education, for 
research, and I certainly would not want to see that harmed in 
any way. I think that my perspective is that we can augment and 
complement, and for those unique specialized and relatively 
rare things where there are pockets of capacity and expertise 
outside of the VA, where it does not really make sense to re-
establish a large capacity that is going to be only transiently 
needed, it makes much more sense to just collaborate and 
cooperate. My perspective is let's come up with a plan. Let's 
have the leadership of the civilian community and the veterans 
and the military plan together and identify those areas where 
augmentation and complementation make sense, plan together 
where it makes sense for the private sector to help support the 
development of the reinvigorated larger capacity within the 
system, but just have it make sense and serve the common good.
    Senator Craig. Well, Doctor, I think you have said it 
better than I did. I appreciate that very much.
    My time is up. Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Craig.
    Senator Murray?
    Senator Murray. Thank you very much, and thank you so much 
to all of you for really excellent testimony and helping us 
wade through these challenges that we have in front of us. I do 
not think any of us disagree that once you get into the VA 
system, you get good care, and it is critical that we get to 
the point, Tammy, where we are not having to play catch-up, 
because these men and women are there, they are coming back, 
and we have to have the capacity to do that.
    There is a system in place that does allow us to contract 
out within the VA for care. Oftentimes, people do not know 
about it. Nobody has told them. The paperwork gets lost. And I 
think we have to be very careful not to just say, well, abandon 
the VA, we will go to private care, when, Dr. Gans, you very 
precisely told us that that kind of capacity is already a 
problem within the private system of care, and we do not want 
to pass people off. They get stuck like Denise did at a private 
facility that was not capable of dealing with them, and the 
paperwork gets behind, and the payments do not get there, and 
we do not support the resources that are needed for private 
care. So there are a lot of dangerous red flags as we look at 
how we deal with this.
    But our responsibility here is to make sure that the VA has 
the capacity it needs for the men and women who are coming back 
today and for our older veterans as they are, as you precisely 
told us, now really getting into our VA system as well.
    Tammy, I wanted to ask you in particular--you mentioned 
testing, and I am deeply concerned that we are not within the 
military testing soldiers for--I think you said PTSD and TBI in 
particular. You mentioned several other things. Ninety percent 
of our soldiers are coming back with this bacterial infection. 
Is that being tested for?
    Ms. Duckworth. You get the infection, and it is very 
quickly you are known to have it. It is just in the soil over 
there, and it gets in your wounds. About 90 percent--I think 
that was the number I was given when I was going through Walter 
Reed--who come through with open wounds have this infection in 
some form or another.
    Senator Murray. And were you recommending that they get 
tested when they went into the VA? Or were you recommending 
that they get tested before they were separated from the 
military?
    Ms. Duckworth. I think that when they enter the VA system, 
there needs to be another round of comprehensive testing for 
traumatic brain injury, post-traumatic stress disorder, vision, 
and hearing, because as scientists found out, a lot of the 
polytrauma patients who come through, they are tested for 
everything else, and sometimes they forgot--``Oh, maybe we need 
to check their vision.'' And they are finding that 60 percent 
of the patients who have entered Hines polytrauma center have 
had some form of functional vision loss that was not----
    Senator Murray. But wouldn't it make sense that they get 
tested before they leave the military--if we get an adequate 
system that makes sure that our military and our VA records are 
copacetic, another challenge. But wouldn't it make sense that 
they get that testing before they are ever separated?
    Ms. Duckworth. Yes, ma'am, but for some of these injuries, 
TBI and post-traumatic stress disorder, they may not reoccur 
for a while, PTSD especially, and this is where the 2-year rule 
is so vitally important, because with the vets of this war, if 
they do not get care for war-related illnesses for 2 years----
    Senator Murray. Well, some of our veterans who are 
returning when they get separated, if they are not tested, may 
not think of going to a VA facility and may show up, you know, 
6 months later not being able to remember.
    Ms. Duckworth. They should be tested both times.
    Mr. Pruden. Can I comment on that, ma'am? I have been 
working with some guys over the past few years who came back 
from 3rd ID with me. Several of them were injured in 2005. One 
of these young men lost both his legs. The guy beside him was 
killed. He was unconscious for an unknown amount of time. I 
believe he suffers from PTSD and has substance abuse issues, 
which I think may have masked some of the symptoms of TBI. His 
mother tells me he cannot remember anything he used to be able 
to remember.
    It was not until 2 weeks ago now, after almost 2 years in 
DOD care, that we got him into the VA system, enrolled, and he 
is just now--we just got him back up to Walter Reed to be 
screened for a TBI just 2 weeks ago.
    Senator Murray. After 2 years of being out?
    Mr. Pruden. Yes, ma'am, and yet he was unconscious--and it 
was after I talked to him, I said, ``Do you think you might 
have a TBI?'' And he said, ``Well, you know, I don't think so. 
I am OK.'' And his Mom said, ``But you can't remember 
anything.'' Sometimes soldiers are not willing or able to 
understand what is going on with them, and especially if they 
have a TBI and PTSD. And it takes someone coming along and 
saying, ``Maybe we should screen you for this.''
    Senator Murray. Yes. Mr. Chairman, I am going to have to 
run to the floor. But I think part of what we do is mandatory 
testing before they separate as well as when they enter the VA 
because we are losing a lot of people out there. That is 
critical.
    Before I run, Denise, if you wanted to comment on that?
    Ms. Mettie. I just wanted to interject something quickly. 
My son spent 15 months in Iraq the first time. When he got 
back, they did a quick PTSD test, and he suffered extreme PTSD. 
They said they could not medicate him because he would not be 
deployable again and that----
    Senator Murray. If they medicated him, he would not be----
    Ms. Mettie. If they medicated----
    Senator Murray. So they did not because----
    Ms. Mettie. No, and so he self-medicated by alcohol. He 
could not sleep at night, and this was what he did for the 
whole year until he was redeployed. And one of his comments, 
``Well, you know, I won't drink anymore because there is no 
alcohol over there.'' That needs to be addressed.
    Senator Murray. And one last question for you, Denise. You 
navigated this system and were an advocate on your own, it 
sounds like, quite a bit of the time.
    Ms. Mettie. Yes.
    Senator Murray. Thank God your son had a family that was 
able to be there. I am certain you have seen many people who do 
not have a close family member who can----
    Ms. Mettie. And that is what scares me. You know, there are 
many members who are probably in nursing homes because they 
have no one to be their advocate. I think these people in 
particular need to be looked at again.
    Senator Murray. Were there any VA case managers that worked 
with you throughout this time?
    Ms. Mettie. Yes.
    [Laughter.]
    Senator Murray. That does not sound positive. Do you want 
to----
    Ms. Mettie. I cannot say I received a lot of help.
    Senator Murray. Well, Mr. Chairman, again, I want to thank 
all of you, and I do have questions for the second panel. I 
have to manage the supplemental on the floor, but I hope that 
the VA and DOD officials who are testifying today will quickly 
respond to our questions. You have heard what these witnesses 
have had to say. We do not want any platitudes. We want to know 
what real solutions are, and we want to be able to support them 
from this Committee.
    So thank you very much, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Murray.
    Senator Burr?
    Senator Burr. Thank you, Mr. Chairman.
    I think we are all struck by the testimony--not surprised, 
but we are struck in, as I think Senator Craig put it, a very 
positive way. The challenge for us is that we all agree that we 
need more money in the system. We all agree that we need to 
look at the services provided, and that they need to represent 
the cases that are walking in the door, but that we cannot 
forget about that last generation that is walking through.
    We all agree that we need to do much better on the health 
IT, that records should follow individuals, whether they are at 
Walter Reed or Bethesda, to the communities they go to and 
potentially to the private sector stops that they make along 
the way.
    Jonathan, I will take one objection with something you 
said. Over 50 is not old, OK?
    [Laughter.]
    Senator Burr. But our big challenge is to try to take 
everything that you have presented to us that are personal 
experiences, personal observations, and extrapolate that out to 
the entire population and make it work. And I want to challenge 
my colleagues here that I do not think this is a construct that 
we can take and just put in legislative language and all of a 
sudden mandate this, this, and this happens.
    We recognized very early on in North Carolina that we were 
going to have a bigger deployment of Guard and reservists in 
this mission, and certainly we have seen it from every State. 
One of the smartest things I think we did was that we started a 
program at UNC-Chapel Hill to follow the deployments and the 
returns of all these Guard and reservists, and to try to 
accumulate the data in real time as we went along as to how we 
do each one better the next time. How do we make the deployment 
smoother? How do we make the return better? And I think 
progressively we have changed that process.
    And I would suggest to my colleagues that we need to look 
at how we turn outside and ask an outside entity to look at the 
VA, to look at Walter Reed and Bethesda, to look at the private 
sector, and to try to figure out how we design this in a way 
that we maximize the care that we provide.
    Ms. Mettie, I wish I could tell you how we can take 
individuals that may not have been as responsive as they should 
have, who work within the VA, who maybe do not make the 
individual assessments that they should, even with a persistent 
parent or persistent spouse. I think all of us would hope that 
it would work beautifully, and the fact is that we hear too 
many stories where it does not, so we know we have still got a 
tremendous amount of work to do.
    But some of the things, maybe most of the things you have 
talked about today, these are fixable, that we can integrate 
them into a seamless process that does not distinguish between 
public and private, that does not distinguish between this 
location or that location, that maximizes the talents that we 
have throughout the health care delivery system in this 
country. It will take some effort on our part to do that in a 
way that, quite frankly, it would work successfully and it 
would protect the VA system, which I know many want to. I think 
every Member of this Committee wants to.
    Ms. Mettie, if there was one point in your process that you 
sit there today and you say, ``If the decision had been 
different here, we would be dealing with a different outcome, 
possibly,'' what would that one point be?
    Ms. Mettie. Oh, no doubt about it, that would be last April 
when we transferred Evan to the private skilled nursing 
facility. We were seeing tremendous progress at that time. He 
was smiling. He was giving thumbs up. He was lifting and 
raising his hands to command.
    My feeling is, if he would have been in a VA facility that 
had acute care, we would have seen progress continue. But as it 
was, by the first or mid-May, he had developed five types of 
infections from being in this facility for 3 weeks, and when he 
was sent back to the VA, he had to recover from all of these 
infections, and we lost everything.
    I strongly feel that if he would have been taken better 
care of at that point, we would see a different person today.
    Senator Burr. It is my hope that our system will get better 
at identifying those critical decision points for these 
warriors that come back and for the families, and that we learn 
from each one how to do it better in the future.
    Mr. Chairman, if I could, I would like to go to Jonathan 
for just a second, because I think, Jonathan, your recovery 
probably mirrors to some degree, I think, what Senator Craig 
was talking about. You were at Johns Hopkins receiving some 
care. You were going back to Walter Reed for some things--or 
was that your buddy that you were talking about?
    Mr. Pruden. That was one of my soldiers.
    Senator Burr. That was one of your soldiers.
    Mr. Pruden. Yes, sir.
    Senator Burr. You know, your question was: Why couldn't you 
do multiple things at the same place? I think that is what 
Senator Craig is getting at. Why can't we do multiple things? 
And I think this fear that there is an attempt to lessen our 
emphasis on the VA or on DOD hospital we have to get over if we 
want to successfully try to create a pathway that fits every 
soldier that comes back in the system. Unfortunately, your 
pathway was a little bit different than your soldier's, and 
Tammy's pathway was a little bit different than your pathway, 
and certainly Evan's has been different than yours.
    Each one is unique, and there is no doubt that when you 
walk in an emergency room as a private citizen, there is a 
triage person that makes an assessment of you and your symptoms 
and a decision that is made hopefully by a group as to what 
their treatment is going to be.
    My fear is that we are not evaluating the patient for the 
problem and try and determine what the best course for that 
individual patient, that individual soldier, that individual 
Marine that is coming back, that we are trying to fit them into 
a system that we have already designed. And that makes 
treatment bifurcated. It makes crucial points of decision not 
make sense. And it changes, more importantly, outcomes.
    I would only suggest to my colleagues, the only thing we 
need to be concerned with is the outcome. Let's not be 
concerned with how we get there. Let's try to raise our success 
rate of the outcomes of these troops that come back with very 
different injuries, very different circumstances, and let's 
make sure that the outcome is more positive tomorrow.
    I once again want to thank each of you.
    Chairman Akaka. Thank you very much, Senator Burr.
    Senator Tester?
    Senator Tester. Thank you, Mr. Chairman, and I, too, want 
to thank the panel members for your testimony and your ideas. I 
think they are outstanding, and we just need to figure out a 
way we can apply them, which I think is what Senator Burr was 
talking about.
    First of all, to Tammy and Jonathan, thank you for your 
service, thank you for your sacrifice. I appreciate that a lot.
    To Denise, you know, the Good Lord gave us the ability to 
love, and a mother's love for her son is pretty special, and I 
thank you for what you have done for your son.
    And thank you, Dr. Gans, for your perspective.
    I just want to touch on a couple of things, and I am not 
going to ask--most of the questions have been asked. I just 
want to touch on a couple of things, because each one of you 
brought up the fact, the need for potential outsourcing of 
services. And, I guess, if I was going to ask a question, it 
would be what kind of parameters would you put around that. 
From previous questions it is apparent that it should not be 
wide open, and I agree with that, by the way. But if it deals 
with prosthetics, if it deals with traumatic brain injury, if 
it deals with other areas by which we can outsource, that would 
be great to really put that into policy.
    I come from a State where it is a long ways to the 
veterans' hospital. Maybe distance should also apply in there. 
But if there are ways we can figure out how to outsource in a 
reasonable way, I think you are right on. And, quite frankly, I 
am glad every one of you brought it up, because that tells me 
that that is probably one of the solutions.
    The other thing deals with testing, and I think, Tammy, you 
brought it up, and I think we need to have our testing very 
complete, and I appreciate that information.
    I am not going to be able to be here for the second panel, 
and I really wanted to be, but I have got a conflict. And so 
for Michael and Ellen, I just want to tell you that my first 
statements stand. Once you get into the system, they do some 
pretty good work, but there are some problems that we have to 
deal with, and these problems cannot be addressed, I do not 
think, by us alone. I think it is going to take a collaborative 
effort. I think it is going to take some honest assessment on 
services rendered, dollars needed, and human resources in the 
kind of job they are doing in the field, and both at the DOD 
level and at the VA level. And I think that is critically 
important.
    Technological and medical transfer, I think Jonathan talked 
about it, with the bacteria, or whatever you got, from the 
Department of Defense to the VA, I think that has got to 
happen. That is as important as passing the medical records 
along so we can get these folks the kind of treatment they 
need.
    But ultimately, in the end, I will just tell you this: As a 
policymaker in the U.S. Senate, it is going to be virtually 
impossible to fix this problem without the bureaucracy's help. 
Senator Burr talked about it, the fact that if we make policies 
and force policies down on the bureaucracy, it is not going to 
fix the problem. We need to work together. And the fact that 
these folks are sitting right here today, I hope that there is 
not one person in the bureaucracy that says these are 
individual cases and this is not the rule. The fact is that the 
reason these folks are here today is because we do have some 
problems and we need to work on the outcomes to make sure that 
we have successes right down the line.
    So with that, thank you very much. I really appreciate 
these panelists coming up today. I appreciate your time. Thank 
you.
    Chairman Akaka. Senator Brown?
    Senator Brown. Thank you, Chairman Akaka. And thank you. I 
was at another hearing and could not hear your testimony, 
although I have read much of all of your testimony.
    Mr. Pruden, you said something that intrigued me about 
having an advocate, and my mother several years ago--she was in 
her early 80's. This is a very different situation. But she 
fell and fractured or shattered her shoulder, and she had my 
brother and me and my wife in the hospital with her in the 
emergency room as an advocate. People were nearby. The hospital 
was crowded, as city emergency rooms often are, or all medical 
facilities are. And because she had family members there really 
advocating for her with doctors and nurses to get pain 
medication, to do all that was needed, she got better 
treatment, frankly, than some others that were there that did 
not have family members.
    I heard you talk about your son a little. I am sorry I did 
not hear the rest of your testimony. And, Director Duckworth, 
you seem to be generally pretty pleased with the treatment you 
got. Talk to me, the three of you, because you have all been so 
much a part of this, how important that would be to whether 
your experience was you had somebody there for you that was an 
advocate. If you read the Post stories about Walter Reed, there 
was the absence of that for them in many cases, too, and how 
our system, how the VA should do this so that every patient 
feels like they have someone there to make sure they get the 
care they need.
    Since you talked about it, Mr. Pruden, do you want to 
start? And then Director Duckworth and then Ms Mettie, if you 
would.
    Mr. Pruden. Thank you. Having an advocate is vitally 
important. I had my wife, Amy, there right along, and, you 
know, in my early days I was in ICU and on a lot of morphine, 
and I did not understand what was going on exactly. And my wife 
was there to make sure things were happening for me.
    I think a lot of times the gap that we see, the problems 
that I addressed for a lot of my soldiers as they were coming 
back wounded have not been because the resources were not 
available to them, but because the information was not 
available or there was a lack of communication somewhere, and 
they could not get from Point A to Point B.
    I had a soldier dragging his foot around for weeks until I 
saw him and said, ``Why are you dragging your foot around?'' 
``Well, sir,'' he said, ``they didn't have an AFO for me.'' It 
is a foot orthosis to correct nerve damage. And he had been 
dragging his foot around because he did not know any better. 
Nobody told him that he could get an AFO.
    And I can give you countless examples of incidents like 
that where people just did not know what was available. 
Secretary Nicholson's hiring of 100 OIF/OEF patient advocates 
is a step in the right direction, and I think we need to see 
more of that on both sides of the house.
    Senator Brown. Director Duckworth?
    Ms. Duckworth. Senator, I have to say the same thing, and 
the reason Jonathan and I are here today is because we did what 
a lot of patients are doing at the medical treatment 
facilities, whether it is DOD or VA. Those of us who are more 
capable of advocating are advocating not just for ourselves but 
for our buddies as well.
    When I was in the ICU, I had my husband,--he is now a major 
as well, but at the time a captain. When somebody told him that 
this is the way things were with the bureaucracy--for example, 
in the first couple of days, they told my 65-year-old mom there 
was no room. She had to sleep on the floor of the ICU waiting 
room. He had 15 years in the military, just saying wrong 
answer, that is not what you do, and fight the bureaucracy.
    When I am at Hines and I go into the prosthetics lab, and 
as I walk through, the prosthetists look at me and say, ``Wow, 
is that a C-leg? Can I touch it?'' I had the wherewithal to 
say, ``This is not acceptable,'' and worked the system myself 
to get to a place where I could go to the prosthetist of my 
choice. But a young troop with a brain injury who does not have 
that cannot make their way through the system. The patient 
advocate at Hines, the ones that I use, Ivy Bryant, is 
excellent. But part of her doing her job is going to be an 
understanding of the military system and also an understanding 
of the medical pipeline, because she is a caseworker, she does 
not necessarily understand that a patient needs a particular 
medical procedure. So there is definitely need for that, and 
that is why you find people like Jonathan and me here, is 
because we found ourselves advocating for our buddies, just 
like there were guys who advocated for us when we were not 
capable of taking care of ourselves.
    Senator Brown. Ms. Mettie?
    Ms. Mettie. I don't know if you were here when I was 
talking about a particular test that was done on Evan last May, 
SSEP, that measures electric impulse activity. And on that one, 
the one on the top of the head that measures the cortical 
impulse was not registering anything, so the rehab doctor said 
it is unlikely that he will ever regain anything. And because 
of movements that we had seen and commands that he had done, I 
just told her that her test was wrong. I have my own faith, and 
we are going on my prognosis.
    Well, from that point on where we were at the VA, it was, 
Let's see more Mom, and took care of Evan to the best of our 
ability. They took personal care of him, but there was no 
therapy.
    In October, he had his cranioplasty done to replace his 
skull, and when we got back to the VA, they redid the SSEP 
test. The rehab doctor called me and apologized for ever doing 
the first one because this one was normal. It was an immediate 
difference on how he was treated. All of a sudden, OT, speech, 
everybody was coming in to work with him. And all of these 
months I had been pushing saying he is there, all you got to do 
is work with him. But nobody would.
    Senator Brown. I guess that answers it. Thank you.
    Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Brown.
    I want to thank this panel very much. We have further 
questions. We will place them in the record, and we will keep 
the record open for a week. But let me tell you, your 
testimonies have been excellent. It has been helpful to us, and 
as you know, we are trying to do our best to help the veterans 
of our country. And you have really helped us to do that.
    So, again, thank you very much for coming. Some of you had 
to travel to get here, and we really do appreciate that. And so 
I want to thank you for your testimonies again and thank the 
audience for being so patient.
    Thank you to the first panel.
    I would like to call the second panel to the desk. I 
welcome our second panel of witnesses. Dr. Kussman is acting 
head of the Veterans Health Administration, though I have been 
informed that your new title is Executive-in-Charge. I hope 
that the Administration will soon send up a nomination for the 
Under Secretary of Health position.
    Ms. Embrey is the Deputy Assistant Secretary of Defense for 
Force Health Protection and Readiness, and Director of 
Deployment Health Support.
    Dr. Kussman and Ms. Embrey, thank you so much for your 
presence. I know that it was a bit unusual to have 
Administration witnesses not testify first, but as I said in my 
opening statement, it is my desire to have you address the 
testimony of the witnesses who preceded you. So I thank both of 
you for being here today. I want you to know that your full 
statements will appear in the record of the Committee.
    So we will begin with testimony from Dr. Kussman.

       STATEMENT OF MICHAEL J. KUSSMAN, M.D., EXECUTIVE-
   IN-CHARGE, VETERANS HEALTH ADMINISTRATION, DEPARTMENT OF 
                        VETERANS AFFAIRS

    Dr. Kussman. Good morning, Mr. Chairman. Before I give my 
prepared remarks, if you will indulge me for a second, I do not 
know if anybody from the first panel is still here, but for the 
record I would like to say that our job is make things better, 
not more complicated. And when I hear these stories where we 
clearly have not met the expectations and done things in the 
manner that I would like to see them, it pains me both 
professionally and personally.
    As you know, I am a veteran and a retiree myself, and so I 
appreciated the testimony of the first panel. I can assure you 
that we will continue to do everything that we can to improve 
the system.
    Mr. Chairman and Members of the Committee, good morning. 
Mr. Chairman, thank you for the opportunity to testify today on 
the polytrauma and prosthetics issues on behalf of the 
Department. While we have learned a great deal on these 
subjects in the past few years, with your help and the help of 
many others, both inside and outside the Government, we 
continue to try to improve our performance. Never in the 75-
year history of the Department of Veterans Affairs has there 
been a greater level of collaboration and cooperation between 
VA and the Department of Defense.
    VA has coordinated the transfer of over 6,800 injured or 
ill active-duty servicemembers and veterans from DOD to the VA. 
Our highest priority is to ensure that those returning from the 
Global War on Terror who transition directly from DOD military 
treatment facilities to VA medical centers continue to receive 
the best care available anywhere.
    This month, we are calling each of those severely injured 
servicemembers and veterans to see if they need additional 
support, and we are directing facilities to provide OIF/OEF 
program managers at each facility. VA social workers, benefits 
counselors, and outreach coordinators advise and explain the 
full array of VA services and benefits to servicemembers while 
they are still being cared for by DOD. In addition, our social 
workers help newly wounded soldiers, sailors, airmen, and 
Marines and their families plan a future course of treatment 
for their injuries after they return home.
    Case management of our patients begins at the time of 
transition from DOD and continues as their medical and 
psychological needs dictate. VA requires that every medical 
center will have full-time nurse and social worker case 
managers for OIF/OEF veterans' needs, and we are in the process 
of hiring 100 OIF/OEF veterans to serve as ombudsmen to support 
severely wounded veterans and their families.
    Each VA medical center also has an OIF/OEF program manager 
to coordinate activities locally for OIF/OEF veterans and to 
ensure the health care and benefits needs of returning 
servicemembers and veterans are fully met. VA has distributed 
specific guidance to field staff to ensure that the roles and 
functions of the OIF/OEF program managers and case managers are 
fully understood and that proper coordination of benefits and 
services occurs at the local level.
    Mr. Chairman, 15 years ago, VA, in collaboration with the 
Defense and Veterans Brain Injury Center, established 4 
comprehensive centers to care for veterans with traumatic brain 
injury. These centers are located in Richmond, Tampa, 
Minneapolis, and Palo Alto and provide exemplary clinical care 
for brain-injured patients and are recognized as leaders in 
their field.
    Today our Polytrauma System of Care provides the highest 
quality of medical and rehabilitation case management and 
support services for veterans and active-duty servicemembers 
who have sustained complex injuries, including traumatic brain 
injury, while in service to our country. Our ability to 
successfully integrate medical care and rehabilitative medicine 
makes our centers unique among health care facilities in the 
United States and possibly the world. We are a flexible, 
dynamic system able to adjust to the changing needs of combat-
injured veterans and proud of the service we provide them.
    Last year, VA's Prosthetic and Sensory Aids Service 
provided service to over 22,000 unique OIF/OEF veterans for a 
variety of services and products. When viewing amputee care 
alone since the beginning of the war, VA's Prosthetic and 
Sensory Aids Service has served a total of 157 of the 560 OIF/
OEF major amputees. Some of these amputees have come to us 
through the Polytrauma Rehabilitation Centers.
    Finally, VA provides outreach to our newest veterans 
through our Vet Center Program. Vet Centers were created by 
Congress as the outreach element in VA's Veterans Health 
Administration. Our Vet Centers have served 180,000 combat 
veterans to date and have provided bereavement services to the 
families of over 900 fallen warriors. VA will open 15 new Vet 
Centers and 8 new Vet Center outstations at locations 
throughout the Nation by the end of 2008. At that time Vet 
Centers will total 232. We also expect to add staff to 61 
existing facilities to augment the services they provide. Seven 
of the 23 new centers will open during calendar year 2007.
    Mr. Chairman, that concludes my presentation, and at this 
time I would be pleased to answer any questions you may have.
    [The prepared statement of Dr. Kussman follows:]
 Prepared Statement of Michael J. Kussman, M.D., Executive-in-Charge, 
     Veterans Health Administration, Department of Veterans Affairs
    Mr. Chairman and Members of the Committee, good afternoon. Thank 
you for this important opportunity to discuss on the Veterans Health 
Administration's (VHA) efforts to ensure a seamless transition process 
for our injured service men and women, and our ongoing efforts to 
continuously improve this process.
    VHA's work to create a seamless transition for men and women as 
they leave the service and take up the honored title of ``veteran'' 
begins early on. Our Benefits Delivery at Discharge Program enables 
active duty members to register for VA health care and to file for 
benefits prior to their separation from active service. Our outreach 
network ensures returning servicemembers receive full information about 
VA benefits and services. And each of our medical centers and benefits 
offices now has a point of contact assigned to work with veterans 
returning from service in Operation Enduring Freedom (OEF) and 
Operation Iraqi Freedom (OIF).
    VHA has coordinated the transfer of over 6,800 severely injured or 
ill active duty servicemembers and veterans from DOD to VA. Our highest 
priority is to ensure that those returning from the Global War on 
Terror transition seamlessly from DOD Military Treatment Facilities 
(MTFs) to VA Medical Centers (VAMCs) and continue to receive the best 
possible care available anywhere. Toward that end, we continually 
strive to improve the delivery of this care.
    In partnership with DOD, VA has implemented a number of strategies 
to provide timely, appropriate, and seamless transition services to the 
most seriously injured OEF/OIF active duty servicemembers and veterans.
    VA social workers, benefits counselors, and outreach coordinators 
advise and explain the full array of VA services and benefits. These 
liaisons and coordinators assist active duty servicemembers as they 
transfer from MTFs to VA medical facilities. In addition, our social 
workers help newly wounded soldiers, sailors, airmen and Marines and 
their families plan a future course of treatment for their injuries 
after they return home. Currently, VA Social Worker and Benefit 
Liaisons are located at 10 MTFs, including Walter Reed Army Medical 
Center, the National Naval Medical Center Bethesda, the Naval Medical 
Center San Diego, and Womack Army Medical Center at Ft. Bragg.
    Since September 2006, a VA Certified Rehabilitation Registered 
Nurse (CRRN) has been assigned to Walter Reed to assess and provide 
regular updates to our Polytrauma Rehabilitation Centers (PRC) 
regarding the medical condition of incoming patients. The CRRN advises 
and assists families and prepares active duty servicemembers for 
transition to VA and the rehabilitation phase of their recovery.
    VA's Social Worker Liaisons and the CRRN fully coordinate care and 
information prior to a patient's transfer to our Department. Social 
Worker Liaisons meet with patients and their families to advise and 
``talk them through'' the transition process. They register 
servicemembers or enroll recently discharged veterans in the VA health 
care system, and coordinate their transfer to the most appropriate VA 
facility for the medical services needed, or to the facility closest to 
their home.
    In the case of transfers of seriously injured patients, both the 
CRRN and the Social Worker Liaison are an integral part of the MTF 
treatment team. They simultaneously provide input into the VA health 
care treatment plan and collaborate with both the patient and his or 
her family throughout the entire health care transition process. Video 
teleconference calls are routinely conducted between DOD MTF treatment 
teams and receiving VA PRC teams. If feasible, the patient and family 
attend these video teleconferences to participate in discussions and to 
``meet'' the VA PRC team.
    I should note that one important aspect of coordination between DOD 
and VA prior to a patient's transfer to VA is access to clinical 
information. This includes a pre-transfer review of electronic medical 
information via remote access capabilities. The VA polytrauma centers 
have been granted direct access into inpatient clinical information 
systems from Walter Reed Army Medical Center (WRAMC) and National Naval 
Medical Center (NNMC). VA and DOD are currently working together to 
ensure that appropriate users are adequately trained and connectivity 
is working and exists for all four polytrauma centers. For those 
inpatient data that are not available in DOD's information systems, VA 
social workers embedded in the military treatment facilities routinely 
ensure that the paper records are manually transferred to the receiving 
polytrauma centers.
    Another data exchange system, the Bidirectional Health Information 
Exchange (BHIE) allows VA and DOD clinicians to share text-based 
outpatient clinical data between VA and the ten MTFs, including Walter 
Reed and Bethesda.
    VA case management for these patients begins at the time of 
transition from the MTF and continues as their medical and 
psychological needs dictate. Once the patient transfers to the 
receiving VAMC, or reports to his or her home VAMC for care, the VA 
Social Worker Liaison at the MTF continues to coordinate with VA to 
address after-transfer issues of care. Seriously injured patients 
receive ongoing case management at the VA facility where they receive 
most of their care. Since April of 2006, points of contact or case 
managers have been identified in every VA medical center. In response 
to the Secretary's request this week, VA is in the process of hiring 
the 100 OIF/OEF veterans to serve as case advocates to support their 
severely injured fellow veterans and their families.
    Moreover, VA's Prosthetic and Sensory Aids Service (PSAS) provided 
service to over 22,000 OIF/OEF unique veterans for a variety of 
services and products. \1\ When viewing amputee care alone since the 
beginning of the war, Prosthetics has served a total of 187 of the 
current 554 OIF/OEF major amputees, including veterans and active duty 
servicemembers. Some of these amputees have come to us through the 
Polytrauma Rehabilitation Centers.
---------------------------------------------------------------------------
    \1\ These services include but are not limited to wheelchairs, 
eyeglasses, hand-cycles, running legs (prostheses), mono-skis, 
prosthetic hands, talking GPS systems for the blind, and Personal 
Digital Assistants for Traumatic Brain Injury patients.
---------------------------------------------------------------------------
    VA has four Polytrauma Rehabilitation Centers, located at Tampa, 
FL; Richmond, VA; Minneapolis, MN; and Palo Alto, CA. The Army has 
assigned full time active duty Liaison Officers to each one in order to 
support military personnel and their families from all Service 
branches. The Liaison officers address a broad array of issues, such as 
travel, housing, military pay, and movement of household goods.
    In addition, Marine Corps representatives from nearby local 
Commands visit and provide support to each of the Polytrauma 
Rehabilitation Centers. At VA Central Office in Washington, DC, an 
active duty Marine Officer and an Army Wounded Warrior representatives 
are assigned to the Office of Seamless Transition to serve as liaisons. 
Both the Army and the Marine Liaisons play a vital role in ensuring the 
provision of a wide bridge of services during the critical time of 
patient recovery and rehabilitation.
    VHA understands the critical importance of supporting families 
during the transition from DOD to VA. We established a Polytrauma Call 
Center in February 2006, to assist the families of our most seriously 
injured combat veterans and servicemembers. The Call Center operates 24 
hours-a-day, 7 days-a-week to answer clinical, administrative, and 
benefit inquiries from polytrauma patients and family members. The 
Center's value is threefold. It furnishes patients and their families 
with a one-stop source of information; it enhances overall coordination 
of care; and, very importantly, it immediately elevates any system 
problems to VA for resolution.
    VA's Office of Seamless Transition includes two Outreach 
Coordinators--a peer-support volunteer and a veteran of the Vietnam 
War--who regularly visit seriously injured servicemembers at Walter 
Reed and Bethesda. Their visits enable them to establish a personal and 
trusted connection with patients and their families.
    These Outreach Coordinators help identify gaps in VA services by 
submitting and tracking follow-up recommendations. They encourage 
patients to consider participating in VA's National Rehabilitation 
Special Events or to attend weekly dinners held in Washington, DC, for 
injured OEF/OIF returnees. In short, they are key to enhancing and 
advancing the successful transition of our service personnel from DOD 
to VA, and, in turn, to their homes and communities.
    In addition, VA has developed a vigorous outreach, education, and 
awareness program for the National Guard and Reserve. To ensure 
coordinated transition services and benefits, VA signed a Memorandum of 
Agreement (MOA) with the National Guard in 2005. Combined with VA/
National Guard State Coalitions in 54 states and territories, VA has 
significantly improved its opportunities to access returning troops and 
their families. We are continuing to partner with community 
organizations and other local resources to enhance the delivery of VA 
services. At the national level, MOAs are under development with both 
the United States Army Reserve and the United States Marine Corps. 
These new partnerships will increase awareness of, and access to, VA 
services and benefits during the demobilization process and as service 
personnel return to their local communities.
    VA is also reaching out to returning veterans whose wounds may be 
less apparent. VA is a participant in the DOD's Post Deployment Health 
Reassessment (PDHRA) program. DOD conducts a health reassessment 90-180 
days after return from deployment to identify health issues that can 
surface weeks or months after servicemembers return home.
    VA actively participates in the administration of PDHRA at Reserve 
and Guard locations in a number of ways. We provide information about 
VA care and benefits; enroll interested Reservists and Guardsmen in the 
VA health care system; and arrange appointments for referred 
servicemembers. As of December 2006, an estimated 68,800 servicemembers 
were screened, resulting in over 17,100 referrals to VA. Of those 
referrals, 32.8 percent were for mental health and readjustment issues; 
the remaining 67.2 percent for physical health issues.
    Congress created the Readjustment Counseling Service (RCS), 
commonly known to veterans as the Vet Center Program, as VHA's outreach 
element. Program eligibility was originally targeted to Vietnam 
veterans; today it serves all returning combat veterans. The Vet Center 
Program receives high ratings in veterans' satisfaction, employee 
satisfaction, and other measurable indicators of quality and effective 
care.
    The approximate number of OEF/OIF combat veterans served by Vet 
Centers to date is 165,000 (119,600 through outreach; 45,400 seen at 
centers). In February of 2004, the Secretary of Veterans Affairs 
approved the hiring of 50 OEF/OIF combat veterans to support the 
Program by reaching out actively to National Guard, and Reserve 
servicemembers returning from combat. An additional 50 were hired in 
March of 2005. This action advanced the continuing success of our Vet 
Centers in their ability to assist our newest veterans and their 
families. VA Vet Centers have provided bereavement services to 900 
families of fallen warriors.
    VA plans to expand its Vet Center Program. We will open 15 new Vet 
Centers and eight new Vet Center outstations at locations throughout 
the Nation by the end of 2008. At that time, Vet Centers will total 
232. We expect to add staff to 61 existing facilities to augment the 
services they provide. Seven of the 23 new centers will open this 
Calendar Year 2007.
    In addition, the President has created an Interagency Task Force on 
Returning Global War on Terror Heroes (Heroes Task Force), chaired by 
the Secretary of Veterans Affairs, to respond to the immediate needs of 
returning Global War on Terror servicemembers. The Heroes Task Force, 
which had its first meeting in early March, will work to identify and 
resolve any gaps in service for servicemembers. As Secretary Nicholson 
said, no task is more important to the VA than ensuring our heroes 
receive the best possible care and services.
    Finally, The VA is partnering with the State VA Directors in the 
``State Benefits Seamless Transition Program'' in which severely 
injured servicemembers can release their contact information to their 
home State VA Office to be educated about their State Benefits.
    VA staff assigned to major MTFs are coordinating with Heroes to 
Hometown as a resource to provide to servicemembers returning to 
civilian life.
    Mr. Chairman, this concludes my presentation. At this time, I would 
be pleased to answer any questions you may have.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Daniel K. Akaka 
   to Michael J. Kussman, M.D., Executive-in-Charge, Veterans Health 
             Administration, Department of Veterans Affairs
    Question 1. In response to [vet] account of VA's inability to deal 
with his recent infection (acinetobacter), you stated that all relevant 
VA clinicians are competent to handle this bacterium. You also promised 
to look into [vet] case in order to identify any shortcomings. Please 
provide the Committee with a brief, informal summary of your 
conclusions as they become available.
    Response. Dr. Gary Roselle, National Program Director for 
Infectious Diseases, has reviewed the veteran's health record and has 
prepared a report. As the report does have protected personal 
information it has been provided under separate cover to the Chairman 
only.

    Question 2. Four times a year, VA submits to Congress a mandated 
report on medical service utilization by veterans of Operations 
Enduring Freedom and Iraqi Freedom. We have not received the latest 
report, which we were expecting in February. I would appreciate you 
looking into this and expediting the production, clearance and 
forwarding of this document to Committee staff.
    Response. Attached is the Veterans Health Administration's (VHA) 
most recent report, Analysis of VA Healthcare Utilization Among US 
Southwest Asian War Veterans, dated April 2007.

    [The Veterans Health Administration's (VHA) report follows:]

             Analysis of VA Health Care Utilization Among 
                    US Southwest Asian War Veterans

                        operation iraqi freedom
                       operation enduring freedom
    (VHA Office of Public Health and Environmental Hazards, April 2007)
               current dod roster of recent war veterans
     Evolving roster development by DOD Defense Manpower Data 
Center (DMDC)
       In September 2003, DMDC developed initial file of 
``separated'' .Iraqi and Afghan troops using proxy files: Active Duty 
and Reserve Pay files, Combat Zone Tax Exclusion, and Imminent Danger 
Pay data.
       In September 2004, DMDC revised procedures for creating 
periodic updates of the roster and now mainly utilizes direct reports 
from service branches of deployed OIF (Operation Iraqi Freedom) and OEF 
(Operation Enduring Freedom) troops.
       DMDC is actively addressing the limitations of the current 
roster to improve the accuracy and completeness of future rosters
               current dod roster of recent war veterans
     Latest Update of roster
       Provided to Dr. Kang, Veterans Health Administration (VHA) 
Environmental Epidemiology Service, on January 11, 2007.

     Qualifications for OIF/OEF deployment roster
       Contains list of veterans who have left active duty and 
does not include currently serving active duty personnel
       Does not distinguish OIF from OEF veterans
       Roster only includes separated OIF/OEF veterans with out-
of-theater dates through November 2006
       3,011 veterans who died in-theater are not included
   updated roster of sw asian war veterans who have left active duty
     686,306 OIF and OEF veterans who have left active duty and 
become eligible for VA health care since Fiscal Year 2002
       46 percent (316,562) Former Active Duty troops
       54 percent (369,744) Reserve and National Guard
       use of dod list of war veterans who have left active duty
     This roster is used to check the VA's electronic inpatient 
and outpatient health records, in which the standard ICD-9 diagnostic 
codes are used to classify health problems, to determine which OIF/OEF 
veterans have accessed VA health care as of December 31, 2006.
     The data available for this analysis are mainly 
administrative information and are not based on a review of each 
patient record or a confirmation of each diagnosis. However, every 
clinical evaluation is captured in VHA's computerized patient record. 
The data used in this analysis are excellent for health care planning 
purposes because the ICD-9 administrative data accurately reflects the 
need for health care resources, although these data cannot be 
considered epidemiologic research data.
     These administrative data have to be interpreted with 
caution because they only apply to OIF/OEF veterans who have accessed 
VHA health care due to a current health question. These data do not 
represent all 686,306 OIF/OEF veterans who have become eligible for VA 
healthcare since Fiscal Year 2002 or the approximately 1.4 million 
troops who have served in the two theaters of operation since the 
beginning of the conflicts in Iraq and Afghanistan.

     use of dod list of war veterans who have left active duty (2)
     Because VA health data are not representative of the 
veterans who have not accessed VA health care, formal epidemiological 
studies will be required to answer specific questions about the overall 
health of recent war veterans.
     Analyses based on this updated roster are not directly 
comparable to prior reports because the denominator (number of OIF/OEF 
veterans eligible for VA health care) and numerator (number of veterans 
enrolling for VA health care) change with each update.
     This report presents data from VHA's health care 
facilities and does not include Vet Center data or DOD health care 
data.
     The following data are ``cumulative totals'' since Fiscal 
Year 2002 and do not represent data from any single year.
     The numbers provided in this report should not be added 
together or subtracted to provide new data without checking on the 
accuracy of these statistical manipulations with VHA's Office of Public 
Health and Environmental Hazards.

   va health care utilization from fiscal year 2002 to 2007 (1st qt) 
                      among sw asian war veterans
     Among all 686,306 separated OIF/OEF Veterans
       33 percent (229,015) of total separated veterans have 
sought VA health care since Fiscal Year 2002
       97 percent (221,255) of 229,015 evaluated OIF/OEF patients 
have been seen as outpatients only by VA and not hospitalized
       3 percent (7,760) of 229,015 evaluated OIF/OEF patients 
have been hospitalized at least once in a VA health care facility
va health care utilization for fiscal year 20022007 (1st qt) by service 
                               component
     316,562 Former Active Duty Troops
       35 percent (112,301) have sought VA health care since 
Fiscal Year 2002
     369,744 Reserve/National Guard Members
       32 percent (116,714) have sought VA health care since 
Fiscal Year 2002
               comparison of va health care requirements
    The 229,015 OIF/OEF veterans evaluated by VA over approximately 5 
years from Fiscal Year 2002 to Fiscal Year 2007 (1st QT) represents 
about 4 percent 5.5 million individual patients who received VHA health 
care in anyone year (total VHA population of 5.5 million in 2006).

  Frequency Distribution of SW Asian War Veterans According to the VISN
                         Providing the Treatment
------------------------------------------------------------------------
                                                     OIF/OEF Veterans
                                                     Treated  at a VA
                 Treatment Site                        Facility \1\
                                                 -----------------------
                                                   Frequency    Percent
------------------------------------------------------------------------
VISN 1  VA New England Healthcare System........      11,163         4.9
VISN 2  VA Healthcare Network Upstate New York..       6,728         2.9
VISN 3  VA New York/New Jersey Healthcare System       9,242         4.0
VISN 4  VA Stars & Stripes Healthcare System....      11,021         4.8
VISN 5  VA Capital Health Care System...........       5,821         2.5
VISN 6  VA Mid-Atlantic Healthcare System.......      12,224         5.3
VISN 7  VA Atlanta Network......................      16,597         7.2
VISN 8  VA Sunshine Healthcare Network..........      19,289         8.4
VISN 9  VA Mid-South Healthcare Network.........      13,660         6.0
VISN 10  VA Healthcare System of Ohio...........       6,351         2.8
VISN 11  Veterans in Partnership Healthcare            8,275         3.6
 Network........................................
VISN 12  VA Great Lakes Health Care System......      14,490         6.3
VISN 15  VA Heartland Network...................       7,645         3.3
VISN 16  South Central VA Health Care Network...      19,871         8.7
VISN 17  VA Heart of Texas Health Care Network..      13,683         6.0
VISN 18  VA Southwest Healthcare Network........      11,636         5.0
VISN 19  VA Rocky Mountain Network..............       9,222         4.0
VISN 20  VA Northwest Network...................      13,186         5.8
VISN 21  VA Sierra Pacific Network..............       9,781         4.3
VISN 22  VA Desert Pacific Healthcare Network...      18,226         8.0
VISN 23  VA Midwest Health Care Network.........      12,749         5.6
------------------------------------------------------------------------
\1\ Veterans can be treated in multiple VISNs. A veteran was counted
  only once in any single VISN but can be counted in multiple VISN
  categories. The total number of OIF-OEF veterans who received
  treatment (n = 229,015) was used to calculate the percentage treated
  in any one VISN.


  Demographic Characteristics of Iraqi and Afghan Veterans Utilizing VA
                               Health Care
------------------------------------------------------------------------
                                                             Percent  SW
                                                                Asian
                                                             Veterans (n
                                                              = 229,015)
------------------------------------------------------------------------
Sex
    Male...................................................           88
    Female.................................................           12
Age Group
    <20....................................................            4
    20-29..................................................           52
    30-39..................................................           23
    40.....................................................           20
Branch
    Air Force..............................................           12
    Army...................................................           66
    Marine.................................................           12
    Navy...................................................           10
Unit Type
    Active.................................................           49
    Reserve/Guard..........................................           51
Rank
    Enlisted...............................................           92
    Officer................................................            8
------------------------------------------------------------------------

                            diagnostic data
     Veterans of recent military conflicts have presented to 
VHA with a wide range of possible medical and psychological conditions.
     Health problems have encompassed more than 7,990 discrete 
ICD-9 diagnostic codes.
     The three most common possible health problems of war 
veterans were musculoskeletal ailments (principally joint and back 
disorders), mental disorders, and ``Symptoms, Signs and Ill-Defined 
Conditions.''
     As in other outpatient populations, the ICD-9 diagnostic 
category, ``Symptoms, Signs and III-Defined Conditions,'' was commonly 
reported. It is important to understand that this is not a diagnosis of 
a mystery syndrome or unusual illness. This ICD-9 code includes 
symptoms and clinical finding that are not coded elsewhere in the IC-
D9. It is a diverse, catch-all category that is commonly used for the 
diagnosis of outpatient populations. It encompasses more than 160 sub-
categories and primarily consists of common symptoms that do not have 
an immediately obvious cause during a single clinic visit or isolated 
laboratory abnormalities that do not point to a particular disease 
process and may be transient.

  Frequency of Possible Diagnoses Among Recent Iraq and Afghan Veterans
------------------------------------------------------------------------
                                                     (n = 229,015)
     Diagnosis (Broad ICD-9 Categories)      ---------------------------
                                              Frequency \1\    Percent
------------------------------------------------------------------------
Infectious and Parasitic Diseases (001-139).        24,114          10.5
Malignant Neoplasms (140-208)...............         1,801           0.8
Benign Neoplasms (210-239)..................         7,506           3.3
Diseases of Endocrine/Nutritional/Metabolic         41,911          18.3
 Systems (240-279)..........................
Diseases of Blood and Blood Forming Organs           4,175           1.8
 (280-289)..................................
Mental Disorders (290-319)..................        83,889          36.6
Diseases of Nervous System/Sense Organs (320-       69,767          30.5
 389).......................................
Diseases of Circulatory System (390-459)....        33,218          14.5
Disease of Respiratory System (460-519).....        41,144          18.0
Disease of Digestive System (520-579).......        70,350          30.7
Diseases of Genitourinary System (580-629)..        21,484           9.4
Diseases of Skin (680-709)..................        32,735          14.3
Diseases of Musculoskeletal System/                 99,484          43.4
 Connective System (710-739)................
Symptoms, Signs and III Defined Conditions          77,275          33.7
 (780-799)..................................
Injury/Poisonings (800-999).................        40,708          17.8
------------------------------------------------------------------------
\1\ Hospitalizations and outpatient visits as of 12/31/2006; veterans
  can have multiple diagnoses with each healthcare encounter. A veteran
  is counted only once in any single diagnostic category but can be
  counted in multiple categories, so the above numbers add up to greater
  than 229,015.


Frequency of Possible Mental Disorders Among OIF/OEF Veterans since 2002
                                   \1\
------------------------------------------------------------------------
                                                            Total Number
                                                             of SW Asian
            Disease Category (ICD 290-319 code)             War Veterans
                                                                 \2\
------------------------------------------------------------------------
PTSD (ICD-9CM 309.81) \3\.................................        39,243
Nondependent Abuse of Drugs (ICD 305) \4\.................        33,099
Depressive Disorders (311)................................        27,023
Neurotic Disorders (300)..................................        21,084
Affective Psychoses (296).................................        14,489
Alcohol Dependence Syndrome (303).........................         6,329
Sexual Deviations and Disorders (302).....................         3,735
Special Symptoms, Not Elsewhere Classified (307)..........         3,701
Drug Dependence (304).....................................         2,798
Acute Reaction to Stress (308)............................         2,643
------------------------------------------------------------------------
\1\ Note: ICD diagnoses used in these analyses are obtained from
  computerized administrative data. Although diagnoses are made by
  trained healthcare providers, up to one-third of coded diagnoses may
  not be confirmed when initially coded because the diagnosis is ``rule-
  out'' or provisional, pending further evaluation.
\2\ A total of 83,889 unique patients received a diagnosis of a possible
  mental disorder. A veteran may have more than one mental disorder
  diagnosis and each diagnosis is entered separately in this table;
  therefore, the total number above will be higher than 83,889.
\3\ This row of data does not include information on PTSD from VA's Vet
  Centers and does not include veterans not enrolled for VHA health
  care. Also, this row of data does not include veterans who did not
  have a diagnosis of PTSD (ICD 309.81) but had a diagnosis of
  adjustment reaction (ICD-9 309).
\4\ 82 percent of these veterans (26,998) had a diagnosis of tobacco use
  disorder (ICD-9 305.1).

                                summary
     Recent Iraq and Afghan veterans are presenting to VA with 
a wide range of possible medical and psychological conditions.
     Recommendations cannot be provided for particular testing 
or evaluation--veterans should be assessed individually to identify all 
outstanding health problems.
     33 percent of separated OIF/OEF veterans have enrolled for 
VA health care since 2002 compared to 32 percent in the last quarterly 
report 3 months ago. As in other cohorts of military veterans, the 
percentage of OIF/OEF veterans receiving health care from the VA and 
the percentage with any type of diagnosis will tend to increase over 
time as these veterans continue to enroll for VA health care and to 
develop new health problems.
                              summary (2)
     Because the 229,015 Iraqi and Afghan veterans who have 
accessed VA health care were not randomly selected and represent just 
16 percent of the approximately 1.4 million recent U.S. war veterans, 
they do not constitute a representative sample of all OIF/OEF veterans.
     Reported diagnostic data are only applicable to the 
229,015 VA patients--a population actively seeking health care--and not 
to all OIF/OEF veterans.
      For example, the fact that about 37 percent of VHA patients' 
encounters were coded as related to a possible mental disorder does not 
indicate that \1/3\ of all recent war veterans are suffering from a 
mental health problem. Only well-designed epidemiological studies can 
evaluate the overall health of Iraqi and Afghan war veterans.
                              summary (3)
     High rates of VA health care utilization by recent Iraqi 
and Afghan veterans reflect the fact that these combat veterans have 
ready access to VA health care, which is free of charge for 2 years 
following separation for any health problem possibly related to wartime 
service.
      Also, an extensive outreach effort has been developed by VA to 
inform these veterans of their benefits, including the mailing of a 
personal letter from the VA Secretary to war veterans identified by DOD 
when they separate from active duty and become eligible for VA 
benefits.
     When a combat veteran's 2-year health care eligibility 
passes, the veteran will be moved to their correct priority group and 
charged all copayments as applicable. If their financial circumstances 
place them in Priority Group 8, their enrollment in VA will be 
continued, regardless of the date of their original VA application.
                               follow-up
     VA will continue to monitor health care utilization of 
recent Iraq and Afghan veterans using updated deployment lists provided 
by DOD to ensure that VA tailors its health care and disability 
programs to meet the needs of this newest generation of war veterans.

    Question 3(a). What steps has VA taken to address the Inspector 
General's recommendations regarding VA's case management for victims of 
Traumatic Brain Injury (TBI)?
    Response. The Department of Veterans Affairs (VA) developed the 
Polytrauma System of Care (PSC) to improve access to specialized 
rehabilitation services for polytrauma and TBI patients. PSC will also 
facilitate delivery of care closer to home, and provide life-long case 
management services to veterans of Operations Enduring Freedom and 
Iraqi Freedom (OEF/OIF) and active duty service members. VA facilities 
participating in the PSC are distributed geographically throughout the 
country so as to facilitate access to specialized care closer to the 
home, and to help veterans and their families to transition back into 
their home communities. Interdisciplinary teams of professionals have 
been designated at these facilities to work together to develop an 
integrated plan of medical and rehabilitation treatment for each 
veteran. In some cases, polytrauma may cause long-term impairments and 
functional disabilities. VA is committed to providing services and 
coordinating the lifelong care needs of these individuals.
    The four components of the PSC include:

     Polytrauma Rehabilitation Centers (PRC)--These four 
regional centers (Richmond, Virginia; Tampa, Florida; Palo Alto, 
California; and Minneapolis, Minnesota) are fully operational. They 
provide acute comprehensive medical and rehabilitation care for complex 
and severe injuries and serve as resources for other facilities in 
the PSC.
     Polytrauma Network Sites (PNS)--These 21 sites including 
the four PRCs, one in each of the Veterans Integrated Service Networks 
(VISN), are also fully operational. Its role is to manage the post-
acute effects of TBI and polytrauma and to coordinate lifelong 
rehabilitation services for patients within their VISN.
     Polytrauma Support Clinic Teams (PSCT)--VA has designated 
72 medical centers as sites for PSCTs. These are local teams of 
providers with rehabilitation expertise that manage patients with 
stable polytrauma sequelae and respond to new problems that might 
emerge in consultation with regional and network specialists. They 
provide proactive case management and assist with patient and family 
support services.
     Polytrauma Points of Contact (PPOC)--All other facilities 
provide local PPOCs. These are smaller facilities without the expertise 
or resources to meet the rehabilitation and prosthetic needs of the 
polytrauma patients. The PPOCs are knowledgeable of the services 
available for veteran with TBI within the VHA system of care and have 
the ability to coordinate care. Each of these facilities ensures that 
at least one person is identified to serve as point of contact for 
consultation and referral of polytrauma patients to a facility capable 
of providing the level of services required.

    The Inspector General's report included four specific 
recommendations, below is VHA response to each of the recommendations:
    Recommended Improvement Action(s) A. The Under Secretary for Health 
should improve case management for TBI patients to ensure lifelong 
coordination of care.
    Case management has a crucial role in ensuring lifelong 
coordination of services for patients with polytrauma and TBI, and is 
an integral part of the system at each polytrauma care site. PSC uses a 
proactive case management model, which requires both nurse and social 
work case managers to maintain regular contact with veterans and their 
families to coordinate services and to address emerging needs. As an 
individual moves from one level of care to another, the case manager at 
the referring facility is responsible for a ``warm hand off'' of care 
to the case manager at the receiving facility closer to the veteran's 
home. Every combat injured veteran with TBI is assigned a case manager 
at the polytrauma system of care facility closest to his or her home. 
The assigned case manager handles the continuum of care and care 
coordination, acts as the point of contact for emerging medical, 
psychosocial, or rehabilitation problems, and provides patient and 
family advocacy.
    The Office of Social Work (OSW) released VHA Handbook 1010.01, 
``Transition Assistance and Case Management for Operation Enduring 
Freedom and Operation Iraqi Freedom Veterans'' in March 2007 which 
details care and services provided to all returning veterans including 
those with seriously and mild TBI. Each combat injured veteran with TBI 
is assigned a case manager at the PSC facility closest to his or her 
home. The assigned case manager handles the continuum of care and care 
coordination, acts as the POC for emerging medical, psychosocial or 
rehabilitation problems and provides patient and family advocacy.
    A Polytrauma Telehealth Network (PTN) links facilities in the PSC 
available to support care coordination and case management. The PTN 
ensures that polytrauma and TBI expertise are available throughout the 
PSC and that care is provided at a location and time that is most 
accessible to the patient. The PTN allows provision of specialized 
expertise available at the PROs and PNSs to be delivered at facilities 
close to the veteran's home.
    Specialized rehabilitation care for patients with polytrauma and 
TBI requires a continuum of services that may include inpatient and 
outpatient rehabilitation, long-term care, transitional living and 
community re-entry programs, and vocational rehabilitation and 
employment services. The 21 PNSs have completed inventories of VA and 
non-VA TBI specific services within its VISNs. These are used to 
coordinate resources to meet individualized treatment needs of patients 
closer to home. The case managers dedicated to the PSC are responsible 
for identifying and coordinating these services for the individual 
patient as close to home as possible.
    During the August 2006 Polytrauma System of Care Conference, 
polytrauma social work case managers received training on expectations 
for proactive and continuing case management of active duty personnel 
and veterans with brain injury and polytrauma. Monthly conference calls 
are held to mentor and educate the PNS case managers.
    The OSW, in collaboration with Physical Medicine & Rehabilitation 
Service (PM&RS), has established a social work case management work 
group. This group is developing a new model of social work TBI and 
polytrauma case management that will address the care coordination, 
psychosocial and family support issues of this special population 
across different sites, levels of rehabilitation, and health care 
service delivery. This group is also identifying training needs and is 
working with the Employee Education System to offer a variety of 
educational programs. A 1-hour training session was held in January 
2007 via conference call to educate social workers concerning the signs 
and symptoms of mild to moderate TBI.
    VHA is publishing a new VHA Handbook on Transition Assistance and 
Case Management of OEF/OIF Veterans. The Handbook requires each VA 
medical center (VAMC) to appoint a master's prepared nurse or social 
worker to serve as the OEF/OIF program manager to oversee all seamless 
transition activities, coordination of care for OEF/OIF service members 
and veterans, and coordination of case management services for severely 
injured OEF/OIF service members/veterans, including those with TBI. The 
Handbook also describes the functions of 100 new transition patient 
advocates, who will be assigned to severely injured service members/
veterans, including those with TBI, and their families. Recruitment for 
the new positions is already underway.
    The Office of Seamless Transition (OST) implemented a seamless 
transition performance measure for Fiscal Year (FY) 2007. Severely 
injured OEF/OIF service members/veterans who are transferred by VA/
Department of Defense (DOD) liaisons at the military treatment 
facilities (MTF) must be assigned a VAMC case manager prior to 
transfer. This VAMC case manager must contact the service member/
veteran within 7 calendar days of notification of the transfer. OST 
developed a tracking system which the VA/DOD social work liaisons, 
stationed at the MTF, enter the patients transferring to VA into. As of 
October 2006, the tracking system automatically generates an e-mail to 
the receiving facility when the VA/DOD liaison enters a potential 
transfer date. The receiving facility assigns a case manager in the 
tracking system and the case manager must contact the patient within 7 
calendar days of notification of the transfer.
    VA has partnered with the Army Wounded Warrior (AW2) Program to 
assign an AW2 soldier and family management specialist to 22 VAMCs 
located in the VISN 21. The AW2 staff will integrate with existing 
polytrauma teams and will function as case managers for both soldiers 
and their families. They will work with soldiers, veterans and their 
families to ensure they are fully linked to VA care and benefits. 
Currently, 17 AW2 staff members are in place, with 5 more scheduled to 
begin their assignments by the end of 3rd quarter Fiscal Year 2007.
    Recommended Improvement Action(s) B: The Under Secretary for Health 
should work with DOD to establish collaborative policies and procedures 
to ensure that TBI patients receive necessary continuing care 
regardless of their active duty status, and that appropriate medical 
records are transmitted.
    The revised VA/DOD memorandum of agreement (MOA) entitled, 
``Department of Veterans Affairs (VA) and Department of Defense 
Memorandum of Agreement Regarding Referral of Active Duty Military 
Personnel Who Sustain Spinal Cord Injury, Traumatic Brain Injury, or 
Blindness to Veterans Affairs Medical Facilities for Health Care and 
Rehabilitative Services'' is currently in the Office of the Assistant 
Secretary of Defense for Health Affairs. DOD is shifting billing and 
reimbursement under this MOA from the Military Medical Support Office 
to the three TRICARE regional offices. There are no changes that impact 
the transfer of clinical care between the two agencies.
    VA and DOD have developed the capability to share electronic 
medical records bidirectionally to coordinate the care of shared 
patients. The VA/DOD Bidirectional Health Information Exchange (BHIE) 
supports the real-time bidirectional exchange of outpatient pharmacy 
data, allergy information, lab results, and radiology reports between 
all VA facilities and select DOD host sites receiving large numbers of 
OEF/OIF combat veterans such as the Walter Reed Army Medical Center 
(WRAMC), the Bethesda National Naval Medical Center (BNNMC), and the 
Landstuhl Army Medical Center in Germany. All VAMCs have the capability 
to view the DOD BHIE data. In addition to BHIE capability, VA and DOD 
have made significant progress toward sharing inpatient data. VA and 
DOD have developed the capability to permit the four VA regional 
polytrauma centers to view DOD inpatient data stored in DOD's clinical 
information system (CIS). This capability provides unprecedented access 
to electronic DOD inpatient data by VA clinicians treating patients 
transferred from DOD and enhances continuity of care between DOD and 
VA. VA and DOD also conducted successful testing of the bidirectional 
sharing of inpatient narrative and discharge summaries.
    Recommended Improvement Action(s) C: The Under Secretary for Health 
should develop new initiatives to support families caring for TBI 
patients, such as those identified by patients and family members we 
interviewed.
    VA and DOD provided a national satellite broadcast, ``Serving our 
Newest Generation of Veterans'' in May 2006. This live broadcast was 
repeated on multiple dates and times to provide VA staff opportunities 
for viewing. The continuing education program included presentations on 
understanding the military culture, providing appropriate care across 
the lifespan; addressing the needs of families of polytrauma patients 
through supportive services; educating patients, families and staff 
about polytrauma rehabilitation (which includes a video about the four 
PRCs), amputation care, cognitive issues, physical and recreation 
therapy needs of polytrauma patients; and transforming the 
rehabilitation environment to better meet the unique needs of young 
polytrauma patients.
    PM&RS National Program Office identified a subject matter expert in 
the area of therapeutic support for families dealing with stress and 
loss. During the August 2006 ``Polytrauma System of Care Conference,'' 
a nationally recognized expert, provided an educational session on the 
impact of trauma on the family, assisting families with coping and 
providing strategies for VA providers. VHA is continuing to work with 
this nationally recognized expert as a consultant. She presented at a 
conference for Polytrauma Rehabilitation Center staff and VA leadership 
in December 2006.
    OSW has held four quarterly educational conference calls for VHA 
social workers on polytrauma and seamless transition. Each call 
stressed different aspects of assessing and meeting the needs of 
families of polytrauma and other OEF/OIF patients.
    VHA has hired seven clinical staff members who are assigned to the 
Center for Intrepid Joint Services Rehabilitation Facility (Center) at 
Brooke Army Medical Center in San Antonio, Texas. VHA staff will 
provide clinical services and seamless transition services to active 
duty service members undergoing rehabilitation at the Center. VHA staff 
further provide supportive services to families such as logistical 
support (e.g., transportation), education regarding VA services, and 
case management support. An MOA for VA's role in the operation of the 
Center was signed by Secretary Nicholson in September 2006, and by the 
Secretary of the Army in January 2007. The Center was dedicated on 
January 29, 2007, and is currently receiving active duty patients for 
rehabilitation.
    The PRCs at Minneapolis, Minnesota and Palo Alto, California have 
Fisher Houses to lodge the families of active duty service members and 
veterans undergoing polytrauma rehabilitation. A Fisher House is under 
construction at the James A. Haley VA Hospital in Tampa, Florida with 
an estimated completion date of June 2007. The Fisher House Foundation 
will break ground for a new Fisher House at the PRC in Richmond, 
Virginia in late Spring/early Summer 2007, with an estimated completion 
date of Fall 2007.
    The Fisher House Foundation has plans to build three additional 
Fisher houses in 2007 (Dallas, Los Angeles, and Seattle) and 10 
additional in 2008 and 2009. The Fisher houses will support families of 
OEF/OIF patients, including polytrauma and TBI patients at the PNS.
    Each PRC and PNS has established a General Post Fund for family 
lodging and associated needs. Voluntary Service accepts donations made 
to VAMCs for family lodging into the Family Lodging General Post Fund. 
Social workers access the funds to help families defray the costs of 
hotel lodging, meals, and local transportation at facilities without 
Fisher Houses or when the Fisher House is full.
    OSW is working with the Fisher House Foundation's Hero Miles 
Program to provide free airline ticket vouchers for the families of 
polytrauma patients so they can visit the patient.
    More than 200 VHA social workers attended the Uniformed Services 
Social Work & Seamless Transition Conference in August 2006. VA hosted 
conference offered a seamless transition track with workshops on 
transferring care from DOD to VA facilities, meeting the needs of 
families, treating combat stress and post traumatic stress disorder 
(PTSD), and working with veterans suffering from polytraumatic 
injuries.
    Recommended Improvement Action(s) D: The Under Secretary for Health 
should work with DOD to ensure that rehabilitation for TBI patients is 
initiated when clinically indicated.
    In April 2006, a VA/DOD TBI Executive Board was established. A TBI 
Summit was held in September 2006 that brought together non-VA, DOD, 
and VA subject matter experts to discuss contemporary practice 
concerning the identification and treatment of individuals with brain 
injuries. Outcomes of this meeting included identification of priority 
issues, and building consensus across DOD and VA concerning case 
management, assessment and treatment.
    In April 2007, VA sponsored a conference to educate VA and DOD 
staff about services and programs for OEF/OIF veterans. Specialized 
educational tracts included mental health, polytrauma and TBI, 
diversity and women's health, pain management, seamless transition, and 
prosthetics and sensory aids. Each VISN developed an action plan for 
management of OEF/OIF veterans.
    A VA/DOD rehabilitation nurse liaison has been hired and assigned 
to WRAMC in September 2006. This individual monitors and follows the 
severely injured, assesses readiness for rehabilitation, communicates 
closely with the rehabilitation nurse admission case managers at the 
PRCs, provides updates on medical status, functional status, recovery 
progress, and nursing care issues. The rehabilitation nurse liaison 
will have close contact with families, providing education concerning 
impairments, rehabilitation process, and orientation to VA PRCs. A 
second nurse liaison is being hired for BNNMC, and should be in place 
by September 2007.

    Question 3b. Additionally, can you please address Denise Mettie's 
concerns about the care afforded to her severely brain injured son, 
including the fact that he was not initially referred to a Polytrauma 
Center?
    Response. While at National Naval Medical Center, this severely 
injured veteran was referred to the PSC and evaluated by the Palo Alto 
VA PRC. Considering the medical presentation of the patient, plans were 
made to move him to a PNS closer to his family--the Puget Sound VA 
Medical Center. The Polytrauma case manager has worked closely with the 
veteran's family, coordinating evaluations from another VA PRC and two 
private sector facilities. All consulting medical facilities concur 
that his care needs are currently best met by a skilled nursing 
facility. The case manager continues to be actively involved in his 
care and support of his family.

    Question 4. I am concerned that some younger veterans have been 
placed into long-term care facilities intended for older patients with 
dementia or other age-related conditions. It seems that the need for 
age-appropriate care for some of our younger veterans has been well 
established. What is VA doing to ensure that younger veterans with 
traumatic brain injuries receive this type of long-term care, including 
opportunities for continued therapy and mental stimulation, if 
warranted?
    Response. VA is taking measures to recognize the generational 
differences of this population and incorporate them into the care 
routines as well as cohort them in the nursing home with populations 
that are similar in ability to communicate and interact. In VA nursing 
homes, transforming the culture of care to make the living space more 
home-friendly is important. Having an Internet cafe, computer games, or 
age appropriate music and videos available for nursing home residents 
is necessary. Allowing for family, especially children, to visit, and 
perhaps even stay over when needed; personalizing care routines such as 
bathing and dining times; offering food items that are palatable to 
younger persons are examples of the changes occurring in VA nursing 
home care. Unlike other cohorts of veterans in nursing home care, this 
cohort thrives on independence, is physically strong, and is part of a 
generation socialized differently than their older counterparts.
    VA has and will continue to admit young veterans into VA nursing 
homes when the veteran presents with sufficient functional impairment 
or health care needs that cannot be adequately addressed in a home and 
community based setting. Many returning veterans are presenting with 
multiple and severe disabilities including speech, hearing and visual 
impairment as well as loss of limbs and compounded with behavioral 
issues due to the stress of combat as well as brain injury. In 
addition, they have families, including children, who want to be 
actively involved in their care.

    Question 5. Denise Mettie's testimony touched on the need of 
families of veterans with traumatic brain injuries for support and 
assistance during the initial rehabilitation stage and throughout 
subsequent years. How does VA plan to provide these families with the 
support and training that they need in order to successfully care for 
their loved ones?
    Response. Consistent with VA's legal authorities, while patients 
are being treated in an inpatient setting at a PRC, their families have 
access to the following services:

     A social work case manager who is responsible for 
coordinating care, ensuring access to psychosocial services for patient 
and family, providing caregiver support within their scope of practice, 
and coordinating support services to meet family needs.
     Accommodations at a Fisher House, if available, hotel 
accommodations where a Fisher House is not yet available, 
transportation, telephone cards, and gift certificates for meals and 
entertainment.
     Clinical psychologists and social work case managers who 
facilitate caregiver support groups and/or individual interventions to 
address issues such as the role of bereavement in family transition, 
expected role changes within the family, intra-familial conflicts, 
marital strife, and other family stressors.
     Referrals as appropriate to mental health or medical 
resources.
     Chaplain services providing counseling and spiritual 
support for families and caregivers.

    Consistent with VA's legal authorities, while patients are being 
treated in the outpatient setting at a PNS or by a PSCT, their families 
have access to the following services:

     Interdisciplinary team that includes a social work and 
nurse case manager. Clinical and psychosocial case management and 
coordination of the veteran's lifelong care needs by an 
interdisciplinary team.
     VA paid home care services (skilled home nurse care, home 
health aide, homemaker, respite care, adult day health care) required 
by the veteran.
     VA Home and Community Care Services (home based primary 
care, adult day health care).
     A 24/7 Polytrauma helpline through the call center 
operated by the Dayton VAMC.
     VA Vet Centers that offer counseling services to combat 
veterans and their families/significant others to help with 
readjustment issues, including treating combat stress and PTSD and 
helping families and caregivers deal with the effects of combat 
service.

    For those patients that require long term care, VA provides access 
to the following services:

     VA nursing home care units with access to rehabilitation 
therapies.
     Contract nursing home care in the local community.
     VA medical foster care.
     Veterans and their families continue to receive 
psychosocial support and case management throughout the continuum of 
care.
                                 ______
                                 
Response to Written Questions Submitted by Hon. John D. Rockefeller IV 
   to Michael J. Kussman, M.D., Executive-in-Charge, Veterans Health 
             Administration, Department of Veterans Affairs
    Question 1. What is the VA policy regarding health care 
professionals and research experts who are willing to volunteer their 
expertise for the care of returning veterans?
    Response. VHA Handbook 1620.1, dated July 15, 2005 provides 
direction for healthcare professional volunteers. Volunteer assistance 
by physicians, dentists, nurses, and other professionally licensed 
persons to assume full responsibility for professional services in 
their respective fields may be accepted under certain circumstances. 
All such volunteer assignments must first be approved in advance by the 
facility chief of staff, or designee, who must ensure that any 
resulting volunteer appointment is first processed through all 
applicable credentialing and privileging procedures as described in VHA 
Handbook 1100.19. Any volunteer serving in this capacity must have 
appropriate training, work under the supervision of a VA compensated 
clinical staff member, and meet the other criteria for acceptance as a 
volunteer in VA's Voluntary Service (VAVS) program. Limited health care 
procedures, not requiring certification, can be approved as volunteer 
assignments by the clinical service involved. Any volunteer serving in 
this capacity must have appropriate training, work under the 
supervision of a VA compensated clinical staff member, and meet the 
other criteria for acceptance as a volunteer in the VAVS Program. The 
assignment must be in the area of supplementary assistance, and may be 
performed by either a lay or professionally licensed person working as 
a volunteer.
    In addition, the professional may not be assigned to their ``area 
of expertise.'' For example, a surgeon may not be assigned to be in an 
area where they would perform surgery. We would use them where their 
skills could best serve the veteran and enhance patient care.

    Question 2(a). Can you provide information on the number of VA 
rehabilitation beds and services?
    Response. VA supports 1768 rehabilitation beds nationwide--578 
inpatient rehabilitation beds, 241 beds allocated for blind 
rehabilitation, and 949 spinal cord injury (SCI) specialty beds. 
Additionally, VA has implemented a rehabilitation treatment specialty 
within nursing homes to further expand availability of rehabilitation 
services for veterans as necessary.
    VA provides highly specialized acute inpatient rehabilitation for 
veterans and active duty service members with TBI and polytrauma at 
four Level I PRCs. Each PRC has 12 rehabilitation beds (48 of the total 
578 inpatient beds) that are accredited for brain injury rehabilitation 
and comprehensive rehabilitation by the Commission for Accreditation of 
Rehabilitation Facilities (CARF). Referral patterns and bed occupancy 
at the PRC are monitored on a weekly basis and VA has consistently 
maintained adequate capacity for patients with polytrauma/TBI.
    An additional 245 rehabilitation beds (of the total 578 inpatient 
beds) are located across 17 Component II PNS that are not co-located 
with a PRC. These beds are CARF accredited for comprehensive inpatient 
rehabilitation and have not required a high demand for inpatient care 
to date; i.e., typically one or two OIF/OEF inpatients at a time.

    Question 2(b). What action has VA taken to date to provide for such 
care, and what are the long term costs to maintain such capacity?
    Response. VA's General Purpose Funding is distributed to its 
facilities based on the Veterans Equitable Resource Allocation (VERA) 
model, which includes funding to maintain capacity for rehabilitation 
care. Conditions such as TBI, SCI and blindness are specifically 
addressed for funding as separate patient classes within the complex 
care group. Long range planning models for these groups of patients use 
higher incidence and prevalence statistics to account for combat-
related injuries.
    Additionally, the PRC and PNS receive Special Purpose Funding from 
VA Central Office to support a portion of the rehabilitation 
specialists, consultants, staff training, and equipment used in 
rehabilitation care. The VISNs and medical centers have also provided 
additional resources to meet specific program needs.

    Question 2(c). Has VA considered other rehabilitation centers to 
meet immediate needs?
    Response. VA contracts with the private sector to provide services 
to eligible veterans as a complement to its system of care whenever 
indicated and authorized. Decisions to contract care are determined 
based on the needs of the individual patient, and VA staff coordinates 
episodes of contracted civilian care in support of the continuum of 
lifelong care for veterans with long-lasting disabilities.

    Question 3. What new research is VA undertaking or commissioning to 
study the interactions of TBI and PTSD? What research is VA doing on 
the effects of vision loss and hearing loss on TBI diagnosis and care?
    Response. VA's Office of Research and Development (ORD) supports a 
broad portfolio in TBI and related neurotrauma research and estimates 
devoting over $29.6 million to this research in Fiscal Year 2007.
    This includes studying the interactions of TBI and PTSD. In one 
ongoing study, VA researchers collaborating with DOD are collecting 
risk factor and health information from military personnel prior to 
their deployments to Iraq. These soldiers will be reassessed upon their 
return and several times after that to identify possible changes that 
occurred in emotions or thinking as a result of their combat exposures, 
and to identify predisposing factors to PTSD as well as other health 
conditions. A goal of this study is to determine whether 
neuropsychological findings observed from pre- to post-deployment 
persist until long-term follow-up, and to examine the associations at 
long-term follow-up of neuropsychological changes and self-reported 
traumatic brain injury with the development of PTSD.
    ORD has also issued a solicitation for new research in combat 
casualty neurotrauma seeking to advance treatment and rehabilitation 
for veterans who suffer TBI and other traumas from improvised explosive 
devices and other blasts. The solicitation is still active and 
applicants are asked to pay special attention to cooperative projects 
in TBI with DOD, including co-morbid conditions with TBI such as PTSD. 
ORD has also issued a special solicitation for new research on TBI and 
polytrauma (i.e., combinations of multiple injuries, including brain 
injuries, sensory loss, nerve damage, infections, emotional problems, 
amputations and/or spinal cord injuries) that includes studying the 
interactions of TBI and PTSD.
    These solicitations are also seeking new research examining sensory 
loss and TBI. Ongoing ORD projects in this area are aiming to identify 
and characterize deficits in neural processing relevant to vision and 
hearing among veterans suffering from blast-related injuries, including 
those with TBI, and to develop effective rehabilitation therapies that 
improve visual and hearing functions important to everyday life. The 
overarching goals of these projects are to develop earlier detection 
strategies and enhanced treatment of blast-related injuries with 
respect to hearing, vision and potentially other important neural 
consequences.
    In addition, VA recently established a Polytrauma and Blast-Related 
Injury Quality Enhancement Research Initiative (PT/BRI QUERI) 
coordinating center to use the results of research to promote the 
successful rehabilitation, psychological adjustment and community 
reintegration of OEF/OIF veterans. The scope of the PT/BRI QUERI 
includes the full range of health problems, healthcare system and 
psychosocial factors that impact returning veterans, and focuses on the 
complex pattern of co-morbidities and related functional problems and 
healthcare needs among the combat-injured. The PT/BRI QUERI links VA 
investigators with VA's polytrauma system of care, including the four 
lead centers located in Minneapolis, Richmond, Tampa, and Palo Alto. 
The polytrauma QUERI has two particular emphases: (1) to accelerate the 
diffusion and use of new knowledge generated by VA research in the 
areas of traumatic brain injury, sensory loss, prosthetics and 
amputation, and (2) to identify and address the needs of informal 
caregivers such as spouses or parents in order to allow veterans to 
remain in home and community-based settings.

    Question 4. What type of comprehensive screening is VA doing for 
returning veterans on 161, PTSD, vision loss, and hearing loss?
    Response. In regards to screening veterans for TBI, VA has 
developed a comprehensive approach to screening and evaluation of TBI 
by implementing a mandatory TBI screening clinical reminder across the 
VA. This includes a screening instrument that uses a data system prompt 
with an algorithm to refer patients with positive screens to a Level II 
or Level Ill polytrauma team for complete evaluation. All OIF/OEF 
veterans receiving medical care in VA facilities will be screened for 
possible TBl. The patient's medical record is checked at every visit 
through the use of computerized clinical reminders, software built into 
VHA's electronic medical record, to determine if screening has been 
completed. If screening was missed or has not yet done, VA providers 
will be ``reminded'' through the use of the computerized clinical 
reminder to perform screening. This approach helps ensure that patients 
who may have been missed or came before screening was mandatory get 
screened. Those who screen positive for TBI will be offered further 
evaluation and treatment by clinicians with expertise in the area of 
TBI.
    Veterans receive comprehensive eye examinations by ophthalmologists 
and/or optometrists in VAMC Eye Clinics. Veterans documented with 
vision loss are referred to VAMC Low Vision Clinics and Blind 
Rehabilitation Centers, where they receive clinical visual 
rehabilitation examinations by Optometrists or Ophthalmologists. Vision 
rehabilitation therapists at these centers conduct functional vision 
assessments to determine veterans' abilities in activities of daily 
living, literacy abilities, orientation and mobility, etc. Patients 
with moderate to severe polytrauma and TBI receive vision evaluations 
as part of the comprehensive rehabilitation management procedures.
    VA does not routinely screen returning veterans for hearing loss; 
however, active duty service members receive a post-deployment health 
survey that addresses hearing-related concerns. Audiology services are 
routinely provided for veterans injured on active duty and undergoing 
physical evaluation boards within MTFS. Injured veterans transferred to 
the VA health care system are typically screened for hearing loss by an 
audiologist or speech-language, and more comprehensive evaluation and 
treatment is completed by an audiologist as warranted (e.g., hearing 
aids, assistive alerting and listening devices, cochlear implants). All 
veterans with hearing concerns may file a claim for military service-
related disability with the Veterans Benefits Administration.
    VA screens all returning veterans who come to VA for care for PTSD, 
depression and alcohol abuse using questions that are used annually for 
all veterans. A screening tool for mild TRI is currently being released 
nationally.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Bernard Sanders 
   to Michael J. Kussman, M.D., Executive-in-Charge, Veterans Health 
             Administration, Department of Veterans Affairs
    Question 1. Is screening for TBI and PTSD currently mandatory at 
VA? If so, then what efforts are being made to re-screen those veterans 
that may have been missed or misdiagnosed, when they first returned, 
before screening was mandatory?
    Response. Screening for PTSD has been mandatory since 2004 for all 
veterans, and screening for TBI in OEF/OIF veterans became mandatory as 
of April 2, 2007.
    Enrolled veterans who screen positive for PTSD or other mental 
disorders are assessed to determine if the diagnosis is accurate or if 
there are other problems which need treatment. If a patient is found to 
have a problem other than PTSD, that condition is treated. Also there 
is re-screening of all enrolled OEF/OIF veterans for PTSD every year 
for the first 5 years after the initial screen. There is also annual 
re-screening for depression and alcohol abuse.
    In regards to screening veterans for TBI, VA has developed a 
comprehensive approach to screening and evaluation of TBI by 
implementing a mandatory TBI screening clinical reminder across VA. 
This includes a screening instrument that uses a data system prompt 
with an algorithm to refer patients with positive screens to a Level II 
or Level III polytrauma team for complete evaluation. All OEF/OIF 
veterans receiving medical care within the VA will be screened for 
possible TBI. The patient's medical record is checked at every visit 
through the use of computerized clinical reminders, software built into 
VHA's electronic medical record, to determine if screening has been 
completed. If screening was missed or has not yet done, VA providers 
will be ``reminded'' through the use of the computerized clinical 
reminder to perform screening. This approach helps ensure that patients 
who may have been missed or came before screening was mandatory get 
screened. Those who screen positive for TBI will be offered further 
evaluation and treatment by clinicians with expertise in the area of 
TBI.
    Question 2. Can you tell me how many veterans in Vermont are 
currently being treated for TBI? And PTSD? Since there are reports of 
reoccurrence of PTSD with older veterans, please break down the answers 
for PTSD into two categories: OEF/OIF and all other veterans. Please 
also provide the answers to the above questions for New England as a 
whole. In addition, how many veterans have been diagnosed with TBI or 
PTSD but have not sought treatment? Again, please break down the 
answers for PTSD into two categories: OEF/OIF and all other veterans. 
Please also provide the answers to the above questions for New England 
as a whole. My staff has asked VA for this data but has not received 
it. This information is crucial for my office to understand the patient 
levels that the facilities in my state and surrounding states should 
plan for and are currently serving.
    Response. The Defense Manpower Data Center roster of 686,306 OEF/
OIF veterans was matched against VA's inpatient (PTF) and outpatient 
(OPC) treatment records to retrieve all VA treatment data as of 
December 31, 2006. A total of 229,015 veterans have sought care from a 
VAMC from the start of OEF in October 2001 to December 2006. Using 
these health care records, 129 OEF/OIF veterans were identified as 
having been evaluated or treated for a condition possibly related to a 
TBI from VISN 1.
    These conditions are listed as follow:

     ICD-9-CM 310.2: Postconcussion Syndrome: n=21
     ICD-9 CM 800: Fracture of skull: n=0
     ICD-9 CM 801: Fracture of base of skull: n=0
     ICD-9 CM 802: Fracture of face bones: n=27
     ICD-9 CM 803: Other and unqualified skull fracture: n=0
     ICD-9 CM 804: Multiple fractures involving skull or face 
with other bones: n=1
     ICD-9 CM 850: Concussion: n=47
     ICD-9 CM 851: Cerebral laceration and contusion: n=1
     ICD-9 CM 852: Subarachnoid, subdural, and extradural 
hemorrhage, following injury: n=0
     ICD-9 CM 853: Other and unspecified intracranial 
hemorrhage following injury: n=0
     ICD-9 CM 854: Intracranial injury of other and unspecified 
nature: n=41
     ICD-9 CM 950: Injury to optic nerve and pathways: n=2

    Of these 129 veterans, 18 patients resided in Vermont.
    Because there is no ICD-9 code specific to TBI, the above number 
should be considered tentative and provisional. The sum of the number 
of patients corresponding to each ICD-9 code (n=140) is more than 129 
because a patient may carry more than one ICD-9 code.
    VHA does not have data on veterans diagnosed with TBI or PTSD who 
have not sought treatment.
    VISN 1 specific OIF/OEF veterans coded with potential PTSD through 
1st Qt Fiscal Year 2007


                    Number of Unique OIF/OEF Veterans with PTSD Using VA Facilities During  Fiscal Year 2002-1st Qt Fiscal Year 2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                           Inpatients          Outpatients       Total Patients\1\         Vet Centers\4\
                                                     ------------------------------------------------------------------------------------------   Grand
                    VISN-Facility                                                                                               Sub-            Total\5\
                                                      Primary\2\   Any\3\  Primary\2\   Any\3\  Primary\2\   Any\3\    PTSD     PTSD    Other
--------------------------------------------------------------------------------------------------------------------------------------------------------
1-BEDFORD...........................................          9        29        162       181         62       186       44        6       51       222
1-BOSTON............................................         25        66        485       565        488       581      270       18      430       713
1-MANCHESTER........................................                             142       179        142       179      123        9      441       261
1-NORTHAMPTON.......................................         18        24        159       171        160       172       77        1    1,416       209
1-PROVIDENCE........................................         11        30        296       348        297       352      106        1      676       404
1-TOGUS.............................................          2        12        240       282        240       285      220       78      373       410
1-WEST HAVEN........................................          6        17        441       483        441       484      186        8      543       556
1-WHITE RIVER JCT...................................         10        15        180       229        180       230      110      726      539       306
    VISN 1..........................................         77       178      2,008     2,312      2,010     2,329    1,136      847    4,469     2,906
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ The ``total patient'' counts were generated by matching a cumulative roster of 686,306 unique OIF/OEF veterans, who had been separated from active
  duty as of November 30, 2006, with VA inpatient (PTF) and outpatient (OPC) databases for Fiscal Year 2002, 2003, 2004, 2005, 2006 and through 1st Qt
  Fiscal Year 2007. The DOD Defense Manpower Data Center identified and provided the identity of these veterans to the VA Environmental Epidemiology
  Service on January 11, 2007.
\2\ The number for ``Primary'' indicates the total number of unique veterans whose primary reason for the inpatient or outpatient visit was for
  treatment or evaluation of PTSD.
\3\ The number for ``Any'' indicates the total number of unique veterans with PTSD, whether or not the primary reasons for the inpatient or outpatient
  visit was for treatment or evaluation of PTSD.
\4\ The Vet Center counts were based on matching the DMDC OIF/OEF roster with Vet Center user's record through 1st Qt Fiscal Year 2007.
\5\ The number for ``Grand Total'' (n=4552l) indicates the sum of ``Any Total Patients''(n=39243) and ``Vet Center PTSD'' (n=11660) after excluding
  known duplicates (n=5382).


    The overall number of unique veterans in VISN 1 who received 
treatment for PTSD in FY 2006 was 19,356.

    Question 3. What do you think of mandatory mental health screening 
by DOD for all service members that are deployed, when they return from 
service? Could this help remove the stigma of service members having to 
ask for mental health treatment, if everyone was required to be 
screened for mental health issues?
    Response. DOD currently screens all returning service members for 
health issues when they return from deployment using the Post 
Deployment Health Assessment (PDHA) and again 3-6 months post 
deployment using the Post Deployment Health Reassessment (PDHRA). Both 
the PDHA and PDHRA include mental health questions. VA also has 
mandatory screening of OEF/OIF veterans who come to VA for care using 
questions on PTSD, depression and alcohol abuse. These questions are 
the same as those used annually to screen all veterans. It is believed 
that screening all service members and veterans is an approach that can 
reduce stigma and at the same time ensure assessment of the population 
at risk.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Johnny Isakson 
    to Michael Kussman, M.D., Executive-in-Charge, Veterans Health 
             Administration, Department of Veterans Affairs
    Question 1: Do you have any plans to expand the Active Duty 
Rehabilitation program at the Augusta VA Medical Center?
    Response: The Department has no current plans to expand the Active 
Duty Rehabilitation program at the Augusta Veterans Affairs Medical 
Center (VAMC). The Augusta Department of VAMC has been able to meet the 
military's needs for all inpatient rehabilitation referrals; 93 percent 
of the referrals come from the southeast regional medical command. Fort 
Gordon remains the primary referral source with 66 percent of 
referrals, followed by 10 percent from Fort Campbell and 7 percent from 
Fort Stewart. The occupancy rate for the 30-bed active duty 
rehabilitation (ADR) inpatient unit at the Augusta VAMC has increased 
in recent months from 35 percent to 86 percent, VA will continue to 
monitor occupancy rates to determine the need for additional 
rehabilitation services in the future.

    Question 2: Do you have any plans to expand the Active Duty 
Rehabilitation program to other VA Medical Centers across the country?
    Response: The Veterans Health Administration (VHA), in consultation 
with the Department of Defense (DOD), is presently evaluating the need 
for additional polytrauma rehabilitation centers (PRC) to augment the 
services currently being provided at VAMCs across the country. VHA 
currently provides the highest quality medical, rehabilitation, and 
support services for veterans and active duty servicemembers through 
the VHA integrated polytrauma/traumatic brain injury (TBI) system of 
care, consisting of: (1) four regional polytrauma/TBI rehabilitation 
centers providing acute intensive medical and rehabilitation care for 
complex and severe polytraumatic injuries; (2) 21 polytrauma/TBI 
rehabilitation network sites, which implement the post-acute 
rehabilitation plan of care; and (3) 72 polytrauma/TBI support clinic 
teams located at local medical centers throughout the 21 Veterans 
Integrated Service Networks (VISN), which provide routine follow-up of 
care for veterans with a history of TBI and polytrauma.

    Question 3: Do you feel that treating active duty troops at VA 
medical centers benefits the Department of Veterans Affairs?
    Response: VA mission is to ``care for him who has borne the 
battle.'' Meeting the comprehensive health care needs of returning 
Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) 
veterans and servicemembers is the Departments highest priority. VA 
works closely with the Department of Defense to ensure our returning 
servicemen and women receive the highest quality of care and seamless 
transition of benefits, without regard to where their care is provided.

    Chairman Akaka. Thank you very much, Dr. Kussman.
    Ms. Embrey?

        STATEMENT OF ELLEN P. EMBREY, DEPUTY ASSISTANT 
     SECRETARY, HEALTH AFFAIRS/FORCE HEALTH PROTECTION AND 
                READINESS, DEPARTMENT OF DEFENSE

    Ms. Embrey. Mr. Chairman, thank you very much the 
opportunity to be here today. On behalf of the Assistant 
Secretary of Defense for Health Affairs, I am going to be 
talking to you about health care needs of returning 
servicemembers and new veterans.
    The Department of Defense, and the military health system 
specifically, is committed to protecting the health of our 
servicemembers, providing the best and world-class health care 
to more than 9 million beneficiaries and coordinating the 
transition of servicemembers' medical care to the Department of 
Veterans Affairs whenever necessary and appropriate.
    Over the last several years, our two Departments have 
fostered a more effective, aligned Federal health care 
partnership by coordinating and developing common health care 
and support services along the continuum of care. The Global 
War on Terrorism has posed a particular challenge to both 
Departments in adapting particularly for long-term 
rehabilitative care for our complex wounded, injured, and ill 
combat veterans. We owe very much to them, as demonstrated by 
the first panel, for their sacrifice to our Nation, and we are 
committed to working together to ensure that they get the very 
best that our health systems can offer and, consistent with Dr. 
Gans' testimony, working with the civilian industry if that is 
appropriate to get them the best care that they need.
    The DOD/VA Joint Executive Council established the core 
partnership, a strategic plan and goals to better align and 
coordinate the health and benefits services of each of our two 
Departments.
    Before continuing more about these efforts, I would like to 
briefly discuss the Department of Defense response to the 
recent findings of inadequate administration of support 
services, care coordination, and disability processing.
    The Department of Defense is strongly committed to taking 
corrective actions to improve performance in these areas. 
Secretary Gates has formed an Independent Review Group to 
advise him on the actions that need to be taken, and they have 
45 days to complete their assessment, and that is coming up 
here very shortly.
    In addition, each military department has undertaken a 
focused review to take actionable actions immediately as they 
find them. And the Under Secretary of Defense for Personnel and 
Readiness, Dr. David Chu, has convened a working group to 
assess ways to improve the policies and programs of the 
Department based on the results of these ongoing reviews.
    DOD is also cooperating with the President's Commission, as 
well as the interagency Veterans Affairs task force that was 
established to review these matters as well.
    DOD's collective focus in these areas is on five major 
programs: facilities; caseworkers and case managers, along with 
the family support that goes with that; the disability 
determination process; traumatic brain injuries and treatment 
of severely injured; and post-traumatic stress disorders and 
mental health.
    With respect to TBI, or traumatic brain injury, I thank you 
very much and your distinguished colleagues in Congress for 
your interest and support in expanding TBI research and 
treatment within the Department.
    Now, I would like to refocus my remarks on overall DOD and 
VA partnerships in health care. The VA and DOD established and 
collaborated on the use of Joint Incentive Fund to eliminate 
budgetary constraints as a possible determinant for that 
sharing. Designated funding covers startup costs associated 
with innovative and unique sharing agreements, and at the end 
of 2006, 47 Joint Incentive Fund projects accounting for $88.8 
million of the $90 million in the fund has been approved by the 
Executive Health Council. We are jointly staffing DOD and VA 
Federal health facilities at several locations around the 
country and have sharing agreements between DOD medical 
treatment facilities and Reserve component units with 157 VA 
medical centers.
    This increased sharing has facilitated improved but not 
perfect coordinated transition of servicemember care from DOD 
to VA. This transition involves effectively managing medical 
care and benefits during the transition from active duty to 
veteran status to ensure continuity of care and services.
    The Department has been working with VA on streamlining and 
better aligning our support for coordinated transition in three 
main areas: medical care and disability benefits, transition to 
home and community, and sharing servicemember personnel and 
health information. The first panel spoke to all three of these 
and the issues that are at hand and the challenges before us.
    Servicemembers who transition directly from DOD medical 
treatment facilities to one of the VA polytrauma centers are 
met by a familiar face in uniform. In 2006, the VA expanded 
their 4 centers for polytrauma to a polytrauma network with an 
additional 21 sites, and DOD assets will be there as well. The 
VA has placed their assets in our military treatment 
facilities. Their Joint Seamless Transition Program has been 
worked by the VA in coordination in with the military services 
and which facilitates a more timely receipt of benefits for the 
severely injured servicemembers while they are still on active 
duty. There are currently 12 VA social workers and counselors 
assigned at 10 military treatment facilities.
    As of the end of last month, VA social workers supported 
7,082 new patient transfers to the Veterans Health 
Administration from participating military hospitals. The VA 
has also placed liaisons at each of our three TRICARE regional 
offices to enhance communications and coordination between us 
to better support our shared beneficiaries.
    DOD and VA partnering has been a key focus with respect to 
shaping common clinical services for our beneficiaries. An area 
of particular concern is our shared clinical focus on 
identification and treatment and follow-up for traumatic brain 
injuries. DOD fielded a clinical practice guideline for the 
management of mild TBI in CENTCOM, the theater of operations, 
in August of 2006, including requiring field use of a standard 
military acute concussion evaluation tool to assess in the 
field and document TBI for medical records upon return.
    Efforts to build a more comprehensive DOD-wide program, 
including VA experts, is now underway to establish common 
protocols and procedures to identify, treat, document, and 
follow up on those who have suffered a TBI while either 
deployed or in garrison.
    I see that my time is up, and I would be happy to yield the 
floor back to the Chairman for further questions.
    [The prepared statement of Ms. Embrey follows:]
  Prepared Statement of Ellen P. Embrey, Deputy Assistant Secretary, 
  Health Affairs/Force Health Protection and Readiness, Department of 
                                Defense
    Thank you, Mr. Chairman, for the opportunity to speak to you today 
on behalf of the Assistant Secretary of Defense for Health Affairs 
regarding the health care needs of returning servicemembers and new 
veterans.
    The Department of Defense, and the military health system in 
particular, is committed to protecting the health of our 
Servicemembers, providing world-class healthcare to more than 9 million 
beneficiaries, and, seamlessly coordinating the transition of 
Servicemembers' medical care to the Department of Veterans Affairs (VA) 
whenever necessary.
    Over the last several years, our two Departments have made 
significant strides in coordinating and developing common health care 
and support services along the entire continuum of care. Both agencies 
have been making concerted efforts to work closely to maintain and 
foster a more effective, aligned Federal healthcare partnership. The 
Global War on Terrorism poses a challenge to both Departments, as the 
severity and complexity of wounds, and the increased survival rates 
yield increasing demands on our system for long term rehabilitative 
care for our wounded, injured and ill combat veterans. We owe much to 
them for their sacrifice to our nation, and we are committed to work 
together to ensure they get the very best that our health systems can 
offer, and keeping their associated bureaucratic burdens to a minimum.
    In April 2003, a DOD-VA Joint Executive Council (JEC), chaired by 
the Under Secretary of Defense for Personnel and Readiness and the 
Deputy Secretary of the Department of Veterans Affairs, was established 
to jointly set strategies, goals and plans to better align and 
coordinate the health and benefit services of the two Departments. The 
JEC meets quarterly to review progress against the mutually developed 
plans.
    The VA/DOD Joint Strategic Plan reflects common goals from both the 
VA Strategic Plan and the Military Health System (MHS) Strategic Plan--
and specifically articulates the shared goals and objectives developed 
and ratified by DOD/VA leadership. Three weeks ago, Dr. David S.C. Chu, 
Under Secretary of Defense for Personnel and Readiness, and Mr. Gordon 
H. Mansfield, Deputy Secretary, Department of Veterans Affairs, 
directed additional joint initiatives to improve alignment, leverage 
shared resources, and improve delivery of care to our returning combat 
veterans.
    The spectrum of DOD-VA collaboration and sharing activities 
encompasses clinical services, education and training, research and 
development, patient administration, and information/data technology 
sharing. Before providing an overview of these activities, I'd like to 
briefly highlight the Departments' response to the recent findings of 
inadequate administration of support services, care coordination, and 
disability processing. The Department is strongly committed to taking 
corrective actions to improve performance in these areas. Secretary 
Gates has formed an Independent Review Group (IRG) to advise him on 
actions that need to be taken, each Military Department has undertaken 
a focused review of these matters, and the Under Secretary of Defense 
for Personnel and Readiness Dr. Chu, has convened a working group to 
assess ways to improve policies and programs based on the results of 
these ongoing reviews. DOD is also cooperating with the President's 
Commission on Care for America's Returning Wounded Warriors and is 
participating actively in the Interagency Task Force on Returning 
Global War on Terror Heroes.
    DOD's collective focus is centered on five major program areas:
    1. Facilities. DOD's medical facilities, outpatient housing, 
medical barracks, and the full spectrum of hotel services provided by 
the Department are being assessed to ensure standards of quality our 
Servicemembers and families expect and deserve are met.
    2. Case Workers/Case Managers and Family Support. Practices for 
case management, including care coordination, case-manager-to-patient 
ratios, family support models, and related support services are being 
assessed to ensure our wounded and ill Servicemembers get needed 
support throughout their healthcare delivery and rehabilitation, 
regardless of whether their care is delivered in DOD or VA facilities. 
In some instances, patients will continue to obtain care in both 
systems. For that reason, establishing case-management protocols and 
systems that seamlessly support all configurations of care in both 
systems is a high priority.
    3. Disability Determination Processes. Medical, personnel, and 
disability-benefit determination experts within and outside the DOD are 
actively involved in an effort to develop and recommend a streamlined 
process that minimizes delay while providing fair, consistent, and 
timely determinations for all Servicemembers.
    4. Traumatic Brain Injuries (TBI) and Treatment of the Severely 
Injured. Since the Global War on Terrorism began, DOD has been 
collaborating with VA on the full spectrum of combat wounds, injuries 
and associated illnesses, particularly those occurring as a result of 
improvised explosive devices. Both Departments are working together to 
identify best practices for providing and supporting highest quality 
acute and long term care for severely injured and ill servicemembers, 
as well as to determine the most effective means to screen, diagnose, 
and treat individuals who experience a TBI. Civilian TBI experts and 
researchers are important collaborators to both Departments in shaping 
how to apply available research outcomes in establishing an evidence-
based, comprehensive program in both systems to detect, diagnose and 
treat this health risk to our servicemembers and veterans.
    5. Post-Traumatic Stress Disorder (PTSD)/Mental Health. The short-
term and long-term mental health needs of our Servicemembers and 
veterans are major priorities of both Departments. To further 
transition support, a VA/DOD Mental Health Working Group was formed in 
2003 under the Joint Executive Council to focus specifically on mental 
health initiatives and transition of care. DOD continues to critically 
evaluate its capabilities, policies and programs to ensure effective 
support for returning servicemembers and new veterans' mental health 
needs, including their families. This includes looking at improved 
methods of information sharing from VA medical records regarding mental 
health conditions and treatments for Reserve Component members that may 
contraindicate future deployments. With the renewed support of the line 
commanders and leaders, new approaches to reducing the stigma of 
seeking mental-health treatment will be explored. We will continue to 
pursue expanded opportunities for collaboration with VA to ensure the 
coordinated transition of veterans with mental-health needs.
    Supporting all of these collaborative efforts, we will continue to 
grow, enhance, align, and integrate the technology infrastructure that 
supports both systems, enabling greater access to clinical and 
administrative information for the benefit of the people we serve.
    The following provides greater detail on our comprehensive sharing 
initiatives:
                     overall dod-va sharing efforts
    As a result of the National Defense Authorization Act for Fiscal 
Year 2003, VA and DOD have been actively collaborating on a wide 
spectrum of joint initiatives. Section 721 of that Act required that 
the departments establish, and fund on an annual basis, an account in 
the Treasury referred to as the Joint Incentive Fund (JIF). The JIF 
provides a means to eliminate budgetary constraints as a possible 
deterrent to sharing initiatives by providing designated funding to 
cover the startup costs associated with innovative and unique sharing 
agreements. At the end of Fiscal Year 2006, 47 JIF projects--accounting 
for $88.8 million of the $90 million in the fund--had been approved by 
the Health Executive Council out of a total of more than 200 proposals. 
The 2006 projects cover such diverse areas of medical care as mental-
health counseling, Web-based training for pharmacy technicians, cardio-
thoracic surgery, neurosurgery, and increased physical therapy services 
for both DOD and VA beneficiaries.
    We also are jointly staffing a number of Federal health facilities. 
These include:
     The Center for the Intrepid--opened in January 2007, 
provides a state-of-the-art facility in San Antonio, Texas, explicitly 
to rehabilitate wounded warriors. This follows the Walter Reed Amputee 
Training Center's example of onsite collaboration.
     Integrated DOD-VA operations in several locations, for 
example: North Chicago (Great Lakes Naval Station); New Mexico 
(Kirtland AFB); Nevada (Nellis AFB); Texas (Fort Bliss); Alaska 
(Elmendorf AFB); Florida (NAS Key West); Hawaii (Tripler AMC), and 
California (Travis AFB).
     At the end of Fiscal Year 2006, DOD military treatment 
facilities and Reserve Units were involved in sharing agreements with 
157 VA Medical Centers, enabling improved visibility of medical needs 
in VA for reservists entitled to VA care after returning from combat 
operations.
                         coordinated transition
    Coordinated transition involves effectively managing medical care 
and benefits during the transition from active duty to veteran status 
to ensure continuity of services and care. Efforts to date have focused 
on enabling Servicemembers to enroll in VA healthcare programs and file 
for VA benefits before separation from active duty status. 
Additionally, the Department has been engaged with VA on initiatives 
and programs supporting coordinated transition focused on three general 
areas: (1) medical care and disability benefits, (2) transition to home 
and community, and (3) sharing Servicemember personnel and health 
information. The Joint Executive Council has established a Coordinated 
Transition Working Group to examine and make recommendations for 
improvement to the transition process.
    For Servicemembers who transition directly from DOD military 
treatment facilities to VA medical centers, DOD and VA implemented the 
Army Liaison/VA Polytrauma Rehabilitation Center Collaboration 
program--also called ``Boots on the Ground''--in March 2005. This 
program is designed to ensure that severely injured Servicemembers 
(primarily Army soldiers) who are transferred directly from a military 
treatment facility to one of the four VA Polytrauma Centers--in 
Richmond, Tampa, Minneapolis, and Palo Alto--are met by a familiar face 
and a uniform. A staff officer or non-commissioned officer assigned to 
the Army Office of the Surgeon General is detailed to each of the four 
locations, to provide support to the family through assistance and 
coordination with a broad array of such issues as travel, housing, and 
military pay. This coordination process has been working exceptionally 
well. However, this transition has not always worked as well when 
Servicemembers are transferred to other locations around the country. 
In response, VA opened 21 new Polytrauma Network Sites in Fiscal Year 
2006 to provide continuity of care to injured Servicemembers. The 
Department deeply values the sacrifices that these veterans and their 
families have made. With our VA colleagues, we are committed to doing 
all we can to improve our coordination and case management of 
Servicemembers who transition to any VA facility.
    VA also is placing personnel in our medical facilities. The Joint 
Seamless Transition assists severely injured Servicemembers while they 
are still on active duty so that they can receive benefits in a timely 
manner. There are 12 VA social workers and counselors assigned at 10 
military treatment facilities, including Walter Reed Army Medical 
Center and the National Naval Medical Center in Bethesda. These social 
workers ensure the seamless transition of healthcare, including a 
comprehensive plan for treatment. Veterans Benefits Administration 
counselors visit all severely injured patients and inform them of the 
full range of VA services, including readjustment programs, educational 
and housing benefits. As of February 28, 2007, VA social worker 
liaisons had processed 7,082 new patient transfers to the Veterans 
Health Administration from participating military hospitals.
    VA also partners with DOD medical facilities through a Cooperative 
Separation Physical Examination and Benefits Delivery at Discharge 
(BDD) program which began in 2004. The BDD program eliminates the 
disadvantage of previous procedures, in which Servicemembers were 
required to undergo two physical examinations within months of each 
other. Under VA's BDD program, Servicemembers can begin the claims 
process with VA up to 180 days before separation at any of the 131 DOD 
sites where local agreements have been established.
    Finally, VA has placed liaisons in each of our three TRICARE 
Regional Offices in Washington, DC, San Antonio, TX, and San Diego, CA, 
providing an important communications and coordination link between the 
DOD and VA to better support our shared beneficiaries.
    Within DOD, providing assistance and support to the families of 
wounded or ill servicemembers during this tumultuous time of transition 
continues to be a high priority. Thus, the Military Severely Injured 
Center (MSIC), established in February 2005 within the Military 
Community and Family Policy Office, operates a hotline center which 
functions 24 hours a day, 7 days a week. The Center's mission is to 
identify and resolve policy and program gaps in support and augments 
and reinforces the support that each of the Service-specific programs 
--the Army Wounded Warrior Program, the Navy Safe Harbor program, the 
Air Force Helping Airmen Recover Together (Palace HART) program, and 
Marine4Life--provide.
                           clinical services
    DOD and VA are working together on some of the most complex 
clinical matters emerging from the current war. We are developing joint 
Evidenced-Based Clinical Practice Guidelines that are means for 
disseminating throughout our systems the most current scientific and 
medical knowledge. These guidelines allow our organizations to provide 
fact-based state-of-the-art medical care that is easily transferable 
between the two medical care delivery systems.
    Although our range of shared clinical activity spans most specialty 
areas, we are placing a particular focus in the following areas:
Mental Health
    Mental-health services are available for all Servicemembers and 
their families before, during, and after deployment. Servicemembers are 
trained to recognize sources of stress and the symptoms of distress in 
themselves and others that might be associated with deployment. Combat-
stress control and mental healthcare are available in-theater. In 
addition, before returning home, we brief Servicemembers on how to 
manage their reintegration into their families, including managing 
expectations, the importance of communication, and the need to control 
alcohol use.
    After returning home, Servicemembers are provided easy and direct 
access to mental healthcare services following a continuum of care 
model. Same-day appointments and daily walk-in appointments are 
available in military mental health clinics, and behavioral healthcare 
providers are integrated into primary care clinics in both the DOD and 
VA. TRICARE also is available for 6 months after return for Reserve and 
Guard members and TRICARE Reserve Select programs are available for 
continuing health insurance coverage for Reserve and Guard members and 
their families after the 6-month transition period. To facilitate 
access for all Servicemembers and family members, especially Reserve 
Component personnel, the Military OneSource Program--a 24/7 referral 
and assistance service--is available by telephone and on the Internet. 
In addition, we provide face-to-face counseling in the local community 
for all Servicemembers and family members. We provide this non-medical 
counseling at no charge to the member, and it is completely 
confidential. For clinical care, family members can access mental 
health services directly in the TRICARE network. Up to eight sessions 
are available without a referral from a primary care manager and 
without pre-authorization requirements from TRICARE.
    The Periodic Health Assessment (PHA) was added to the continuum of 
assessments in February 2006. This annual requirement for all 
deployable assets of the Department includes a robust mental health 
section that complements the deployment health assessment process, 
allowing the opportunity for assessment, referral to care, and 
treatment outside the deployment cycle.
    To supplement mental-health screening and education resources, we 
added the Mental Health Self-Assessment Program (MHSAP) in 2006. This 
program provides Web-based, phone-based, and in-person screening for 
common mental health conditions and customized referrals to appropriate 
local treatment resources. The program also includes parental screening 
instruments to assess depression and risk for self-injurious behavior 
in their children, along with suicide prevention programs in DOD 
schools. Spanish versions of the screening tools are available as well.
Traumatic Brain Injury (TBI)
    The Department is working on a number of measures to evaluate and 
treat Servicemembers affected or possibly affected with traumatic brain 
injury (TBI). For example, in August 2006, a clinical practice 
guideline for management of mild TBI in-theater for the Services was 
developed and fielded. Detailed guidance was provided to Army and 
Marine Corps line medical personnel in the field to advise them on ways 
to deal with TBI. The clinical practice guideline included a standard 
Military Acute Concussion Evaluation (MACE) tool to assess and document 
TBI for the medical record. TBI research in the inpatient medical area 
is also underway.
    A program to integrate the outstanding work completed in TBI by the 
military departments has been initiated to establish a comprehensive 
DOD program, and experts from VA are included in this effort. This 
comprehensive program will provide system-wide common protocols and 
procedures to identify, treat, document, and follow up on those who 
have suffered a TBI while either deployed or in garrison. In addition, 
it will address TBI surveillance, transition to non-DOD care, long-term 
care, education and training, and research.
    DOD has also modified the questions asked during the Post-
deployment Health Assessment, the Post-deployment Health Reassessment, 
and the Periodic Health Assessment to help identify individuals who may 
have suffered a TBI.
                      administration and logistics
    The DOD/VA Health Executive Council worked with industry to 
synchronize data on approximately 16,000 items from 17 manufacturers 
and more than 160,000 items from Prime Vendor distributors. A contract 
was awarded for a data synchronization pilot study to determine the 
best purchase of medical items from the healthcare industry. We 
continue to make progress on joint procurement activities. As of 
September 2006, there were 77 joint National contracts, 7 Blanket 
Purchase Agreements (BPAs) and 46 medical/surgical shared contracts.
    Both Departments face a challenge familiar to health organizations, 
insurers, employers and individuals across the country--the rising 
costs of healthcare. One area--pharmacy--is particularly noteworthy. 
Nearly 6.7 million beneficiaries use our pharmacy benefit, and in 
Fiscal Year 2006, our total pharmacy cost was more than $6 billion. Our 
partnership with VA on joint contracting for prescription drugs is part 
of this solution, and our collective purchasing efforts have saved DOD 
more than $784 million in Fiscal Year 2006.
                         occupational exposures
    DOD and VA have collaborated on a number of recent projects related 
to occupational and environmental exposures. Projects related to 
chemical warfare agents and depleted uranium are two examples. DOD 
undertook a wide-ranging initiative to identify all exposures to 
chemical and biological agents from World War II to the present. To 
date, DOD has provided more than 19,000 names of test participants to 
VA. As part of this effort, DOD declassified the medically relevant 
information from test records and identified the records of 
approximately 6,700 soldiers who were involved in testing of chemical 
agents, placebos, and/or pharmaceuticals in Edgewood, MD, during the 
period of 1955-75. DOD provided the names of these individuals, the 
dates of the tests, and the types of exposures to VA. VA and DOD 
collaborated on writing a letter to veterans to explain the history of 
the testing program and to provide information about the availability 
of VA healthcare. VA started mailing notification letters in June 2006.
    We continue to monitor the health affects of our Servicemembers 
exposed to depleted uranium (DU) munitions. DOD policy requires urine 
uranium testing for those wounded by DU munitions. We also test those 
in, on, or near a vehicle hit by a DU round, as well as those 
conducting damage assessments or repairs in or around a vehicle hit by 
a DU round. The policy directs testing for any Servicemember who 
requests it. More than 2,215 Servicemember veterans of Operation Iraqi 
Freedom have been tested for DU exposures. Of this group, only nine had 
positive tests, and these all had fragment exposures.
    Testing continues for veterans exposed to DU munitions from the 
1990-1991 Persian Gulf War. The 74 individuals with the most 
significant exposures to DU in a Department of Veterans Affairs medical 
follow-up program have been extensively studied with physical exams and 
laboratory analyses for over 12 years. To date, none have developed any 
uranium-related health problems. This DU follow-up program is in place 
today for all Servicemembers with similar exposures.
             health information technology and data sharing
    In the health information technology arena, DOD and VA have engaged 
in a number of important efforts to share essential clinical and 
management information in support of health care services to our 
wounded servicemembers and all eligible former military members who 
seek care from VA.
    The work of capturing and sharing relevant clinical information 
between the DOD and VA begins on the battlefield. With the expanded use 
of the Web-based Joint Patient Tracking Application (JPTA), our medical 
providers should have improved visibility into the continuum of care 
across the battlefield, and from theater to sustaining base. DOD grants 
access to JPTA for VA providers who are treating Servicemembers in VA. 
In addition, we are working with VA to explore ways to share relevant 
patient injury/wound trend data to assist VA in predicting and 
preparing for treatment of OIF and OEF combat veterans.
    Since September 2003, DOD has provided a roster to VA periodically, 
which lists OIF and OEF veterans who have either deactivated back to 
the Reserve/National Guard, or who have separated entirely from the 
military. VA uses this roster to evaluate the healthcare utilization of 
OIF/OEF veterans. VA performed its most recent analysis related to 
631,174 veterans in November 2006. Thirty-two percent of these 
individuals had sought VA healthcare at least once. The three most 
common diagnostic categories were musculoskeletal disorders (mostly 
joint and back disorders), mental disorders, and dental problems. These 
data are quite useful in VA's planning for allocation of healthcare 
resources.
    Servicemembers who have substantial medical conditions are 
evaluated in the Physical Evaluation Board (PEB) process to determine 
if they are fit to stay on active duty or if they should be medically 
separated. DOD provides the names of individuals who enter the PEB 
process to VA, to facilitate the transition of care and to assist in 
starting the paperwork to provide VA benefits. In 2005, DOD and VA 
signed a memorandum of understanding that stated that DOD would send 
these data to VA. In October 2005, DOD delivered the first list to VA 
of names, current locations, and medical conditions. Since then, DOD 
has sent a list of names to VA periodically, which will continue in the 
future. Data on more than 16,000 individuals have been transferred to 
VA. The Veterans Health Administration and Veterans Benefit 
Administration plan to send letters to these individuals to inform them 
about the availability of VA healthcare and disability benefits, 
respectively.
    The Federal Health Information Exchange (FHIE) enables the transfer 
of protected electronic health information from DOD to VA at the time 
of a Servicemember's separation. Every month, DOD transmits laboratory 
results, radiology results, outpatient pharmacy data, allergy 
information, discharge summaries, consult reports, admission, 
disposition and transfer information, elements of the standard 
ambulatory data records, and demographic data on separated 
Servicemembers. As of February 2007, DOD had transmitted more than 182 
million messages to the FHIE data repository on more than 3.8 million 
retired or discharged Servicemembers. This number grows each month.
    DOD expanded the breadth of data transferred under the FHIE in 
recent years. In September 2005, we began monthly transmission of the 
electronic Pre- and Post-Deployment Health Assessment information to 
VA, followed in November 2006 with monthly transmission of Post-
Deployment Health Reassessments (PDHRAs) for separated Servicemembers 
and demobilized National Guard and Reserve members. Weekly transmission 
of PDHRAs for individuals referred to VA for care or evaluation started 
in December 2006. As of February 2007, VA has access to more than 1.6 
million assessment forms on more than 681,000 separated Servicemembers 
and demobilized Reserve and National Guard members.
    The FHIE has been successful in improving data sharing as 
Servicemembers' transition from DOD to VA care. In some communities, 
however, beneficiaries eligible for both DOD and VA care may obtain 
care from both systems. The Bidirectional Health Information Exchange 
(BHIE) enables the real-time sharing of allergy, outpatient pharmacy, 
demographic, laboratory, and radiology data between DOD BHIE sites and 
all VA treatment facilities for patients treated in both DOD and VA 
facilities. As of January 2007, BHIE was operational at 14 DOD medical 
centers, 17 hospitals, and more than 170 outlying clinics. In the 3rd 
Quarter Fiscal Year 2007, all DOD sites and all VA sites will be able 
to view allergy information, outpatient pharmacy data, radiology 
reports, and laboratory results (chemistry and hematology) on shared 
patients.
    We have begun testing our ability to share inpatient information, 
and successfully completed initial testing at Madigan Army Medical 
Center (AMC) and VA Puget Sound Health Care System (HCS) in August 
2006--enabling access to inpatient discharge summaries from Madigan 
AMC's Clinical Information System (CIS) and VA's VistA system. We 
implemented this functionality in November 2006 at Tripler AMC where we 
make emergency department discharge summaries available to VA on shared 
patients. We also installed this functionality at Womack AMC in 
February 2007. We plan further deployment in additional DOD sites in 
Fiscal Year 2007. In the future, we will make additional inpatient 
documentation, such as operative notes and inpatient consultations 
available to VA.
    We also began the exchange of important clinical information 
between each of our clinical data repositories. The Clinical Data 
Repository/Health Data Repository (CHDR) establishes interoperability 
between DOD's Clinical Data Repository (CDR) and VA's Health Data 
Repository (HDR). In September 2006, the CHDR interface successfully 
exchanged standardized and computable pharmacy and medication allergy 
data between William Beaumont AMC and El Paso VA HCS on patients who 
receive medical care from both healthcare systems. Exchanging 
computable pharmacy and allergy data supports drug-drug and drug-
allergy order checking for shared patients using data from both DOD and 
VA.
    In December 2006, DOD also began deployment and VA continued field 
testing at Eisenhower AMC and Augusta VA Medical Center (MC) and at 
Naval Hospital Pensacola and VA Gulf Coast HCS. During the 2nd Quarter 
Fiscal Year 2007, the organizations implemented CHDR at Madigan AMC and 
VA Puget Sound HCS, Naval Health Clinic Great Lakes and North Chicago 
VA HCS, Naval Hospital San Diego-Balboa and VA San Diego HCS, and Mike 
O'Callaghan Federal Hospital and VA Southern Nevada HCS. By July 2007, 
DOD will send out instructions to sites to allow remaining DOD AHLTA 
locations to begin using CHDR.
    Finally, the Laboratory Data Sharing Initiative (LDSI) facilitates 
the electronic sharing of laboratory order entry and results retrieval 
between DOD, VA, and commercial reference laboratories for chemistry 
tests. LDSI is available to all DOD and VA sites with a business case 
for its use. Either Department may function as a reference lab for the 
other. We are currently testing the addition of laboratory anatomic 
pathology and microbiology orders and results retrieval using the 
Logical Observation Identifiers Names and Codes (LOINC) and 
Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) 
standards.
    While the DOD and VA are pleased with this accelerated data sharing 
over the last several years, we remain interested in even more 
collaborative efforts in the information technology arena. Both Federal 
health systems are proud of their successful deployments of enterprise-
wide health information technologies, AHLTA and VistA, yet we both are 
seeking a new inpatient electronic medical record system. Consequently, 
we have embarked on a study to explore the potential for a joint 
inpatient system. This would offer several potential benefits. First 
and foremost, electronic sharing of inpatient data would enhance our 
ability to provide ``seamless transition'' of medical data for our 
severely injured and wounded Servicemembers to VA care. Second, there 
are potential cost efficiencies that would derive from joint-license 
procurements and joint-development activities. Finally, such an effort 
would likely proliferate opportunities for additional data sharing 
between DOD and VA. The Departments have embarked on a joint assessment 
that will recommend to DOD and VA leadership the best strategy for 
accomplishing these objectives.
    Our efforts in enhancing DOD-VA collaboration over the last several 
years have been successful. Yet, we are not satisfied that we have 
achieved all that is possible. We have an aggressive plan to work 
through some of the greater technological and management challenges in 
the coming year. With the support of the Congress, we are confident we 
will be successful.
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Daniel K. Akaka to 
 Ellen Embrey, Deputy Assistant Secretary, Health Affairs/Force Health 
            Protection and Readiness, Department of Defense
    Question 1. What are your thoughts on providing seriously injured, 
separating servicemembers or their families with an electronic medium 
containing as complete a medical record as possible, perhaps to include 
scanned representations of paper records? This matter was raised by 
Senator Burr at the Committee's hearing. I would appreciate your 
thoughts on the feasibility of this additional precaution on behalf of 
our injured veterans.
    Response. Separating Servicemembers may receive a copy of their 
medical records now. Further, providing Servicemembers with their 
electronic health information is part of the Military Health System 
strategic plan. But it is not clear that scanning older paper records 
for all is the best approach. Rather, we should focus on those with 
serious injuries, as we are doing with patients going to the VA 
polytrauma clinics.

    Question 2. The Fiscal Year 2007 Defense Authorization Bill 
mandated that DOD include brain injury-related questions on its Post-
Deployment Health Assessment (PDHA) questionnaire, which is 
administered to all returning servicemembers. This action was supposed 
to have occurred within 6 months of the bill's passage. As we have now 
reached this deadline, has DOD added this requirement to the PDHA in 
compliance with the law? Additionally, has DOD begun to distribute the 
new questionnaire for use by returning units?
    Response. The existing Post-Deployment Health Assessment (PDHA) 
questionnaire has always contained questions about several general 
symptoms that are often associated with traumatic brain injury (TBI) or 
post-concussive syndrome. Also, the Post-Deployment Health Re-
Assessment (PDHRA) questionnaire specifically asks if the servicemember 
was exposed to a blast or explosion during their deployment. The DOD 
issued policy guidance to add two TBI-specific screening questions to 
all assessments, and is in the process of modifying the various 
electronic versions of these assessment tools. The Assistant Secretary 
of Defense for Health Affairs' policy memo mandating the use of these 
screening questions set an implementation date of June 1, 2007.
    In addition, in August 2006, a clinical practice guideline for 
management of mild TBI in-theater was developed and fielded. The 
clinical practice guideline included a standard Military Acute 
Concussion Evaluation (MACE) tool to assess and document TBI for the 
medical record. This clinical practice guideline and the MACE are in 
use in the USCENTCOM Theater of Operation today.

    Question 3. Several weeks ago, the Committee staff requested from 
DOD's legislative office a detailed listing of non-mortal casualties of 
the Global War on Terror, by specific type of injury or condition. They 
were told that such information will take some time to obtain, as each 
service keeps its own detailed casualty records. Please expedite the 
collection of the data that staff has requested, and forward it as soon 
as possible.
    Response.

                     Injuries and Wounded in Action
------------------------------------------------------------------------
                                    Operation    Operation
                                     Enduring      Iraqi
                                     Freedom      Freedom       Total
                                      (OEF)        (OIF)
------------------------------------------------------------------------
Total............................        1,133       24,187       25,320
Returned to duty within 72 hours.          40%          56%          55%
------------------------------------------------------------------------
 Source: Defense Manpower Data Center, as of March 17, 2007.



   Disease and Non-Battle Injuries (DNBI) USCENTCOM (OEF/OIF) Combined
               [Overall DNBI rate--4% of forces per week]
------------------------------------------------------------------------
 
------------------------------------------------------------------------
Injuries, all types........................................         26%
Respiratory (colds, allergies, etc.).......................         13%
Dermatologic (rashes, lesions, etc.).......................         12%
Diarrhea and other abdominal problems......................          6%
Mental Health..............................................          3%
Combat Stress..............................................          2%
All other categories combined..............................         38%
------------------------------------------------------------------------
 Source: Air Force Institute for Operational Health, as of March 10,
  2007.

    Question 4. Director Duckworth testified at the Committee's hearing 
about the need for States to be able to track returning servicemembers 
and new veterans. What is DOD doing to ensure that State Directors of 
Veterans Affairs have the most complete and up-to-date information on 
separating servicemembers?
    Response. The Department of Defense (DOD) is coordinating with the 
Department of Veterans Affairs (VA) and State Directors of Veterans 
Affairs in the ``State Benefits Seamless Transition Program.'' This 
initiative expands the communication links and coordination between VA, 
DOD, and the State departments of Veterans Affairs. This program began 
as a pilot project with the Florida State Department of Veterans' 
Affairs in September 2006. The Defense Veterans Program Coordination 
Office, in DOD, has participated in the planning of this program since 
its inception.
    The State Benefits Seamless Transition Program involves VA staff 
located at ten DOD medical facilities around the country. The VA 
personnel at the military hospitals identify injured servicemembers who 
will transfer to VA facilities, such as the four VA Polytrauma Centers. 
After veterans sign an informed consent form, VA staff contact State 
Veterans' Affairs offices on behalf of the veterans. The State offices, 
in turn, contact the veterans to inform them about available State 
benefits. This should facilitate earlier access to State benefits and 
enhance the States' capabilities to provide long-term support to 
veterans and their families.
                                 ______
                                 
 Response to Written Questions Submitted by Hon. Patty Murray to Ellen 
    Embrey, Deputy Assistant Secretary, Health Affairs/Force Health 
            Protection and Readiness, Department of Defense
                         traumatic brain injury
    Secretary Embrey, I've been having a very hard time getting real 
numbers from your department on how many servicemembers need treatment 
for Traumatic Brain Injury (TBI).
    I asked the Defense Secretary last month. He got back to me last 
week with a preliminary figure. He said that 2,121 Iraq and Afghanistan 
war veterans have been treated for TBI since October 2001.
    But--and this is important--he said that number is incomplete 
because it does NOT include cases from every Pentagon medical facility. 
And it does NOT include all mild-to-moderate cases of TBI that occur in 
the field.
    As I said, if we don't have accurate numbers, we can't set the 
right budgets, and we can't solve the problem.
    One solution is to document any time that a servicemember is 
exposed to an IED incident. This would be noted in their medical 
records--so even if they don't suffer an immediate injury--we can 
follow up with them later to see if they have TBI.
    I understand that in August 2006--your office received a report 
from an Armed Forces advisory board outlining a comprehensive plan to 
address the TBI problems.

    Question 1. Is that system up and running today? If not, why not?
    Response. The Department of Defense (DOD) has responded to the 
recommendations of the Armed Forces Advisory Board. In November, we 
convened a panel of experts to address detection and treatment of mild 
traumatic brain injury. From that meeting and other efforts in the DOD, 
we now have clinical practice guidelines for in-theater management of 
mild traumatic brain injury as well as a tool, the Military Acute 
Concussion Evaluation (MACE), to help assess the severity of a possible 
traumatic brain injury. Both the clinical practice guidelines and the 
MACE are in use in the Operation Iraqi Freedom and Operation Enduring 
Freedom theaters of operation.
    In addition, the Assistant Secretary of Defense for Health Affairs 
has requested a comprehensive plan to address TBI within the DOD. I am 
the lead, with Vice Admiral Arthur, the Navy Surgeon General in 
support. We have planned meetings in April and May with the Service 
Surgeons General and personnel from the Services' Manpower and Reserve 
Affairs offices, along with representatives from the Department of 
Veterans Affairs and the principal supporting DOD organizations such as 
the U.S. Army Medical Research and Materiel Command, and the Defense 
and Veterans Brain Injury Center. The goal is to coordinate all current 
Service and DOD efforts to develop a comprehensive program from the 
point of injury to resolution. This will include attention to baseline 
assessment, field evaluation, and treatment, screening post-deployment 
and in the periodic health assessment, education for military and 
family members, and research into protective, mitigating, and post-
incident treatment and rehabilitation techniques that will maximize 
recovery.

    Question 2. Have you run into anyone at the Pentagon who's opposed 
to tracking IED exposure in medical records for servicemembers who are 
not visibly injured on the battlefield?
    Response. No. The primary issue regarding recording exposure to IED 
explosions in the medical record is setting boundaries for what is 
determined to be an IED exposure. Any person injured or symptomatic 
after an exposure is considered exposed. For those not injured and not 
symptomatic, we do not have a methodology to decide who was 
``exposed.'' Such a determination might be dependent on distance from 
the explosion, whether the explosion occurred near buildings or in an 
open environment, etc.

               joint patient tracking application (jpta)
    Secretary Embrey, today we don't have a ``seamless transition'' 
between the Pentagon and the VA. More than two years ago, Congress 
required the Pentagon to improve patient tracking and management. This 
would ensure that servicemembers do not fall through the cracks and 
that their records move with them so they can get timely, complete 
care. It would create one record of all medical services a patient 
receives from the battlefield onward. It's known as the Joint Patient 
Tracking Application.
    Question 3. Is this system up and running today? If not, why not?
    Response. The DOD has improved patient tracking and management from 
the theater to definitive care facilities. The Theater Medical 
Information Program (TMIP) is running today on the battlefield, and it 
includes capabilities to document inpatient, outpatient, and ancillary 
care in an electronic health record. The Joint Patient Tracking 
Application (JPTA) is also up and running today and it tracks patients 
as they move from our combat support hospitals into receiving 
facilities. The JPTA is only one of several information sources the DOD 
makes available to the Department of Veterans Affairs (VA) to provide 
information that helps VA providers care for our wounded 
servicemembers. The JPTA is a Web-based patient tracking application 
that gives DOD and VA providers an ability to track and report some of 
their patient data, but it is not an electronic health record. When DOD 
patients transfer to the VA for care, the DOD sends copies of all 
medical records documenting treatment provided by the referring DOD 
facility along with them. Other sources of medical records for the VA 
are available through the Bidirectional Health Information Exchange and 
the Federal Health Information Exchange, where we have transferred over 
182 million messages on more than 3.8 million retired or discharged 
servicemembers. Through these systems, the VA has access to patients' 
electronic health records and medical histories.

    Question 4. Why didn't your office follow through with the new 
policy?
    Response. The Department has made great strides to assure 
compliance with the law as documented in the Joint Medical Readiness 
Oversight Committee Report to Congress on our implementation of the 
National Defense Authorization Act of Fiscal Year 2005. The Joint 
Patient Tracking Application (JPTA) was developed at Landstuhl Regional 
Medical Center to streamline the process of tracking patients for 
Operations Enduring Freedom and Iraqi Freedom as they moved from the 
USCENTCOM Theater. The system was piloted and put into use to track 
patients from USCENTCOM to Landstuhl beginning in January 2004. In 
November 2004, the Assistant Secretary of Defense for Health Affairs 
issued a memorandum directing JPTA be implemented for patient tracking 
throughout the Military Health System by November 2007.

    Question 5. How many stateside military hospitals do not use JPTA 
as required by law?
    Response. Currently all 21 receiving facilities in CONUS that 
support movement/transition of servicemembers from theater use the 
Joint Patient Tracking Application (JPTA). More facilities will 
implement the tracking capabilities when required. Additionally, there 
are currently 17 Department of Veterans Affairs (VA) receiving 
facilities using the JPTA for tracking VA eligible patients coming from 
the Department of Defense.

    Question 6. What reason would they have for not using it?
    Response. The Joint Patient Tracking Application (JPTA) is but one 
of several capabilities used to meet our force health protection 
imperatives, and it is not an electronic health record. Most physicians 
are aware of JPTA as a patient tracking system to assist in transfer of 
essential patient information to the next level of care. The physicians 
who do use JPTA as a means to capture electronic information do so if 
no other primary or authoritative system for patient care is available, 
e.g., Theater Medical Information Program systems or Service-specific 
health care applications. Common JPTA users are patient administrators, 
clinicians, case managers, and the medical liaisons who track 
servicemember locations for commanders.

    Question 7. Do you agree that not following the law places the 
wounded soldier at a disadvantage and creates delays in data collection 
while denying access to care and compensation?
    Response. The Department has made great strides to assure 
compliance with the law as documented in the Joint Medical Readiness 
Oversight Committee Report to Congress on our implementation of the 
National Defense Authorization Act of Fiscal Year 2005. I believe our 
ongoing initiatives address Congressional direction and enable us to 
increase responsiveness to medical situations from the point-of-injury 
through the health care continuum. The Theater Medical Information 
Program systems are a critical part of AHLTA that empowers us to 
collect information to provide the most complete electronic medical 
record possible. This helps to promote quality and efficient health 
care for our servicemembers throughout the continuum of care.

    Question 8. If you truly want a seamless transition why have you 
not implemented the law?
    Response. The Department has made great strides to assure 
compliance with the law as documented in the Joint Medical Readiness 
Oversight Committee Report to Congress on our implementation of the 
National Defense Authorization Act of Fiscal Year 2005. DOD initiatives 
directly support coordinated transition and title 10 (Subtitle A, Part 
II, Chapter 55, Section 1074f) requirement for electronic capture of 
medical data in theater. It supports Public Law 105-85, subtitle F, 
section 765, which states that the ``Secretary of Defense shall 
establish a system to assess the medical condition of members of the 
Armed Forces . . . who are deployed outside the United States . . . as 
part of a contingency operation . . . or combat operation.'' DOD 
initiatives also support the Presidential Executive Order Promoting 
Quality and Efficient Health Care in Federal Government Administered or 
Sponsored Health Care Programs, Presidential Special Directive, dated 
April 2004, and Presidential Directive/Endorsement, dated November 
1997.

    Question 9. What do you think happens when soldiers have to wait on 
paperwork the DOD is required by law to collect and produce?
    Response. The Department is committed to protect the health of our 
servicemembers as one of our highest priorities. With or without the 
Joint Patient Tracking Application (JPTA), the Department of Defense 
(DOD) provides information on servicemembers who are treated in 
Department of Veterans Affairs (VA) facilities or are on their way to 
the VA for care. When our patients are referred to the VA for care, DOD 
sends with them copies of all paper and electronic records from AHLTA 
and JPTA, documenting treatment provided by the referring DOD facility. 
Normally, a discussion of the details of the case takes place between 
the referring DOD physician and the receiving VA physician.
    It is important to note that JPTA does not contain all patient 
medical information and, therefore, must be included with other data 
system information to ensure a more complete transfer of patient 
information to the VA.
    In addition, the Bidirectional Health Information Exchange and the 
Federal Health Information Exchange support information exchange 
between DOD and VA, and the DOD has transferred over 182 million 
messages on more than 3.8 million retired or discharged servicemembers. 
Through these systems, the VA has access to patients' electronic health 
records and medical histories.
    The DOD welcomes the opportunity to brief Members of the Committee 
on DOD's strategy and current capabilities for managing in-theater 
medical tracking and surveillance.

                               amputation
    Question 10. Please define the locations and dates for the ``Global 
War on Terror (GWOT),'' ``Operation Iraqi Freedom (OIF),'' ``Operation 
Enduring Freedom (OEF),'' the Iraq War, the Afghanistan War, and 
``Operation Noble Eagle'' (ONE).
    Response. Global War on Terror (GWOT): September 11, 2001--current, 
multiple locations.
    Operation Iraqi Freedom (OIF): March 19, 2003--current, location: 
Iraq.
    Operation Enduring Freedom (OEF): October 7, 2001--current, 
location: Afghanistan.
    The Iraq War is the same as Operation Iraqi Freedom.
    The Afghanistan War is the same as Operation Enduring Freedom.
    Operation Noble Eagle: September 11, 2001--current, location: 
various, primarily homeland defense and civil support.
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Bernard Sanders to 
 Ellen Embrey, Deputy Assistant Secretary, Health Affairs/Force Health 
            Protection and Readiness, Department of Defense
    Question 1. Is screening for TBI and PTSD currently mandatory at 
DOD? If so, then what efforts are being made to re-screen those 
servicemembers that may have been missed or misdiagnosed when they 
first returned, before screening was mandatory?
    Response. The existing Post-Deployment Health Assessment (PDHA) 
questionnaire always contained questions about several general symptoms 
that are often associated with traumatic brain injury (TBI) or post-
concussive syndrome. Also, the Post-Deployment Health Re-Assessment 
(PDHRA) questionnaire specifically asks if the servicemember was 
exposed to a blast or explosion during their deployment. On March 8, 
2007, the Assistant Secretary of Defense for Health Affairs issued 
policy guidance that requires the addition of two TBI-specific 
screening questions to both the PDHA and PDHA self-reporting tools as 
well as the Health Assessment Review Tool (a required part of each 
servicemember's annual Periodic Health Assessment), with an effective 
date of June 1, 2007. All three of these assessment tools already 
include the validated four-question Primary Care Post-Traumatic Stress 
Disorder screening scale. In addition, in August 2006, a clinical 
practice guideline for management of mild TBI in-theater was developed 
and fielded. The clinical practice guideline included a standard 
Military Acute Concussion Evaluation (MACE) tool to assess and document 
TBI for the medical record. This clinical practice guideline and the 
MACE are in use in the USCENTCOM Theater of Operation today.
    There is no plan to re-screen servicemembers, except at the time of 
their Periodic Health Assessments or next deployments. Because the 
Periodic Health Assessment is an annual requirement, all servicemembers 
will have been screened after the passage of one year.

    Question 2. What do you think of mandatory mental health screening 
by the DOD for all servicemembers that are deployed, when they return 
from service? Could this help remove the stigma of servicemembers 
having to ask for mental health treatment, if everyone was required to 
be screened for mental health issues?
    Response. There already is mandatory mental health screening 
accomplished during every Post-deployment Health Assessment and the 
Post-deployment Health Re-assessment. This is accomplished through the 
inclusion of various mental health screening questions on the two self-
reporting tools, the responses of which are then evaluated by primary 
care providers who interview the individuals and make clinical 
judgments regarding the need for additional evaluation or treatment, 
including potential referral to mental health specialists. We have no 
evidence that a mandatory screening by a mental health professional 
would be more effective than the current approach. A trial program is 
underway at Fort Lewis and a formal validation study is underway to 
compare mental health outcomes of the two different approaches. The 
results of the study are expected in 2008.

    Question 3. How many OIF/OEF soldiers, who have their home of 
record in Vermont, has the DOD diagnosed with PTSD or some form of TBI?
    Response. From 2002, the number of servicemembers from Vermont with 
a PTSD diagnosis is 73. For TBI, there have been 11.
                                 ______
                                 
Response to Written Question Submitted by Hon. Johnny Isakson to Ellen 
    Embrey, Deputy Assistant Secretary, Health Affairs/Force Health 
            Protection and Readiness, Department of Defense
    Question. Do you feel that treating active duty troops at 
Department of Veterans Affairs (VA) medical centers benefits the 
Department of Defense (DOD)?
    Response. The VA's treatment of active duty personnel continues to 
be of great benefit to DOD. VA medical facilities have been providing a 
wide range of health services to active duty personnel under agreements 
with the military services and DOD for more than twenty years. These 
agreements range from basic medical services in geographically remote 
areas to specialized care for personnel with severe brain and spinal 
cord injuries.

    Chairman Akaka. Well, I thank you both very much for your 
testimony.
    One of the concerns has been medical hold. Mr. Pruden's 
testimony discussed a veteran who was in medical hold for 3 
years and 8 months, and it is difficult to think that that has 
happened.
    Ms. Embrey, both Mr. Pruden and Ms. Mettie talked about 
lengthy medical holds and holdovers. It is our understanding 
that the Army maintains patients in medical hold much longer 
than the Navy and the Marines.
    What is DOD doing to ensure that medical holds are 
appropriate and are not unnecessarily long?
    Ms. Embrey. Mr. Chairman, I believe that the Army was 
dedicated to giving the most time possible for injured and ill 
reservists who are put on medical holdover--those are the 
principal population that are retained on active duty--to give 
them an opportunity to heal so that they could return to duty. 
And medical hold is a status for individuals where they are 
allowed the time to heal until such time that no further or 
additional medical treatment would improve their outcome. And 
for some individuals, that is a very long time, and for others 
it is a very short time.
    In 2004, the Department initiated a monthly reporting 
process where we reviewed the number of gains and losses to the 
medical hold process from each of the services, and we get that 
monthly report and we actively engage each of the Surgeons 
General in the Departments to ask what they are doing to 
address the time that is involved while these individuals are 
in the medical hold status.
    So, I think, we have actively working with the services to 
make sure that it is being effectively managed. It is clear 
that we could do a better job.
    Chairman Akaka. I am glad to note that. We know that VA's 
prosthetics services are geared toward patients with diabetes 
and other diseases rather than combat wounds. DOD has the best 
prosthetics around, but at some point DOD will shed some of its 
prosthetic and rehabilitation functions.
    Dr. Kussman, the Department of Defense has taken primary 
responsibility for rehabilitating young combat amputees and for 
fitting them with state-of-the-art prosthetic devices. Director 
Duckworth testified about her view that the Hines VA does not 
have the same level of prosthetic care that exists at Walter 
Reed.
    We also know about the state-of-the-art work being done at 
the Center for the Intrepid. In time, some of the newer 
veterans will come to VA for prosthetic replacements or for 
other reasons.
    What steps is VA taking to ensure that VA will be prepared 
to take over the care of these amputees from war zones?
    Dr. Kussman. Thank you, Mr. Chairman, for the question. I 
also obviously listened to the testimony that was given by the 
first panel.
    We have been a national leader with prosthetics for a long 
time, as you know, and there is no argument about the fact that 
prior to the war, half of our patients were over 60 years of 
age, and by that mere nature, most of the amputees.
    But we have adapted to do that. We have over 600 contracts 
with private contractors around the country to provide the 
care, 63 labs, 125 certified prosthetists throughout the 
system.
    One of the challenges has been that some of the care that 
comes at Walter Reed, for instance, is truly state-of-the-art 
and only available there because it is research. And so a lot 
of times when somebody comes to us, it is done in a partnership 
with the handoff, and the patients go back to Walter Reed 
because the expertise and the technology is not available 
anywhere but at Walter Reed.
    With our leadership of Fred Downs, who is there on a weekly 
basis, who runs our prosthetic services, he meets with all the 
amputees, explains to them the services that are available. In 
truth, Walter Reed contracts a large amount of its prosthetic 
care, just like we do. And so we believe that we have the 
services available.
    As Major Duckworth talked about, she preferred to see a 
specialist down in Florida--which, by the way, we are paying 
for--and she also commented on a physical therapist not being 
able to come with her today. I do not know the specifics about 
that, but we sent the prosthetists from Hines with her down to 
Orlando, I believe, to see what was going on and to be sure 
that we could provide her the same level of care in Hines.
    So I think that we are continuing to improve. I think we 
have a robust program. For somebody to say, a prosthetist in 
our system to say they have never seen a C-leg or whatever, I 
can't--I wouldn't take umbrage with the comment except that we 
certainly provide a large number of C-legs and anything else 
that is commercially available.
    Chairman Akaka. Thank you very much. We will have a second 
round.
    Now I would like to call on Senator Burr.
    Senator Burr. Thank you, Mr. Chairman.
    I want both of you to know how much we appreciate your 
service. You are in two vitally important areas to this country 
and, more importantly, to our military and to our veterans.
    Having said that, I hope that both of you really did listen 
to the witnesses before--and I appreciate the recap of 
everything we are doing. Ms. Embrey, your testimony is filled 
with a tremendous detail of collaboration between the VA and 
DOD in so many areas--clinical service, education, training, 
research and development, patient administration, joint 
initiatives to improve alignment, leverage shared resources.
    We are now in the fifth year of this current conflict. At 
what point do we actually look at what is going on and 
implement changes? I get the impression--and I say this to you, 
Dr. Kussman, with the firm reality you have not been there that 
long from the standpoint of what you are doing now. How many 
real-life experiences do we have to listen to before we do away 
with the committees and the working groups and the interagency 
collaboration efforts and we actually implement some of this in 
the system?
    So my question, Ms. Embrey, is real simple. Does DOD have 
the capabilities today to electronically transfer the records 
to VA of people that we are transferring over into that system?
    Ms. Embrey. Yes.
    Senator Burr. And do we do that?
    Ms. Embrey. Yes.
    Senator Burr. Then how can somebody enter the VA system or 
how can a mother be entrusted to be the delivery point of a 
son's medical records if we have got a system that 
electronically transfers that into the other side that works?
    Ms. Embrey. That is a good question.
    Senator Burr. It is an important question.
    Ms. Embrey. I think that both Departments have implemented 
initiatives in their electronic health systems that allow them 
to capture electronic health records, but they do not 
necessarily transfer along--they have laboratory information 
and things like that, but they do not give that electronically 
directly to the individual, and the individual is entitled to 
their medical records, copies of their medical records as well.
    Senator Burr. But do you not agree that the single most 
important thing in that transfer to the VA is to transfer all 
of the medical data that is pertinent to that patient?
    Ms. Embrey. And we believe we are doing that. We have 
extensive meetings. We have a comprehensive management plan 
that we discuss DOD providers are the individual to be 
transitioned to the VA. There are conference calls. There are 
dialogues between the losing provider and the gaining 
providers. There is a plan for how that individual is supposed 
to be managed, and the records that go along with that are 
transferred electronically.
    Senator Burr. Does it concern you that out of the two 
witnesses that spoke on today, they had trouble having their 
medical records provided in the VA system?
    Ms. Embrey. I think that is absolutely evident, and I would 
wonder what the root cause is. I think we have institutional 
structures in place to make that happen, but at the individual 
level, I believe some things don't get included because 
somebody didn't update something.
    Senator Burr. Well, let me suggest rather than to make this 
complicated, if we admit there is a problem, and if, in fact, 
DOD has the capacity today to download the medical records of 
any patient, why don't we invest in little flash drives and why 
don't we download the information to the patient, to the 
parent, to the spouse, to whoever, as well as transferring it 
to the VA so that at least in full detail we have got some 
redundancy? Because, clearly, the system of electronically 
transferring it isn't either doing it successfully or in total 
or, in fact, we need to look at the DOD system and, in fact, 
ask ourselves, ``Does it truly capture all the medical data 
that is needed by the patient or by the next facility, VA or 
private sector?''
    Let me ask you, Dr. Kussman: Are you getting the medical 
records for all the----
    Dr. Kussman. I believe that we are getting all the 
information that is available. As you know, the Secretary made 
an announcement a few weeks ago, concurrently with Dr. 
Winkenwerder, to work on a combined single inpatient electronic 
health record. The information that is presently available is 
lab tests and x-rays and other things, and both Departments 
have worked hard to get that going. But the record itself still 
is in paper.
    Senator Burr. And I have tremendous respect for the 
Secretary and Dr. Winkenwerder, whom I talk to on an occasional 
basis. But let me go back to you, Ms. Embrey. We do have the 
capabilities within DOD to produce all the medical records 
electronically. Is that correct?
    Ms. Embrey. We do not have a common inpatient system, 
electronic system. Each of the services uses different 
applications, and so that is, again, going back to what Dr. 
Kussman just said, both of us need to and have agreed to 
collaborate on acquiring or developing a joint application for 
inpatient care that would provide complete seamless transaction 
inpatient care to both systems.
    Senator Burr. So the data exists within DOD. We just cannot 
pull it all together. Is that what you are saying? Or part of 
the DOD is still paper and part is electronic?
    Ms. Embrey. That is correct.
    Senator Burr. OK. So that makes it impossible to capture 
all the data.
    Ms. Embrey. Some of the military treatment facilities 
capture inpatient data electronically, but it differs between 
services. And so there is no common way for us to set up an 
exchange electronically with the VA. Our solution to that has 
been to capture as much information as has been available to 
capture electronically and put it into a central data 
repository, and it is that repository we use to provide VA with 
the information.
    Senator Burr. You know, an amazing thing happened before I 
came to this hearing. I need to know something real quick, and 
I went to my computer, and I Googled it. And instantaneously it 
looked at a lot of different databases around the world, and it 
came up with the information that I needed.
    We are way past needing to combine databases, if, in fact, 
we want to glean the information out of multiple databases. If 
we are trying to merge databases, whether it is DOD or whether 
it is CMS, we are going to be sitting here years from now not 
having the capabilities to extract the information we need for 
somebody who really needs the information.
    So, one, we have learned something today. If, in fact, even 
though they are different, each area electronically stores the 
information, we can get it today. If we cannot figure it out, 
call Google. They can tell us how to do it.
    If, in fact, we are not electronically storing it today, 
then we know the first step. We do not need the collaboration 
between the Secretary and Dr. Winkenwerder. We know exactly 
what we need to do, and we probably ought to have done that 
years ago.
    The transfer between the two of you, if, in fact, we fix 
those first two pieces, is easy. It did not take a working 
group to do it. It did not take any collaborative agreement. It 
took sitting down and figuring out what is it we need to do to 
have this capability. And, Mr. Chairman, it frustrates me.
    Again, I have great respect for both of you for everything 
that you commit to do. I pledge continually, whether it is DOD 
or VA, to be here as an ally to make sure that we have got 
sufficient resources. But to me, for us not to move forward as 
quickly as we can at a time that you have heard witnesses say 
we are not doing it, time is absolutely essential to the 
outcome of the individuals that are affected, and we are 
dealing with something as it relates to medical records that 
does not really need a tremendous amount more study.
    And as I said at the beginning, the thing that frustrates 
me is the road blocks that you are currently running into. We 
cannot even get a piece of legislation out of this body that 
addresses health IT from the standpoint of the private sector 
because of the competing--so I understand how difficult it is, 
but the difficulty is both of you are in areas that have very 
specific responsibilities. You can do this tomorrow if, in 
fact, you will just commit to doing it. And I will follow up 
with Secretary Nicholson, and I will follow up with Dr. 
Winkenwerder to make sure that at least this piece is 
emphasized with them, and my hope is that you will take to 
heart the fact that three of these witnesses told very personal 
stories today. And I believe that we could rotate those chairs 
and you could hear personal stories, like I do, as long as we 
are willing to sit here. And each of those stories are unique 
and they are different, and all of them we have made the same 
promise to, that this will be the best, that this will address 
their needs, and the fact that we still fall short--and we 
probably always will in some cases--just lets us know how 
important the work that we are going to do is.
    So, again, I thank both of you. I thank you, Mr. Chairman, 
because I know I went over my time.
    Chairman Akaka. Thank you very much, Senator Burr. I want 
to thank you for your thoughtful questions and your remarks 
that touch on collaboration and coordination that we are 
seeking here.
    Let me go on to a second round and touch on the diseases 
that were mentioned by our first panel.
    A program has been developed by medical staff at Fort Sam 
Houston in conjunction with Walter Reed to provide guidance to 
military clinicians on diagnosing and treating severe 
infection. We heard Mr. Pruden and Director Duckworth talk 
about this issue.
    Ms. Embrey, what is DOD doing about serious illnesses and 
fatalities in DOD facilities resulting from antibiotic-
resistant infections, some of which may have been picked up in 
Iraq? Has DOD shared this expertise with VA?
    Ms. Embrey. The acinetobacter infection that was referred 
to is endemic in Iraq. It does embed in the wounds of injured 
and wounded soldiers. Early in the conflict, we did discover 
this, and an aggressive infection control program was developed 
and issued and is abided by in theater and at every receiving 
facility in the United States because it could spread, 
especially if it is resistant to antibiotics.
    We have issued bulletins. We have clinical working groups 
with the VA who participate with us on all of the protocols 
that we learn as we care for our wounded servicemembers, and we 
share that with the VA. VA is well aware of the acinetobacter 
threat, and they issue guidance to their community as well.
    So I believe we are doing everything we can to aggressively 
address infection control in our treatment facilities.
    Chairman Akaka. Yes. Another seeming problem that has 
occurred has been tracking of veterans. Dr. Kussman and Ms. 
Embrey, Director Duckworth testified about the need for States 
to be able to track returning servicemembers and veterans. What 
is being done to ensure that State Directors have the best and 
most up-to-date information?
    Dr. Kussman?
    Dr. Kussman. Mr. Chairman, before I answer the question, if 
I could go back for just a second to the acinetobacter thing. 
As Ms. Embrey said, we have had combined teams looking at the 
protocols and clinical guidance we put out to all our 
facilities years ago when this first came up. So I was really 
disturbed about Captain Pruden's comment that an infectious 
disease specialist there said he did not know what to do about 
that, and I certainly will look into it because it is well 
known as a problem, and we have certainly disseminated that 
knowledge.
    Major Duckworth raised the issue. We had a test case in 
Florida. The Governor of Florida approached the VA and said, 
look, we do not have any exposure of when people are going to 
leave your facilities and come home. And we tested that for 
about 3 or 4 months, and it was a great success. We now have 
agreements with 19 States. I don't know why exactly Illinois is 
not part of that, but I will certainly contact Major Duckworth 
and see how we can move Illinois. But our hope is that all 50 
or 52 jurisdictions--we take Puerto Rico and the District, and 
others--that we will have that in place where all the States--
we have a very robust memorandum of agreement with the States, 
as well as the Reserve and National Guard, to be sure that we 
are communicating with them regularly.
    When it does not work, we need to know about it, and we 
need to fix it.
    Chairman Akaka. Yes, Ms. Embrey, would you like to comment 
on that?
    Ms. Embrey. I just want to say that Guard and Reserve 
individuals who continue to serve in the Department of Defense, 
we are very interested in maintaining visibility on their 
treatment and continuing health and wellness to continue to 
serve. And so I took and listened with interest on the State 
VA's role in helping us work with our Reserve component members 
and sustaining their health. And so we will be doing that. We 
will be looking into that.
    Chairman Akaka. Well, thank you.
    Director Duckworth made the case for increasing the window 
of automatic eligibility for VA care from 2 to 5 years. This is 
something that I believe is important for dealing with what we 
call ``invisible wounds,'' which sometimes do not manifest 
itself for many, many years.
    Secretary Nicholson has testified before this Committee 
that the current 2-year period provides ample opportunity for a 
veteran to apply for enrollment in the VA system, and that an 
expansion of this window is not necessary.
    Dr. Kussman, has VA's position changed on this?
    Dr. Kussman. I think it is under review, but if I could 
comment on it, when the 2 years pass, these patients are not 
refused or not eligible for care. As you know, they are all 
veterans. They all have got a DD214. So whether it is 3 years 
or 10 years later, you can come to the VA, be evaluated, and if 
it is for--certainly for TBI that is related to things that 
have happened when you are on active duty or PTSD, it will be 
determined to be service connected and the person would 
continue to get care.
    The only difference of the 2 years or greater is that for 
those 2 years we automatically enroll the person as a Priority 
6, a level 6, with no copays, regardless of what their income 
status or anything else is. But after that, they still could 
come and regardless of what their income status is, if they 
have a service connection, they would still be eligible to 
enroll and get compensation and pension for that injury.
    Chairman Akaka. Dr. Kussman, as Mr. Pruden testified, VA 
seems to be out of practice in dealing with injuries resulting 
from war rather than from diseases or illness. What can be done 
about this so that we are giving our younger veterans the care 
they need in the most sensitive manner?
    Dr. Kussman. As I mentioned, there are some learning things 
related to some of the new prosthetics and everything. But as 
far as the injuries related, we have been a national and 
international expert for the last almost 30 years on PTSD, and 
since 1991 when we developed our four traumatic brain injury 
centers in partnership with DOD, the Defense and Veterans Brain 
Injury Center, we have actually been leading the country in the 
treatment of that. And as you know, Major Duckworth did mention 
about screening and things and checking. For quite a while now, 
we have had an automatic screen in our electronic health record 
for PTSD. So whenever an OIF/OEF veteran comes in, regardless 
of what the symptoms are--because generally they will not come 
and say, ``I have got PTSD,'' or ``I have got a mental health 
problem.'' They come for something else. We have an automatic 
drop-down menu that requires the primary care person, who 
generally sees that person, to ask the questions related to 
PTSD.
    As you probably know, we have developed that same thing for 
TBI. We have tested it in 12 sites, and the only reason we did 
not implement it right away totally was that we have a very 
robust electronic health record, probably the world's leader in 
that, and that we wanted to be sure that when we put this 
electronic drop-down menu we did not break something in the 
electronic health record.
    But as of April 1st, this electronic reminder for TBI as 
well as PTSD will be implemented around our system because, 
obviously, people don't come and say, ``I have got TBI,'' just 
as they do not say--and I applaud your comments on invisible 
illness. So we need to be aggressive in our outreach to 
determine whether the individuals have it. If they are positive 
for the screen, then they are referred to more sophisticated 
neuropsychiatric evaluation. As you know, it is difficult. We 
all know what to do with significant, severe traumatic brain 
injury. Those are the ones that come back in the medical 
evacuation chain and then come to us generally through our 
polytrauma centers. But mild to moderate TBI is a challenge in 
the civilian community as well as in the DOD and VA. And we are 
trying to develop--we have worked with DOD and the civilian 
community to develop this screening mechanism that will allow 
us to try to determine mild to moderate TBI where the 
individual might not even know they have got a problem, no one 
has picked it up. And we need to track these people to be sure 
that whatever we can do to help them, we should do it.
    Chairman Akaka. I would tell you that this has been a good 
hearing today, and I thank you so much for your responses. I 
want to thank all the witnesses for appearing at today's 
hearing. We truly appreciate your taking the time to give us 
all a better understanding of the issues that our servicemen 
and women are facing.
    My hope is that today's hearing will help promote more 
thoughtful and focused interaction between VA and DOD, 
particularly when they are taking care of seriously injured 
servicemembers. And, again, I want to thank you so much for 
being helpful to the cause, and we are here to try to improve 
the system. And we can do well doing it together.
    Thank you very much, and this hearing is adjourned.
    [Whereupon, at 12:12 p.m., the Committee was adjourned.]
                            A P P E N D I X

                                ------                                

    [Note: The following questions were submitted by Hon. Daniel K. 
Akaka to Hon. Daniel L. Cooper at the hearing held on March 7, 2007, 
which was already at press when the Committee received VBA's response.]

 Questions Submitted by Hon. Daniel K. Akaka to Hon. Daniel L. Cooper, 
      Under Secretary for Benefits, Department of Veterans Affairs
    Question 1. What would be the cost of expanding the BDD program to 
all OIF/OEF veterans?
    Response. Resources necessary to open additional intake sites 
include dedicated funds, staffing reallocation, support infrastructure, 
equipment, and telecom needs. DOD is required to establish a Memorandum 
of Understanding with VA at each site and the military installation 
must provide space. Given the significant level of investment, one of 
the criteria in establishing the current BDD intake sites was the size 
of the separation site.
    A BDD claim is a pre-discharge claim taken from a servicemember at 
one of the 140 BDD intake sites and processed through the BDD program. 
There are specific criteria for BDD claims to include servicemembers 
having 60-180 days remaining on active duty and availability for all 
required medical examinations. However, any servicemember may file a 
pre-discharge claim for disability compensation. A pre-discharge claim 
may be accepted from a servicemember with 180 days or less remaining on 
active duty. All claims from servicemembers who have participated in 
the Global War on Terrorism receive priority handling of their claim.

    Question 2. What is VBA's rationale for rating headaches associated 
with traumatic brain injury at 10 percent while migraines are rated at 
50 percent? What type of guidance has VBA provided to the field 
concerning rating headaches that stem from traumatic brain injuries?
    Response. The diagnostic code for rating headaches is 8100. 
Although it is titled ``Migraine,'' any type of headache can be 
evaluated analogously under this diagnostic code. The possible 
evaluation levels are 0, 10, 30, and 50 percent, depending on the 
severity (the frequency and duration of attacks and whether or not they 
are prostrating).
    There is not currently a special diagnostic code or set of 
evaluation criteria for headaches from traumatic brain injury. 
Subjective complaints such as headache, dizziness, insomnia, etc., 
recognized as symptomatic of brain trauma are rated under a hyphenated 
diagnostic code, 8045-9304 with a maximum rating of 10 percent, 
according to instructions contained in diagnostic code 8045. We are 
currently in the process of reviewing and potentially revising the 
entire neurology section of the rating schedule. We plan to address all 
types of headaches, including headaches due to trauma.
    We are preparing additional training material for adjudicators on 
evaluating the residuals of traumatic brain injury. This will include a 
discussion of post-traumatic headaches.
    [Note: The following is a summary of the VA/DOD seamless transition 
study conducted by the Government Accountability Office.]

       DOD and VA Health Care: Challenges Encountered by Injured 
             Servicemembers During Their Recovery Process*
                             what gao found
    Despite coordinated efforts, DOD and VA have had problems sharing 
medical records for servicemembers transferred from DOD to VA medical 
facilities. GAO reported in 2006 that two VA facilities lacked real-
time access to electronic medical records at DOD facilities. To obtain 
additional medical information, facilities exchanged information by 
means of a time-consuming process resulting in multiple faxes and phone 
calls.
    In 2005, GAO reported that VA and DOD collaboration is important 
for providing early intervention for rehabilitation. VA has taken steps 
to initiate early intervention efforts, which could facilitate 
servicemembers' return to duty or to a civilian occupation if the 
servicemembers were unable to remain in the military. However, 
according to DOD, VA's outreach process may overlap with DOD's process 
for evaluating servicemembers for a possible return to duty. DOD was 
also concerned that VA's efforts may conflict with the military's 
retention goals. In this regard, DOD and VA face both a challenge and 
an opportunity to collaborate to provide better outcomes for seriously 
injured servicemembers.
    DOD screens servicemembers for PTSD but, as GAO reported in 2006, 
it cannot ensure that further mental health evaluations occur. DOD 
health care providers review questionnaires, interview servicemembers, 
and use clinical judgment in determining the need for further mental 
health evaluations. However, GAO found that 22 percent of the OEF/OIF 
servicemembers in GAO's review who may have been at risk for developing 
PTSD were referred by DOD health care providers for further 
evaluations. According to DOD officials, not all of the servicemembers 
at risk will need referrals. However, at the time of GAO's review DOD 
had not identified the factors its health care providers used to 
determine which OEF/OIF servicemembers needed referrals. Although OEF/
OIF servicemembers may obtain mental health evaluations or treatment 
for PTSD through VA, VA may face a challenge in meeting the demand for 
PTSD services. VA officials estimated that follow-up appointments for 
veterans receiving care for PTSD may be delayed up to 90 days.
    GAO's 2006 testimony pointed out problems related to military pay 
have resulted in debt and other hardships for hundreds of sick and 
injured servicemembers. Some servicemembers were pursued for repayment 
of military debts through no fault of their own. As a result, 
servicemembers have been reported to credit bureaus and private 
collections agencies, been prevented from getting loans, gone months 
without paychecks, and sent into financial crisis. In a 2005 testimony 
GAO reported that poorly defined requirements and processes for 
extending the active duty of injured and ill reserve component 
servicemembers have caused them to be inappropriately dropped from 
active duty, leading to significant gaps in pay and health insurance 
for some servicemembers and their families.
                                 ______
                                 
    [Note: The following is a summary of the VA/DOD seamless transition 
study conducted by the VA Office of Inspector General.]

          Health Status of and Services for OEF/OIF Veterans 
             After Traumatic Brain Injury Rehabilitation *
                           executive summary
    In response to the influx of servicemembers returning from recent 
conflicts in Afghanistan and Iraq, the Office of Inspector General, 
Office of Healthcare Inspections undertook an assessment of selected 
aspects of the health care and other services provided for these 
patients by the Department of Veterans Affairs. This review addresses 
the care of individuals with traumatic brain injury (TBI), focusing on 
their status approximately 1 year following inpatient rehabilitation. 
We interviewed a group of these patients to directly ascertain their 
overall well-being, functional status, and social integration, and to 
measure their perceptions of VA health care and services. In order to 
gauge the effectiveness of VA rehabilitation efforts, we also compared 
outcomes with those of TBI patients in the largest national civilian 
database. Finally, we visited Veterans Health Administration (VHA) 
facilities, met with TBI program leaders, and surveyed those 
responsible for coordination of care for TBI patients.
    Our inspection found that many of the 52 patients we interviewed 
continued to suffer some degree of cognitive or behavioral impairment 
approximately 16 months after injury. These patients had very similar 
outcomes when compared with a matched group of TBI patients from the 
private sector.
    VHA has enhanced case management for TBI patients, but long-term 
case management needs further improvement. In addition, improvement is 
needed in coordination of care, so that patients are able to make a 
smoother transition between Department of Defense (DOD) and VA care. A 
recent VHA Directive, published after data collection for this report, 
defines roles for staff at all VHA facilities to ensure a seamless 
transition of care for servicemembers and veterans from DOD to the VA 
health care system.
    We found that families often provide heroic support for injured 
servicemembers, but we also found that they frequently do so with 
limited assistance. To adequately meet the needs of its TBI patients, 
VHA needs to provide additional help for the family members and other 
caregivers so vital to the well-being of these patients in the long-
term.
    We recommended that the Under Secretary for Health should: (a) 
improve case management for TBI patients to ensure lifelong 
coordination of care, (b) work with DOD to establish collaborative 
policies and procedures to ensure that TBI patients receive necessary 
continuing care regardless of their active duty status and that 
appropriate medical records are transmitted, (c) develop new 
initiatives to support families caring for TBI patients, and (d) work 
with DOD to ensure that rehabilitation for TBI patients is initiated 
when clinically indicated.

  

                                  
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