[Senate Hearing 110-223]
[From the U.S. Government Publishing Office]
S. Hrg. 110-223
ACCESS TO VA HEALTH CARE AND BENEFITS IN HAWAII
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
AUGUST 21, 2007, AUGUST 23, 2007, AUGUST 27, 2007
__________
Printed for the use of the Committee on Veterans' Affairs
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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
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August 21, 2007
SENATORS
Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........ 1
Inouye, Hon. Daniel K., U.S. Senator from Hawaii................. 3
WITNESSES
Del Negro, Ariana, Spouse of Operation Enduring Freedom Veteran.. 5
Prepared statement........................................... 7
Hoe, Allen K., Vietnam Veteran................................... 12
Prepared statement........................................... 15
Joaquin, Thomas L., Senior Vice President of Operations, Hawaiian
Electric Company, Inc., and Member VA Advisory Council......... 18
Prepared statement........................................... 19
Victor Opiopio, Vietnam Veteran.................................. 19
Park, William Clayton Sam, Case Manager/Veterans Specialist,
Helping Hands-Hawaii........................................... 21
Prepared statement........................................... 25
Vincent, Darryl J., Site Director, United States Veterans
Initiative-Hawaii.............................................. 28
Prepared statement........................................... 31
Kussman, Hon. Michael J., M.D., M.S., M.A.C.P., Under Secretary
for Health, Department of Veterans Affairs; accompanied by
Robert L. Wiebe, M.D., Director, VISN 21, Department of
Veterans Affairs; and James Hastings, M.D., F.A.C.P., Director,
VA Pacific Islands Health Care System, Veterans Health
Administration, Department of Veterans Affairs................. 35
Prepared statement........................................... 37
Tuerk, Hon. William F., Under Secretary for Memorial Affairs,
Department of Veterans Affairs; accompanied by Gene
Castignetti, Director, National Memorial Cemetery of the
Pacific........................................................ 42
Satellite images, National Cemetery of the Pacific........... 79
Prepared statement........................................... 43
Aument, Ronald R., Deputy Under Secretary for Benefits,
Department of Veterans Affairs; accompanied by Gregory Reed,
Director, Honolulu Regional Office, Department of Veterans
Affairs........................................................ 46
Prepared statement........................................... 47
Watrous, Julie, R.N., Regional Director, Office of Healthcare
Inspections, Office of Inspector General, Department of
Veterans Affairs; accompanied by Dr. Michael Shepherd,
Physician, Office of Healthcare Inspections, Office of
Inspector General, Department of Veterans Affairs.............. 50
Prepared statement........................................... 51
Wallace, Colonel Arthur P., Deputy Commander for Nursing, Tripler
Army Medical Center; on Behalf of Major General Carla Hawley-
Bowland, Commanding General, Tripler Army Medical Center (TAMC)
and Pacific Regional Medical Command........................... 66
Prepared statement........................................... 68
Lee, Major General Robert G.F., Adjutant General, State of Hawaii 71
Prepared statement........................................... 74
Moses, Mark S., Director, Office of Veterans Services, Department
of Defense, State of Hawaii.................................... 75
Prepared statement........................................... 77
Attachment, Hawaii Office of Veterans Services fact sheet.. 79
APPENDIX
WW II Fil-Am Veterans and Ladies Auxiliary, Hawaii Chapter,
prepared statement............................................. 83
Caleda, Luz N., President, Ladies Auxiliary, WWII Fil-Am
Veterans, Hawaii Chapter, prepared statement................... 83
Clark, Charles L., President, Radiated Veterans of America,
prepared statement............................................. 84
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August 23, 2007
SENATOR
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........ 87
WITNESSES
Evangelista, Rogelio, President, Maui Veterans Council........... 89
Kamai, Clarence, Jr., Member, VA Advisory Council................ 91
Kanahele, Danny, Member, VA Advisory Council..................... 92
Skaggerberg, Mitch, President, Vietnam Veterans of Maui County... 93
Haupt, Prentiss Carl, Vietnam Veterans of Maui County............ 95
Prepared statement of Prentiss Carl Haupt and Mitch
Skaggerberg, on behalf of the Vietnam Veterans of Maui
County..................................................... 97
Karl Calleon, Vietnam Veteran.................................... 98
Steward, Grant, Operation Iraqi Freedom Veteran.................. 99
Prepared statement........................................... 100
Stroud, William Fielding, Past President, Vietnam Veterans of
Maui County.................................................... 101
Prepared statement........................................... 103
Kussman, Hon. Michael J., M.D., M.S., M.A.C.P., Under Secretary
for Health, Department of Veterans Affairs; accompanied by
Robert L. Wiebe, M.D., Director, VISN 21, and James Hastings,
M.D., F.A.C.P., Director, VA Pacific Islands Health Care
System, Veterans Health Administration, Department of Veterans
Affairs........................................................ 108
Prepared statement........................................... 110
Moses, Mark S., Director, Office of Veterans Services, Department
of Defense, State of Hawaii.................................... 113
Prepared statement........................................... 116
Attachment, Hawaii Office of Veterans Services fact sheet.. 79
Shepherd, Michael, M.D., Physician, Office of Healthcare
Inspections, Office of the Inspector General, Department of
Veterans Affairs; accompanied by Julie Watrous, R.N., Regional
Director, Office of Healthcare Inspections, Office of Inspector
General, Department of Veterans Affairs........................ 119
Prepared statement........................................... 121
APPENDIX
Concerned Maui Disabled Vets, letter............................. 129
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August 27, 2007
SENATOR
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........ 131
WITNESSES
Ferreira, David T., Family Assistance Specialist, Hawaii Army
National Guard................................................. 132
Prepared statement........................................... 134
Yano, First Sergeant Allison T., Operation Iraqi Freedom Veteran. 134
Prepared statement........................................... 136
Ishikawa, Brigadier General Gary, Deputy Adjutant General, Hawaii
Army National Guard............................................ 140
Prepared statement........................................... 141
Gibbons, Colonel Gerald, Chief of Staff, 9th Regional Readiness
Command, U.S. Army Reserve..................................... 142
Prepared statement........................................... 143
Hastings, James E., M.D., F.A.C.P., Director, VA Pacific Islands
Health Care System, Veterans Health Administration, Department
of Veterans Affairs............................................ 147
Prepared statement........................................... 149
Moses, Mark, Director, Office of Veterans Services, Department of
Defense, State of Hawaii....................................... 153
Prepared statement........................................... 155
Attachment, Hawaii Office of Veterans Services fact sheet.. 157
Reed, Gregory, Director, Honolulu Regional Office, Veterans
Benefits Administration, Department of Veterans Affairs........ 159
Prepared statement........................................... 161
APPENDIX
Michael Kilpatrick, M.D., Deputy Director, Force Health
Protection and Readiness, Office of the Assistant Secretary of
Defense for Health Affairs, Department of Defense, prepared
statement...................................................... 173
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HEARING ON HEALTH CARE AND BENEFITS FOR VETERANS IN HAWAII--HONOLULU,
HAWAII
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TUESDAY, AUGUST 21, 2007
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10 a.m., in Oahu
Veterans Center, Honolulu, Hawaii, Hon. Daniel K. Akaka,
Chairman of the Committee, presiding.
OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN,
U.S. SENATOR FROM HAWAII
Senator Akaka. Aloha.
Audience. Aloha.
Senator Akaka. I want to welcome you to today's hearing of
the Senate Committee on Veterans' Affairs. This is the first of
three field hearings that I'm chairing here in the state this
week and next week.
As you know, we held similar hearings at the start of 2006.
Much of it has been improved since that time for which I am
grateful.
Audience. We cannot hear back here, sir. Turn the mic on,
Senator Akaka.
Senator Akaka. Can you hear now?
Audience. (Applause.)
Senator Akaka. Thank you. We held similar hearings before.
And since then. I want to tell you that the Department of
Veterans Affairs has done so much more than they were doing
before, and we look forward to this hearing and continuing to
improve services to our veterans. And it is important for the
Committee to understand the remaining challenges we have now,
which is the reason for these hearings.
The VA Pacific Islands Health Care System's flagship is
Hawaii. The Spark M. Matsunaga VA Medical Center is a very busy
place and is in need of better ambulatory surgery space. We
know, too, that the VA nursing home here is full and there are
pockets on Oahu, especially on Leeward Oahu, that are
underserved.
I want to applaud the efforts of every VA employee on Oahu.
These men and women work hard to help the veterans who seek
their assistance and there are many things that VA does well in
Hawaii. However, there is always room for improvement. I want
to hear about how we can give VA the tools to make a difference
in the lives of Hawaii's veterans.
Back in Washington, we have worked hard to ensure that VA
has the resources to provide the best possible care. The VA
spending bill, which the Senate will take up early in
September, includes $43 billion for VA, $3.6 billion more than
was sought in the President's budget request. We are finally on
track to adequate funding for VA mental health care and care
for those veterans with traumatic brain injuries.
We have also been spending time to ensure that DOD and VA
work together to improve the transition process for
servicemembers and veterans. Given the existing relationship
between VA and Tripler Army Hospital, Hawaii should be at the
forefront of national efforts to ensure that the two
departments work closely together. We will explore that issue
today.
Congress has also given VA a significant increase in
funding to hire new staff to deal with VA's claims backlog. The
Veterans' Affairs Committee will carry out focused oversight to
ensure that the hiring and training process proceeds in a
timely fashion. And I've been sending my staff in Washington
across the country to do this. VA and several veterans service
organizations are working on innovative ways to process claims
in a more efficient manner. I will ask VA to describe specific
plans for using this funding to improve the claims adjudication
process here in Hawaii.
Another concern that the Committee will be looking into is
the status of Punchbowl. VA erected columbaria at the cemetery
to accommodate cremated remains but the demand has been much
greater than we anticipated. I have worked with VA on how to
address this problem and look forward to VA's testimony today.
Over this week and next, I will examine health care and
benefits in Hawaii. I want to tell you that when most of you
were in here prior to our coming into this building and into
this hall, we had a ceremony, an important ceremony outside in
which Under Secretary Tuerk presented a check for $743,035,
which will fund the next phase of the West Hawaii Veterans
Cemetery in Kailua-Kona. This is a great plus for Hawaii and
for its cemeteries, and I want to thank Under Secretary Tuerk
for that. Given the state's unique features, VA must adjust its
strategies that may be successful on the mainland but do not
work as well here.
It is vitally important that you share your thoughts with
us so we know how to help VA help you and the rest of Hawaii's
veterans. VA officials are here to listen to and respond to the
concerns raised by the witnesses on the first two panels.
Finally, I note that there are many veterans today who
would like to testify. Following the more formal part of
today's hearing, we are going to invite members of the audience
to address the Committee. We ask that your comments be focused
on veterans' issues only, and that you stick to the three
minutes that you will have for your comments at that time.
My staff is here to follow up with each of you and you will
receive further information on that. If you do not wish to
speak, feel free to provide a written comment to my staff. Once
again, I want to say mahalo nui loa to all of you who are in
attendance today. I look forward to hearing from today's
witnesses, and we are so fortunate to have with us today, and
to have him in the United States Senate, Senator Inouye. We are
delighted to have him here.
We do not have time to tell you all about him, but you know
about him and how he has been such a leader in helping Hawaii
over the years. We are so fortunate to have him here with us
today, so I call on Senator Inouye for his opening comments.
STATEMENT OF HON. DANIEL K. INOUYE,
U.S. SENATOR FROM HAWAII
Senator Inouye. Thank you very much, Mr. Chairman, and I'm
pleased to join you and the Senate Committee on Veterans'
Affairs on this field hearing on the topic of health care and
benefits for veterans. And I thank you for your leadership in
this very important area.
Before I proceed, I'd like to join my Chairman in thanking
the Department of Veterans Affairs through Under Secretary
Tuerk. His presence here is a demonstration of the support of
the Department that no veteran will be forgotten. It's very
important. West Kona is not in the big city, but they are
remembered. And Washington is here to tell us that and I'm most
grateful to you, Mr. Secretary. Thank you.
Mr. Chairman, I'm a wounded veteran of World War II, the
very ancient war. There are many differences between that war
and the current war in which we find ourselves embroiled. These
differences are in one sense very simple and yet very profound
and should be taken into consideration as we all work to ensure
a more seamless continuum of care for our Nation's veterans.
I'd like to make a few comments on this matter.
First, the wounded veterans in the war in Iraq are usually
transported on helicopters and find themselves receiving
medical care in the field hospital within a half-hour of the
infliction of the injury, which clearly increases their
survivability rate.
In World War II, there were no helicopters. The wounded
were transported by stretchers, sometimes by ambulances and
often times carried over rivers and mountains. My evacuation
began at 3 o'clock in the afternoon on a stretcher, and we
arrived at a field hospital at midnight nine hours later. As a
result of the prolonged transport period, many of those who
were wounded perished before they reached the hospital. I was
lucky.
Second, with the advancement of medical technology and the
sophisticated capacity available in the field hospitals,
today's veterans would survive much greater injuries. According
to studies, double amputations are much more common in today's
war as compared to World War II. Very seldom would you see a
double amp World War II veteran. I think the reason is simple,
the bleeding and trauma could not be sustained for nine hours.
Additionally, during World War II great battles involving
divisions, regiments were commonplace. The landing on Normandy,
the Battle of the Bulge, and in the case of fire rescue of the
Lost Battalion, it's no secret that medical facilities were
inadequate to care for the thousands of wounded. We would never
readily admit, but very difficult decisions and choices had to
be made.
In today's war, there are no great battles with thousands
of injured. Fatalities are more likely caused by roadside
bombing, terrorist suicide attacks, and loss of helicopter and
the crew. The number of injured has not been too large to
manage. Moreover, advancements in medical care have greatly
increased the number of wounded veterans who survive life-
threatening injuries.
Today's wounded veterans spend less time in hospitals than
the veterans of my era. According to the best information
available, if I had been wounded in Iraq with identical
injuries, I would very likely be discharged from a military
hospital in about six or seven months. And after that, spend a
few months in a VA hospital.
I spent 21 months in a military hospital. Nine months taken
up for medical and surgical purposes and the fitting of a
prosthetic device. There's no question that the prosthetic
device I received was inferior to the state-of-the-art
prosthetic device that today's veterans are receiving. Then I
spent a year in a military rehab hospital. During that period,
I learned how to drive. I was young when I left Hawaii. I
didn't know how to drive. I received the license to drive in
all states. I was taught carpentry, plumbing, taught how to do
some electrical work.
In fact, they taught me how to dine. After all, when I left
Hawaii, I was accustomed to the spoon, the fork and a
chopstick. I didn't know what an oyster fork looked like. I
learned to play a musical instrument. It was required in my
hospital. I couldn't play a saxophone because you needed two
hands for that; so finally they decided to teach me how to play
the piano, and I got approval of my peers and instructors to
perform. And I was required to take up two sports, basketball
and swimming. My swimming lessons were not in the hospital
pool. It was in a public place with people all over the place.
So my first lesson was a rather difficult one. I did what
most humans do. I wrapped myself in a big towel to hide my
scar. I didn't want to expose them. However, after two or three
lessons, no big deal. That's rehab. I remember when I returned
home to Hawaii and I told my mother I'm going to Waikiki, and
she was very happy. She thought I was going to do some
shopping. I said, ``No I'm going swimming.'' Her first reaction
was, ``Are you going to swim with your clothes on?'' It's human
nature to hide scars from your friends and your beloved ones.
Well, when I told her I'm going to swim in a regular pair
of shorts, she was stunned. But rehabilitation is very
important. It's not enough just for the physical, but you must
take care of the mental and the emotional well being of the
person. I can honestly tell you that I left the hospital with a
measure of confidence in myself, and I was ready to face the
world.
Today our advancements in technology has allowed us to
swiftly transport our injured to high quality field hospitals
where our advancements in medicine have resulted in a high
survival rate such as brain injuries. There are very few
internal injuries because you have your armored vest. The
double amps are very common. Brain injuries are very common.
You don't see too much of that on the front pages. That's what
it is.
There are many fellow veterans who lie today looking at the
ceiling and nothing else. So may I suggest that we do not
forget the importance of also healing the mind, healing the
spirit which comes often times from basic human contact. And
advancement of technology cannot replace that. Time, patience,
counseling should also be a part of the rehab package. Our
obligations should not end after the operating table. The
standard for which we must strive for today's veterans is to
leave government care completely healed both body, mind, and
soul and be ready to face the world with a measure of
confidence and hope.
Mr. Chairman, I look forward to hearing the testimony of
the witness panels which we'll touch upon the issues and the
needs of Hawaii's veterans, veterans of my age, veterans of
those who recently came home.
Mr. Secretary, I'm happy to tell you that our VA in Hawaii
is doing an absolutely great job. The service at Tripler is
unbelievably good. In fact, we set the motto for the rest of
the Nation to follow. But we must build upon this to continue
and ensure access to quality health care services. May I once
again tell you publicly you got a good man in chain. He's doing
a good job in Washington.
Thank you very much.
Audience. (Applause.)
Senator Akaka. Thank you very much, Senator Inouye. Many of
you know that he has shared very personal information about
what has happened to him and how much he cares for veterans. I
want to welcome the first panel, and I want to thank them all
for being here.
First, I welcome Ariana Del Negro. She is the wife of an
Operation Enduring Freedom veteran with Traumatic Brain Injury.
Second, I welcome my good friend Allen Hoe, a veteran of the
Vietnam War and member of the VA's Advisory Committee on the
Readjustment of Veterans. I also welcome Tom Joaquin, a member
of VA's advisory council.
I welcome Victor H. Opiopio, who suffered a back injury
while serving in the military. I welcome Clay Park, a case
manager for Helping Hands-Hawaii and a former medic in the
Vietnam War. Darryl J. Vincent will be our last witness on
panel one. He is the site director of the United States
Veterans Initiative.
I want to thank each of you for being here today. Your full
statements will appear in the record of the Committee.
Ms. Del Negro, would you please begin with your statement.
STATEMENT OF ARIANA DEL NEGRO,
SPOUSE OF OPERATION IRAQI FREEDOM VETERAN
Ms. Del Negro. Good morning.
Senators, thank for very much for the opportunity to share
our experience regarding our medical care my husband received
in Hawaii for his Traumatic Brain Injury also known as TBI.
I'll do my best to keep this brief and will refer you to my
written testimony for further detail and discussion.
My name is Ariana Del Negro, and, sadly, I represent one of
the many military wives or caregivers coping with the hardships
of having a soldier return wounded from Iraq or Afghanistan.
What my husband and I have had to endure over the course of the
last 10 months struggling to navigate through a convoluted,
outdated, unprepared bureaucratic military health care system
has been absolutely untenable.
The treatment we received here in Hawaii fell well short of
what the standard of care should be for those who fought to
protect democracy and freedom. It is my hope that sharing our
story today will increase awareness regarding the gaps in care
for TBI, will highlight the importance of supporting and
educating families and will emphasize the benefits of early and
appropriate referrals to Centers of Excellence.
On September 28, 2006, my husband suffered a TBI when a
7,000 pound VBIED (vehicular-borne improvised explosive
device), detonated 45 yards from where he was standing. The
primary, secondary and tertiary concussive forces from the
blast rendered him unconscious for at least 10 minutes. He
spent three days in the intensive care ward at Balad Military
Hospital and was subsequently released and returned to his base
in Iraq with the anticipation that the fog of his closed-head
TBI would subside sufficiently enough that he could return to
duty.
An Army Ranger, my husband is a well-respected member of
his battalion and held one of the most esteemed and coveted
positions for a lieutenant, that of a Scout Platoon Leader
responsible for collecting intelligence in an area rich with
diverse religious and political sects. He commanded deep
respect from his men and performed his job to the highest
degree of excellence and professionalism. He deserved the same
from the system that he served.
Instead, this brain-injured soldier and Purple Heart
recipient was returned three weeks later to his home base in
Hawaii and told to follow up with the system for evaluation and
treatment. My husband could barely keep his balance, let alone
figure out where he was supposed to go and who he was supposed
to see. From his first doctor's appointment, it became clear
that the system was reactive, not proactive. There was no
initiative taken to get him care. We had to do it all alone
facing obstacle after obstacle.
In short, referrals were not made and there was absolutely
no communication or consensus between the providers we were
ultimately able to see and only able to see after demanding
that those appointments be made.
My husband describes the struggles we've had with Tripler
Army Medical Center as being as painful as sustaining the
injury itself. Perhaps some of our difficulties were because
his injury was hidden, only overtly apparent to those familiar
with the man that he was before his injury. As we would
eventually learn, the subtleties of TBI often lead to claims
that soldiers are malingering, shirking out of having to
redeploy to the battlefield. Such flagrant accusations were
thrust upon my husband adding salt to an already open wound.
This was a system that was supposed to heal wounds, not create
new ones.
My husband was fortunate enough to have remarkable support
from his command. His commander took interest in his case,
provided support and dedicated many hours of his time seeking
resolution to our long list of outstanding issues. Without his
support and the support of the 25th Infantry Division, it's
likely I would be sharing a different story with you today.
Our frustrations with my husband's care endured for long
and frustrating weeks. After not being a priority in the system
and after no coordinated plan of care meeting was organized, my
husband's request for a referral to an experienced center was
granted. Five months after his injury, a pivotal time during
the acute rehabilitation stage, and with the help of the 25th
Infantry Division, we were fortunate enough to report to the
Defense and Veterans Brain Injury Center, the DVBIC, at Balboa
Naval Medical Center in San Diego, which coordinated with the
community reentry program at Sharp Rehabilitation Center, a
civilian center for follow-up care.
The care in San Diego represented the complete antithesis
of what we received in Hawaii. My husband underwent intensive
rehabilitation six hours a day, four days a week, care he
should have received all along. The providers at Sharp
Rehabilitation Center addressed all of my husband's needs,
integrated our requests into their rehab program and provided
amazing support to both of us.
Importantly, they educated us. We learned that the adverse
effects of the injury would have resolved faster had some of
the frustration with his medical care been avoided.
My husband left San Diego a changed man. He regained his
ability to accomplish complex tasks, his speech was fluid, he
was able to run and he passed a driving evaluation. He has
since returned to duty in an administrative capacity working
with his units, Rear Detachment here in Hawaii.
Since our return to Hawaii, we learned that Tripler Army
Medical Center has launched several initiatives to assist its
wounded warriors.
I am pleased to know that Tripler recognizes the need to
make the care of wounded soldiers its top priority and has
begun to implement programs that have the potential to improve
tracking and coordination of care as well as support for
families. There is still much work to be done, however. My
husband and I hope to collaborate with Tripler to help ensure
that no other wounded warriors and their families experience
similar hardships.
Senators, I urge you and your and colleagues to remain
steadfast in your endeavors to ensure: (1) that programs are
instituted to increase awareness of the signs, symptoms and
appropriate treatments for TBI especially closed-head TBI; (2)
that soldiers with TBI and their families receive education
about the injury, are provided access to resources and receive
unconditional support; and (3) that appropriate and early
referrals are made to dedicated centers adequately prepared to
treat the complexities of Traumatic Brain Injury.
Certainly we can all agree that it's time the excellence
that these soldiers dedicated in the battlefield be matched by
the system for which they sacrificed. I again, thank you for
the opportunity to participate in this vital forum.
[The prepared statement of Ms. Del Negro follows:]
Prepared Statement of Ariana Del Negro,
Spouse of Operation Iraqi Freedom Veteran
Mr. Chairman, Members of the Committee, and panel members, thank
you for the opportunity to participate in this vital forum on veterans'
care and benefits in Hawaii. By sharing our story today, I hope to
increase awareness regarding the gaps in medical care for veterans
receiving treatment in Hawaii, as it is my opinion that the military
healthcare system here on Oahu, as it now stands, is insufficiently
prepared to address the needs of our wounded veterans and their
families suffering from Traumatic Brain Injury (TBI). There is much
work to be done that requires diligent initiatives for research,
education, and family support. My hope is that our story demonstrates
the importance of prompt referral to centers specifically tailored to
the individual needs of each wounded warrior and highlights the need to
streamline the transition from active duty to veteran status.
My name is Ariana Del Negro and, sadly, I represent one of the many
military wives/caregivers coping with the hardships of having a soldier
return wounded from Iraq or Afghanistan. But I'm one of the lucky ones.
My husband and I are well educated, I work in the healthcare industry,
and we are financially independent. What we have had to endure over the
course of the last 10+ months struggling to navigate through a
convoluted, outdated, unprepared bureaucratic military healthcare
system has been absolutely untenable. If it has been this difficult for
us, I cannot imagine what it must be like for the other families--those
with warriors who return far worse off than my husband; families with
children; with mothers who have to work to supplement the family
income; and those who don't know that the care they are receiving is
far inferior to what they need and, importantly, deserve. The wounds
suffered from these injuries extend beyond the soldier; the
frustrations, gaps in care, and lack of support also wound the families
fighting for their loved ones. There are soldiers and families out
there that need help and the onus to get them that help falls on the
Nation for whom these warriors fought to protect democracy and freedom.
On September 28, 2006, my husband suffered a TBI when a 7,000 pound
VBIED (vehicular-borne improvised explosive device) detonated 45 yards
from where he was standing. He was exposed to 3 concussive forces:
first the explosion; then the engine block from the vehicle which
struck him on the back of the head as he was thrown into the air; and
finally when he hit his head again after falling to the ground on his
back, where he remained unconscious for at least 10 minutes. He spent 3
days in the intensive care ward at Balad Military Hospital and was
subsequently released and returned to his base in Iraq with the
anticipation that the fog of his mild/moderate (closed-head) TBI would
subside sufficiently enough that he could return to full duty.
An Army Ranger, my husband is a well-respected member of his
battalion and held one of the most esteemed and coveted positions for a
lieutenant--that of a Scout Platoon Leader responsible for collecting
intelligence in an area rich with diverse religious and political
sects. He commanded deep respect from his men and performed his job to
the highest degree of excellence and professionalism. He deserved the
same from the system that he served.
Instead, this brain-injured soldier and Purple Heart recipient was
returned 3 weeks later to his home base in Hawaii and told to follow-up
with the system for evaluation and treatment. My husband could barely
keep his balance, let alone figure out where he was supposed to go and
who he was supposed to see. Unfortunately, the system he reported to
didn't know either. From his first doctor's appointment in Hawaii, it
became abundantly clear that the system was ``reactive,'' not
``proactive''. There was no initiative taken to get him care; we had to
do it all alone, facing obstacle after obstacle along the way. In
short, referrals were not made, diagnostic tests were not ordered,
complaints of mental duress (anxiety) went ignored, and there was
absolutely no communication or consensus between the providers we were
ultimately able to see (and only able to see after demanding that those
appointments be made). In my opinion, regardless of the medical
setting--military or otherwise--this care or the lack thereof amounts
to negligence and malpractice.
My husband describes the struggles we have had with Tripler Army
Medical Center as being as painful as sustaining the injury itself.
Perhaps some of our difficulties were related to the fact that a
closed-head TBI is literally a hidden injury; an injury with the
potential for subtle (yet devastating) sequelae that go unnoticed by
those who are unfamiliar with the individual's function before his or
her injury. Healthcare professionals are used to having physical
evidence of an injury, but typically, the diffuse axonal injury pattern
that results from the blast wave of pressure from an exploding IED
cannot be neuroimaged and proper identification and referral to
treatment are made on the basis of neurologic examination, self-and
family reported symptoms, and the results of neuropsychological
testing. Oftentimes, this can lead providers to think that soldiers are
malingering, shirking out of having to return to duty in Iraq or
Afghanistan. Such accusations were wrongly thrust upon my husband,
adding salt to an open wound. This was a system that was supposed to
heal wounds, not create new ones. It failed and it has not failed us
only; it has failed many of the returning wounded warriors.
However, my husband was fortunate enough to have remarkable support
from his Command. His Commander took interest in my husband's case,
provided support, and dedicated many hours of his time seeking
resolution to our long list of outstanding issues. Without his support
(and the support of the 25th Infantry Division), it's likely that I
would be sharing a different story with you.
EARLY DISAPPOINTMENTS
My husband returned to Hawaii approximately 3 weeks after he was
wounded. At that time, he complained of debilitating headaches, chronic
vertigo, memory lapses, anxiety, and hearing loss. He always leaned to
the left, had hand and facial tics, and could not maintain eye contact
when speaking. Two weeks thereafter, some symptoms worsened and new
ones emerged. He developed a significant stutter, had difficulty with
word recall, and had a propensity to drop things. It was also at this
time that he began to withdraw socially, avoiding public and busy
areas. His time was mostly spent sitting, staring blankly. My husband
is an exceptionally accomplished and strong individual and it was very
hard for me to see him struggle with simple tasks.
After much insistence, he was referred for speech pathology and
received speech cognition therapy once a week. The next mountain to be
climbed was to get his vision checked and then to obtain referral for
vestibular and audiology testing. During this time his symptoms
persisted, and although some subsided, they never fully resolved. After
14 long and frustrating weeks of not being a priority in the system,
after no coordinated plan of care meeting was organized, and after
being denied access to additional care (i.e., occupational therapy),
our request to be referred to the Defense and Veterans Brain Injury
Center (DVBIC) in San Diego for thorough evaluation and intensive
treatment was finally granted. We waited another 6 weeks for all
paperwork to be finalized and then reported to the DVBIC at Balboa
Naval Medical Center who coordinated with the Community Re-entry
Program at Sharp Rehabilitation Center (civilian) for follow-up care.
All told, it took us more than 5 months to get access to excellent
care. This was 5 months of valuable time lost, during what should have
been the important acute rehabilitation stage of TBI.
FINE EXAMPLE OF EXCELLENT CARE AND INVALUABLE EDUCATION
The care in San Diego represented the complete antithesis of what
we received in Hawaii. The providers at Sharp addressed all of my
husband's needs (physical, occupational, and speech therapy),
integrated our requests into their rehab program, and provided amazing
support to both of us. My husband underwent intensive rehabilitation 6
hours a day, 4 days a week--care he should have received all along. We
had biweekly coordination meetings with providers at both Sharp and
Balboa who met with us to discuss his progress, make suggestions, and
ask for feedback. And, importantly, they educated us. We learned that
our situation was not unique and that many closed-head TBI patients
face similar obstacles and frustrations that compound their symptoms.
They explained that the adverse effects of the injury would have
resolved faster had some of the frustration with his medical care been
avoided. They also explained that my husband would have probably made
greater progress during rehabilitation had he been referred earlier in
the treatment process; likely he would have reached the same degree of
benefit, but at a much faster rate. Importantly, they also explained to
us that there may be some symptoms that will never resolve and that the
success of his rehabilitative therapy requires us to recognize
reasonable goals while maintaining practical expectations.
Shortly after coming home from Iraq, my husband commented that
because he wasn't missing a limb and/or didn't have scars on his head
or body, he didn't consider himself as seriously wounded as those with
visible injuries, a sentiment reinforced by Tripler Army Medical
Center's lack of initiative for his care. The absence of a visible sign
of his injury took away from its severity, as well as his perceived
need to treat it. The education we received from Sharp Rehabilitation
as well as from the DVBIC helped alleviate some of those concerns and
provided affirmation to my husband that he was seriously injured and
did deserve the best possible care. It is our hope that with greater
awareness of the consequences of TBI, providers will appreciate the
importance of educating and supporting the patient and his/her family.
My husband left San Diego a changed man. He regained his ability to
accomplish complex tasks, his speech was fluid, he was able to run, and
he passed a driving evaluation. He has since returned to duty in an
administrative capacity, working with his unit's Rear-Detachment here
in Hawaii. Although he still suffers from intermittent headaches,
vertigo, fine motor skill deficits, and some memory problems, they are
far less intense than when he first came home and he has applied the
lessons we learned in San Diego and is accepting and compensating for
these limitations accordingly.
Our success with Sharp's Community Re-entry Program was the result
of receiving excellent individualized care and education from a
multidisciplinary group of providers who worked well together and
integrated the family unit into the decision-making process. This
medical model supports the plans outlined in Section 3 of the Veterans
Traumatic Brain Injury Rehabilitation Act of 2007 (cited as S. 1233)
describing rehabilitation programs that provide individualized care and
family support to veterans with TBI. Section 3 of S. 1233 also
identifies the importance of periodic evaluation and adjusting care as
needed, which we experienced at the Sharp Rehabilitation Center.
COMPREHENSIVE CARE: WHEN A REFERRAL IS REALLY NECESSARY
My husband was very high-functioning after his injury and was not
an individual who one would typically consider eligible for intensive
rehabilitation. However, with the increasing awareness of the
deleterious and long-term consequences of TBI--namely through the
adoption of the DVBICs across the country--my husband was properly
identified as someone who could benefit from such care. We utilized all
of the tools at our disposal to the fullest. We knew that he was one of
the lucky ones to get treatment and it is our hope that the success he
(and Sharp Rehabilitation, in collaboration with the DVBIC and Balboa
Naval Medical Center) achieved sets a fine example for what the
standard of care should be for all soldiers returning with TBI. Our
experience at the Sharp Rehabilitation Center also represents the
importance of extending civilian healthcare services to returning
soldiers. Programs, such as the one at Sharp, have experience with the
injury, have an effective and efficient program in place, and clearly
yield excellent results. More initiatives need to be taken to institute
similar programs partnering military and civilian healthcare services.
In addition, consideration must be given to properly pairing the
offerings of a rehabilitation center with the specific needs of a
veteran with TBI. In our case, and because my husband was high-
functioning, referral to the Sharp Community Re-entry Program was more
appropriate than referral to the Veterans' Affairs (VA) Palo Alto
Health Care System because the latter primarily manages patients with
more severe TBIs. Veterans with TBI will be greatly served by having
access to non-Department facilities for rehabilitation, as outlined in
Section 4 of S. 1233.
Our referral to the DVBIC in San Diego was absolutely appropriate,
but the decision should have been made much earlier. In fact, my
husband never should have been returned to Hawaii for evaluation and
treatment of TBI. Typically, soldiers that are wounded and returned
home are routed to Landstuhl for referral to Walter Reed or another
center adequately equipped to treat the specific injury. Tripler was
not an experienced center for TBI and should have recognized the
importance of referring my husband to a center that could provide the
necessary comprehensive care. This also speaks to the importance of
Section 4 of S. 1233 for referral to a non-Department facility when
``the Secretary is unable to provide such intervention, treatment, or
services at the frequency or for the duration prescribed in such
plan''. Tripler's unpreparedness to adequately treat TBI was reflected
in the fact that appointments were few and far between and no
coordination efforts were put forth to institute a plan of care for my
husband's treatment--a necessary course of action mandated in Section 3
of S. 1233.
Since our return from San Diego, awareness of TBI has increased and
programs are now being instituted to assist wounded warriors at all
Army facilities, including Tripler. I am pleased to know that Tripler
recognizes the need to make the care of wounded soldiers its top
priority and has begun to implement programs that have the potential to
improve tracking and coordination of care, as well as support for
families.
Although these initial steps are very promising, I remain concerned
that much more work needs to be done before Tripler Army Medical Center
has the necessary tools in place to effectively coordinate and manage
the care of soldiers or veterans with TBI. Noted in Section 3 of S.
1233, and also listed in a Veteran's Health Initiative, \1\ optimal
care for TBI requires a multidisciplinary approach consisting of a team
of providers from at least 9 specialties. I do not believe that Tripler
will be able to establish a team that could coordinate or collaborate
effectively enough to yield the necessary outcomes owed to a TBI
wounded warrior, at least not at the present time.
---------------------------------------------------------------------------
\1\ Veterans Health Initiative. Traumatic Brain Injury. Independent
Study Course Released: January 2004.
---------------------------------------------------------------------------
ACCESS TO RESOURCES
We hope to work with Tripler and its faculty to help ensure that no
other wounded warriors and their families endure the same hardships
that we faced. Furthermore, it is our hope that we will be given the
opportunity to meet with some of the soldiers and their families to
provide support, whether that be as simple as lending an ear or a
shoulder or helping them gain access to important resources.
It is critically important that soldiers and their families are
proactively made aware of the resources that are available to them;
they shouldn't have to seek them out. I wouldn't have known about the
DVBIC unless I had actively sought out information and made contact
with both Walter Reed and San Diego. I wouldn't have known that my
husband wasn't getting the standard of care if I didn't work in the
healthcare industry and if I hadn't done extensive research to educate
myself on TBI and the multiple disciplines that must work together to
treat the condition.
Our endeavors paid off, it would seem. But what about those
individuals who, in addition to the needs of their wounded loved one,
have to tend to the needs of their children, or who don't have the
flexibility with their work, or who don't have the benefit of higher
education, or who don't know that they can ask questions? Those are the
families in need. These families need immediate access to resources,
they need advocates, and they need support. It's one thing to develop
resources--it's another to actually utilize them. If the families don't
know these resources exist, then they are certainly not likely to ever
reap the benefits from said programs.
TRANSITIONING FROM ACTIVE DUTY TO VETERAN STATUS
The above traces the trials and tribulations that my husband and I
faced during the early phases of his injury. Our frustrations, I fear,
will continue for months and years to come. My husband is still on
active duty and we are no closer to definitively determining his
potential for return to full duty status than we were when he first
returned from Iraq in October 2006. Unfortunately, the obstacles we
faced during active duty will likely be inevitably revisited once he is
discharged from the service and once he enters and seeks care in a
backlogged and overwhelmed VA system (described as such after reading
media accounts); whether that happens in the next year or in 12 years
when he retires, remains to be determined.
Although my husband is still on active duty, our experience
represents what most young veterans suffering TBI have had to face
before being discharged from the service. We must be able to learn from
these initial experiences to avoid similar obstacles within the VA
system. The continuum of care begins on the battlefield, moves to the
military healthcare system, and then to the VA system. The Dignity for
Wounded Warriors Act of 2007 (H.R. 1268) aims to overcome many of the
limitations associated with wounded servicemembers' access to care.
However, the success of both S. 1233 and H.R. 1268 are contingent on
establishing an effective transition system. As noted in Section 2 of
S. 1233, a collaborative effort between the Department of Defense and
the VA is absolutely necessary to facilitate care and streamline the
transition of soldiers from active duty to veteran status. More
research and greater awareness of blast-related TBIs will likely
facilitate this transition process.
MORE RESEARCH IS NEEDED
Recovery from and treatment for TBI requires patience. The
complexity of the injury and its pathophysiology require a long-term
multi-tiered management approach. In the acute setting, management is
focused on stabilizing the patient and ruling out life-threatening
complications, such as shrapnel wounds or spinal injuries. The second
step is assessing and treating the intermediate effects of the injury,
namely, neurocognitive difficulties, reflected in self-reports of
symptoms such as forgetfulness, anxiety, headaches, balance
difficulties, and other sequelae commonly associated with post-
concussive syndrome. Less defined at this time, however, is what will
be needed in the long run. How long should care be administered? When
is a patient considered fully recovered and what are the long-term
consequences of closed-head TBI (i.e., epilepsy, Alzheimer's,
Parkinson's)? Answers to these questions remain ambiguous, at best.
Data suggest that a person with a mild TBI who does not receive
early adequate treatment and education is more likely to endure a long
recovery process with lingering symptoms. However, these data are
largely based on older studies evaluating outcomes of patients who
sustained a TBI in an automobile accident, a fall, or a sports injury.
It does not take into consideration that a blast-related TBI may injure
cells at a more severe microscopic, sub-cellular level.\2\, \3\ Injury
to this fine of a degree may influence outcomes and possibly require
longer periods for maximum recovery than TBIs suffered in a non-combat
setting.
---------------------------------------------------------------------------
\2\ The Washington Post National Weekly Edition, April 16-22, 2007,
page 25.
\3\ Taber, et al., J. Neuropsychiatry Clin Neurosci.
2006;18(2):141-145.
---------------------------------------------------------------------------
There is little doubt that more research on blast-related TBI is
needed, particularly as it relates to the effects of exposure to
multiple primary blasts and long-term outcomes. TBI in a combat
environment is a complex injury. A thorough understanding of the
nuances of the injury, whether physically evident or otherwise, is
absolutely essential to identify effective therapies and maximize
outcomes. Currently, much of the evidence on blast-related TBIs is
derived from animal studies, which have helped researchers understand
the pathophysiologic effects of the injury; however, the implications
of these findings in the clinical setting have not been well studied.
As the number of TBI wounds increase, so too does the need for
allocated funding to support clinical research and facilitate the
drafting of practice guidelines, as well as the need to develop
educational tools and implement training requirements for all
providers.
The importance of more research in this area is recognized in
Section 5 of S. 1233, which states that the ``Secretary shall establish
a program on research, education, and clinical care to provide
intensive neuro-rehabilitation to veterans with a severe Traumatic
Brain Injury''. However, this language excludes the majority (80
percent) of TBI injuries--those classified as mild or moderate. It is
my opinion that without documentation from large clinical studies with
long-term follow-up, it may be premature to assume that veterans with
mild or moderate TBI do not need the same services offered by this
initiative. Furthermore, persistent post-concussive syndrome (defined
as symptoms that continue beyond 6 months post-injury) is more common
after mild TBI than moderate or severe TBI and individuals with
persistent post-concussive syndrome are likely to continue to suffer
symptoms for a number of years.
It took months for me to convince my husband that he deserved the
same priority of care as those soldiers with visible injuries.
Hopefully, with more research and greater awareness, soldiers in
similar situations will be counseled appropriately by the system
responsible for helping these individuals maximize their potential.
These soldiers (and their families) need validation and they need
dedicated support.
I am aware that this continues to be an ongoing learning process,
but I also believe that measures need to be put in place to assess the
efficacy of these programs, that specific benchmarks need to be set to
reduce the length of time between presentation and treatment
initiation, and that processing of disability claims must be
streamlined. The proposed programs set forth by S. 1233 and H.R. 1268
are promising in theory, but without adequate resources and without
intense coordination and organization, the therapy and these efforts
will likely fail for most.
I urge you and your colleagues to remain steadfast in your
endeavors to ensure: (1) that soldiers with TBI and their families get
the care that they need and deserve; (2) that appropriate funding be
allocated for research; and (3) that immediate actions are put into
place to increase the awareness of the devastating effects of TBI. It's
time that the excellence that these soldiers dedicated and displayed in
the war zone be matched by the system for which they sacrificed.
I thank you for your time.
Senator Inouye. Thank you very much.
The Audience. (Applause.)
Senator Akaka. Thank you very much, Ms. Del Negro, and now
we'll receive the testimony of Allen Hoe.
STATEMENT OF ALLEN HOE, VIETNAM VETERAN
Mr. Hoe. Good morning, Senator Akaka and Senator Inouye.
The Hawaii Veterans Community is honored by your presence and
continuing dedication in fulfilling your promise to serve those
who have served our country in uniform.
My name is Allen Hoe and like many here this morning, I am
a proud veteran who wore the U.S. Army jungle fatigues in
combat in Vietnam in 1967 and 1968. However, for me a greater
source of pride is my two sons who also wore the uniform as
infantrymen in service of their country. I would like to
believe that our family is not unique. Hawaii sons and
daughters have a long and honored tradition of service and
sacrifice to our country.
Duty, honor, country, those three simple words have the
power to motivate young men and women to do remarkable things
when called upon by their country. To the veteran who has worn
the uniform to the young warriors who wear it today, we owe
them our gratitude for their selfless service, but more
importantly, we must ensure that they receive the fullest
measure of those benefits to which they are entitled to.
I have had the privilege to wear many different hats over
the years. As a Vietnam veteran, the one I wear as a member of
the Advisory Committee on the Readjustment of Veterans provides
the greatest sense of duty for me. I accepted that role several
years ago when I realized my sons would soon be going off to
service and I needed to focus my energies on protecting our
veterans' benefits programs and to secure them for the current
generation of our brave young heroes. As we, Vietnam vets, are
so fond of saying never again will one generation abandon
another.
My testimony this morning is not in any official capacity
with my service on the advisory committee. I'm here simply as a
veteran, a member of this proud community of veterans and the
father of a couple of young soldiers to whom our obligations
must be fulfilled.
Earlier this year our Committee issued its 11th Annual
Report. I merely wish to highlight the report's recommendations
which are presented to the secretary. If there is any ulterior
motive on my part, it is merely to provide this honorable
Committee and its Members the perspective of ``boots on the
ground'' regarding the importance of the work done by my
colleagues who serve on the Advisory Committee on the
Readjustment of Veterans.
Number one, Vet Centers have become as we say in Olelo
Hawaii, ``Puuhonua'' or sanctuaries, special place of refuge.
Veterans are utilizing its services and programs in increasing
numbers. Two new Vet Centers and staff augmentation at existing
Vet Centers are in progress.
However, based on a number of findings as listed, it is
clear that additional augmentation of the Vet Center program is
needed. The high number of National Guard and Reserve
combatants in OEF and OIF and our own experience especially
with the mobilization of the 29th Infantry Brigade and the
100th Battalion, along with the continuing separate unit
mobilization throughout the Pacific Command, many of these
young warriors are now coming from widely dispersed, rural
areas. Thus, the need exists to prioritize the creation of Vet
Centers outstations and augmenting staff in Vet Centers that
provide access to these rural areas. The capacity to respond to
the service needs of the increasing number of OEF/OIF veterans
and family members will be critical for years to come and that
expanding the Vet Center program to provide access would
perhaps be an effective way to build and expand the veterans'
benefits infrastructure to meet their needs over time.
In our Hawaiian family tradition of Ohana, we are defined
as who we are as veterans and the importance of our families in
every aspect of our lives as we serve our country. Thus, the
recent legislative authority allowing for treating veterans'
families at Vet Centers is a great accomplishment. It is truly
a no brainer that a veteran's successful readjustment also
includes their Ohana's readjustment as well. Providing family
treatment by Vet Centers which have qualified family therapists
on staff needs to be expanded. The augmentation of family
counselors at Vet Centers would enhance the program's capacity
to clinically address the more complicated family adjustment
problems among the increasing numbers of returning combat
veterans.
A very key factor in the Vet Center program's success is
its design to function as an off-campus entity, if you will. It
provides a safe haven for many veterans. Thus, it is important
to validate its rule with the secure and separate system of
client records and related policy of guaranteeing
confidentiality for the veteran. This is perhaps the most
essential item in serving war-traumatized veteran population
and goes a long way toward mitigating the stigmas manifested by
this population against accessing care.
Nakoa Wahine or women warriors are an integral part of our
ancient Hawaiian tradition and culture. They stood along side
their husbands in battle. And in some instances, due to a
greater family allegiance, they found themselves opposite their
husband. Today American women in service uniform comprise an
ever increasing component of who we are as veterans. With
increasing numbers of female military personnel serving in
combat areas, the Vet Centers will need to carefully monitor
the demographics of this local catchment areas to ensure that
the female veterans service providers are represented on the
Vet Center Teams at appropriate levels.
Increasing awareness of the impacts of multiple
deployments, extended deployments and traumatic battlefield
experiences have exposed a higher incidence of mental health
needs of returning OEF/OIF veterans as documented by the Land
Combat Study research by Colonel Charles Hogue. Veterans must
be extended priority access to VA medical centers for mental
health screening, assessment and treatment to avoid the barrier
of waiting lists of several months of appointment.
The blending of our Armed Forces of active duty, Guard and
Reserve units are presenting some unique issues on tracking
these individual heroes as they change out of uniform into
civilian attire. The establishment of the aggressive Global War
on Terrorism veteran outreach program which consists of 100
OEF/OIF veterans whose mission is to provide early contact
program information and educational briefings to veterans at
military demobilization and National Guard and Reserve sites,
is vital to the efforts to service all our veterans. There must
be a system to closely monitor the program's outcomes to
further access the feasibility of further extensions to this
program.
There is a realization that as time increases following
demobilization and separation from active military, increasing
numbers of veterans will experience readjustment concerns to
include the delayed onset of PTSD. To facilitate a veteran's
ease of access for care, the more traditional methods of
community outreach in addition to the Global War on Terrorism
outreach program at the demobilization sites need to be
enhanced. Such methods would include liaison with community
emergency responders, educational presentations at community
mental health and social service agencies and any other form of
community liaison that will result in facilitating veteran
referrals for follow up readjustment counseling.
The points above clearly represent a cross section of those
issues of services which are of great importance to our veteran
community not just in Hawaii but at large.
More particular with regard to Hawaii veterans' community,
the disability claims need more resources to decrease the
current backlog in the disability claims. Two critical areas
are elderly veterans who often give up or die before their
claim is resolved, and the OIF/OEF veterans who often
experience serious financial difficulties while awaiting a VA
decision on their disability.
OIF and OEF vets need greater focus on unique needs of
soldiers and veterans from those combat areas. The need for
more full-time personnel assigned to coordinate care to ensure
a seamless transition. Too often VA personnel are assigned
duties as ancillary to primary job responsibilities.
Each VA facility should have a full-time fully staffed OIF/
OEF treatment team. As pointed out by Ariana, Traumatic Brain
Injury treatment, there needs to be great improvement in the
VA's ability to assess and treat TBI. Increase number of neuro-
psychologists to do the testing for TBI.
Eligibility periods: Returning soldiers and veterans must
apply for medical benefits within two years after returning
from a war zone. Unfortunately, many do not seek VA care within
this allotted time period. Eligibility for peer should be
extended to years after return.
In short, there are many things which the VA does that is
absolutely wonderful and, as we know, there are many things
that needs great improvement. And again, I wish to extend my
heartfelt gratitude for the opportunity to offer some of my
observations and concerns to the Committee this morning.
For those of you who know me, you understand the importance
of symbolisms to me. I wear my cap. This flag is a special
flag. This flag I carried 40 years ago with me in combat in
Vietnam. And we carry that to honor 18 of my fellow recon team
members who were killed. And we promised their families that
when they were recovered and brought home, that this flag would
fly at their service.
This past January we had the honor, after my lieutenant was
missing for 38 years and my RTO missing for 38 years, to have
this flag accompany us as we attended the services at Arlington
as well as Oklahoma. And as a tribute to how important these
symbols are to our kids and our families, this flag was carried
by my son in Mosul in January of 2005 in honor of his dad's
lieutenant who was killed and missing in Vietnam. And this flag
was carried by my son the morning he was killed in Iraq. So if
you look at it, it really says a lot of who we are as a people,
who we are as veterans in this community and who we are as a
Nation. Thank you.
[The prepared statement of Mr. Hoe follows:]
Prepared Statement of Allen K. Hoe, Vietnam Veteran
Good morning Senator Akaka, Senator Craig and Members of the
Committee on Veterans' Affairs. Your presence and your continuing
dedication in fulfilling your promise to serve those who have served
our Country in uniform is deeply appreciated.
My name is Allen Hoe, I am a proud veteran who wore U.S. Army
jungle fatigues in combat in Vietnam in 1967 and 1968; however, for me
a greater source of pride is in my 2 sons who also wore the uniform as
infantrymen in service of their country. I would like to believe that
our family is not unique. Hawaii's sons and daughters have a very long
and honored tradition of service and sacrifice to our country.
Duty, Honor, Country, those three simple words have the power to
motivate young men and women to do remarkable things when called upon
by their country. To the Veteran who has worn the uniform, to the young
warriors who wear it today, we owe them our gratitude for their
selfless service but more importantly we must ensure that they receive,
to the fullest measure those benefits to which they are entitled to.
Of the many hats which I have had the privilege to wear over the
years, from my veteran's perspective, the one I wear as a member of the
``Advisory Committee on the Readjustment of Veterans'' provides the
greatest sense of duty for me. I accepted that role several years ago,
when I realized that my sons would soon be going off to serve and that
I needed to focus my energies on veterans benefits programs to secure
them for the current generation of our brave young heroes. As we
Vietnam Vets are so fond of saying, ``never again will one generation
of veterans abandon another.''
The Advisory Committee on the Readjustment of Veterans, which I
have the honor to serve as a member is mandated under Public Law 104-
262, to:
Assemble and review information relating to the needs of
veterans in readjusting to civilian life.
Provide information relating to the nature and character
of psychological problems arising from service in the Armed Forces.
Provide an ongoing assessment of the effectiveness of the
policies, organizational structures, and services of the Department of
Veterans Affairs (VA) in assisting veterans in readjusting to civilian
life.
Provide ongoing advice on the most appropriate means of
responding to the readjustment needs of veterans in the future.
In carrying out these activities, the Committee shall take
into special account the needs of veterans who have served in a combat
theater of operations.
My testimony this morning is not in any official capacity with my
service on the Advisory Committee on the Readjustment of Veterans. I am
here simply as a veteran, a member of this proud community of veterans
and the father of young soldiers, to whom our obligations must be
fulfilled.
Earlier this year the Committee issued its Eleventh Annual Report.
I would merely wish to highlight the report's recommendations which are
presented to the Secretary. If there is any ulterior motive here it is
merely to provide this honorable Committee and its Members, the
perspective of ``boots on the ground'' regarding the importance of the
work done by my colleagues who serve on the Advisory Committee on the
Readjustment of Veterans.
1. The Vet Centers have become, as we say in Olelo Hawaii,
``Puuhonua'' or sanctuaries, a special place of refuge. Veterans are
utilizing its services and programs in increasing numbers. Two new Vet
Centers and staff augmentation at 11 existing Vet centers is in
progress. However, based on a number of findings as listed below, it is
clear that additional augmentation of the Vet Center program is needed:
The growing number of separated servicemembers from OEF/
OIF to date.
The high number of National Guard and Reserve component
forces who disperse to all corners of the country upon separation from
OEF/OIF.
The Army studies conducted by Colonel Charles W. Hogue,
that document the incidence of combat related stigma and readjustment
problems among OEF/OIF returnees.
The effectiveness of VA's community-based Vet Centers in
contacting the new veterans through an aggressive GWOT outreach
campaign and in providing timely readjustment counseling to veterans
and veterans' family members.
The high number of National Guard/Reserve combatants in OEF/OIF;
our own experience with mobilizations of the 29th Infantry Brigade and
the 100th Bn., and the continuing separate unit mobilizations
throughout the Pacific Command, many of whom come from widely dispersed
rural areas, the need exists to prioritize the creation of Vet Center
outstations and augmenting staff in Vet Centers that serve rural areas.
The capacity to respond to the service needs of the increasing number
of OEF/OIF veterans and family members will be critical for years to
come, and that expanding the Vet Center program is perhaps an effective
way to build and expand the veterans benefits infrastructure to meet
their needs over time.
2. Our Hawaiian tradition of Ohana defines who we are as veterans
and the importance of our families in every aspect of our lives as we
serve our country. Thus, the legislative authority for treating
veterans' families at Vet Centers, is a great accomplishment. It really
is a no brainer that a veterans' successful readjustment also includes
the Ohana's readjustment. Providing family treatment by Vet Centers
which have qualified family therapist on staff needs to be expanded.
The augmentation of family counselors at Vet Centers would enhance the
program's capacity to clinically address the more complicated family
adjustment problems among increasing numbers of returning OEF/OIF
combat veterans.
3. A key factor in the Vet Center program's success is due to
structure as an ``off campus'' entity, if you will. Thus it is
important to validate that with a secure and separate system of client
records and related policy of guaranteeing confidentiality for the
veteran. This is perhaps the most essential item in serving the war-
traumatized veteran population and goes a long way toward mitigating
the stigmas manifested by this population against accessing care.
4. Nakoa Wahine, women warriors are an ancient Hawaiian tradition,
they fought along side their husbands, and in some instance due to a
greater family allegiance that found themselves opposite their husband;
in any regards women in service as another trait of who we are as
veterans. With the higher number of female military personnel serving
in OEF/OIF, the Vet Centers continue to carefully monitor the
demographics of local catchment areas to ensure that female veteran
service providers are represented on Vet Center teams at appropriate
levels.
5. Increasing awareness of the impacts of multiple deployments,
extended deployments and traumatic battlefield experiences, have
exposed a higher incidence of mental health needs of returning OEF/OIF
veterans as documented by the ``Land Combat Study'' research of Colonel
Charles W. Hogue, M.D., OEF/OIF veterans must be extended priority
access to VA medical centers for mental health screening, assessment
and treatment to avoid the barrier of waiting lists of several months
for an appointment.
6. The blending of our Armed Forces of active duty, Guard and
Reserve units presents some unique issues on tracking these individual
heroes as they change out of uniform into civilian attire. The
establishment of the aggressive GWOT veteran outreach program which
consisted of 100 OEF/OIF veterans whose mission is to provide early
contact, program information and educational briefings to veterans at
military demobilization and National Guard and Reserve sites is vital
in the efforts to service all our veterans. Thus, there must be a
system to closely monitor the program's outcomes to further assess the
feasibility of further extensions to this program initiative contingent
upon increasing workload volume among returning OEF/OIF veterans.
7. There is the realization that as time increases following
demobilization and separation from active military, many veterans will
develop readjustment problems to include the delayed onset of PTSD. To
facilitate a veterans' ease of access for care, the more traditional
methods of community outreach in addition to the GWOT outreach at
demobilization sites need to be enhanced. Such methods would include
liaison with community emergency responders, educational presentations
at community mental health and social service agencies, and any other
form of community liaison that will result in facilitating veteran
referrals for follow-up readjustment counseling.
The points referenced above represent a cross section of those
issues or services which are of great importance to our veteran
community not just in Hawaii but at-large.
The following issues are what I have surmised as being specific
needs to our Hawaii veterans community as they have been shared with
me.
Disability Claims: More resources are needed to decrease the
current backlog in the disability claims process. Two critical areas:
Elderly veterans often ``give up'' or ``die'' before their
claim is resolved.
OIF/OEF veterans can often experience serious financial
difficulties while awaiting a VA decision on their disability.
OIF/OEF: Need greater focus on unique aspects/needs of OIF/OEF
soldiers/veterans:
Need more full-time personnel assigned/designated to
coordinate OIF/OEF care to ensure a seamless transition. To often VA
personnel are assigned OIF/OEF duties as ancillary to primary job
responsibilities. Each VA facility should have a full-time and fully
staffed OIF/OEF treatment team.
Traumatic Brain Injury treatment. Need to improve VA's
ability to assess and treat TBI. Increase number of neuro-psychologists
to do testing for TBI.
Eligibility Period: Returning soldiers/veterans must apply for
medical benefits within 2 years after returning to the U.S. from the
war zone. Unfortunately, many do not seek VA care within this allotted
time period. Eligibility for care should be extended to 5 years after
return.
Access to Care: Need to expand resources and increase
accessibility/availability of care:
Sometimes difficult to get an appointment in a timely
manner and there often is too much time between appointments.
Increase medical staff and expand specialties
(orthopedics, endocrinologists, OB/GYN, TBI) to improve care and
alleviate wait time.
Expand hours of operation for both medical and mental
health services. Present hours of 0800 to 1600 may be sufficient for
unemployed and elderly veterans; however, it often poses a hardship for
the younger veteran making the transition from the military to a new
job or school. Often, they do not have the ``sick-leave'' or
``vacation'' time accrued.
Develop mobile clinics that travel to communities to
provide general health care. It is sometimes difficult for veterans to
go to VA. This is particularly critical for elderly, disabled, or
homeless veterans who often need increased medical care for chronic
medical problems or for service-connected conditions. Elderly and the
disabled often can't drive, don't want to inconvenience family and
cannot endure long rides on the bus or handi-van. Taking health care to
their community via a medically equipped bus/van can provide a valuable
service to these veterans.
Veterans Service Organizations: Veterans Service Organizations
(DAV, VFW, American Legion, etc.) are congressionally chartered
organizations that advocate for veterans and assist in filing
disability claims. Unfortunately only the DAV provides a full-time
National Service Officer in Hawaii to assist veterans with their
claims. As a result, many veterans are not properly represented in
filing their disability claims.
Again I wish to extend my heartfelt gratitude for the opportunity
to offer some of my observations and concerns to the Committee this
morning.
A very special aloha and mahalo to Senator Akaka and to Congressman
Abercrombie for being there for my family and for your loving tributes
in honor of my son.
The Audience. (Applause.)
Senator Akaka. Thank you very much, Allen Hoe, for your
testimony. Now, we'll hear from Tom Joaquin.
STATEMENT OF THOMAS L. JOAQUIN, SENIOR VICE PRESIDENT OF
OPERATIONS, HAWAIIAN ELECTRIC COMPANY, INC., AND MEMBER VA
ADVISORY COUNCIL
Mr. Joaquin. Good morning, everyone, Mr. Chairman and
Members of the Committee. Mahalo for the opportunity to appear
here today to discuss VA care in Hawaii. While I'm here today
to praise the VA, most of my involvement over the last 43 years
has been adversary.
I want to thank you, Mr. Chairman, as well as Senator
Inouye for your steadfast commitment to our veterans.
Legislation that you and others have introduced have led to
unprecedented care for veterans. From humble beginnings on Ward
Avenue in the 1960s to world-class medical facilities today,
not only on Oahu, but serving all of the neighbor islands with
Community Based Outpatient Clinics (CBOCs).
Recently, an accreditation audit found our facilities on
Oahu to be one of the best in the VA. I can attest to the level
of care and concern of my VA doctor and her staff. I can assure
you that it rivals my civilian experience.
Many of these accomplishments have come about under the
capable leadership of Dr. James Hastings, the director of
Pacific Islands Health Care System. I belong to an advisory
board that meets with Dr. Hastings and his leadership staff
quite often. We have a very healthy exchange of concerns and
ideas, all designed to allow input into the local VA and
subsequent buy in from our constituents we serve. I suggest
that the VA consider these advisory boards elsewhere.
I live in Kapolei, the fastest growing area on Oahu quickly
living up to the expectations of the Second City of Oahu. I
understand that we are looking to establish a CBOC in this area
and are awaiting availability of facilities closed by the Navy.
I would encourage a more aggressive approach perhaps
working with the state or even just building or leasing a
facility. The population of the area surrounding Kapolei
exceeds any of the neighbor islands and there are many, many
veterans that reside in that area.
Mr. Chairman, I thank you again for the opportunity to
testify at this hearing.
[The prepared statement of Mr. Joaquin follows:]
Prepared Statement of Thomas L. Joaquin, Senior Vice President of
Operations, Hawaiian Electric Company, Inc., and Member VA Advisory
Council
Mr. Chairman and Members of the Committee, mahalo for the
opportunity to appear before you today to discuss VA care in Hawaii.
While I am here today to praise the VA, most of my involvement over the
last 43 years had been adversarial.
I want to thank you, Mr. Chairman, for your steadfast commitment to
our veterans. Legislation that you and others have introduced has led
to unprecedented care for veterans. From humble beginnings on Ward
Avenue in the 1960s to world class medical facilities today, not only
on Oahu, but serving all of the neighbor islands with community based
outpatient clients (CBOCs).
Recently, an Accreditation audit found our facilities on Oahu to be
one of the best in the VA. I can attest to the level of care and
concern of my VA doctor and her staff. I can assure you that it rivals
my civilian experience.
Many of these accomplishments have come about under the capable
leadership of Dr. James Hastings, the Director of the Pacific Islands
Health Care System. I belong to an advisory board that meet with Dr.
Hastings and his leadership staff quite often. We have a very healthy
exchange of concerns and ideas, all designed to allow input into the
local VA and subsequent buy in from the constituents we serve. I
suggest that the VA consider these advisory boards elsewhere.
I live in Kapolei, the fastest growing area of Oahu; quickly living
up to the expectations of the Second city of Oahu. I understand that we
are looking to establish a CBOC in this area and are awaiting
availability of facilities closed by the Navy.
I would encourage a more aggressive approach, perhaps working with
the State or even just building or leasing a facility. The population
of the area surrounding Kapolei exceeds any of the neighbor islands.
Mr. Chairman, I thank you again for the opportunity to testify at
this hearing. I would be happy to take any questions you might have.
The Audience. (Applause.)
Senator Akaka. Thank you very much Tom Joaquin. And now
we'll hear from Victor Opiopio.
Victor is, as you know, a kamaaina here and I know him as
Crash.
STATEMENT OF VICTOR OPIOPIO, VIETNAM VETERAN
Mr. Opiopio. I want to say good morning to everyone, to
all the ladies and gentlemen from the States that have come
here. You heard me use the term ``the states.'' People say to
me, ``but isn't this is a state? '' And I say to them, ``Well,
let's look at it. I was born here, I was raised here and I live
here. This is my mainland. And you guys are from the states.
But welcome.
Onakala, Kaniala, aloha to your family very talented,
talented family. Danny, who just happens to be my mother's
godfather. He doesn't even realize. My grandfather was Byron
Bridges and--well, my mom has passed away, but I remember you
when I was young. But aloha and welcome and thank you for
listening to us.
I don't have a prepared speech. I don't have anything in
writing in front of me because when I speak, I speak from my
heart. And sometimes I get messed up or I mess up along the
way. But when it comes to the VA, it's an issue that is very
important to me. Because, number one, I love the VA. Number
two, I hate the VA.
I mean, there's no ``ifs'', ands and ``buts.'' The VA has
done a lot for me recently. But for 20 years I had to bang my
head against the wall asking for help, and at no time did
anyone step forward and say, ``Could I help you?'' I joined the
organizations that said we are set up to help the veterans. I
signed up. I sent in my money. I never heard from them.
When I received a rating, I would get a letter from them
inviting me to join. I was already a lifetime member. So I felt
deserted. I felt lost. This is my story because I can't speak
for all the veterans. I can't. But I can speak about myself. I
want to share this with all of you because I have not shared it
before.
For the last 30 years here in the islands, I have been in
radio and in television. I know a lot of you are smiling
because I'm sure you remember me. The name Crash Kealoha was
given to me by Lucky Luck many, many years ago. I was one of
his students. Well, when I wanted to get into radio, I was only
14 and you had to be 15. So, I messed around till I was 15.
This was 1965. There was something going on on the other
side of the world that was called a conflict or a police
action. It wasn't called a war. Right? It was a conflict. It
was a police action. Only now it's called a war. What happened?
When we came home, there were no cheers. People didn't say,
``Welcome home.'' Today I walk up to veterans and say welcome
home. And they look at me and they know what I'm saying. So
when I talk about the VA, I've got to talk about myself.
I fell and hurt myself. I hurt my back. I cracked my spine.
They put me in the hospital, put me in a body cast and told me
that the best way for your body to heal is to heal naturally. I
was in a body cast for about six months. By the way, it was
done in Missile Shack. After my fall, they found blood in my
urine. It was a total surprise because that never happened to
me.
I took so many physical exams before joining the military.
There was no blood in my urine. And they said you know
something? You have a kidney condition that you had before you
joined the military. And I said what? You had this before you
joined the military. So we're going to discharge you with your
back condition, but your kidney condition is not service
connected. And I said, now wait a minute. They said no, it's
not service connected.
I did some research and what I had was a UPJ obstruction
which is something that people are born with. I didn't know
that. It's a more common incidence among babies. It happens
that's when it's discovered. Very rarely does it linger on.
Well, I did not know of this condition. But something happened
to make my kidney bleed.
What happened? I fell down. I hurt my back. I was
discharged for my back. And the doctors, private doctors told
me it would cost about $30,000 to work with my kidney. I
couldn't afford $30,000. So I went to VA, and I said I need
help because of my kidney problem. VA said no problem, we'll
take care of you. I was surprised. The next day I was at
Tripler meeting with my doctor who said we're going to operate
next Thursday. I said fantastic, how long is this going to keep
me in the hospital? He said well, 10 days, 2 weeks at the most.
Go home, relax. You'll be fine.
They worked on my kidney. The morning before the operation,
I spoke with my doctor and he took my hand and I shook his
hand. I said to him, you know, God bless everything. I woke up.
I was in so much pain that I could not believe it. I asked for
my doctor and they said he was rotated out. I didn't know what
that meant. But where is my doctor? He's rotated out. Hmm.
What's going on? Well, my kidney did not work at all after
that. And I was up there for 15 months in total, total pain.
Finally, they removed my kidney because there was nothing else
they could do. After that I went to the VA to file a claim and
they said to me, it's not service connected. I said what? That
kidney condition was not service connected. You lost your
kidney. Sorry.
I couldn't believe that. And then my back condition. I was
given--and you guys don't know about this--painkillers and
muscle relaxers. Painkillers and muscle relaxers and go home
and lie down. Take it easy, painkillers and muscle relaxers.
This one doctor I had--the very first doctor I had--I thought
he was nuts. And I found out he was nuts because he burned his
house down because he was treating his children to a lesson not
to play with fire so he burned his house down. Needless to say
he was let go from the VA and I was appointed another whacko.
This one I won't even talk about because he's still there. And
if it was up to me, I would get rid of him.
But anyway, the fight with my back I was granted for my
lower back. The pain in my back started started going up to my
spine. And the doctors saw all of this. They saw all of this
pain, and I went through all of the MRIs and all of that, and
they said your condition has worsened. And it's gotten to the
point where it hit my neck, I had to have three surgeries done
on my neck that VA paid for, sent me to Straub. Thank you VA.
And then when I filed for a claim they said, no. The neck and
the back are not service connected.
Now I'm going to wrap it up right here because, like I
said, I have a love and hate relationship with the VA. After
all those years of fighting, this beautiful woman walked into
my life. Her name is Jane Watson, and she is a doctor at VA.
She was the very first person I met who actually care about
veterans. Without that lady's help, I probably would not be
here today.
There's one other person, without him I probably would have
blown myself away a long time ago, and this man is incredible.
He suffered from a personal problem that took him away from the
VA. I never thought I'd ever see him again, but he came back. I
asked him why he came back, and he said because he wants to
help the veterans. His name is Dr. Cameron, and I know he's
sitting in the back. Dr. Cameron, thank you. Thank you for
saving my life. That's why I said I have this love-hate
relationship with the VA. And you guys know what I'm talking
about. Mahalo.
The Audience. (Applause.)
Senator Akaka. Thank you. Now we'll hear from Clay Park.
STATEMENT OF WILLIAM CLAYTON SAM PARK, CASE MANAGER/VETERANS
SPECIALIST, HELPING HANDS-HAWAII
Mr. Park. Senator Akaka, Senator Inouye, my name is William
Clayton Sam Park. I am of Native Hawaiian ancestry, a disabled
veteran who served as a combat medic during the Vietnam War,
and a retired master sergeant with three years active duty with
the U.S. Army and 21 years of service with the Hawaii Army
National Guard.
Thank you for this opportunity to address the Senate
Veterans' Affairs Committee. I am a case manager/veterans
specialist with the agency on whose behalf I testify today,
Helping Handss-Hawaii.
Helping Hands is a nonprofit agency with 33 years of
service to the people of Hawaii, providing behavioral health
and mental health service. It also offers other community-based
services such as Bilingual Access Line (providing
interpreters), the Community Clearinghouse and the Ready-to-
Learn Program, known to many because of Senator Inouye's and
his wife's (Maggie) efforts. I will speak today primarily of
community, linkage and advocacy on behalf of our veterans.
Helping Hands has been an active partner in this community
for over 30 years. As our community welcomes back our newest
warrior, there's no doubt that we face significant challenges
not only for these veterans and their families, but also for
the generations of veterans who went before them who also have
been affected by this war.
The need for support in our veterans community became more
and more evident over the past year or two. While no formal
program had yet been developed, the need did not wait.
Veterans' concerns and problems began to surface on the day-to-
day activities of Helping Hands' staff, such as myself. As a
case manager and also as a veteran, the veterans with
psychological problems, many of whom were homeless, were
assigned to me.
While some came directly to us from the State Department of
Health, the Adult Mental Health Division, others came by word
of mouth from social service workers. A contact would say
something like this: There is a veteran who lives on the side
of the Pali and we have not seen him for days. Can you help?
Outreach often means doing what is unconventional and that is
what was required in this case. Using my tracking skills and my
familiarity with the mountains as a long-time pig hunter, to
find this veteran who was using his military skills to hide
from the populated area.
Having found this particular veteran, it was not possible
to convince him to seek VA benefits and services because he did
not understand the VA system and feared that he would lose his
existing social security benefits if he chose to go through the
VA. While this veteran now has a different life, attending the
State's Club House and sharing his life with a girlfriend, he
still is not receiving services from the VA which he would be
entitled to.
Outreach is not simply about finding someone and providing
services. Often times it is about support and direction for the
veteran who is about to give up on seeking or accepting
services. Some of the time that means the veteran has become so
frustrated with the obstacles along the way to accessing
benefits for services that he or she woud simply say forget it
and struggles to survive without the VA assistance. Other
times, more drastically, the veteran has decided it is better
to give up his life rather than to continue to struggle.
The desperate call then comes from many family members
hoping to find someone who knows what to do to change his mind.
A recent example comes from a case management situation where
an individual was seen at the request of a family member
concerned about how discouraged and despondent he was. He had
been deployed with the Oregon Army National Guard unit to Iraq.
Upon return, he applied for VA services and encouraged prior to
leaving the unit, he waited for the VA's reply while trying to
provide for his wife and his three children. He was not with
his family since his wife already had filed a temporary
restraining order on him.
He had changed so much since his return, especially in
terms of his inability to control his frustration and anger, a
sign that we would consider possibly related to Post Traumatic
Stress Disorder from his time in combat. When the VA letter
arrived, he was informed that he was not eligible since there
was no evidence that he was an OEF/OIF veteran who had served
in combat.
In helping this veteran follow up through the VA Benefits
Administration, there had been some confusion due to the
veteran's prior service with the U.S. Navy, at which time he
was not deployed to combat. It is this separate DD-214 and not
the one he submitted documenting his combat with the National
Guard unit which was reviewed when his benefits application was
not being considered. Rather than the depression he was
experiencing, when he first was seen by the Helping Hands
staff, he is now reconnected with the VA and is pursuing
benefits and services.
Just how critical timely outreach can be was recently
brought home very painfully when I and Dr. Rodney Torigoe, the
psychologist who consults with Helping Hands-Hawaii, were
invited to address the Army National Guard unit in Hilo. This
was the unit which had made the newspapers because a fellow
soldier had been arrested and charged with killing his son and
his wife's unborn child, as he reportedly attacked his wife in
a fit of rage.
Upon initial contact to set up a time for our visit, one of
the members of the unit commented, ``You're a little too
late.'' Though they had been back from their service in Iraq
for 18 months, the majority of the members of the unit did not
understand that they had entitlement to VA services, because
the briefing which explained this occurred only five hours
after they arrived on U.S. soil.
Meanwhile, other wives were heard on news reports stating
that they just wanted their husbands back, and the men who
returned were not the same as those who left. By way of follow
up and preventive measures, the unit's First Sergeant has now
been encouraging his cunning soldiers to seek assistance from
the VA. This unit is now in training and expects to be deployed
again.
Being a responsible member of this community is being
responsive to the needs of our veterans community. I have been
joined by four other veterans, one of whom is here today who
just testified. Mr. Victor Opiopio. Also included are Mr. Sam
Stone, James Kimo Opiana and Mr. Charles Kanehailua, who
volunteered their time and mana'o, and under the auspices of
Helping Hands, began what was called the ``Uncle's Project.''
This project was about veterans reaching out to veterans
bringing them in for services, encouraging them to have trust
in the system and persist even when frustrated and undoing the
attitude instilled through a military culture which labels
psychological distress as a weakness.
Helping Hands now has a dedicated program to reach out to
veterans and their families--veterans of all wars and all
eras--in order to provide support and, when needed, direct
linkage with appropriate social service and government
agencies. The linkage is about providing what is needed upfront
and not after the fact. It is about providing guidance to
families of our veterans who help welcome back our newest
veterans and their spouses, fathers, mothers sons and daughters
to be sure that the transition is as smooth as possible.
For our earlier generations of veterans, it is also about
continuing the transition home or, in some case, may be
beginning that transition after 40 years or more of emotional
pain. I want to emphasize the government agency link,
especially the link with the Department of Veterans Affairs. As
Senator Akaka has noted in his recent legislation S. 1233,
``the Department of Defense and the Department of Veterans'
Affairs have made efforts to provide smooth transition . . .
but more can be done to assist our veterans and their families
in the reintegration of the wounded or injured veterans into
our community.''
Our newest program is a community-based Native Hawaiian
Veterans Resource Program. The cornerstone of this program is
what started as the ``Uncle's Project,'' and is now Na Hana
No'eau No Na Mea Pono (the Work Toward Righteous Things), which
is supported by grants from the Castle Foundation and from Papa
Ola Lokahi. Recently, Trustees of OHA met with some of the
``Uncles'' and representatives of Helping Hands-Hawaii
administration to discuss what role they may take in supporting
this program so that no veteran will be left behind. We look
forward to the benefit of their mana'o as well.
The veterans we have seen have been referred to state or
private social service agencies, at times identified by our own
case managers or even referred through the VA benefits system
itself. We have identified our mission quite clearly as not one
that will duplicate services nor in any way distract from the
VA or what the VA offers. Rather, we intend to assist the
veteran in navigating the VA system and support the VA system
in accomplishing its mission.
As the report of 2007 President's Commission on Care for
America's Returning Wounded Warriors acknowledges both the DOD
and VA benefits and health care systems are complicated and
complex. Both are difficult to understand and marked by
inequities. By having Helping Hands staff available who are
familiar with the VA system, and working closely with current
VA staff, our goal is to help veterans become aware of and find
it easier to access the services for which they may be eligible
because they will have a coach, a partner, and a helping hand
available to guide them.
We do not doubt that there are caring and concerned
individuals among the staff at the VA, but things do not always
go smoothly. The VA staff must contend with complexity of the
paperwork, the rules and the regulations and they're only
human. This very same paperwork and those rules and regulations
often are perceived by the veterans as obstacles and hurdles,
confirming whatever beliefs they may already have developed
about not trusting that their government can see them as
anything other than a number.
Their frustration in dealing with the system often leads to
anger or despair and a tendency to abandon any hope for
assistance. It is our hope that our newest program will allow
the VA to more easily find those veterans who are eligible for
service and facilitate their access to the most appropriate
care in a timely manner. Helping Hands is all too aware of the
benefit which can come from improving access to services in
order to prevent more serious problems at a later time.
For our veterans who do not find the VA system accessible,
the cost in terms of economic, emotional and social hardship is
an added burden to which they already are experiencing. Being
successful as we carry out this newest of our missions will
honor the sacrifice our soldiers have made as we support the
mission of the VA in making the veteran's mental health and
adjustment to civilian life among the highest priorities of our
Nation.
Having addressed the importance of community partnership
and linkage, I come to the final area of importance to Na Hana
No'eau No Na Mean Pono, that is, advocacy. There is research
showing that Native Hawaiians experience significant
disparities in health care, opting to avoid health care
services when dealing with bureaucratic systems, cultural
insensitivity and other similar barriers to care. Our work is
guided by the experience of Papa Ola Lokahi with the federally
funded comprehensive health care centers so that the
intimidation created by the bureaucracy and the potential for
culturally insensitive delivery of service within the large
and, at time, impersonal VA system can be reduced.
There is also documentation that Native Hawaiians serving
in the Vietnam war experienced symptoms of Post Traumatic
Stress Disorder to a greater degree than the general population
of soldiers serving in that war. There is no reason to expect
that there will be any significant change either in the health
disparities or in the incidence of psychological symptoms among
Hawaii's current military force returning from combat.
This situation is likely to be made even worse by the fact
that many of the members of our Guard and Reserveunits come
from our rural areas both on Oahu and on our neighbor islands,
where access to health care, especially mental health care and
continuity of care are already problems. While our program will
certainly be accepting veterans of any ethnicity, and not just
Native Hawaiian veterans, our primary focus remains to provide
service for our generally underserved Hawaiian population.
Consequently, the mission of our program as we extend a
helping hand will be to provide the advocacy necessary to each
individual veteran, their families, their family members so
that they have ready and easy access to care as well as having
the most appropriate care.
Mahalo nui loa for allowing me the time to share my mana'o
with you today. Thank you.
[Prepared statement of Mr. Park follows:]
Prepared Statement of William Clayton Sam Park,
Case Manager/Veterans Specialist, Helping Hands-Hawaii
Mr. Chairman and Members of the U.S. Senate Committee on Veterans'
Affairs:
My name is William Clayton Sam Park. I am of Native Hawaiian
ancestry, a disabled veteran, who served as a combat medic during the
Vietnam War, and a retired Master Sergeant with 3 years active duty
with the U.S. Army and 21 years of service with the Hawai'i Army
National Guard.
Thank you for this opportunity to address the Senate Veterans'
Affairs Committee. I am a Case Manager/Veterans Specialist with the
agency on whose behalf I testify today--Helping Hands Hawaii (HHH).
Helping Hands is a nonprofit agency with 33 years of service to the
people of Hawai'i, in particular providing behavioral and mental health
services, but also offering such other community-based services as the
Bilingual Access Line (providing interpreters), the Community
Clearinghouse, and the Ready-to-Learn program (known to many because of
Senator Inouye and his wife Maggie's efforts). I will speak today
primarily of community, linkages, and advocacy on behalf of our
veterans.
Helping Hands Hawaii has been an active partner in this community
for over 30 years. As our community welcomes back our newest warriors,
there is no doubt that we face significant challenges, not only for
these veterans and their families, but also for the generations of
veterans who went before them who also have been affected by this war.
The need for support in our veteran community became more and more
evident over the past year or two. While no formal program had yet been
developed, the need did not wait. Veterans' concerns and problems began
to surface in the day-to-day activities of HHH staff, such as myself.
As a case manager but also a veteran, the veterans with psychological
problems, many of whom were homeless, were assigned to me. While some
came directly to us through the State Department of Health (Adult
Mental Health Division), others came by word of mouth from other social
service workers. A contact would say something like: ``there is a
veteran who lives on the side of the Pali and we have not seen him for
days . . . can you help? '' Outreach often means doing what is
unconventional, and that is what was required in this case: using my
tracking skills and familiarity with the mountain as a long-time pig
hunter to find this veteran who was using his military skills to hide
away from the populated area. Having found this particular veteran, it
was not possible to convince him to seek VA benefits and services
because he did not understand the VA system and feared that he would
lose his existing Social Security benefit if he chose to go through the
VA. While this veteran now has a different life, attending the State's
Club House and sharing his life with a girlfriend, he still is not
receiving services of the VA to which he would be entitled.
Outreach is not simply about finding someone and providing
services. Oftentimes, it is about support and direction for the veteran
who is about to give up on seeking or accepting services. Some of the
time that means the veteran has become so frustrated with the obstacles
along the way to accessing benefits or services that he or she has
simply said ``forget it'' and struggles to survive without the VA's
assistance. Other times and more drastically, the veteran has decided
it is better to give up his life rather than to continue the struggle.
The desperate call then comes from the family member hoping to find
someone who knows what to do to change his mind. A recent example comes
from a case management situation where an individual was seen at the
request of a family member concerned about how discouraged and
despondent he was. He had been deployed with the Oregon Army National
Guard Unit to Iraq and upon return applied for VA service as encouraged
prior to leaving the Unit. He waited for the VA's reply, while trying
to provide for his wife and three children. He was not with his family
since his wife already had filed a Temporary Restraining Order on him.
He had changed so much since his return, especially in terms of his
inability to control his frustration and anger--a sign that we would
consider possibly related to Post Traumatic Stress Disorder from his
time in combat. When the VA letter arrived, he was informed that he was
not eligible since there was no evidence he was an OEF/OIF veteran who
had served in combat. In helping this veteran follow-up through the VA
Benefits Administration (VBA), there had been some confusion due to the
veteran's prior service with the U.S. Navy, at which time he was not
deployed to combat. It was this separate DD-214 and not the one he
submitted documenting his combat with the National Guard Unit which was
reviewed when his benefits application was being considered. Rather
than the depression he was experiencing when he first was seen by HHH,
he now has re-connected with the VA and is pursuing benefits and
services.
Just how critical timely outreach can be was recently brought home
very painfully when I and Dr. Rodney Torigoe, the psychologist who
consults with HHH, were invited to address the Army National Guard Unit
in Hilo. This was the Unit which had made the newspapers because a
fellow soldier had been arrested and charged with killing his young son
and his wife's unborn child, as he reportedly attacked his wife in a
fit of rage. Upon initial contact to set up the time for our visit, one
of the members of that Unit commented, ``you're a little too late.''
Though they had been back from their service in Iraq for 18 months, the
majority of the Unit did not understand that they had entitlement to VA
services, since their briefing which explained this occurred only 5
hours after they arrived back on U.S. soil. Meanwhile, other wives were
heard on news reports stating that they just wanted their husbands back
and the men who returned were not the same as those who left. By way of
follow-up and as a preventive measure, the Unit's First Sergeant has
now been encouraging his soldiers to seek the assistance of the VA.
This Unit is now in training and expects to be deployed again.
Being a responsible member of this community means being responsive
to the needs of our veteran community. I have been joined by four other
veterans (one of whom is here today to testify before you also, Victor
Opiopio, and also including Sam Stone, James ``Kimo'' Opiana, and
Charles Kanehailua), who volunteered their time and mana'o, and under
the auspices of Helping Hands began what was called ``The Uncle's
Project.'' This project was about veterans reaching out to veterans,
bringing them in for services, encouraging them to have trust in the
system and persist even when frustrated, and undoing the attitude
instilled through a military culture which labels psychological
distress as a weakness.
HHH now has a dedicated program to reach out to veterans and their
families--veterans of all wars and all eras--in order to provide
support and, when needed, direct linkage with appropriate social
service and government agencies. The linkage is about providing what is
needed up front, and not after the fact. It is about providing guidance
to the families of our veterans, to help welcome back our newest
veterans and their spouses, fathers, mothers, sons and daughters, to be
sure that the transition is as smooth as possible. For our earlier
generations of veterans, it also is about continuing the transition
home, or in some case may be only beginning that transition after 40
years or more of emotional pain.
I want to emphasize the government agency link, and especially the
link with the Department of Veterans Affairs. As Senator Akaka has
noted in his recent legislation (S. 1233), ``the Department of Defense
and Department of Veterans Affairs have made efforts to provide a
smooth transition . . . but more can be done to assist veterans and
their families in the . . . reintegration of the wounded or injured
veterans into their community.'' Our newest program is the community-
based Native Hawaiian Veterans Resource Program. The cornerstone of
this program is what started as ``the Uncle's Project'' and is now Na
Hana No'eau No Na Mea Pono (``The Work Toward Righteous Things''),
which is supported by grants from the Castle Foundation and from Papa
Ola Lokahi. Recently, Trustees of OHA met with some of the ``Uncles''
and representatives of Helping Hands Hawaii's administration to discuss
what role they might take in also supporting this program so that no
veteran will be left behind. We look forward to the benefit of their
mana'o, as well.
The veterans we have seen have been referred through State or
private social service agencies, at times identified by our own case
managers, or even referred through the VA benefits system, itself We
have identified our mission quite clearly as not one that will
duplicate services nor in any way detract from what the VA offers.
Rather, we intend to assist the veteran in navigating the VA system,
and support the VA system in accomplishing its mission. As the report
of the 2007 President's Commission on Care for America's Returning
Wounded Warriors acknowledges, both the DOD and VA benefits and health
care systems are complicated and complex; both are difficult to
understand and marked by inequities. By having HHH staff available who
are familiar with the VA system and by working closely with the current
VA staff, our goal is to help veterans become aware of and find it
easier to access the services for which they may be eligible because
they will have a coach, a partner, and a helping hand available to
guide them. We do not doubt that there are caring and concerned
individuals among the staff at the VA, but things do not always go
smoothly. The VA staff must contend with the complexity of the
paperwork, the rules, and the regulations, and they are only human.
This very same paperwork, and those rules and regulations, often are
perceived by the veterans as obstacles and hurdles, confirming whatever
beliefs they may already have developed about not trusting that their
government can see them as anything other than a number. Their
frustration in dealing with the system often leads to anger or despair,
and a tendency to abandon any hope for assistance. It is our hope that
our newest program will allow the VA to more easily find those veterans
who are eligible for services and facilitate their access to the most
appropriate care in a timely manner. HHH is all too aware of the
benefit which can come from improving access to services in order to
prevent more serious problems at a later time. For our veterans who do
not find the VA system accessible, the cost in terms of economic,
emotional, and social hardships is an added burden to that which they
already are experiencing. Being successful as we carry out this newest
of our missions will honor the sacrifice our soldiers have made as we
support the mission of the VA in making the veteran's mental health and
adjustment to civilian life among the highest priorities of our Nation.
Having addressed the importance of community partnership and
linkages, I come to the final area of importance to Na Hana No'eau No
Na Mea Pono--that is, advocacy. There is research showing that Native
Hawaiians experience significant disparities in health care, opting to
avoid health care services when dealing with bureaucratic systems,
cultural insensitivity, and other similar barriers to care. Our work is
guided by the experience of Papa Ola Lokahi with the federally funded
comprehensive health care centers, so that the intimidation created by
the bureaucracy and the potential for culturally insensitive delivery
of service within the large and at time impersonal VA system can be
reduced. There also is documentation that Native Hawaiians serving in
the Vietnam War experienced symptoms of post traumatic stress to a
greater degree than the general population of soldiers serving in that
war. There is no reason to expect that there will be any significant
change in either the health disparities or in the incidence of
psychological symptoms among Hawaii's current military force returning
from combat. This situation is likely to be made even worse by the fact
that many of the members of our Guard and Reserve Units come from our
rural areas, both on Oahu and on our neighbor islands, where access to
health care, especially mental health care, and continuity of care are
already problems. While our program will certainly be accepting
veterans of any ethnicity, and not just our Native Hawaiian veterans, a
primary focus remains to provide support services for our generally
underserved Native Hawaiian population. Consequently, the mission of
our program, as we extend a helping hand, will be to provide the
advocacy necessary for each individual veteran and their family members
so that they have ready and easy access to care, as well as having the
most appropriate care.
Mahalo nui loa for allowing me the time to share my mana'o with you
today.
Mr. Chairman, I would be pleased to answer any questions that you
or the Committee Members have for me at this time.
Aloha.
Senator Akaka. Thank you very much, Clay Park. And now the
last member of this panel is Darryl Vincent, site director of
U.S. Veterans Initiative.
STATEMENT OF DARRYL J. VINCENT, SITE DIRECTOR,
UNITED STATES VETERANS INITIATIVE-HAWAII
Mr. Vincent. Good morning, Senator Akaka and Senator
Inouye, and others distinguished officials, my name is Darryl
Vincent, I'm the Hawaii Site Director of the United States
Veterans Initiative, a nonprofit agency that helps military
veterans experiencing homelessness. In Hawaii, our facilities
are located at Kalaeloa, at the former Barbers Point Naval Air
Station where we currently serve approximately 200 veterans.
I'm here to speak to you about the realities of
homelessness among veterans in Hawaii, what United States
Veterans Initiative is currently doing to reduce homelessness
among Hawaii veterans. Most importantly, I'm here to advocate
for expansion of known solutions that can reduce homelessness
for military veterans and to request that solutions be
seriously considered in upcoming Federal legislation and
appropriations.
First the realities. For many, the face of the modern
homeless began with the image of homeless veterans--sign in
hand asking for food, shelter, job--on the streets, stop signs
at nearly every town in America. Still today despite pockets of
progress, the VA estimates that 250,000 military veterans in
America will be sleeping in the streets tonight. And I hope we
can only grasp that number 250,000. The number is estimated to
be as many as a thousand veterans in Hawaii.
One-third of the America's adult male homeless population
is estimated to be veterans, and in Hawaii it's no different.
Tonight many homeless veterans in Hawaii will be sleeping at
the beach, parks, in cars, at bus stops, sidewalks and other
places not suitable for human habitation. Others remain in
emergency shelters without appropriate services and treatment.
And the flow of veterans continues from the older veterans
who served during the Vietnam era to the veterans of the Gulf
War and most tragically even young veterans back from Iraq and
Afghanistan. For soldiers who escape physical and mental
injury, it remains tough for many that are returning without
jobs, and to a rental market that has priced them out of a home
or even an affordable apartment rental.
For veterans returning with PTSD and other trauma related
injuries from war, the transition back to the community will be
a most difficult one. Research shows that veterans typically
experience homelessness a few years after military discharge,
after the support of the family and friends have been exhausted
and failed attempts to successfully reintegrate back into
community or after the full effects of their physical and
mental injuries have taken their toll. Whenever they call for
help, we must remain firm in our commitment to honor these
honorable men and women.
We also wonder how many veterans will come to our doors in
the next year, two years and five years. We wonder, with so
many soldiers from Hawaii being deployed, will the state be
prepared for their unique needs in the future. The full effects
are not often seen for years, but 30 years of modern
homelessness guarantee us that more veterans will need
assistance. As a veteran myself, I feel that it's a crime that
we have allowed those who once committed themselves to die for
our freedoms to plummet to homelessness. That's the reality,
past, present and future.
Now, just a little bit about what United States Veterans
Initiative does. It offers a strong blueprint of what can be
done to help our veterans. Since we opened up in 2002 in
Hawaii, we provided services to over 800 homeless veterans with
holistic, residential treatment approach, including medical,
mental health and substance abuse treatment, employment
reintegration and housing placement. We also provided an
additional 1,500 veterans with outreach and referral to other
needed programs.
Services are provided in collaboration with the local VA
and through key partnerships with other service providers. The
initiative in Hawaii is one of 11 sites operated by the
Initiative based in Inglewood, California that's been serving
homeless veterans since 1992.
The Initiative offers a two-stage housing and treatment
program that incorporates time tested best practice treatments
and recovery principles. The first stage is our Veterans-in-
Progress program which serves about 250 homeless veterans
annually. Our outreach staff scours over 60 public areas on
Oahu where homeless veterans congregate. They engage them, talk
to them and encourage them to come to Barbers Point facility.
Interested homeless veterans are enrolled in the program
where they receive immediate housing, meals, laundry, mail,
transportation and other essential services. There are no
program fees if the veteran doesn't have an income. This allows
the veterans to focus first on addressing substance abuse and
mental health issues and medical problems, key barriers to
employment, house retention and full social integration. For
those in need of substance abuse treatment, the vast majority
of those we serve, the veteran immediately enrolls in intensive
outpatient substance abuse treatment. Those with a little more
complex dual-diagnosis needs are typically served by the VA.
At our site in Hawaii, eight out of every ten veterans that
are enrolled in our program need substance abuse and/or mental
health services. All receive a minimum of 90 days of treatment,
more depending on their needs. To be sure, many veterans have
lost their job, housing and too often their family because of
substance abuse. Substance abuse is often caused by underlying
mental illness like depression and PTSD. Substance abuse often
grows worse during the time of service and we certainly
advocate for better identification, prevention and treatment of
substance abuse while in the military.
Our program works. During 2006, 83 percent of our veterans
maintain their sobriety while in the program. Seventy-three
percent of veterans enrolled in workforce development found a
job, and 76 percent transitioned to some type of permanent
housing or appropriate transitional housing. Many of those that
were unsuccessful become successful after reenrolling in a
program for the second time. Much of the success of our program
is due to a therapeutic community we foster at Barbers Point.
Staff cannot do it alone. Veterans help veterans as buddies,
peers, chaperones and informal counselors. We attribute our
success to the fact that after a veteran completes our program,
they have the opportunity to move into a sober-living, long-
term affordable housing which is co-located right there at
Barbers Point. The long term housing is offered to veterans who
have successfully completed the program and have at least 90
days of being clean and sober and can support living
independently.
The veteran continues to receive supportive services
through case management and workforce development, but they're
not held to the same structure as they were in the program.
They continue to be drug tested and this allows them to stay
connected with the services that helped them in the first
place. More than over 150 veterans have taken advantage of this
sober living.
So what do we need to handle both today's homeless veterans
and tomorrow's homeless veterans?
There are three things that I'd like to emphasize.
First, funding must be increased through the VA's Grant and
Per Diem program. Success from our VIP program funded by the
Grant and Per Diem Program shows that, yes, money when funding
a successful program model can reduce homelessness. Currently,
the approximate rate is $29.00 per day per person. In Hawaii,
it takes about $55.00 a day to serve a homeless veteran in our
program. And while we do look for collateral funding sources,
it becomes more competitive as the cost of services grow. A
long-term commitment to funding the VA's Grant and Per Diem
Program must include greater funding commitment. Programs like
ours need to spend less time trying to find additional money
each year and more time serving homeless veterans. Veterans
deserve high quality treatment by skilled professionals not
barely above minimum wage workers. We would like to open a
program on outer islands, but it would not be possible without
other funding.
Second, more allocations are needed for funding alternative
vocational training programs. We found it very effective to
place veterans in the early stages of substance abuse into pre-
employment vocational internship positions. These positions
such as running our veteran store, supervising the career
center, directing meal services, apprenticing to be a resident
manager and assisting our maintenance and landscaping manager,
providing the veteran with a transitional period of employment-
like experience while they go through their treatment program.
They can be given a small stipend while they learn a new skill
and maintain participation in a treatment program.
We feel modest funding in these areas can produce great
benefits. As you know, getting a job is the easy part.
Maintaining the job and getting a job that has a career is the
difficult part. Veterans often need a stepping stone that
vocational program, which we refer to as the Transitional Work
Experience, can offer. A program that they can participate in
while in treatment, that complements the success achieved in
treatment while laying a stronger foundation for long-term
recovery and self-sufficiency. An increase in the general per
diem rate could help fund this type of program or through
separate appropriations.
Congress can also take a more active role in helping to
provide scholarships for retraining veterans in union
apprentice programs and business training programs which are
quite costly.
Finally, more funding is needed for sober housing
supportive housing services. As I mentioned, the key component
of our long-term success of our program and the key component
of any substance abuse program is the ability to maintain
individuals in a sober and supportive atmosphere.
Our independent living apartments offer that opportunity
and over 150 veterans have taken advantage of that opportunity.
As we expand these units, we ask that the VA consider a funding
stream to provide long-term supportive services to sober-living
housing like ours. The cost is minimal. We estimate $5.00 per
day per individual compared to the cost of relapse, recidivism
to homelessness.
On behalf of all the veterans we serve at the United States
Veterans Initiative, I appreciate the time you've given me to
share with you, how together, we can do a much better job for
our military veterans in Hawaii and throughout the country.
These three points I've emphasized come from day-to-day tasks
of delivering high-quality services to your veteran heroes that
have served our country. Thank you, sir.
[The prepared statement of Mr. Vincent follows:]
Prepared Statement of Darryl J. Vincent, Site Director,
United States Veterans Initiative-Hawaii
Aloha Senator Akaka and other distinguished officials, my name is
Darryl Vincent and I am the Hawaii Site Director for the United States
Veterans Initiative, a nonprofit agency that helps military veterans
experiencing homelessness. In Hawaii, our facilities are located at
Kalaeloa, at the former Barbers Point Naval Air Station, where we
currently serve approximately 200 veterans.
I am here today to speak to you about the realities of homelessness
among veterans in Hawaii, what United States Veterans Initiative is
currently doing to reduce homelessness among Hawaii veterans, and, most
importantly, I am here today to advocate for an expansion of known
solutions that can reduce homelessness for our military veterans--and
to request that these solutions be seriously considered in upcoming
Federal legislation and appropriations.
First the realities--
For many, the face of modern homelessness began with the image of
the homeless veteran--sign in hand, often wheelchair-bound, asking for
food, shelter, a job--on the streets and at the stop signs of nearly
every town in America. Still today, despite pockets of progress, the VA
estimates that 250,000 military veterans in America will be sleeping on
the streets tonight. In Hawaii, that number is estimated to be as many
as one thousand (1,000) veterans. One third of America's adult male
homeless population is estimated to be veterans and in Hawaii it is no
different. Tonight, many homeless veterans in Hawaii will be sleeping
at beach parks, in cars, at bus-stops, on sidewalks, and other places
not suitable for human habitation. Others remain in emergency shelters,
without appropriate services and treatment.
And the flow of veterans continues--from older veterans who served
during the Vietnam era, to veterans of the Gulf War, and most
tragically even young veterans back from Iraq and Afghanistan.
For soldiers who escape physical and mental injury, it remains
tough for many that are returning without jobs, and to a rental market
that has priced them out of a home or even an affordable apartment
rental. For veterans returning with Post Traumatic Stress Disorder and
other trauma-related injuries from war, the transition back into their
community will be a most difficult one. Research shows that veterans
typically experience homelessness a few years after military discharge,
after the support of family and friends has been exhausted, after
failed attempts at successfully reintegrating back into the community,
or after the full effects of their physical and mental injuries have
taken their toll. Whenever they call for help, we must remain firm in
our commitment to these honorable men and women.
We also wonder how many more veterans will come through our doors
in the next year, 2 years, and 5 years. We wonder, with so many
soldiers from Hawaii having been deployed, will the state be prepared
for their unique needs in the future? The full effects are often not
seen for a few years--but 30 years of modern homelessness guarantees
us--that more veterans will need assistance. As a veteran myself, I
feel that is a crime that we have allowed those who once committed
themselves to die for our freedoms to plummet to homelessness.
That's the reality--past, present and future. Now, a little about
what United States Veterans Initiative does--which offers a strong
blueprint for what can be done to help more veterans.
Since opening in 2002, United States Veterans Initiative has
provided over 800 homeless veterans with holistic, residential
treatment services--including medical, mental health and substance
abuse treatment, employment reintegration and housing placement. We
have also provided an additional 1,500 veterans with outreach and
referral to other needed programs. Services are provided in
collaboration with the local VA and through key partnerships with other
service provider agencies. United States Veterans Initiative-Hawaii is
one of 11 sites operated by the United States Veterans Initiative,
based in Inglewood, California that has been serving homeless veterans
since 1992.
United States Veterans Initiative offers a two-stage housing and
treatment program that incorporates time-tested, best-practice
treatment and recovery principles. The first stage is our Veterans-in-
Progress, or VIP program which serves about 250 homeless veterans
annually. Our outreach staff scours over 60 public areas on Oahu where
homeless veterans congregate--they engage them, talk to them, and
encourage them to come to the Barbers Point facilities. Interested
homeless veterans are then enrolled in the VIP program, where they
receive immediate housing, meals, laundry, mail, transportation and all
other essential services. Program fees are waived for veterans, until
they begin receiving income. This allows the veterans to focus first on
addressing substance abuse, mental illness and other medical problems--
key barriers to employment, housing retention and full social
integration.
For those in need of substance abuse treatment--the vast majority
of those we serve--the veteran immediately enrolls in intensive
outpatient substance abuse treatment--those with more complex dual-
diagnosis needs are typically served by the VA. At our site in Hawaii,
8 of every 10 veterans we enroll will need substance abuse services.
All receive a minimum of 90 days of treatment, more depending on their
needs. To be sure, many veterans have lost their job, housing, and too
often their family, because of substance abuse. Substance abuse is
often caused by underlying mental illnesses like depression and Post
Traumatic Stress Disorder. Substance abuse often grew worse during
their time of service. And we certainly advocate for better
identification, prevention and treatment of substance abuse while in
the military.
And our VIP program works. During 2006, over 83 percent maintain
their sobriety while in the program and at time of discharge, 73
percent of veterans enrolled in Workforce Development find jobs, and 76
percent successfully transition into permanent housing or appropriate
transitional housing. Many of those unsuccessful can often be served by
re-enrolling them into the program--a second chance--when they are
better ready and able to change their lives. Much of the success of the
VIP program is due to the therapeutic community we foster at Barbers
Point--staff cannot do it alone, veterans help fellow veterans, as
buddies, peers, chaperones and informal counselors.
We also attribute program success to the fact that after a veteran
completes our VIP program they have the opportunity to move into our
sober-living, long-term affordable housing, co-located at the Barbers
Point facility.
This long-term housing is offered to veterans who have successfully
completed the requirements of the VIP program, that have at least 90
days of being clean and sober, and that have an income to support
living independently. The veteran continues to receive supportive
services through case management and workforce development, but they
are not held to the same structure as if they were in the program. And
Veterans continue to be drug-tested on a regular basis. This allows a
veteran to stay connected with the services that helped them in first
place, while allowing the veteran to become more independent and self
reliant--knowing there is still help just a few feet away. More than
150 individuals have taken advantage of these sober-living independent
housing, with many using it as a stepping-stone to full community
reintegration.
So, what do we need? To handle both today's homeless veterans and
tomorrow's homeless veterans there are three things that I would like
to emphasize:
(1) Funding Must Be Increased Through the VA's Grant and Per Diem
Program--Success with our VIP program funded by the Grant and Per Diem
program shows that yes, money, when funding a successful program model,
can reduce homelessness. Unfortunately, the current Per Diem rate of
approximately $29 per day per person, pays for only half of the real
costs of effective treatment services--which for our Hawaii site is
about $55 per day--and that cost is delivered with a bare bones staff,
paid much lower than VA staff salaries.
Access to collateral funding sources through HUD and the DOL have
slowly evaporated--while the cost of services continues to grow. A
long-term commitment to funding the VA's Grant and Per Diem program
must include a greater funding commitment.
Programs like ours need to spend less time trying to find this
additional money each year, and more time serving homeless veterans.
Veterans deserve high-quality treatment by skilled professionals, not
barely above minimum wage workers. We would like to open a program on
Maui and the Big Island, but collateral funds will not be present. Try
providing housing, treatment, transportation, food and other amenities
on Maui for $850 a month (the monthly per diem for one veteran)--you
can't even rent an apartment for that amount.
At a minimum, we strongly advocate for a 20 percent increase in the
Per Diem rate, an annual cost to the Federal Government of $15-$20
million, a sum that will ensure the continuation of services provided
by the other 300 per diem veteran service providers throughout America,
and one that will ensure new programs can open to serve the remaining
gap of homeless veterans identified by the VA.
(2) Second, More Allocations Are Needed for Funding Alternative
Vocational Training at Our Barbers Point Program--We have found it very
effective to place veterans in the early stages of substance abuse into
pre-employment vocational internship positions. These positions, such
as running our veteran store, supervising the career center, directing
meal services, apprenticing to be a resident manager, and assisting our
maintenance and landscaping manager, provide the veteran with a
transitional period of an employment-like experience while they go
through our treatment program. Veterans are given small, but important
stipends, $200 per month or so, and learn a new skill, while
maintaining participation in the treatment program, contributing to the
healthy environment at United States Veterans Initiative and preparing
for the eventual re-entry into the marketplace.
We feel modest funding in this area can produce great benefits. As
you know, getting a job is often the easy part, maintaining the job and
getting a job that has a career is the difficult job. Veterans often
need a stepping stone that a vocational program--which we refer to as
the Transitional Work Experience program--can offer. A program that
they can participate in while still in treatment--that complements the
successes achieved in treatment while laying a stronger foundation for
long-term recovery and self-sufficiency. An increase in the general per
diem rate could help fund this type of program, and through separate
appropriations. Congress can also take a more active role in helping to
provide scholarships for retraining veterans in union apprentice
programs and business training programs which are quite costly.
(3) Finally, More Funding is Needed For Sober Housing Supportive
Housing Services--As I mentioned, a key component of the long-term
success of our program, and the key component of any substance abuse
program is the ability to maintain individuals in a sober and
supportive atmosphere. Our independent living apartments offer that
opportunity and over 150 veterans have taken advantage of this
opportunity. As we expand these units, we ask that the VA consider a
funding stream to provide long-term supportive services to sober-living
housing like ours--the cost is so minimal--we estimate $5 per day per
individual--compared to the cost of relapse and recidivism to
homelessness.
On behalf of all the veterans we serve at United States Veterans
Initiative, I appreciate the time given to me to share with you how,
together we can do a much better job for our military veterans--in
Hawaii and throughout the country. These three points I have emphasized
come from the day-to-day tasks of delivering high-quality services--to
our veteran heroes that have served their country.
I am available for questions or further elaboration. I would like
to specifically thank Senator Akaka for his tireless dedication to
serving our veterans and the people of Hawaii. As a veteran himself we
know that he can relate and empathize with the many issues faced by our
veterans and with his strong leadership and vision we can start to
address and solve these issues one day at a time.
The Audience. (Applause.)
Senator Akaka. Thank you very much.
I want to thank this panel very much for your personal and
heartfelt testimony. For the Committee, we are really grateful
for what you have shared with us. You have questions that will
be helpful to the work that the Committee will be doing.
Senator Inouye will not be able to stay. I would like to
ask Senator Inouye if he has any concluding remarks. And then
following that, we'll conclude the first panel.
Senator Inouye. Well, Mr. Chairman, I thank you very much.
I must say that I am impressed by your testimony and willing to
come publicly to candidly advise us of your concerns whether
it's good or bad. And Ms. Del Negro, we'll do our very best to
see that it's not repeated again.
To all of you, I feel a special bond and kinship and I can
assure you that I will not knowingly let my fellow veteran
down. Thank you.
The Audience. (Applause.)
Senator Akaka. Thank you, Senator Inouye. I want to again
thank the first panel and mahalo nui loa, and it will be
helpful to the Committee and we appreciate all that you're
doing.
Mahalo. I want to welcome the second panel of witnesses.
Thank you everyone. I know many of you have messages to pass
on. But we would like to continue with the second panel, and I
want to welcome here today, Dr. Michael Kussman, who is the
former Deputy Under Secretary for Health and is now the top man
here across the country in VA health care. I'm so delighted
that he had the time to join us here.
He is accompanied by Dr. Jim Hastings, who is Director of
the VA Pacific Islands Health Care System; and Dr. Robert
Wiebe, Director of Network 21. He has been here before and he
has been so helpful in our cause to improve care for Hawaii's
veterans. Also, Under Secretary Tuerk is here, and he is
accompanied by Gene Castignetti, the Director of the National
Memorial Cemetery of the Pacific. Finally, I want to welcome
Ronald Aument, who is the Deputy Under Secretary for Benefits.
We have the top people here from VA to testify this
morning. And let me say that Ronald Aument here is accompanied
by Gregory Reed, who has been doing a good job as the Director
of the Honolulu Regional Office. Finally, I welcome Julie
Watrous, Director of the Los Angeles Regional Office, Office of
Healthcare Inspections, Office of the Inspector General. She is
accompanied by Dr. Michael Shepherd, also from the IG's office.
I want to welcome this panel with much aloha and thank each
of them for being here. I will just remind you that your full
statements will appear in the record of the Committee. And with
that, those of you standing if there are seats, please find a
seat and be comfortable. And at this time I'd like to call Dr.
Kussman to begin with his testimony.
STATEMENT OF HON. MICHAEL J. KUSSMAN, M.D., M.S., M.A.C.P.,
UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY ROBERT L. WIEBE, M.D., DIRECTOR, VISN 21,
DEPARTMENT OF VETERANS AFFAIRS; AND JAMES HASTINGS, M.D.,
F.A.C.P.,
DIRECTOR, VA PACIFIC ISLANDS HEALTH CARE SYSTEM,
VETERANS HEALTH ADMINISTRATION, DEPARTMENT OF
VETERANS AFFAIRS
Dr. Kussman. Aloha, Mr. Chairman, mahalo nui loa. Thank you
very much for the opportunity to appear before you today to
discuss the VA health care services in Hawaii and the Pacific
Region. It is a privilege to be here again on Oahu, the
Gathering Place, to speak and answer questions about health
care issues important to veterans residing in Hawaii.
As you know, I was fortunate enough to be stationed here in
the past, at Tripler Army Medical Center, as a division surgeon
for the 25th Infantry Division. I have a great passion for what
I do and great appreciation and respect for the people of these
wonderful islands.
Before I get into my prepared remarks, I'd like to make a
few quick comments about the first panel, if that's OK with
you. I want to recognize them and appreciate and thank them for
their comments. I appreciate the good things, but I more
appreciate many ways the negative things that they said, so we
can learn from that and be better. As was mentioned, we believe
that we're not your father's VA and that we've made quantum
leap changes in our approach to the veterans on all levels. I
appreciate Mrs. Del Negro's comments and thank her husband for
his service and continuing service as a Ranger in the United
States Army.
I did then talk to her a little bit after the testimony.
And although her husband did not avail himself at the present
time of the VA services, I assured her that we stand ready in
every way to help her husband and people like that. We have a
very robust TBI service. And as you know, Mr. Chairman, we
screen everyone who comes to us from Hawaii for TBI along with
other ailments. We appreciate the comments of the Vet Centers,
and we're increasing our capacity. We've increased 32 Vet
Centers around the country in the last year and we'll probably
continue to expand that capacity.
The VA has achieved some remarkable accomplishments in
providing better and more accessible care to veterans in Hawaii
and the Pacific Islands. I'd like to share some of this good
news with you today, news about the superior care that we
provide and information on new developments regarding our
facilities. In fiscal year 2006, the VA Sierra Pacific Network,
was the highest ranked network in overall performance based on
quality access, satisfaction and business metrics.
The Network is home to more Centers of Excellence than any
other and has the highest funded research programs in the
Veterans Health Administration. In the most recent all employee
survey, VA staff from this Network reported the highest overall
job satisfaction throughout the Veterans Health Administration.
I understand that in the next few months, the State of Hawaii
Veterans Home in Hilo will accept its first patient. In no
small part due to the more than $18 million VA contributed to
this project. A 95-bed facility will provide more inpatient
long-term care and adult day-care center services for Hawaii
veterans.
VA recently dedicated the Community Based Outpatient Clinic
in America Samoa on July 21, 2007. The Capital Asset
Realignment for Enhanced Services process that we use to build
new facilities identified some additional locations for
consideration of future CBOCs here in Hawaii. VA learned about
the possibility of opening--of obtaining the vacant U.S. Navy
medical clinic at Barbers Point near Kapolei.
Although this clinic is about 13 miles from Waianae, this
location could open quickly to support the veterans homeless
shelter at Barbers Point and relieve some of the space crunch
at the VA clinic on the Tripler campus. It's not clear whether
or not the VA will be able to obtain this property, and so we
will continue to explore other options on the west side of Oahu
if that turns out to be necessary.
In fiscal year 2005, the VA approved $5.6 million for a
minor construction project to build a 15,000 square foot
facility on the Tripler campus that will house the relocated
inpatient PTSD residential rehabilitation unit, and the new
outpatient PSTD program. The contract for an environmental
assessment and design phase of the project is expected to be
awarded before the end of the current fiscal year and
construction should begin in fiscal year 2008.
VA also approved a minor construction project estimated at
$6.9 million to build a new ambulatory surgery center on the
Tripler campus. This will greatly enhance the ability of the
health care system here to provide ambulatory services and
procedures and reduce the need for referrals elsewhere.
Construction should begin in fiscal year 2009. For our Guam
veterans, VA determined the best option to improve care is to
build a new clinic at the periphery of the U.S. Naval Hospital
Guam campus.
I'm pleased to report that on July 30 of this year
Secretary Nicholson announced plans for the VA to build this
clinic at an estimated cost of $5.4 million. The clinic will be
about 6,000 square feet and will have its own parking. The Navy
will relocate its fence around the clinic so veterans will not
have to pass through the Navy security to enter the facility.
The new clinic is scheduled to open in the summer of 2009.
In summary, Mr. Chairman, the support of the Senate
Committee on Veterans Affairs and the Hawaiian congressional
delegation, VA is providing an unprecedented level of health
care services to veterans residing in Hawaii and the Pacific
Region. VA now has a state-of-the-art facilities and enhance
services in Honolulu as well as robust staffing in the neighbor
islands and has expanded or renovated clinics in many
locations.
Mr. Chairman, again, mahalo nui aloha for the opportunity
to testify this morning. And I and all the members of the panel
and my associates, Dr. Wiebe and Dr. Hastings, will be
delighted to address any questions that you may have of us.
Thank you.
[The prepared statement of Dr. Kussman follows:]
Prepared Statement of Hon. Michael J. Kussman, M.D., M.S., M.A.C.P.,
Under Secretary for Health, Department of Veterans Affairs
Mr. Chairman and Members of the Committee, mahalo nui loa for the
opportunity to appear before you today to discuss VA care in Hawaii and
the Pacific Region. It is a privilege to be on Oahu--The Gathering
Place--to speak and answer questions about VA health care issues that
are important to veterans residing in Hawaii. I was fortunate to have
been stationed in Honolulu at Tripler Army Medical Center (AMC) and
Schofield Barracks (as Division Surgeon for the 25th Infantry Division)
from 1979 to 1983. It is always a pleasure to return to Hawaii.
First, Mr. Chairman, I would like to thank you for your outstanding
leadership and advocacy on behalf of our Nation's veterans. During your
tenures as Ranking Member and Chairman of this Committee, you have
consistently demonstrated your commitment to veterans by introducing
legislation designed to meet the needs of veterans. As I will highlight
later, your vision and support have led to an unprecedented level of
health care services for veterans, construction of state-of-the-art
facilities here in Honolulu and remarkable improvements in access to
health care services for veterans residing on neighbor islands. In
addition, I appreciate your interest in and support of the Department
of Veterans Affairs (VA).
Today, I will briefly review the VA Sierra Pacific Network that
includes Hawaii and the Pacific Region; provide an overview of the VA
Pacific Islands Health Care System (VAPIHCS) and the VA facilities here
on Oahu; and highlight issues of particular interest to veterans
residing in Hawaii, including long-term care (LTC) services, potential
new VA clinics on Oahu, planned VA construction projects and our VA-
Department of Defense (DOD) joint venture at Tripler AMC. I will also
discuss our plans to build a replacement VA clinic in Guam and address
any questions you might have for me and my staff.
VA SIERRA PACIFIC NETWORK (VISN 21)
The VA Sierra Pacific Network (Veterans Integrated Service Network
[VISN] 21) is one of 21 integrated health care networks in the Veterans
Health Administration (VHA). The VA Sierra Pacific Network provides
services to veterans residing in Hawaii and the Pacific Region
(including the Philippines, Guam, American Samoa and Commonwealth of
the Northern Marianas Islands), northern Nevada and central/northern
California. There were an estimated 1.1 million veterans living within
the boundaries of the VA Sierra Pacific Network in Fiscal Year (FY)
2006.
The VA Sierra Pacific Network includes six major health care
systems based in Honolulu, HI; Palo Alto, CA; San Francisco, CA;
Sacramento, CA; Fresno, CA; and Reno, NV. Dr. Robert Wiebe serves as
director and oversees clinical and administrative operations throughout
the Network. In FY 2006, the Network provided services to 235,000
veterans. There were about 2.9 million clinic stops and 24,500
inpatient discharges. The cumulative full-time employment equivalents
(FTEE) level was 8,400 and the operating budget was about $1.5 billion.
The VA Sierra Pacific Network is remarkable in several ways. In FY
2006, VISN 21 was the highest-ranked Network in overall performance
(based on an aggregation of quality, access, patient satisfaction and
business metrics). The Network hosts the most Centers of Excellence and
also has the highest funded research programs in VHA. In the most
recent all-employee survey, staffs in VISN 21 reported the highest
overall job satisfaction in VHA. Finally, VISN 21 operates one of four
Polytrauma units in VHA that are dedicated to addressing the clinical
needs of the most severely wounded Operation Enduring Freedom/Operation
Iraqi Freedom (OEF/OIF) veterans.
VA PACIFIC ISLANDS HEALTH CARE SYSTEM (VAPIHCS)
As noted above, VAPIHCS is one of six major health care systems in
VISN 21. Dr. James Hastings is the director at VAPIHCS. VAPIHCS is
unique in several important aspects: its vast catchment area covering
2.6 million square-miles (including Hawaii, Guam, American Samoa and
Commonwealth of the Northern Marianas); island topography and the
challenges to access it creates; richness of the culture of Pacific
Islanders; and the ethnic diversity of patients and staff. In FY 2006,
there were an estimated 102,000 veterans living in Hawaii (representing
8 percent of the total population in Hawaii and 9 percent of total
veteran population in VISN 21).
VAPIHCS currently provides care in seven locations: Ambulatory Care
Center (ACC) and Center for Aging (CFA) on the campus of the Tripler
AMC in Honolulu; and Community Based Outpatient Clinics (CBOCs) in
Lihue (Kauai), Kahului (Maui), Kailua-Kona (Hawaii), Hilo (Hawaii),
Hagatna (Guam) and Pago Pago (American Samoa). VAPIHCS also has
outreach clinics in Molokai and Lanai. The inpatient Post Traumatic
Stress Disorder (PTSD) unit is now also on the campus of Tripler AMC
(the unit was formerly in Hilo). In addition to VAPIHCS, VHA operates
five Readjustment Counseling Centers (Vet Centers) in Honolulu, Lihue,
Wailuku, Kailua-Kona and Hilo that provide counseling, psychosocial
support and outreach.
In FY 2006, VAPIHCS provided services to nearly 22,500 veterans,
19,000 of whom reside in Hawaii. There were 198,000 clinic stops in
Hawaii during FY 2006 (7 percent of Network total). The cumulative FTEE
in FY 2006 for the health care system was 502 employees. The operating
budget for VAPIHCS (i.e., General Purpose allocation from appropriated
funds) increased from $68.0 million in FY 2002 to $110 million in FY
2007--an increase of 62 percent. For comparison, during this same time
period, the operating budgets for VISN 21 increased 48 percent and VHA
increased 43 percent. (Please note these amounts do not include
Specific Purpose funds and Medical Care Cost Funds [MCCF].)
VAPIHCS provides or contracts for a comprehensive array of health
care services. VAPIHCS directly provides primary care, including
preventive services and health screenings, and mental health services
at all locations. VAPIHCS does not operate its own acute medical-
surgical hospital and consequently, faces challenges in providing
specialty services. VAPIHCS recently hired specialists in orthopedics,
ophthalmology, nephrology and inpatient medicine (``hospitalist'') and
is providing selected specialty care in Honolulu and to a lesser
extent, CBOCs. VAPIHCS is actively recruiting additional specialists
(e.g., urology) and will continue to refer patients to DOD and
community facilities.
Inpatient long-term and acute rehabilitation care is available at
the CFA. Inpatient mental health services are provided by VA staff on a
20-bed ward within Tripler AMC and at the 16-bed PTSD Residential
Rehabilitation Program (PRRP). VAPIHCS contracts for care with DOD (at
Tripler AMC and Guam Naval Hospital) and community facilities for
inpatient medical-surgical care.
The current constellation of VA facilities and services represents
a remarkable transformation over the past several years. Previously,
the VAPIHCS (formerly known as the VA Medical and Regional Office
Center [VAMROC] Honolulu) operated primary care and mental health
clinics based in the Prince Kuhio Federal Building in downtown Honolulu
and CBOCs on the neighbor islands that were staffed primarily with
nurse practitioners. Congress approved $83 million in Major
Construction funds to build a state-of-the-art ambulatory care facility
(i.e., ACC) and long-term care/rehabilitation unit (i.e., CFA) on the
Tripler AMC campus and these facilities were activated in 2000 and
1997, respectively. VISN 21 allocated nearly $17 million from FY 1998-
FY 2000 to activate these projects. VISN 21 also provided dedicated
funds to enhance care on the neighbor islands by expanding/renovating
clinic space and adding additional staff to ensure there are primary
care physicians and mental health providers at all CBOCs.
OAHU FACILITIES
VA operates the Spark M. Matsunaga VA Medical Center in Oahu,
located on the campus of Tripler AMC at 459 Patterson Road, Honolulu,
HI 96815. The medical center consists of the ACC, CFA and
administrative space (located on the E wing of Tripler AMC). Congress
appropriated $25.1 million Major Construction funds during FY 1993/1994
to build the CFA; $14.9 million in FY 1995 to construct the parking
garage; and $43.0 million in FY 1994/1995/1997 to build the ACC and
renovate the E Wing of Tripler AMC for VA administrative use. Veterans
Benefits Administration (VBA) is co-located with VHA on this campus.
The Honolulu Vet Center is located nearby at 1680 Kapiolani Boulevard.
The VA facilities in Oahu serve an estimated island veteran
population in FY 2006 of 73,000. In FY 2006, 25,800 veterans on Oahu
were enrolled for care and 13,400 of these veterans received VA care
(``users''). The market penetrations for enrollees and ``users'' are 35
percent and 18 percent, respectively and compare favorably with rates
within VISN 21 and VHA.
The average FTEE level on Oahu in FY 2007 is 440. With this staff,
VAPIHCS provides a wide range of outpatient services, including primary
care, several medical subspecialties (e.g., cardiology,
gastroenterology, nephrology, orthopedics, pulmonary and women's
health), mental health and dental care. In addition, VAPIHCS provides
diagnostic services such as laboratory, echocardiography and radiology.
As noted earlier, VA staffs a 20-bed inpatient mental health unit
within Tripler AMC, 60-bed nursing home care unit (i.e., CFA) and 16-
bed PRRP. If veterans need services not available at the ACC or CFA,
VAPIHCS arranges and pays for care at Tripler AMC, local community or
VA facilities in California.
In FY 2006, VA facilities in Oahu recorded about 161,000 clinic
stops, representing a 39 percent increase from FY 2000 (i.e., 116,000
stops). Although some veterans waited more than 30 days in FY 2007 for
their first primary care appointment, at this time, there are very few
patients on a waiting list for an initial primary care appointment. In
FY 2006, the combined average daily census (ADC) was 11 in the mental
health ward and 54 at the CFA. VAPIHCS spent about $15.5 million for
clinical services for veterans at Tripler AMC and another $20 million
for non-VA care in the community.
SPECIAL ISSUES
Long-term care (LTC)
Older veterans have special needs and LTC services are a critical
issue for many of them. In FY 2006, about 40 percent of all veterans
seen at VAPIHCS were 65 years or older. VAPIHCS meets their special
needs with a full spectrum of inpatient, ambulatory and home services.
VAPIHCS provides inpatient LTC and transitional rehabilitative care
at the CFA. Over the past several years, the average daily census in
the CFA has been around 90 percent of capacity. In addition, VA manages
a community nursing home (CNH) care program and pays for care of
eligible veterans in private nursing homes. Currently, VAPIHCS has
contracts with four community LTC facilities in Oahu. VA is motivated
to expand CNH in Oahu and neighbor islands, but other facilities appear
to be unwilling or unable to meet VA standards (e.g., life-safety
codes) and contractual requirements.
In addition to the LTC services directly provided by VAPIHCS, VA
has contributed over $18 million to construct the State of Hawaii
Veterans Home in Hilo. This 95-bed facility will provide both inpatient
LTC and adult day care services for Hawaii veterans. I understand the
facility will accept its first admission this month (i.e., August
2007). I commend the State Advisory Board on Veterans Services for the
recommendation to name the facility in honor of Mr. Yukio Okutsu. As
you know, Mr. Chairman, Mr. Okutsu was a resident of Hilo and a
recipient of our Nation's highest award for valor, the Medal of Honor,
for his heroism during World War II.
VA understands that most veterans prefer to remain at home for as
long as possible. Consequently, VA emphasizes non-institutional care
(NIC) services. NIC includes Adult Day Health Care (ADHC), Contract
Adult Day Health Care (CADHC), Home-based Primary Care (HBPC), Contract
Home Health Care (CHHC), Homemaker/Home Health Aid (H/HHA), Home
Hospice, Home Respite and Spinal Cord Injury (SCI) Home Program.
VA has substantially increased these programs over the past several
years and has ambitious plans to expand further. This trend is also
present in Hawaii. Since this Committee held hearings here in January
2006, the ADC for all NIC services at VAPIHCS increased nearly 40
percent (i.e., from 109.9 in FY 2006 to 153.2 in FY 2007 through June
2007). In addition, since FY 2005, VAPIHCS has aggressively implemented
Care Coordination Home Telehealth (CCHT) technologies. Through CCHT,
veterans have daily contact with VA clinicians by using telehealth
devices in their homes. Currently, VAPIHCS has about 60 patients
utilizing CCHT.
CCHT is especially important for veterans who receive care on Oahu
and live on a neighbor island. As an example, Mr. Delbert Watson is a
61 year-old disabled veteran who lives on Kauai and had major heart
surgeries at Tripler AMC. In a recent letter he wrote, ``The VA saved
my life. I'd be dead without them. They identified my heart condition
and got me where I needed to be. I had two heart operations at Tripler,
but the VA was always there for me. I have a VA health buddy [Health
Buddy' is a type of CCHT equipment] so the VA nurse still
keeps an eye on my blood pressure regularly.'' This coordinated system
of VA, DOD and telehealth care ensures veterans in Hawaii receive
leading-edge medicine.
Additional Community Based Outpatient Clinics (CBOCs)
In 2000, VA formally began its long-range capital and strategic
planning process known as Capital Asset Realignment for Enhanced
Services (CARES). One of the major goals of the CARES initiative is to
improve access to health care services and the CARES Commission
specifically assessed the need for new CBOCs. The CARES Decision
announced in May 2004 identified one high-priority CBOC for VAPIHCS--
namely, a new outpatient facility in American Samoa. The CBOC in
American Samoa was dedicated on July 21, 2007. The CARES Decision also
identified two additional locations for consideration of future CBOCs.
These locations are Waianae (west side of Oahu) and Kaneohe (east side
of Oahu).
Waianae
Originally, VA planned to activate a CBOC on the west side of Oahu.
However, recently VAPIHCS became aware of the possibility of obtaining
the vacant U.S. Navy medical clinic at Barber's Point near Kapolei
(just west of Ewa Beach). Although this clinic is about 13 miles from
Waianae, it offers the potential advantages of earlier activation,
support for the veterans' homeless shelter at Barber's Point and
partial decompression of the ``space crunch'' at the VA clinic building
on the Tripler AMC campus. It is not clear whether or not VA will be
able to obtain this property (i.e., Navy has until September 2008 to
convey its assets at Barber's Point), so we will continue to explore
other options on the west side of Oahu.
Kaneohe
VA is also interested in the possibility of having a CBOC on the
east side of Oahu since the distance and travel times (especially
during ``rush hour'') to and from Honolulu are significant. We are
currently reviewing demographic information and potential locations. We
plan to open a CBOC on the west side of Oahu first (particularly if the
opportunity at Barber's point comes to fruition).
Construction Projects
VA has several important construction projects planned for VAPIHCS
that will enhance services for veterans in Hawaii. In FY 2005, VA
approved a Minor Construction project to build a facility on the
Tripler AMC campus that will house the relocated inpatient PRRP and new
outpatient PTSD program. The facility will be about 15,000 square-feet
and have an estimated total project cost of $5.6 million. The specific
location on the Tripler AMC campus has not been determined and will, in
part, depend on an upcoming environmental study. The contract for the
environmental assessment and design phase of the project is expected to
be awarded before the end of the current fiscal year. Construction
should begin in FY 2008.
Earlier this fiscal year, VA approved a Minor Construction project
to build a new ambulatory surgery center on the Tripler AMC campus. The
facility will be used for ``same day'' surgery and other outpatient
procedures. This will greatly enhance the ability of VAPIHCS to provide
ambulatory procedures and reduce the need for referrals elsewhere. We
are also exploring the opportunities to share the facility with Tripler
AMC and/or provide services to its beneficiaries through a sharing
agreement. The total project cost is estimated to be about $6.9
million. The contract for the design of the facility should be awarded
in FY 2008, with construction in FY 2009 and activation in FY 2010.
In addition to these Minor Construction projects, VA spends more
than $1 million of Non Recurring Maintenance (NRM) funds annually at
VAPIHCS to renovate and maintain existing structures (e.g., $1.2
million in FY 2007). As I will discuss at the hearing in Maui on August
23, 2007, VA has and will continue to expand and improve clinic
buildings and parking at CBOCs on neighbor islands. I would like to
thank you, Mr. Chairman, and your colleagues in Congress for your
generous support of the capital asset programs in VHA (i.e., VHA
Medical Facilities Appropriation). Without this support, these
improvements would not be possible.
VA-DOD Joint Ventures
VAPIHCS participates in one of the largest and most complex VA-DOD
partnerships. As I noted earlier, I had the privilege of serving at
Tripler AMC in the early 1980s as chief of Internal Medicine. Both my
military and VA experiences have helped me understand the systemic
barriers that VA-DOD joint ventures face: conflicting mission
priorities, lack of computer interoperability, ambiguities regarding
dual-eligible beneficiaries and differences in financial systems.
Further, deployments and increased obligations to TRICARE beneficiaries
have constrained the ability of Tripler AMC to provide services to VA
beneficiaries.
The VA-DOD joint venture in Honolulu has addressed these challenges
and made great strides in both clinical and administrative areas. The
partnership with Tripler AMC accelerated when VA began to move clinical
and administrative functions from the Prince Kuhio Federal Building to
the Tripler AMC campus in 1997. The co-location of VAPIHCS and Tripler
AMC allows functional integration and opportunities to provide high
quality care to Federal beneficiaries residing in Hawaii and the
Pacific Region. VAPIHCS relies on Tripler AMC for emergency room care,
acute medical-surgical inpatient care (including intensive care unit),
outpatient specialty care and ancillary services. Tripler AMC admits
about 1,400 VA beneficiaries and provides about 12,000 specialty clinic
visits to VA beneficiaries each year. VAPIHCS also partners with
Tripler AMC for nutritional services (e.g., inpatient meals at Tripler
AMC and CFA), housekeeping, security, instrument sterilization and
medical maintenance. In FY 2006, VAPIHCS purchased a total of about $20
million of clinical and support services from Tripler AMC.
VAPIHCS and Tripler AMC also collaborate in several other important
endeavors. The joint venture in Honolulu has successfully competed for
several Joint Incentive Fund (JIF) projects. JIF was established by
Congress in the National Defense Authorization Act (NDAA) in FY 2003 to
encourage ongoing collaboration. The VA-DOD joint venture in Honolulu
has secured about $4 million in JIF funding since FY 2004 for projects
related to computer-aided design and manufacturing of prosthetic
devices; chronic dialysis center; and chronic pain management program.
The venture was also selected as one of eight formal VA-DOD Joint
Venture Demonstration Sites and will specifically assess budget and
financial management systems.
VA appreciates the leadership of Major General (MG) Carla Hawley-
Bowland and the responsiveness her staff to VA concerns. She has
continued the tradition of a productive working relationship between
senior VA and DOD leaders. I am confident that Dr. Hastings (a former
Commanding General at Tripler AMC) and MG Hawley-Bowland will continue
the growth and accomplishments of this very important joint venture.
Guam
VA has operated a clinic in Guam since 1989 and potentially serves
an island population of about 9,000 veterans. The VA clinic is
currently located in leased space within the U.S. Naval Hospital Guam.
The clinic has nine staff members, including an internal medicine
physician, psychiatrist and nurse practitioner. The clinic provides
primary care, mental health care, limited specialty services (through
telehealth technologies and visiting clinicians) and compensation and
pension (C&P) examinations. In FY 2006, the clinic evaluated and
treated 1,235 veterans with 5,824 clinic stops.
The current clinic site is problematic in many respects, including
its small size (i.e., 2,700 square feet), related concerns regarding
patient privacy and lack of parking. Moreover, due to security measures
imposed by Navy, it is often difficult for veterans to traverse the
security gate and access the clinic. These challenges will be
exacerbated in the upcoming years when Navy relocates an estimated
8,000 U.S. Marines (and 9,000 dependents) from Okinawa to Guam.
VA Sierra Pacific Network and VAPIHCS collaborated with U.S. Naval
Hospital Guam to address these concerns. Based on a combination of
cost, access, timelines and VA-DOD sharing considerations, we
determined the best option is for VA to build a new clinic at the
periphery of the U.S. Naval Hospital Guam campus. I am pleased to
report to the Committee that on July 30, 2007, Secretary Nicholson
announced plans for VA to build this clinic at an estimated cost of
about $5.4 million. The clinic will be about 6,000 square-feet and will
have its own parking. Navy will relocate its fence around the clinic so
veterans will not have to pass through Navy security to enter the
facility. The new clinic is scheduled to open in the summer of 2009.
CONCLUSION
In summary, with the support of the Senate Committee on Veterans'
Affairs and the Hawaiian congressional delegation, VA is providing an
unprecedented level of health care services to veterans residing in
Hawaii and the Pacific Region. VA has state-of-the-art facilities and
enhanced services in Honolulu, as well as robust staffing on the
neighbor islands and has expanded or renovated clinics in many
locations. VA is bringing more mental health providers and specialists
on board to meet the needs of veterans.
VAPIHCS still faces several challenges including timely access to
health care services (in part due to the topography of its catchment
area and lack of an acute medical-surgical hospital), aging veteran
population and special needs of our newest veterans who bravely served
in southwest Asia. VAPIHCS will meet these challenges by working with
DOD and community partners, activating an ambulatory surgery center,
utilizing telehealth technologies and opening new clinics as
demographics suggest and resources allow. I am proud of what VA has
accomplished in Hawaii and the Pacific Region, but I understand that
our job is not done.
Again, Mr. Chairman, mahalo nui loa for the opportunity to testify
at this hearing. I and the staff who accompany me would be delighted to
address any questions you may have for us.
Senator Akaka. Thank you. Thank you very much, Dr. Kussman.
The Audience. (Applaud.)
Senator Akaka. Your testimony has really revealed many
things that will be happening here in Hawaii and across the
country, and we are delighted to hear all of that. And now I
would like to welcome the testimony of William Tuerk, Under
Secretary for Memorial Affairs, Department Veterans Affairs.
Under Secretary Tuerk.
STATEMENT OF HON. WILLIAM F. TUERK, UNDER SECRETARY FOR
MEMORIAL AFFAIRS, DEPARTMENT OF VETERANS
AFFAIRS; ACCOMPANIED BY GENE CASTIGNETTI, DIRECTOR, NATIONAL
MEMORIAL CEMETERY OF THE PACIFIC
Mr. Tuerk. Thank you, Mr. Chairman.
Mr. Chairman, I appreciate the opportunity to testify today
on issues of great interest to Hawaii veterans. With the
Committee's permission, I will offer a brief summary statement
and request that my written testimony be accepted by the
Committee for placement in its hearing record.
Senator Akaka. Without objection, it will be accepted and
it will be included in the record.
Mr. Tuerk. Mr. Chairman, for my oral presentation, I will
focus on three items, each of which, I think, represents good
news for the veterans of Hawaii. The first item concerns VA
initiatives to ensure that the National Memorial Cemetery of
the Pacific remains open to provide uninterrupted service in
meeting the burial needs of Hawaii veterans and their families.
These initiatives will also ensure that the Punchbowl is
preserved as an active national treasure in the spirit of the
ancient Hawaiians who know this site as puuvana.
NCA is proceeding now to design a columbarium expansion
project which we anticipate will add over 30,000 niches for the
inurnment of cremated remains at NMCP. Subject to the
availability of fiscal year 2008 funding, we intend to advance
a project that would extend the life of the cemetery to
approximately 2016. We are, in addition, studying the
feasibility of other columbarium projects into the future.
Mr. Chairman, we will seek every opportunity, every
opportunity, to maximize the space available for columbarium
inurnments at the Punchbowl and to extend the time frame within
which that national treasure will remain an active cemetery. We
understand what the Punchbowl means to the citizens of Hawaii.
We understand what it means to the citizens of the Nation.
The second item I will discuss this morning relates to the
strong partnership between the Federal Government and the State
of Hawaii in providing options for burial through the State
Cemetery Grants Program. This morning's presentation of
$743,000 in grant funds for the phased expansion of West Hawaii
State Veterans Cemetery marks the newest era in that long-
standing partnership.
The state veterans cemetery expansion project at Kailua-
Kona will allow for continued access to a full casket burial
option on both the east and west sides of the Big Island of
Hawaii. Hawaii leads all states in the development and
operation of state veterans cemeteries. This grant will assist
Hawaii in maintaining that national leadership position into
the future. We hope, Mr. Chairman, that other states will
follow Hawaii's lead in building successful partnerships with
the VA.
The third item I'd like to discuss this morning relates to
further future improvements planned for West Hawaii State
Veterans Cemetery. Last December, staff members of both Hawaii
senators expressed concerns to me about the appearance of some
sections of that cemetery, and they asked me to give this
matter my personal attention. As you know, Mr. Chairman, I have
visited the West Hawaii State Veterans Cemetery along with four
other Hawaii State Cemeteries, and today I'm prepared to report
our response to those concerns.
To meet the unique challenges of this site, the state
cemetery grant, which was announced this morning, will fund the
purchase of grave liners to assist cemetery staff in
maintaining the grounds to the highest standards of appearance.
This was an issue that I know that both you and Senator Inouye
were particularly concerned about. We will attend to it.
In the future, we anticipate additional funding of
approximately $3.5 million to construct a permanent committal
shelter, restrooms, roadway infrastructure and other
improvements at West Hawaii State Veterans Cemetery. Be
assured, Mr. Chairman, that VA will continue in its strong
support of the veterans cemeteries here in Hawaii today and
into the future. We are grateful, Mr. Chairman, for your
steadfast support of NCA, the VA, and the Nation's veterans.
Thank you again for this opportunity to testify. I'd be
happy to entertain any questions that you may have for me.
Thank you.
[The prepared statement of Under Secretary Tuerk follows:]
Prepared Statement of Hon. William F. Tuerk, Under Secretary
for Memorial Affairs, Department of Veterans Affairs
Mr. Chairman, Mr. Ranking Member and Members of the Committee,
thank you for the opportunity to testify today on issues of great
interest to Hawaii veterans.
The National Cemetery Administration (NCA) and the Veterans
Benefits Administration (VBA), which is responsible for burial flags
and monetary burial benefits, jointly administer the Department of
Veterans Affair's burial and funeral benefits for veterans. We, in NCA,
have four statutory missions under title 38, United States Code:
To provide burial for eligible veterans and their eligible
dependents and to maintain those places of burial as national shrines;
To provide Government-furnished headstones and markers for
the graves of eligible veterans worldwide;
To administer the State Cemetery Grants Program (SCGP),
which provides Federal funds up to 100 percent of the development cost
for establishing, expanding and improving veterans cemeteries owned and
operated by the States; and
To administer the Presidential Memorial Certificate (PMC)
program, which provides the families of honorably discharged, deceased
veterans Certificates bearing the signature of the President, to
commemorate the veterans' service.
NCA currently maintains more than 2.8 million gravesites at 125
national cemeteries in 39 States and Puerto Rico, as well as 33
soldiers' lots and monument sites. Since 1973, when Congress created a
National Cemetery System under the jurisdiction of VA, annual
interments in VA national cemeteries have almost tripled from 36,400 to
about 97,000 in fiscal year 2006. We expect to perform nearly 105,000
interments in 2008, an 8.3 percent increase over the number performed
in 2006. NCA processed more than 336,000 applications for Government-
furnished headstones and markers for the graves of veterans worldwide
and issued nearly 406,000 Presidential Memorial Certificates to the
families of eligible veterans in fiscal year 2006. Sixty-seven State
veterans cemeteries funded under the SCGP are operated in 34 States,
Guam and Saipan--of which 8 are located in Hawaii.
MEETING THE BURIAL NEEDS OF VETERANS
One of VA's primary missions is to ensure that the burial needs of
veterans are met. In support of this mission, VA's goal is to provide
veterans with reasonable access to a burial option (whether for
casketed or cremated remains) in a national or State veterans cemetery
within 75 miles of their residence.
Our ability to provide reasonable access to a burial option is a
critical measure of the effectiveness of our service delivery to
veterans and their families. Currently, 83.5 percent of all veterans in
the Nation are served by a burial option in a national or State
veterans cemetery within 75 miles of their homes. NCA intends to
increase the percentage of veterans served to 90 percent by fiscal year
2010. Strategic initiatives are in place to meet this goal. They are:
Establishment of additional national cemeteries in
unserved areas;
Expansion of existing national cemeteries to provide
continued service; and
Establishment or expansion of State veterans cemeteries
through the SCGP.
NCA will continue to expand, and make improvements to, existing
national cemeteries by acquiring additional land, where possible, and
completing development projects that make additional gravesites or
columbaria available for interments. We have major and minor
construction projects underway to expand the life cycles of several
national cemeteries so that they can continue to meet the burial needs
of veterans in their geographic regions. One such project was here at
the National Memorial Cemetery of the Pacific (NMCP) where a
columbarium expansion project was undertaken to add 4,160 niches to
allow the cemetery to remain open for cremated remains until 2011.
Dedicated on September 2, 1949, on the fourth anniversary of the
end of World War II, the National Memorial Cemetery of the Pacific (the
Punchbowl) originally provided a final resting place for approximately
13,000 World War II casualties from Guadalcanal, Burma, Saipan, Guam,
Iwo Jima, the prison camps of Japan and other battlegrounds of the
Pacific as well as Hawaii's own sons from other theaters of war. Among
the nearly 30,000 graves tended today, 57 Medal of Honor recipients are
interred or memorialized.
In 2006, over 950 burials were performed at NMCP; 105 were full-
casket burials of eligible family members of those already buried at
the cemetery. NCA also furnished 477 headstones or markers for eligible
Hawaii veterans interred at private cemeteries and provided over 500
Presidential Memorial Certificates to honor the service of Hawaii
veterans.
NMCP has undergone numerous improvements over the years to ensure
that it remains a national shrine to honor all those who served their
country. Several projects currently in design illustrate NCA's
commitment to retaining this unique national treasure as an active
national cemetery and as a special ceremonial venue for commemorating
the dedicated men and women who have made the ultimate sacrifice.
NCA is designing an additional columbarium expansion project at
NMCP which we anticipate will add over 3,000 niches for the inurnment
of cremated remains. This project would extend the life of the cemetery
to approximately 2016. We are committed to constructing this project to
ensure there could be no lapse in future gravesite availability until
that date. We are also studying the feasibility of potential
columbarium projects further into the future. Among the options to be
considered will be the relocation of administrative functions, where
possible, to provide for grave site expansion in suitable areas. Toward
this end, options for the design of a new administration building and
visitors information center are under development. I assure you that we
will take every opportunity to employ innovative methods to maximize
the space available to continue to serve the needs of our veterans at
NMCP. We are determined to preserve NMCP as the cherished icon that it
is, one that is known throughout the world.
STATE CEMETERY GRANTS PROGRAM
Established by Public Law 95-476 in 1978 to complement VA's network
of national cemeteries, the NCA State Cemetery Grants Program (SCGP)
provides funding up to 100 percent for the development and startup
equipment costs for State veterans cemetery projects. At of the end of
July 2007, VA had awarded 156 grants totaling more than $286 million to
establish, expand or improve 71 veterans cemeteries nationwide.
Utilizing VA grant funding, sixty-seven State cemeteries are currently
operational and four new State cemeteries are under construction. In
fiscal year 2006, State veterans cemeteries provided for 22,434
burials, 19 percent of all burials in either a national or State
veterans cemetery.
As a complement to our national cemeteries, the State Cemetery
Grants Program is vital to achieving NCA's burial access goal and
permitting NCA to meet the needs of veterans in less populated areas
where the concentration of veterans cannot meet NCA's criterion for the
establishment of a national cemetery. Nowhere is access to veterans
cemeteries more extensive than in Hawaii, where 100 percent of veterans
are served within 75 miles of their homes by the presence of a State
veterans cemetery.
Hawaii leads all States in the development and operation of State
veterans cemeteries, and ranks as the ninth busiest State in providing
burial services to veterans and their families in State veterans
cemeteries. Of its eight State veterans cemeteries, only East Hawaii
Veterans Cemetery No. 1 is closed to new interments. The seven
operating Hawaii veterans cemeteries are:
Hawaii State Veterans Cemetery (Island of Oahu); East Hawaii
Veterans Cemetery No. 2 (in Hilo on the Island of Hawaii); West Hawaii
Veterans Cemetery (on the Kona Coast of the Island of Hawaii); Kauai
Veterans Cemetery (Island of Kauai); Maui Veterans Cemetery (Island of
Maui); Molokai Hawaii Veterans Cemetery (Island of Molokai); and Lanai
Veterans Cemetery (Island of Lanai).
I am privileged to have had an opportunity visit five of these
sites. In 2006, 1,171 veterans were interred in a Hawaii veterans
cemetery, either at NMCP or in one of the 7 open Hawaii State veterans
cemeteries.
NCA has provided over $11 million in grants for Hawaii State
veterans cemeteries. Recently, the Hawaii Congressional delegation
requested assistance from NCA to work with the West Hawaii State
Veterans Cemetery to ensure national shrine standards were being met.
To do so, we are currently processing an award for more than $700,000
for the phased expansion at West Hawaii State Veterans Cemetery that
will provide local veterans with access to a full-casket burial option
on both the east and west side of the island of Hawaii. This project
includes the purchase of grave liners to assist cemetery staff in
maintaining the grounds to meet the highest standards of appearance.
Project plans also address infrastructure needs at the facility, to
include construction of a permanent committal shelter, rest rooms,
improved equipment storage facilities, and roadways. NCA will continue
to serve as a partner with the State in the expansion and improvement
of Hawaii State cemeteries to serve Hawaii veterans on every island.
In addition to grants, NCA also provides technical assistance and
support to State cemetery field and administrative staff through site
visits and invitations to participate in NCA's annual and regional
conferences where innovative operational techniques, best management
practices and ideas are exchanged. Hawaii has also cultivated
successful working partnerships with the counties in operating and
maintaining the State cemeteries, a technique now being considered by
other States.
Hawaii has met the challenge of operating multiple State cemeteries
through the use of innovative cooperative agreements between public and
private entities. The recent water and planting improvement project the
State undertook at West Hawaii State Cemetery addressed the difficult
and unique site conditions at the cemetery. Successful projects such as
this demonstrate Hawaii's ingenuity in maintaining all veterans
cemeteries as national shrines that honor the service of our country's
servicemembers. We hope that other States will follow Hawaii's lead. We
hope that they will build successful partnerships with VA as pioneered
by the State of Hawaii. Be assured that NCA will continue in its strong
support of the cemeteries here in Hawaii today and in the future. We
are grateful for your vital cooperation in commemorating our Nation's
veterans. We are also grateful, Mr. Chairman, for your steadfast
support for NCA, and for our Nation's veterans.
That concludes my statement, Mr. Chairman. I would be happy to
entertain any questions you or the other Members of the Committee may
have.
Senator Akaka. Thank you very much.
The Audience. (Applause.)
Senator Akaka. Thank you very much for your work in our
state, and we are really grateful for that.
Now, we will hear from Deputy Under Secretary Aument.
STATEMENT OF RONALD R. AUMENT, DEPUTY UNDER
SECRETARY FOR BENEFITS, DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY GREGORY REED, DIRECTOR, HONOLULU REGIONAL
OFFICE, DEPARTMENT OF VETERANS AFFAIRS
Mr. Aument. Thank you, Mr. Chairman.
Chairman Akaka, thank you for the privilege of being here
today to discuss our efforts to meet the needs of veterans
residing in Hawaii and the Pacific Region. I am pleased to be
accompanied by Gregory Reed, Director of the Honolulu VA
Regional Office.
Like Dr. Kussman, I listened to the first panel with great
interest today. We have much to learn from the veterans that we
serve, the Honolulu Regional Office is responsible for
delivering VA benefits and services to veterans residing in the
Pacific Region including Hawaii, Guam, American Samoa and the
Commonwealth of the Marianas.
Today I will discuss the important services provided by the
Honolulu Regional Office. My comments will also focus on the
actions we are taking to expedite the processing of claims from
Operations Iraqi and Enduring Freedom veterans, VBA's national
hiring initiatives that will improve our ability to provide
more timely, accurate and consistent determinations on
veterans' claims.
More than 107,000 veterans are served by the dedicated
employees of the Honolulu Regional Office. Of these veterans,
approximately 16,700 are receiving disability compensation.
This fiscal year through June, the Honolulu Regional Office
processed approximately 3,500 veterans disability claims.
Through their aggressive outreach and public contact
activities, the Regional Office employees have this year alone
conducted nearly 1,350 personal interviews and 2,250 telephone
interviews, and briefed approximately 800 separating
servicemembers.
The Honolulu office recently extended telephone service,
benefits counseling and other inter-island itinerant services
to the South Pacific encompassing the Federated States of
Micronesia. Expediting the claims process is critical to
assisting OIF and OEF veterans in their transition from combat
operations back to civilian life.
Since the onset of combat operations in Iraq and
Afghanistan, VA has provided expedited and case-managed
services for all seriously injured OIF/OEF veterans and their
families.
These individualized service begins at the military
treatment facilities where the injured servicemembers return
for treatment, and continue as these servicemembers are
medically separated and enter the VA medical care and benefits
systems. VA assigns benefits counselors, social workers and
case managers to work with these servicemembers and their
families to assist in the transition to VA care and benefits
systems and to ensure the expedited delivery of all benefits.
Since February of this year, VA has provided priority
processing of all OIF/OEF veterans' disability claims. This
issue covers all active duty, National Guard and Reserve
veterans who are deployed, in the OIF/OEF or in support of
these combat operations as identified by the Department of
Defense. This allows all the brave men and women returning from
the OIF/OEF theaters who are not seriously injured in combat,
but who nevertheless have a disability incurred or aggravated
during their military service, to enter the VA system and begin
receiving disability compensation as soon as possible after
separation.
We are also continuing to focus on reducing pending
workload and providing more timely claims decisions to veterans
of all periods of service. I'm especially pleased today to be
able to discuss with you our national hiring initiative. We've
already added more than 800 new employees since April of this
year and our plans call for adding a total of 3,100 new
employees by the end of next fiscal year.
These employees will be placed in critically needed
positions in our regional offices throughout the Nation. The
Honolulu Regional Office has been authorized to increase its
staffing level by over 10 percent as a result of this hiring
initiative. A number of the new employees are already onboard,
and the Regional Office is in the process of filling another
five vacancies. These additional resources will enable the
Regional Office employees to make great strides to improve the
delivery of benefits and conduct more outreach in the Pacific
Region.
Since 1993, VA has made almost 600 loans to Native American
veterans for the purchase, construction or improvement of homes
on Federal Trust land under the Native American Direct Loan
program. Over 75 percent of all loans made under this program
will be Native American veterans living in the Pacific Region.
As an aside, I just noted today that during fiscal 2006, almost
$4 billion worth of loans are guaranteed for veterans here in
Hawaii. We believe that much of the credit for these successes
must go to the ongoing partnerships of the Department of
Hawaiian Homelands, the Community Development Bank of American
Samoa, the Territorial Government of Guam, the Commonwealth of
the Northern Marianas and the Department of Community and
Cultural Affairs' Veterans Affairs Office, and the Mariana
Islands Housing Authority.
Further, veterans are eligible through VA-guaranteed and
direct loans equal to the Freddie Mac conforming loan limit. As
of January 2006, that rate increase is $625,500 for high cost
areas such as Hawaii and Guam. VA anticipates that this will
make VA guaranteed home loans much more attractive to veterans.
Mr. Chairman, this concludes my testimony. I greatly
appreciate being here today, and look forward to answering any
questions you may have.
[The prepared statement of Deputy Under Secretary Aument
follows:]
Prepared Statement of Ronald R. Aument, Deputy Under Secretary
for Benefits, Department of Veterans Affairs
Chairman Akaka, it is my pleasure to be here today to discuss our
efforts to meet the needs of veterans residing in the Pacific Region. I
am pleased to be accompanied by Gregory Reed, Director of the Honolulu
VA Regional Office.
The Veterans Benefits Administration (VBA) is responsible for
administering a wide range of benefits and services for veterans, their
families, and their survivors. Today I will discuss the important
services provided by the Honolulu Regional Office. My comments will
also focus on the actions we are taking to expedite the processing of
claims from Operations Iraqi and Enduring Freedom (OIF/OEF) veterans
and VBA's national hiring initiative that will improve our ability to
provide more timely, accurate, and consistent determinations on
veterans' claims.
HONOLULU REGIONAL OFFICE
The Honolulu Regional Office is responsible for delivering VA
benefits and services to veterans residing in the Pacific Region,
including Hawaii, Guam, American Samoa, and the Commonwealth of the
Northern Marianas.
The Honolulu Regional Office administers the following benefits and
services:
Disability Compensation
Dependency and Indemnity Compensation
Disability and Death Pensions
Vocational Rehabilitation and Employment Assistance
Home Loan Guaranties and Native American Direct Home Loans
Outreach
Burial Benefits
More than 107,000 veterans are served by the dedicated employees of
the Honolulu Regional Office. Of these veterans, approximately 16,700
are receiving disability compensation. This fiscal year through June,
the Honolulu Regional Office provided approximately 3,500 veterans with
decisions on their disability claims. Through their aggressive outreach
and public contact activities, the regional office employees have this
year alone conducted nearly 1,350 personal interviews and 2,250
telephone interviews, and briefed approximately 850 separating
servicemembers.
The Honolulu office recently extended telephone service, benefits
counseling, and other inter-island itinerant services to the South
Pacific area encompassing the Federated States of Micronesia. Telephone
service is also provided to veterans residing in the Republic of Palau
and the Marshall Islands by the Honolulu Regional Office.
PRIORITY PROCESSING FOR OIF/OEF VETERANS
Since the onset of the combat operations in Iraq and Afghanistan,
VA has provided expedited and case-managed services for all seriously
injured OIF/OEF veterans and their families. This individualized
service begins at the military medical facilities where the injured
servicemembers return for treatment, and continues as these
servicemembers are medically separated and enter the VA medical care
and benefits systems. VA assigns special benefits counselors, social
workers, and case-managers to work with these servicemembers and their
families throughout the transition to VA care and benefits systems, and
to ensure expedited delivery of all benefits.
Since February 2007, VA has provided priority processing of all
OIF/OEF veterans' disability claims. This initiative covers all active
duty, National Guard, and Reserve veterans who were deployed in the
OIF/OEF theaters or in support of these combat operations, as
identified by the Department of Defense (DOD). This allows all the
brave men and women returning from the OIF/OEF theaters who were not
seriously injured in combat, but who nevertheless have a disability
incurred or aggravated during their military service, to enter the VA
system and begin receiving disability benefits as soon as possible
after separation.
We designated our two Development Centers in Roanoke, Virginia, and
Phoenix, Arizona, as well as three of our Resource Centers, as a
special ``Tiger Team'' for processing OIF/OEF claims. The two
Development Centers assist regional offices in obtaining the evidence
needed to properly develop the OIF/OEF claims. Medical examinations
needed to support OIF/OEF veterans' claims are also expedited.
We expanded our outreach programs for National Guard and Reserve
components and our participation in OIF/OEF community events and other
information dissemination activities. An OIF/OEF team at VBA
Headquarters addresses OIF/OEF operational and outreach issues at the
national level and provides support to the newly designated OIF/OEF
managers at each regional office. The OIF/OEF team is also coordinating
the development of national memoranda of understanding (MOUs) with each
of the Reserve Components to formalize relationships with them,
mirroring the agreement between VA and the National Guard Bureau signed
in 2005. Having an MOU with each Reserve Component will help ensure
that VA is provided service medical records and notified of ``when and
where'' Reserve members are available to be briefed during the
demobilization process and at later times.
In order to ensure that VA benefits information is provided to all
separating servicemembers, including Reserve and Guard members, we are
working with DOD to expand our role in DOD's military pre-separation
process. Specifically, we are now providing ``Claims Workshops'' in
conjunction with many of our VA benefits briefings for separating
servicemembers. At such workshops, groups of servicemembers are
instructed on how to complete the VA application forms. Personal
interviews are also conducted with those applying for VA disability
benefits.
Expediting the claims process is critical to assisting OIF/OEF
veterans in their transition from combat operations back to civilian
life. We are also continuing to focus on reducing the pending workload
and providing more timely claims decisions to veterans of all periods
of service.
NATIONAL HIRING INITIATIVE
I am especially pleased today to be able to discuss with you our
national hiring initiative. We are extremely grateful for the funding
support we have received from Congress that has allowed us to undertake
this unprecedented hiring program. We have already added more than 800
new employees since April, and our plans call for adding a total of
3,100 new employees by the end of next year. These employees will be
placed in critically needed positions in our regional offices
throughout the nation.
Along with the multitude of activities involved in a recruitment
program of this magnitude, we have begun the critical tasks of
training, equipping, and acquiring space to house our new employees. We
are accelerating the training of these employees and focusing in
specialized areas of claims processing in order to have them ``on-
line'' and productive within a few months. This will be followed by
ongoing, carefully structured, and progressively complex training until
full journey expertise is achieved.
The Honolulu Regional Office has been authorized to increase its
staffing level by over 10 percent as a result of this hiring
initiative. A number of the new employees are already on board, and the
Regional Office is in the process of filling another five vacancies.
These additional resources will enable the Regional Office employees to
make great strides in improving the delivery of benefits and conducting
more outreach in the Pacific Region.
HOME LOAN GUARANTY SERVICES
Since 1993 VA has made almost 600 loans to Native American veterans
for the purchase, construction, or improvement of homes on Federal
Trust land under the Native American Veteran Direct Loan Program. Far
and away our greatest successes under this program have been in the
South Pacific. Over 75 percent of all loans made under this program
have been to Native American veterans living on the homeland
territories of American Samoa, Guam, Hawaii, and the Commonwealth of
the Northern Marianas.
We believe that much of the credit for these successes must go to
our ongoing partnerships with the Department of Hawaiian Homelands, the
Community Development Bank of American Samoa, the Territorial
Government of Guam, the Commonwealth of the Northern Marianas (CNMI),
the CNMI Department of Community and Cultural Affairs Veterans Affairs
Office and the Mariana Islands Housing Authority. These offices have
played crucial roles in assisting with outreach and delivery of the VA
home loan benefit to veterans located throughout the South Pacific.
They have acted as our partners in assisting with loan packaging,
appraisals, and construction-related inspections, as well as providing
crucial communication links between our staff and the veterans we
serve.
With the ongoing activation of Reserve and National Guard members
in support of the military operations in Iraq and Afghanistan,
servicemembers are becoming eligible for VA home loan benefits faster
and in greater numbers. Instead of the time-in-service requirement of 6
years for members of the Reserves or National Guard, eligibility is
established under the Loan Guaranty and Native American Veteran Direct
Loan Programs after 90 days or more of active wartime service. Further,
as a result of P.L. 108-454, veterans are eligible for VA-guaranteed
and direct loans equal to the Freddie Mac conforming loan limit. As of
January 2006, that rate increased to $625,500 for high cost areas such
as Hawaii and Guam. VA anticipates that this will make VA guaranteed
home loans much more attractive to veterans. As a result, we anticipate
continued growth in the Loan Guaranty Program and Native American
Direct Loan Program in the Pacific Region.
Mr. Chairman, this concludes my testimony. I greatly appreciate
being here today and look forward to answering your questions.
Senator Akaka. Thank you very much.
The Audience. (Applause.)
Senator Akaka. Thank you very, very much, Deputy Under
Secretary Aument. And now we will hear from Julie Watrous,
Director of the Inspector General's Regional Office.
STATEMENT OF JULIE WATROUS, R.N., REGIONAL DIRECTOR, OFFICE OF
HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR GENERAL, DEPARTMENT
OF VETERANS AFFAIRS;
ACCOMPANIED BY DR. MICHAEL SHEPHERD, PHYSICIAN,
OFFICE OF HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR GENERAL,
DEPARTMENT OF VETERANS AFFAIRS
Ms. Watrous. Mr. Chairman, mahalo for the opportunity to
testify today on VA health care in Hawaii. Thanks also for your
strong commitment to veterans and your interest in the
oversight work that we do.
I've been the Director of the Office of Healthcare
Inspections Regional Office in Los Angeles for the past eight
years. Prior to that, I served as a staff nurse and also a
quality manager in various VA facilities. My current territory
is the western United States and includes the VA Pacific
Islands Health Care System. I'm accompanied today by my
colleague Dr. Michael Shepherd, a physician in the Office of
Healthcare Inspections.
As you requested, I will discuss the relationship between
the Tripler Army Medical Center and the Pacific Islands Health
Care System from our perspective as well as highlight some of
the findings from two reports we issued in 2006. In preparation
for this hearing, I visited Honolulu last month to interview
staff at both the VA and Tripler. There are at least three
issues in the sharing agreement relationship that would benefit
from further attention. I believe you're familiar with all
three.
The first concerns differences between the two electronic
patient health record systems which cause difficulties in
clinician communication and patient care coordination. I
understand that efforts are underway to connect the two
systems, and the sooner the better. The second issue concerns
the two financial systems with problems such as late billings
and delayed payments. The third issue concerns access to care
for veterans at Tripler. Because of deployments and active duty
military members needing care, care for veterans at Tripler is
not always available or timely.
As part of our oversight mandate, we conduct periodic
reviews of VA health care facilities which we call CAPs. We
conducted a CAP review of the Honolulu facility in June 2006.
We made recommendations to improve patient information
security, community nursing home oversights and oversight of
veterans' care in Tripler. The details are published in our CAP
report as well as in my written testimony. We accepted the
actions taken by Dr. Hastings and closed this report on March
30, 2007.
In early fiscal year 2006, at your request, we conducted a
review that included access to non-institutional care and
timely elective procedures. We visited five medical facilities
in this national review including the Honolulu facility.
Regarding non-institutional care, we made a number of
recommendations to increase access. VHA agreed and submitted an
action plan that included monitoring the demand and supply of
non-institutional services, increasing capacity and expanding
coverage to geographic areas that did not offer these services.
The Pacific Islands Health Care System's 2006 workload
numbers show that the number of veterans using these services
has increased. Regarding access to timely electives specialty
procedures, we reviewed procedures that had been performed in
fiscal year 2005 in cardiology, gastroenterology and orthopedic
surgery.
Many veterans waited a very long time for the procedures
from the date they were ordered until the date they were
performed. Reasons for these delays included difficulty
recruiting specialists, lack of support staff and insufficient
space including inpatient beds and operating rooms. These
barriers to timely care existed across the country but were
especially applicable to Hawaii.
This past February, the Pacific Islands Health Care System
hired a part-time orthopedic surgeon to operate at Tripler.
Both facilities agree that this move has helped stabilize the
planning for orthopedic surgery, but stated that more staffing
is needed. As Dr. Kussman mentioned, additional operating rooms
will be constructed as part of the VA's same-day surgery
project and will provide more capacity, but only when fully
staffed.
We were told repeatedly about the difficulty in recruiting
specialists to work in Hawaii. In our access to care report, we
recommend that VHA establish appropriate performance metrics to
evaluate and improve the timeliness of elective procedures. VHA
agreed and plans to develop performance metrics to evaluate
timeliness of elective procedures. This recommendation remains
open and we are tracking progress to complete it.
In summary, with respect to VA care in Hawaii, Dr. Kussman
for VHA, Dr. Wiebe for VISN 21 and Dr. Hastings for the VA
Pacific Islands Health Care System, have responded
appropriately to specific recommendations made by the OIG in
these two reports. However, the three issues relating to the
sharing agreement, the electronic medical record systems,
billing and payment systems and consistent and timely access to
care would benefit from additional attention at the highest
level of VA and DOD.
Mr. Chairman, thank you again for this opportunity. Dr.
Shepherd and I would be happy to answer any questions that you
may have.
[The prepared statement of Ms. Watrous follows:]
Prepared Statement of Julie Watrous, R.N., Regional Director, Office of
Healthcare Inspections, Office of Inspector General, Department of
Veterans Affairs
INTRODUCTION
Mr. Chairman and Members of the Committee, thank you for the
opportunity to testify today on VA health care in Hawaii. I will
discuss the relationship between the Tripler Army Medical Center (TAMC)
and the Spark M. Matsunaga Medical Center (part of the VA Pacific
Islands Health Care System), as well as the status of findings from two
reports the Office of Inspector General (OIG) issued in 2006. I am
accompanied by Michael Shepherd, M.D., Physician, Office of Healthcare
Inspections, OIG.
In preparation for this hearing, I traveled to Honolulu July 23-24,
2007, to interview managers and staff at the VA Pacific Islands Health
Care System and at TAMC. Based on these interviews, as well as previous
reviews conducted here, I would like to highlight three issues in the
sharing agreement relationship that would benefit from further
attention. The first concerns differences between the two facilities'
electronic patient health record systems, which make it difficult for
clinicians to document veterans' care, as well as to review other
clinicians' documentation. The second issue concerns the billing and
payment systems, which both facilities' managers complained result in
problems such as late billings and delayed payments. The third issue
concerns equal access to care for veterans at the TAMC. Because of TAMC
staff deployments and the influx of active duty military members
needing care, access to care for veteran patients at TAMC is not always
consistently available or timely. I will discuss this issue in more
detail later in my testimony.
COMBINED ASSESSMENT PROGRAM REVIEW \1\
---------------------------------------------------------------------------
\1\ Combined Assessment Program Review of the VA Pacific Islands
Health Care System, Honolulu, Hawaii, Report No. 06-02003-225,
September 26, 2006.
---------------------------------------------------------------------------
The OIG conducts periodic reviews of VA health care facilities.
These Combined Assessment Program (CAP) reviews are part of the OIG's
efforts to ensure that high quality care is provided to our Nation's
veterans. We reviewed documents and medical records and visited the
Honolulu facility June 19 through 23, 2006, and in September 2006, we
published the CAP review report of the VA Pacific Islands Health Care
System.
In the CAP report, we noted four areas that were in compliance:
quality management, breast cancer management, patient satisfaction
survey results action plans, and monitoring patients on atypical
antipsychotic medications. We made recommendations concerning security
of patient information, follow-up care for patients in community
nursing homes, and communication and oversight of veteran patients
treated at TAMC.
With regards to security of patient information, we found unsecured
patient information in hard copy paper and on unattended computer
terminals and recommended that the facility's managers ensure that all
patient information is protected. In response to our recommendation,
managers provided privacy training and increased their oversight of
patient information management throughout their facilities.
With regards to follow-up care for patients in community nursing
homes, we recommended that the facility's managers improve care plans
for veterans residing in community nursing homes and increase facility
oversight of these homes. In response, managers standardized care plan
notes and increased the membership on the oversight committee.
The issue of communication about and oversight of veteran patients
treated at TAMC was not a new finding. We had a similar finding during
our 2001 CAP review and closed the recommendation based on the
corrective action plan submitted. However, the corrective actions were
only partially implemented. We again recommended that senior managers
at the two facilities formalize their communication mechanisms and
ensure that key staff attend the meetings. Several committees were
formed as a result of this recommendation, including a Joint Venture
Committee, to address clinical care and quality improvement issues
between the two organizations.
We reviewed the actions taken by the facility's managers in
response to our CAP recommendations and concluded that the
recommendations were appropriately addressed. We closed the report on
March 30, 2007.
REVIEW OF ACCESS TO CARE IN THE
VETERANS HEALTH ADMINISTRATION \2\
---------------------------------------------------------------------------
\2\ Review of Access to Care in the Veterans Health Administration,
Report, No. 05-03028-145, May 17, 2006.
---------------------------------------------------------------------------
In early fiscal year (FY) 2006, at the request of Senator Akaka,
we reviewed access to non-institutional care, appropriateness of
enrollment practices, and timeliness of clinically indicated elective
procedures. We visited five medical facilities in this national review,
including the Spark M. Matsunaga VA Medical Center. We interviewed
facility personnel, reviewed medical records, and analyzed workload
data through fiscal year 2005 provided to us by the facilities.
Non-Institutional Care
The Millennium Act, passed in 1999, directed VA to provide veterans
eligible for medical services with certain non-institutional care
services--services that are provided to veterans in their own homes or
in community settings. In response, VHA implemented policies requiring
medical facilities to provide non-institutional care services to all
eligible veterans, when appropriate. These services include:
Home based primary care.
Purchased skilled home health care.
Homemaker and home health aides.
Adult day health care.
Geriatric evaluation and management.
Respite care.
Hospice and palliative care.
Care coordination and telehealth.
We noted that veteran access to non-institutional care services had
increased from fiscal year 2003 to fiscal year 2005 in several of the
non-institutional care services. However, we found that improvement was
still needed and made a number of recommendations aimed at further
increasing access. VHA agreed with the recommendations and submitted an
action plan that included monitoring the demand and supply of non-
institutional services, increasing capacity, and expanding coverage to
geographic areas that did not offer non-institutional care services.
The VA Pacific Islands Health Care System's fiscal year 2006 workload
numbers show that all the non-institutional care services are
available, and the number of veterans using these services increased in
fiscal year 2006 in almost all services.
Enrollment Process
The enrollment process at the five facilities we visited complied
with national enrollment policies. We made several recommendations
aimed at improving the tracking of new veterans who desire VA care. VHA
agreed with the recommendations and planned to issue revised directives
establishing policies for use of electronic wait lists and scheduling
processes. VHA issued the directive ``Process for Ensuring Timely
Access to Outpatient Clinical Care'' on May 8, 2006.
Timeliness of Elective Specialty Procedures
Eligible veterans did not always receive clinically indicated
specialty procedures within reasonable time frames. VHA has not
established a method to measure the length of time veterans wait for
elective procedures; in some cases, veterans experienced excessive
waiting times. While a VHA performance measure requires facility
directors to track the length of time veterans wait for their specialty
care appointments, facilities are not required to track the length of
time veterans must wait from the requests or authorizations for
elective procedures until the procedures are actually performed. To
better assess and manage their workload and ensure that veterans
receive timely care, facility managers need to track veterans' entire
waiting time--not just the waiting time to the appointment.
We reviewed elective procedures that had been performed in fiscal
year 2005 in three specialty areas: (1) cardiology, (2)
gastroenterology, and (3) orthopedic surgery. We found lengthy average
waiting times. For example, at the VA Pacific Islands Health Care
System, the average wait for elective orthopedic procedures was 182
days, and the range was 14-379 days.
We could not locate any timeliness standards within VHA or United
States medical organizations for the procedures we reviewed. However,
several countries with national health systems have set timeliness
goals of 6 months for orthopedic surgery. Evidence indicates that
deterioration in functional health status occurs in patients waiting
more than 6 months for joint replacement surgery.
We interviewed the chiefs of cardiology, gastroenterology, and
orthopedic surgery services, as well as a number of primary care
providers, to gain their perspectives on the timeliness of elective
procedures. Although the five facilities varied greatly in size and
capacity, the reasons for delays given by these providers were
consistent and fell into four themes:
Physician vacancies and difficulty recruiting specialty
physicians.
Lack of support staff, such as nurses, physician
assistants, and anesthesiologists.
Insufficient space, including inpatient beds and operating
rooms.
Lack of equipment, such as scopes and data processors for
colonoscopies.
Some barriers to timely care were unique to one or two facilities.
For example, some orthopedic surgery for Hawaii veterans occurs in
operating rooms at TAMC. Delays occurred when procedures scheduled to
be performed at TAMC were canceled due to military deployments. Some of
these veterans had to be re-prioritized and worked into the referral
lists to the VA Palo Alto Health Care System. In other cases, veterans
were referred to community providers at VA expense, depending on
veteran condition and availability of fee basis funds.
Within the past year, the VA Pacific Islands Health Care System
hired a part-time orthopedic surgeon to operate at TAMC. Both
facilities' managers agreed that this move has helped stabilize the
planning for orthopedic surgery but stated that more staffing is needed
to manage the workload. Additional operating rooms that will be
constructed as part of the VA Pacific Islands Health Care System's
same-day surgery project will provide more capacity, but only when
fully staffed. We were told repeatedly about the difficulty in
recruiting specialists to work in Hawaii. In preparation for this
hearing, we reviewed the VA Pacific Islands Health Care System's fiscal
year 2006 elective procedures data and found that the average wait
times from authorization until the procedures had been performed had
improved in cardiology and gastroenterology, but had actually gotten
worse in orthopedic surgery.
In our report, we recommended that VHA establish appropriate
performance metrics to evaluate and improve the timeliness of elective
procedures and implement prioritization processes to ensure that
veterans receive clinically indicated elective procedures according to
their clinical needs. VHA agreed with the recommendation and plans to
develop performance metrics to evaluate timeliness of elective
procedures. This recommendation remains open.
SUMMARY
With respect to VA care in Hawaii, we believe that VHA, Veterans
Integrated Service Network 21, and the VA Pacific Islands Health Care
System have responded appropriately to specific recommendations made by
the OIG in these two reports. However, the three issues related to
TAMC--electronic medical record systems, billing and payment systems,
and consistent and timely access to care--would benefit from additional
attention.
Mr. Chairman, thank you again for this opportunity. I would be
pleased to answer any questions that you or other Members of the
Committee may have.
The Audience. (Applause.)
Senator Akaka. Thank you. Thank you very much, Julie
Watrous, for your testimony. I have some questions for the
panel. Dr. Hastings and Dr. Wiebe, these questions have to do
with the new Oahu clinic.
I want you to know that I'm very concerned about the need
for additional ambulatory care capacity here on Oahu. I know VA
has been looking at the possibility of clinics at both Barbers
Point and at Kaneohe at the east side of the island. I
understand that because of the need to coordinate with the
Navy, that there have been some challenges in getting the
clinic at Barbers Point up and running. My question to you, Dr.
Hastings and Dr. Wiebe, is whether it's possible to move
forward with a clinic at Kaneohe?
Dr. Hastings. Mr. Chairman, thank you for the opportunity
to address this very important issue for us. We are in
negotiations with the Navy and with the state. They are moving
forward. They're under a mandate to make progress and dispense
with this land by September 2008. So they are under pressure to
get the problem solved. And we think that when we look at the
distribution of our patients, that the best decision would be
if we could build and take over that property at Barbers Point.
So we're in negotiations with them, and we think that we're
going to get some decisions about that from the Navy within the
next couple of months.
As I talk to the engineers, they tell me that we're much
better off if we take an old existing building, we have looked
at it, and it will be less costly for the government to do this
than to try to go out and start from the beginning in building
another facility. So we think this is the best decision to keep
pushing ahead on the Barbers Point issue.
Senator Akaka. Well, thank you very much, Dr. Hastings.
Mr. Aument, I appreciate your willingness to travel to
Hawaii to participate in this hearing, and I want to thank you
for your service to our Nation's veterans. Around 33 percent of
rating claims at the Honolulu Regional Office have been pending
for more than 180 days. This is the highest in the Western
Area, as I understand.
Please explain the factors that have contributed to the
already overburdened RO's problems with timeliness and
adjudicating claims for compensation and what VA can do to
reverse this.
Mr. Aument. We share your concern with that particular
issue, Mr. Chairman, the timeliness of the pending claims for
the regional office. I think there are three factors that we
can point to that are largely responsible for this, and I
believe we're trying to do something about each and every one
of them.
First of all, number one, is making sure that we have an
adequate workforce in place at the regional office to make sure
that we're prepared to provide timely service to the veterans
ourselves from the Veterans Benefits Administration
perspective. As I mentioned earlier in my testimony, we've
increased the staff already this year by 10 percent. We've
really actually reached the limits of the physical capacity to
add staff to the office, but we stand ready to add the
additional staff if we find that the increase so far is
insufficient.
Number two, we've been particularly challenged in obtaining
transitioning servicemembers' military records. In particular,
their service medical records. I am told by Dr. Wiebe, the
Director of VISN 21s, that this had been a particular challenge
for the servicemembers filing claims from Guam which have added
to the overall timeliness of the office.
We're working very diligently to try to improve that
relationship. We've recently entered into a Memorandum of
Agreement with the National Guard units where we've been
particularly challenged with the Guard and Reserve units
obtaining those records. I believe that we're moving forward to
try and improve that relationship.
Third, the final item is with the timeliness of our medical
exams. We've heard before the difficulties in some cases of
recruiting and maintaining medical support here in the Pacific
Islands region. We've been working very closely with Dr. Wiebe
and others to address this issue. And Dr. Wiebe even this
morning assured me that, by the end of this year, he expects to
be able to have the timeliness of the exams provided in this
area up to the national standard.
Senator Akaka. Thank you for your comment.
Dr. Kussman. Mr. Chairman, I had a chance to talk to Dr.
Hastings yesterday about this and he's working very
aggressively making adjustments getting more space to do it and
more people. And as Ron mentioned, I believe, Jim's got this
under control and next time we talk, it won't be a problem.
Senator Akaka. Thank you. I also want to say that I've
heard from the Representative from Samoa and, apparently, he
tells me that Samoan veterans are having problems as well. I'm
sure you know about that, but I just want you to know that he
did speak to me about that. I just want to say Dr. Wiebe also
has been helpful in these areas.
Under Secretary Tuerk, I'm very pleased that VA recognizes
the importance of Punchbowl to Hawaii's veterans. And of
course, your comments and remarks today about what you are
doing, please us greatly.
Can you please elaborate on the plan to provide additional
niches at Punchbowl?
Mr. Tuerk. I'd be delighted to elaborate on the plan, Mr.
Chairman. I think the old adage that a picture is worth a
thousand words might apply here. If you'll bear with me for a
second, I'll show you what we intend to do.
Senator Akaka. Thank you.
Mr. Tuerk. Thank you, Mr. Chairman for your forbearance.
This, as you can see, is a satellite image of the National
Memorial Cemetery of the Pacific. The entrance is down here,
the memorial is right here.
The existing columbarium at the cemetery is shown right
here. You asked me this morning--and you asked me last
December--whether we would study the feasibility of how we
might expand columbarium space in the National Memorial
Cemetery of the Pacific. This is what we've come up with.
We have four distinct possibilities for expansion, each of
which I'll show you on a separate chart. Chart number one shows
the existing columbarium. You'll notice it stops here. Our
first plan--and the plan that I've already commissioned a
design for--is to extend the existing columbarium space up
further into the cemetery. That project, which we are committed
to doing in fiscal year 2008 so long as we receive funding,
will add another 1,265 niches to the cemetery's inventory and
will buy us another couple of years. We currently have an
inventory, as of the close of business yesterday of 1,845
niches. So this new capacity added to the 1,800 that currently
exist will get us about an additional 5 years worth of
inurnments at the National Memorial Cemetery of the Pacific.
An additional proposed project will be to take the existing
columbarium that extends up the perimeter of the cemetery just
below the Punchbowl's rim and to add further niches on the
backside and on the outside of the walls that currently house
the niches. So, for example, whereas here we have columbarium
niches only within these courtyards, we can add niches to the
exterior walls on both the back and, I believe, the frontside
of those walls. The addition of niches to the front side is not
shown in this diagram but my inspection of the site yesterday
revealed to me that might be a possibility. Just adding niches
on the backside we can gain another 2,000-plus niches and an
additional four to five years time to extend the time frame of
available niches at cemetery.
Option C. If you recall, Mr. Chairman, as you approach the
memorial to the left here below the rim, there's a very, very
steep slope. We propose here to terrace into the slope below
the road and have stairs coming down to a terraced columbarium
down from the road. There would be, first, a corridor here with
niches on both sides. Additionally, there would be a second
corridor on the cemetery side of the rim with an additional row
of niches along here. This concept would add almost 5,000
additional niches and at current burial rates, that would buy
us approximately eight additional years of life in the
cemetery.
And finally, Mr. Chairman, we have a fourth concept and
that is marked on this map as option D. I might add
parenthetically these are labeled A, B, C and D. We might not
progress in that precise order, though project A will be the
first one that we will do. These are four alternatives. This
one is rather straightforward. Our administration building is
located right inside the gate to the right as you enter the
cemetery. It's an aging facility. It's an inadequate facility.
It's an inappropriate facility. We have had under consideration
for time the idea of demolishing it and building a new one.
The new thought that we have is to demolish the current
administration building and use the land inside the cemetery
grounds to build additional columbaria inside the cemetery
gate. Now the question might arise what then happens to the
administration building? We're now studying the feasibility of
building a new administration building outside the gate so that
we can preserve the precious land within the crater itself for
burial spaces.
[The satellite images of the National Memorial Cemetery of
the Pacific follow:]
[GRAPHIC] [TIFF OMITTED] T8961.001
[GRAPHIC] [TIFF OMITTED] T8961.002
[GRAPHIC] [TIFF OMITTED] T8961.003
[GRAPHIC] [TIFF OMITTED] T8961.004
[GRAPHIC] [TIFF OMITTED] T8961.005
[GRAPHIC] [TIFF OMITTED] T8961.006
So in summary, Mr. Chairman, with these four concepts--with
at least these four concepts and we're receptive to other
ideas--we anticipate that we can add 12,000 additional niches
or more which would allow the cemetery to conduct inurnments
into the future for another 20 years.
Senator Akaka. Thank you very much, Under Secretary Tuerk.
Thank you for that presentation.
The Audience. (Applause.)
Senator Akaka. Ms. Watrous, have you conducted oversight
visits in other VA facilities that use DOD sharing agreements
to provide a significant share of veterans care, as is the case
in Hawaii? Do you see the same issues at those facilities?
Ms. Watrous. Yes, Mr. Chairman. In my territory, I have two
other large sharing agreements. One is in Anchorage and the
other is in Las Vegas, and I have seen very similar situations
in terms of the electronic medical record and also with access
to care issue.
In the best of times, the consistency issues are not
optimal because of the regular deployments on the military
side. In this time of war, there are certain higher degrees of
difficulties that both sides experience. So yes, I have seen
the same issues. Those are the only two I can speak of.
Senator Akaka. Thank you very much.
Dr. Hastings and Dr. Wiebe, I'm concerned about the
overcrowding at the Center for Aging in Honolulu. I understand
that this facility is at full capacity. Compounding this
problem, few options exist for aging Hawaiian veterans outside
of VA. What is VA doing to meet the high demand for nursing
home services?
Dr. Hasting. Thank you, Mr. Chairman. As you know, Hawaii
has a very extreme problem with long-term care perhaps the most
challenging in the country. And we, of course, are no
different. We are working very diligently at trying to develop
our noninstitutional care. And as you heard the testimony
today, we have significantly increased our ability to increase
this noninstitutional care. And we're going to continue to try
to do that. The VA is very interested in this, and we're
getting a lot of support and we're putting resources into it
and so I think that's going to help us out a great deal.
We are also working with Tripler to look at trying to get
some more beds that we can use for an intermediate care ward
which would give us a little more flexibility and give Tripler
a little more flexibility. Many of our hospitals in Hawaii
cannot place patients and Tripler is one of them.
As a result, beds are held for patients that can be placed.
So we are in the process of studying with Tripler the
possibility of getting a ward there that we can operate which
would also give us more flexibility and allow us to use more of
the resources at Tripler for acute care patients.
The other issue, of course, is that we are trying to
contract with nursing homes. Since the last hearings, we have
had two more nursing homes that we were able to work with and
develop agreements with so that we can place veterans. And of
course, the big issue is the new veterans homes in Hilo that we
have been very much involved with. It's a state home, but we
are looking at it. And hopefully, this process of looking at
some other homes in the state will be able to take place in the
future. Thank you, sir.
Senator Akaka. Thank you, Dr. Hastings. Dr. Wiebe has been
a part of this effort.
Dr. Wiebe, do you have any comments to make at this time?
Dr. Wiebe. Mr. Chairman, just to add one other option we're
looking at to extend long-term care services and that's to use
telehealth. As you know with the island geography, telehealth
is especially applicable here in the islands. And so we're
looking at telehealth technologies not only for long-term care,
but also for our specialty services.
As you know, VA has a very aggressive telehealth program
where we can put devices in the homes of the veterans and have
daily contact with the veterans and their caretakers to help
them stay at home where otherwise they would have to be in
institutions. So we appreciate the leadership that you and your
colleagues here in Hawaii have provided in the telehealth arena
and these applications are being extended across the United
States. Again, thank you, Mr. Chairman.
Senator Akaka. Thank you very much, Dr. Wiebe.
May I ask Dr. Kussman for any final comments?
Dr. Kussman. Well, sir, again thank you very much for
inviting us. We very much appreciate your leadership on the
Senate Veterans' Affair Committee, and we very much appreciate
the partnering that we do together. And again, Mahalo.
Senator Akaka. Thank you very much, Dr. Kussman. I want to
thank this panel very much.
As you know, this is a high-ranking panel that we have
before us today. And I want to thank them for coming out to
Hawaii to testify as they have. As you have heard, they are
really making a difference in helping our veterans in Hawaii
and across the country, as well. Without question, all of us,
as was mentioned, are partners in trying to bring this about.
The Senate, the Congress, the Administration and VA have been
working at this and will continue to do that, so it is great to
hear from you all.
I want you to know that I have more questions, but we do
not have the time, so we will include them in the record for
this panel. So I want to thank you again very much for your
appearance today and for coming to Hawaii to testify.
The Audience. (Applause.)
Senator Akaka. Now, I would like to invite the third panel
to come forward. The hearing will be in order.
I want to welcome our third and final panel of witnesses.
First I welcome Colonel Arthur Wallace, Deputy Commander for
Nursing of the U.S. Army Pacific Regional Command at Tripler
Medical Center. I also want to welcome General Robert Lee,
Adjutant General for the State of Hawaii Department of Defense.
And finally, I welcome Mark Moses, Director of Office of
Veterans Services for the State of Hawaii. I want to thank the
panel for being here. Your full statements will appear in the
record of the Committee.
Colonel Wallace, will you please begin with your testimony.
COLONEL ARTHUR P. WALLACE, DEPUTY COMMANDER FOR NURSING,
TRIPLER ARMY MEDICAL CENTER; ON BEHALF OF MAJOR GENERAL CARLA
HAWLEY-BOWLAND, COMMANDING GENERAL, TRIPLER ARMY MEDICAL CENTER
(TAMC) AND PACIFIC REGIONAL MEDICAL COMMAND
Colonel Wallace. Aloha, Mr. Chairman.
Aloha on behalf of Major General Hawley-Bowland who's
currently off island. Thank you for the opportunity to share
information about the collaborative relationship between
Tripler Army Medical Center and the VA Pacific Islands Health
Care System. At this time, I would like to submit my written
testimony for the record.
Senator Akaka. It will be included in the record.
Colonel Wallace. Thank you. Mr. Chairman, Tripler
represents the largest military medical treatment facility in
the entire Pacific Region providing medical support to nearly
450,000 beneficiaries. Our partnership with the Veterans'
Administration here is the largest integrated joint venture in
the Nation.
What was initially conceived as a small veterans hospital
adjunct to the military medical center is now a vast $20
million sharing agreement spanning inpatient medical, surgical
and psychiatric services, as well as outpatient specialty
services and non-medical support such as security, meals, and
housekeeping.
Within the past year, the VA relocated the Post Traumatic
Stress Disorder (PTSD) Residential Rehabilitation Program or
PRRP from Hilo to Tripler. The current PRRP program admits both
veteran and active duty patients as a cohort group and provides
a 7-week program of integrated treatment. In the past year,
we've also signed several new sharing agreements including
provision of central sterilization support for the ambulatory
care clinic at Matsunaga, provision of meals to the VA Center
for Aging, and several agreements supporting joint clinical
research projects.
Our dedicated staff continues to identify and develop new
initiatives to provide a seamless transition between our
organizations. As mentioned earlier by Dr. Hastings, we are
planning to create the shared same day surgery center in 2009.
On a daily basis, VA patients represent a noteworthy part of
Tripler's workload. Last month, approximately 22 percent of our
hospital average daily census and 29 percent of our average
daily admissions from the emergency room were veterans. Also
the VA operated psychiatric inpatient ward averaged nine
psychiatric veterans as patients daily.
Over the years, additional clinical staff have been hired
to accommodate the growing VA workload. This year, we also
started to imbed VA providers into Tripler specialty clinics to
add stability and support of VA requirements and Graduate
Health Education programs. These providers are now evident in
our hospitalist program, ophthalmology and orthopedic surgery
with plans to continue to evaluate other areas for expansion.
For the military, caring for veterans represents a commitment
to sustain the services provided when they were on active duty.
We must remain competent and caring for acutely ill patients
through our Graduate Health Education programs.
Recently several new initiatives have occurred under the
Joint Incentive Fund Program including state-of-the-art
computer aided system for orthotics and prosthetics with tele
medicine capability, a chronic dialysis center for veterans,
and a joint pain management improvement project. These
initiatives will improve access to care to our joint
beneficiaries and decrease wait times. Last week, two new Joint
Incentive Fund Programs were approved. These include a sleep
study laboratory and an integrated pain management program. Our
ongoing joint demonstration project establishes technical
improvements in how we exchange information for referrals and
clinical documentation.
This year, the Army Medical action plan has placed emphasis
on care of our warriors in transition and the seamless
transition to care under the Veterans Benefits Administration
and Veterans Health Administration. Our programs in support of
returning warriors and our ties between Tripler and the VA have
been longstanding and well established. We assigned case
managers to all returning wounded and had specialized treatment
programs such as our Soldier and Family Assistance Center at
Schofield Barracks providing a whole range of behavioral health
and advocacy programs.
We have had representation from the Veterans Benefits
Administration on our Patient and Family Assistance Team since
inception. Our case managers work daily with the Veterans
Benefits Administration and Veterans Health Administration to
foster a smooth transition to VA benefits, including health
care. The Oahu Joint Executive Council's Behavioral Health
working group, which includes the VA, is taking a greater role
in determining needs for PTSD and mild Traumatic Brain Injury
or TBI. Tripler recently launched training for all military
personnel on recognizing PTSD and mild TBI to encourage self-
reporting and referrals of OIF/OEF soldiers and reduce the
stigma associated with reporting. This field is an excellent
opportunity for DOD and VA collaboration, and we are already
moving forward with such joint planning.
As with most larger type activities, there continue to be
challenges. We need interoperability of health care computer
systems between DOD and the VA to coordinate patient care and
conduct financial business. Lack of integrated computerized
patient record will continue to cause inefficiency and impact
patient care until resolved. In terms of DOD-VA joint venture
development, our future is now. This functional integration is
just the beginning. The additional opportunities for improved
coordination and cooperation are numerous. Achieving these
goals will be dependent upon obtaining needed policy, program
and resource support.
There is local VA and DOD top management support to make
Tripler a model joint venture site. We must address and resolve
the challenges to achieve our ultimate goal: High quality care
for our beneficiaries in a seamless health care system.
Thank you, Mr. Chairman, for this opportunity to share our
thoughts and this important topic. Mr. Chairman, I'm now ready
to take any questions.
[The prepared statement of Colonel Wallace follows:]
Prepared Statement of Colonel Arthur P. Wallace, Deputy Commander for
Nursing, Tripler Army Medical Center; on Behalf of Major General Carla
Hawley-Bowland, Commanding General, Tripler Army Medical Center (TAMC)
and Pacific Regional Medical Command
Mr. Chairman and distinguished Members of the Committee, on behalf
of Major General Hawley-Bowland, Commanding General of Tripler Army
Medical Center (TAMC) and Pacific Regional Medical Command who is
visiting medical facilities in the Pacific Region, thank you for the
opportunity to share information about the collaborative relationship
and initiatives under the auspices of the Department of Defense (DOD)-
Department of Veterans Affairs (VA) Joint Venture in Hawaii. I
represent the largest military medical treatment facility in the entire
Pacific Basin. TAMC's area of responsibility spans more than 52 percent
of the entire Earth's surface and provides medical support to nearly
450,000 beneficiaries, including Active Duty Service Members of all
branches of service; their eligible Family Members; military Retirees
and their Family Members; Veterans; and many Pacific Islands Nation
Residents.
In 1991, Under Secretary of the Army and the Deputy Secretary of
Veterans Affairs approved the basic concept of a Joint Venture for
Hawaii. What was initially conceived as a small veteran's hospital
adjunct to the military medical center, is now a vast $20 million
sharing agreement spanning inpatient medical, surgical and psychiatric
services, as well as outpatient specialty services and non-medical
support, such as security, meals and housekeeping. Beginning in 1997,
the VA began to relocate administrative and health care services to the
TAMC campus. Construction and renovation to portions of the medical
center infrastructure have resulted in both new and relocated veteran
services on the Tripler campus, including an inpatient psychiatric
unit, a new parking structure, the Center for Aging, the Ambulatory
Care Clinic and renovation of the E-Wing of TAMC for both the Veterans
Health Administration and Veterans Benefits Administration (VBA)
administrative functions. The relocation of the Post Traumatic Stress
Disorders (PTSD) Residential Rehabilitation Program (PRRP) from Hilo to
TAMC has been a very successful initiative. The current PRRP program
admits both Veteran and Active Duty patients as a cohort group, and
provides a 7-week program of integrated treatment, including but not
limited to PTSD symptom management, communication skills, anger
management, relaxation training, behavior therapy, trauma focus
therapy, adjustment counseling, substance abuse and relapse prevention
treatment, and general health education. The relocation of the VA to
the TAMC campus has resulted in increased workload for both TAMC and
the VA Pacific Islands Healthcare System (VAPIHCS). We continue to move
forward, using joint strategic planning sessions. New initiatives
currently underway today include planned additions for a new facility
for the Post Traumatic Stress Disorder (PTSD) Residential
Rehabilitation Program in 2008, a shared Same Day Surgery Center in
2009, and a proposed inpatient tower at TAMC to consolidate nursing
units.
A collaborative effort of this magnitude requires diligent planning
and oversight. Both the VA and TAMC have dedicated staff to ensure the
exploration and development of joint efforts. On a daily basis, VA
patients represent a large part of our workload. For example, last
month my hospital's average daily census was 151 patients.
Approximately 33 of those patients, or 22 percent, were veterans.
Additionally, 29 percent of our admissions from the emergency room were
veterans. The VA-operated psychiatric ward averaged nine psychiatric
veterans as patients per day.
Over the years, additional clinical staff have been hired to
accommodate the growing VA workload, forming a reliance on the
reimbursement from the VA. We have also begun a new program of
embedding VA providers into specialty clinics to add stability and
increased workload to support the Graduate Health Education programs.
These additions are now evident in our hospitalist program, in
ophthalmology and in orthopedic surgery. There are plans to continue to
evaluate other areas for expansion.
While reimbursement is essential to a successful DOD/VA
partnership, it is not the primary motivation. For the military, caring
for veterans represents a continuation of the services we provided when
they were Active Duty. Our ultimate status will be as veterans. Another
dimension of caring for the veteran is that the illnesses and surgeries
associated with aging are very relevant to keeping Active Duty medical
personnel trained and ready for our battlefield mission. We must remain
competent caring for acutely ill patients. At Tripler we have a robust
Graduate Health Education program spanning 10 different medical
specialties and training 220 individuals per year. Our graduate medical
education occurs in Orthopedics, Radiology, Urology, Medicine,
Obstetrics and Gynecology, Psychiatry, ENT, Pediatrics, Family Practice
and General Surgery. We have found that these programs benefit from
caring for the veterans population.
Recently several new initiatives have been undertaken under the
Joint Incentive Program and the Joint Demonstration Project.
Development of several Joint Incentive Fund proposals totaling $4
million have been completed and funded including a state-of-the-art
computer-aided design/computer-aided manufacturing system for orthotics
and prosthetics with telemedicine capability, a chronic dialysis center
for veterans and a joint pain management improvement project. All three
of these initiatives will improve access to care to our joint
beneficiaries and decrease wait times. We have submitted two additional
Joint Incentive Fund projects--one for a joint sleep study lab and a
second for an integrative medicine approach to pain management. These
two projects are pending approval and funding at this time. The Hawaii
Collaborative was also selected as one of eight sites to serve as a
demonstration project. Our Joint Demonstration Collaborative proposes
to meet the need of establishing a structure and process to jointly
assess, execute, and evaluate improvements in Referral Management, Fee
Authorization, and Document Management. The collaborative expects to
garner benefits from these demonstration studies including transparent
tracking of consultations and authorizations, as well as improved
access to documents for information exchange between our organizations
for improved continuity of patient care.
We continue to explore opportunities and initiatives that allow
Tripler and VA to share staffing. In the past year, we've signed
several new sharing agreements, including provision of Central
Sterilization support for the Ambulatory Care Clinic, additions of VA
specialists in ophthalmology and orthopedic surgery, provision of meals
to the VA Center for Aging and several agreements supporting joint
clinical research projects. We have also undertaken a joint approach in
planning for pandemic flu response. Our dedicated staff continues to
identify and develop new initiatives including joint decontamination
support, joint purchase of medical supplies, evaluation of a VA
transitional/subacute care unit and increased attention to the seamless
transition between our organizations for our Warriors in Transition.
This year, the Department of the Army, through the Army Medical
Action Plan (AMAP), has placed a lot of emphasis on care of our Wounded
Warriors and a seamless transition from Active Duty military service
and the Military Health System to care under the Veterans Benefits
Administration and Veterans Health Administration. Our programs in
support of returning Wounded Warriors and our ties between TAMC and VBA
and VAPIHCS were well established even before the advent of the AMAP.
We assigned Case Managers to all returning wounded and had specialized
treatment programs such as our Soldier and Family Assistance Center at
Schofield Barracks which provides a whole range of behavioral health
and advocacy programs. We have had representation from VBA on our
Patient and Family Assistance Team since inception and our Case
Managers work daily with the VBA and VAPIHCS to foster a smooth
transition to VA benefits including health care. We have also had
VAPIHCS as a partner in our Multi-Service Market Management Office-
sponsored Joint Executive Council and subordinate working groups. At
these forums, we explore healthcare options for Veterans, past and
future. One key group is the Behavioral Health Working Group which is
taking a greater role in determining needs for PTSD and mild Traumatic
Brain Injury (TBI) to serve the greater Hawaii market of eligible
beneficiaries. Under the AMAP directive, Tripler has launched training
of all military personnel on recognizing PTSD and mild TBI and to
encourage self reporting and referrals of others returning from
Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF).
Additionally, our Social Workers, Case Managers, Psychiatric Nurses and
Psychiatric Nurse Practitioners are taking more focused clinical
training courses. We are also adding Neuropsychologists and other
clinical staff to assist with diagnosis and treatment. This area of
urgent need is an excellent opportunity for DOD and VA collaboration
and we are already leaning forward in our planning.
As with most merger type activities, there are barriers that impede
unfettered, efficient coordination. I believe, however, most of our
Joint Venture barriers are systemic in nature. These barriers include:
(1) The separate VA and DOD healthcare information systems which
make data sharing difficult. We need interoperability of healthcare
computer systems between DOD and the VA to coordinate patient care and
conduct financial business. Our demonstration project addresses a
portion of the identification and business processes that will support
the joint revenue process. However, we cannot continue to conduct
business without commercial-type claim processing software and support.
Currently, development and release of the Charge Master Based Billing
module has been put on hold indefinitely. As patients move between
Tripler and the VA, the lack of an integrated, computerized patient
record causes inefficiency and staff dissatisfaction.
(2) Lack of venture capital to invest in joint initiatives. We
cannot pool our resources to spend for a common need. While the Joint
Incentive Fund is one-step in this direction--and we have taken
advantage of funding available through this program since its inception
in 2004--the application and reporting processes are time consuming and
complex. Again, without truly dedicated staff, many good proposals do
not come to fruition due to our inability to jointly address the
requirements.
(3) Business processes associated with Joint Ventures are not well
defined at the VA and DOD enterprise level and impair efficient
coordination locally. National guidance must be developed based on the
needs of sharing sites which considers cost analyses and feedback
whenever possible. Some of these processes have financial implications
that cause delays in billing and payment. When there are billing and
payment issues, ultimately there are cash-flow problems.
(4) Other valid business process questions and issues related to
the management of the TRICARE program. For example, do VA patients
compete with TRICARE patients in DOD? For TRICARE Prime, this is not an
issue because by law Prime patients have precedence. Should the medical
treatment facility commander dedicate capacity to TRICARE eligible
beneficiaries or commit resources to caring for VA patients? This has
long been a point of contention with VAPIHCS, as they desire dedicated
support from military MTFs. Lack of this dedication at Joint Venture
sites undermines the premise of sharing and generates additional costs
when access levels cannot be maintained resulting in sporadic need for
high cost contracted support. The eligibility rules and associated
entitlements for the VA's categories of veterans and dual eligible
beneficiaries are complex and constantly changing. This complexity is
compounded when such patients seek care at a joint venture site. We
need to establish joint service units at these sites to not only help
these patients understand and make informed choices but also to more
efficiently evaluate the need for available resources and track their
use.
(5) Lack of policy guidance for dual eligibility. We don't need to
require patients to choose between an entitlement to a military medical
retirement benefit and a VA benefit but we do need to have the
authority to coordinate access to the respective benefit. If we do not,
we have patients duplicating services by seeking care from both
systems. This increases the costs of providing care to both DOD and VA,
and also results in patient safety concerns.
(6) Neither DOD or VA has established accountability and
responsibility for the success of joint ventures. Jointly we need to
develop metrics and a business strategy that reflect good stewardship
of the resources invested in both systems.
(7) Competition between the convenience of healthcare that is
available locally and the Veterans Integrated Service Networks' (VISNs)
regional investment in healthcare delivery services produces a barrier
to local coordination. For the VISNs it is an out-of-pocket cost when
they pay DOD rather than use their own facilities. VISNs are structured
and funded using a concept whereby satellite medical centers are
supported by one or two flagship medical centers. In our case, Honolulu
is a satellite center and their flagship facilities are in California
at Palo Alto and San Francisco. Emergent care is provided at Tripler
and, if necessary, within the local community. Non-emergent care is
referred to the California facilities. The current VA resource
allocation system does not provide additional dollars for VISNs to
allow satellite centers to seek a significant amount of care from non-
VA providers.
Despite the systemic barriers we confront, we continue to work
together diligently to devise local solutions. Wherever possible, we
have leveraged advances in technology to provide seamless flow of
information. We have incorporated Pharmacy Bi-Directional Data
Interchange, Common Data View through a program called ``Janus'' and
Laboratory Interoperability. The Pharmacy Bi-Directional Data
Interchange allows both DOD and VA providers to order and receive
prescriptions from either information system. The common data view
presents patient data (demographics, lab, pharmacy, etc.) on a common
computer screen. Finally, the current laboratory interoperability
allows lab orders and results to be communicated between both systems.
We look forward to expanding this program in the near future. The
common goal of these initiatives is to improve patient care by
developing interfaces to allow the electronic sharing of pertinent
patient information between the VA, DOD and other clinical data
providers.
In terms of DOD/VA joint venture development, our future is now. We
are ahead of most localities in that we are already one of the most
functionally integrated joint ventures. Instead of two freestanding
medical centers, we have only one emergency room; one inpatient
medical, surgical, and psychiatric service; and essentially one major
specialty outpatient service. We have integrated clinical services for
psychiatric on-call support, hospitalist support, ophthalmology,
orthopedic surgery, nephrology support and psychology services.
However, this functional integration is just the beginning.
While we are ahead of most of the other joint venture sites in the
Nation in developing our sharing agreements and establishing policies
and procedures, there are still opportunities for continued development
of our joint venture. The two key determinants when developing
opportunities for improved coordination are expansion of our patient
care services to care for more patients and elimination of redundant
overhead. We have worked diligently to develop initiatives for VA
chronic dialysis, shared pain management resources and expanded
orthotic/prosthetic support to veteran patients through the Joint
Incentive Fund. However, additional opportunities for improved
coordination and cooperation are numerous. Achieving these
opportunities will be dependent upon obtaining needed policy, program,
and resource support.
There is local VA and DOD top management support to make Tripler
Army Medical Center a model joint venture site. In this respect,
countless hours have been invested by both activities to improve our
joint venture. In order to perpetuate sharing between VA and DOD
entities, national initiatives applicable to all types of sharing
should be developed, providing guidance and policy on dual-eligibility,
authorization, and reimbursement. Venture capital monies should be
allocated for developing proposals and procuring dedicated joint
venture staff. Information systems must be evaluated for applicability
to sharing, and solutions to systemic issues should be identified and
resolved expeditiously. We must address and resolve the barriers
described if we are to achieve our ultimate goal--high quality care for
our respective beneficiaries in a seamless healthcare system.
Senator Akaka. Thank you very much, Colonel Wallace.
The Audience. (Applause.)
Senator Akaka. Now, we will receive testimony from Major
General Robert Lee.
MAJOR GENERAL ROBERT G.F. LEE,
ADJUTANT GENERAL, STATE OF HAWAII
General Lee. Good afternoon, Chairman Akaka, I want to
personally thank you on behalf of all the veterans in the State
of Hawaii and the members of the Armed Forces for your superb
work not only as Chairman of the Veterans' Affairs Committee,
but your hard work on the Senate Armed Services Committee that
we all appreciate especially during these difficult times. I
know men and women in uniform always count on you and Senator
Inouye for the top level support for all of us. Mahalo again.
We have five divisions in the State Department of Defense,
and you help all of us out. From the big ones like the Army and
the Air National Guard to our smallest Youth ChalleNGe Academy
where we turn around at-risk kids, we thank you very much for
it. Today, Mark Moses, the Director of Office of Veterans
Services will talk a lot more on that. On behalf of Governor
Lingle, thank you very much, the Office of Veterans Services of
the State of Hawaii can interface with VA at the Federal level
to make transition as seamless as possible and to make sure our
veterans that reside in the State of Hawaii get their full
benefits.
Let me talk about the veterans in the State of Hawaii.
Currently, the numbers run about 10 percent of our population,
our veterans who have served in the Armed Forces of the United
States and other recognized agencies. But over the past decade
we saw a decline in the number of veterans in the State of
Hawaii. Primarily from the great World War II veterans such as
yourself, Senator, I'm kind of losing my friends in Club 100
and the 442nd Veterans Club and all my friends in the other
veterans organizations throughout the state.
But after September 11, the downturn stopped. Primarily
with our National Guard and Reserve troops being called up at
unprecedent levels and even active duty folks from the State of
Hawaii serving on active duty in Iraq and Afghanistan and
returning home, the trend now goes up and we need all the
veterans services that the previous two panels talked about.
In the Hawaii National Guard, both Army and Air on the Army
side of the house, nine out of our ten soldiers wear a combat
patch. They have already served in Iraq and Afghanistan. We got
a smaller group right now. We have 75 soldiers from the Hawaii
Army Guard with their brothers from 1st Battalion, 158
infantry, 29th Brigade Combat Team currently hunting down the
Taliban on the Afghan/Pakistan border. At the same time, we
have our Black Hawk Unit, Charlie Company 207 aviation that
provided the medical airlift this past year. They're now in
Bilad in the center of the Sunni Triangle providing the airlift
that Senator Inouye talked about for our troops should they run
into trouble. We also have two dozen airmen from the Hawaii Air
National Guard from the Civil Engineering Squadron recently
deployed to Iraq. Although smaller numbers than before in 2005,
absolutely critical in the War on Terror, the Hawaii National
Guard is doing their part just like all the other Reserve
forces in the State of Hawaii.
So we must ensure that these veterans from the Guard and
Reserve when they return home to their civilian lives, they
also can transition back from military duty to civilian life in
good health. And our Office of Veterans Services enjoys a great
partnership with Hawaii VA Administration, and they're with us
every step of the way especially during the demobilization of
our soldiers when they come off active duty.
Right now we're pretty sure that none of our soldiers or
airmen will have their benefits fall through the crack because
our government has an obligation to our military members from
when they first enlisted through the service years to veterans
benefits and finally their death benefits--they're entitled to
all that they are due today and in the years to come.
I want to point out that the National Guard Bureau headed
by General Blum recently authorized both the Army and the Air
National Guard to release medical records to the Department of
Veterans Affairs without the veteran's signature.
So Mr. Aument, I'd like some feedback whether that's
working or not, and I noted your concern about lack of medical
records from Guam. I'm going to see my colleague General
Goldberg this weekend, and I'll mention it to him. I just
wanted you to know that the medical records may be kind of
lacking because all of the Guam National Guard soldiers serve
all of the current rotations in Africa. As you know, the
medical facilities are not as robust in Africa like in Iraq or
Afghanistan. But I will surely bring this up to General
Goldberg. So I'd like really some feedback whether this is
working better to make sure that the records from the National
Guard are reaching the Department of Veterans Affairs, and I
can help to make sure the transition is a lot smoother.
This afternoon, Senator, I want to share a few concerns
with your Committee. My most important concern is access to the
Veterans' Administration services for all of our veterans. And
I want to talk about Hawaii National Guard's 29th Brigade
Combat because it's the Brigade from Polynesia. Although I'm
the Adjutant General from the State of Hawaii, it was a
Polynesian Brigade from the State of Hawaii, American Samoa,
Guam, Saipan, Rota and Tinian that formed the bulk of the force
in Iraq.
I'm especially gratified to see finally the opening of a VA
clinic in American Samoa, and I know you have facilities in
Guam and that they should be beefed up to handle our soldiers
from Saipan, Tinian and Rota. Telehealth is real good, but at
least just a lot of cases where they need to come to Honolulu,
Hawaii and Tripler to see the very expert and great physicians
and caregivers in that capacity. And we just need to kind of
figure out a better way to bring the injured soldiers and their
family members when they need special treatment because it's
quite a beauracracy to go through that right now. That's the
feedback that I'm getting from my troops all across the board.
Senator, I'm sure Congress and Governor Lingle have shared that
with you. I've directed our C-17 squadron that flies down to
Pago Pago to bring up veterans whenever they can on a space-A
(available) basis.
My next concern deals with certification of disability by
Department of Veterans Affairs. Rather than, I guess, pick on a
wound or, you know, along we discuss the lengthy period of the
caseworker taking for a certification of disability, I'd like
to make a recommendation, Senator, that we kind of cut through
the red tape a little bit. And my recommendation is that, if
any soldier earns Combat Infantryman's Badge, shot at, gets a
bomb go off close to them and earns a Combat Action Badge and
is a combat medic that goes out with the troops, or it's a
Marine ground pounded and earns a Combat Action Badge, that we
just cut to the chase and recognize the service and the problem
that servicemember has. I listened intently to Senator Inouye's
World War II recollections about how things were. I can provide
the records of all the attacks or the rocket attacks on Bilad
with the 29th Division Headquarters and also Camp Victory and
the Green Zone and the 29th Brigade Combat Team lost 16 of its
17 brave soldiers to improvise explosive devices.
I want to shed some doubt on the caseworker's ability to
say hey, we give you the disability because the bomb went off
50 meters away from you, 500 meters, 1,000 meters, every
soldier behaves differently. So my recommnedation is to have a
combat records on file, not necessarily on the medical side,
because, I'll share this with you, in 2005, Brigade Commander
General Chavez called me up with the time zone difference,
around midnight, to report that a member of the 29th Brigade
was killed in action. But at that time, I also was elated
because many of the reports that I received say that patrol so
and so encountered an improvised explosive device, treated for
headache and returned to duty.
You know, no one got killed and I was happy then. But I
know a lot more now because it came to my final concern to have
adequate staffing at the VA hospitals and clinics, especially
in the mental health area, to provide service to veterans who
suffer from the delayed effects of PTSD.
It was earlier brought up that when our Guard troops came
home, no doubt they wanted to go home to their families.
Eighteen months on active duty, 12 months in Iraq. That's why
we have a program to periodically revisit these soldiers, and
they're called the Post Deployment Health Reassessment program.
But when the 29th Brigade came back and when we did this in
early 2006, Traumatic Brain Injury was not part of the
checklist. That's why we need to go back out and reconnect with
all the soldiers and we have records of this, and you know the
proud Polynesian warrior tradition. We're tough. We can take
it. I'm OK. Let me go home. We need to make sure we have the
opportunity to revisit this.
I'll be meeting with General Blum and my colleagues from
the Adjutants General across the 50 states and we're going to
recommend that this Post Deployment Health Reassessment not end
at the 2-year period beyond active duty because everyone
behaves differently. We'd like that extended. I really can't
give a recommendation right now extended another year, two,
three. I'd like to see how the track history goes. And this is
what we're finding out. As I talk to other Guard units, I think
the Hawaii National Guard is, as far as the percentage of PTSD,
is no different from our active folks that have come back. But
yet I've heard other stories like infantry battalions out of
New Hampshire 75 percent PTSD after 2 years. So I'd like to
keep that option open.
In closing, I want to make a note that all the services
received by our soldiers from VA clinics and caregivers have
been exceptional, and we thank you for that. We just need to
close the gap of getting our soldiers there to you. Thank you
very much.
[The prepared statement of General Lee follows:]
Prepared Statement of Major General Robert G.F. Lee,
Adjutant General, State of Hawaii,
Chairman Akaka, Senator Craig and Members of the Senate Committee
on Veterans' Affairs, I am Major General Robert G.F. Lee, the Adjutant
General for the State of Hawaii.
Within the State Department of Defense, there are five major
divisions: the Hawaii Army and Air National Guard, State Civil Defense,
Youth Challenge Academy, and the Office of Veterans Services (OVS). The
Director of Office of Veterans Service is Mr. Mark Moses, a retired
Marine major and a former state legislator.
The Office of Veterans Services is the single office in the State
government responsible for the welfare of our veterans and their
families. OVS serves as the liaison between Governor Linda Lingle and
the veterans groups and organizations. They also act as an intermediary
between the Department of Veterans Affairs and Hawaii's veterans.
Veterans make up more that 10 percent of Hawaii's total population.
The majority of them--about 72 percent--live on the island of Oahu.
About 13 percent reside on the island of Hawaii, 10 percent live on one
of the three islands that comprise Maui County, and about 5 percent
live on the island of Kauai.
Within this large veteran population are many World War II
veterans, many members of the famed 100th Battalion and the 442nd
Regimental Combat Team. Hawaii's overall numbers were declining because
many veterans of this era, most in their 80's, are passing on in large
numbers.
But since September 11, 2001, mobilizations have involved nine of
every ten Army National Guard and Reserve soldiers. They served
honorably in Iraq, Afghanistan and other locations; and have returned
to Hawaii after their 12-15 month activations. Air National Guard
members have also deployed in support of Operations Iraqi Freedom and
Enduring Freedom. Therefore, Hawaii's overall veteran population has
increased.
We must insure these new veterans return to their civilian lives in
good health. The Office of Veterans Services partners with the
Veterans' Administration here during the soldiers demobilization
process. This partnership works to insure no one or no benefit falls
through the crack.
The United States Government has an obligation to our military
members from enlistment, through their service years, to veterans'
benefits and finally, death benefits. We must insure that all veterans
receive all entitled benefits now and in the years to come.
The National Guard Bureau recently issued a memorandum authorizing
both the Army and Air National Guard to release medical records to the
Department Veterans Affairs without the veteran's signature. This new
procedure speeds the Department of Veterans Affairs adjudication of
veterans' claims and provides medical care to Guard members.
I come to you with a few concerns.
My most important concern is the access to Veterans' Administration
services to all our veterans, especially, on our neighbor islands and
our Pacific Islander veterans from Tinian, Rota and Saipan. In July
2007, a VA clinic opened in American Samoa that supports our veterans
there. However, veterans from other Pacific islands must pay the high
cost of airline and hotel accommodations to receive follow-on VA
medical treatment. In Hawaii, a similar situation occurs when neighbor
island veterans must come in to Tripler Army Medical Center or the
Matsunaga VA Hospital in Honolulu for treatment. We must work to find a
solution to this situation.
My next concern deals with the certification of a disability by the
Department of Veterans Affairs. Often a servicemember is awarded a
decoration recognizing the specific incident that is associated with an
injury or disability. However, when filing for a disability, the VA
requires a complete recertification of the incident causing the injury
or disability. Approval and certification of this letter of
determination is required prior to providing any services.
My final concern is the recruitment and staffing of VA hospitals to
the levels that they are authorized. For example, the Post-Deployment
Health Reassessment Program (PDHRA) requires an initial appointment
within 30 days of VA registration. On average, the VA hospital
schedules initial appointments as much as 90-120 days from the
registration date. Our local VA hospital staff has been doing their
best to provide services, but needs a full staff to serve all our
veterans. They have stretched their limited health care provider
resources to support veterans in the Pacific Basin.
In closing, I want to thank the Committee for their continuing
support of our veterans. Thank you for coming to Hawaii to conduct
these hearings.
Are there any questions?
The Audience. (Applause.)
Senator Akaka. Thank you. And now we will hear from Mark
Moses. Your testimony?
STATEMENT OF MARK MOSES, DIRECTOR, OFFICE OF
VETERANS SERVICES, DEPARTMENT OF DEFENSE, STATE OF
HAWAII
Mr. Moses. Thank you, Mr. Chairman.
I'm Mark Moses, Director of the Office of Veterans
Services. OVS is the state lead agency responsible for the
welfare of veterans and family members. As the Governor's
liaison to veterans and veteran groups, we serve as an
intermediary between them and the Department of Veterans
Affairs and provide access to state services and benefits.
We have provided services and information to nearly 33,000
veterans and survivors this past fiscal year. I've attached a
summary sheet describing some of the services and activities
made available for your review. The final service we can
provide a veteran is interment in a veteran's cemetery with
appropriate honors. The VA has consistently supported our
efforts to expand Hawaii cemetery plots and columbarium space
to keep pace with need, and they are deserving of our
gratitude. And as you saw today, we got the new grant which we
desperately need.
It is important for us to take this opportunity to thank
you, Senator Akaka, for your unwavering support for our
Veterans Cemetery Program, and our veterans in general. We are
particularly grateful for your assistance in obtaining the new
grant we just discussed.
The April 2000 data from the VA Office of Actuary, Office
of Policy Planning Preparedness, estimated 120,000 veterans in
Hawaii. As you heard, those numbers may have changed. I don't
know if they're necessarily decreasing. About 72 percent of
those lived on Oahu, 13 percent on the Big Island, 10 percent
on one of the Maui County islands and approximately 5 percent
on Kauai. For that very reason, we have offices on neighbor
islands to support our veterans.
Our Island State presents unique challenges for Department
of Veterans Affairs. Despite these challenges, though, I want
to share with you comments that we hear from veterans. They
speak to the excellence of VA medical care, how VA staff treats
veterans with dignity and respect and that the services
rendered by the dedicated health care professional are superior
to what they received on the mainland. In the past, you heard
stories to the contrary, Senator, I share reports from veterans
we have met. I think now there has been a change for the
better.
These comments are from local veterans and those visiting
Hawaii, and those who need to seek services from the Spark M.
Matsunaga medical staff. Similar comments are shared about the
VA benefit staff. As you know, though, we still have a backlog
and that is being addressed. I'm not going to go into it again.
Hawaii's VA supports Guard and Reserves prior to deployment
and upon their return, as well as those members in the military
service from the active forces. As a disabled veteran, I can
attest to the fact that the services provided by the VA locally
are top in the Nation. Nevertheless, given the proper
resources, they are capable of doing better. You recall that
nearly 30 percent of our veterans live on the neighbor islands.
Many of them are referred for surgical services to mainland VA
medical centers, civilian medical facilities on Oahu or at
Tripler Army Medical Center. For neighbor island veterans sent
to mainland VA hospitals, this can be very traumatic. They're
booked on flights, sent to a big city to find a VA facility,
operated on and sent back to their homes in Hawaii.
We ask that sufficient funding be provided for direct
mainland flights from, and whenever possible, return flights to
the veteran's islands of residence. Now, they are, of course,
placed on flights that come through Honolulu.
Changes to 38 U.S.C. 1151, Benefits for persons disabled
due to treatment provided at a VA facility means that the only
facilities covered under the law are those over which the VA
Secretary has direct jurisdiction, or a government facility
contracted by him. Tripler, Straub, Kuakini, Queen's and St.
Francis do not qualify.
Veterans suffering any additional disability, or worse, are
on their own and must sue the medical facility for damages.
That's an overwhelming task for most veterans. We suggest the
definitions that are listed in 38 U.S.C. 170 and 38 U.S.C. 1151
be changed allowing Hawaii veterans the same protection as
veterans receiving care in VA facilities on the mainland.
At a minimum, veterans must be given the opportunity to
make an informed consent about the benefits and shortfalls
between having medical procedures performed at a mainland VA
facility or locally in non-VA facilities. Hawaii's neighbor
islands must be offered the same level of medical care and
services as veterans located on Oahu.
Neighbor island Community Based Outpatient Clinics place
veterans on a wait list where they are scheduled for specialty
medical care. With the use of telemedicine and more frequent
visits to CBOC, this backlog is being addressed. Nevertheless
not fast enough, sir. Some veterans must wait several months to
see a specialist.
VA has a difficult time recruiting and maintaining
competent medical staff in these rural areas. VA should be
allowed to offer a premium to rural medical service providers
and be allowed to contract for additional medical care in rural
areas such as the neighbor islands. Thousands of National
Guardsmen and Reservists have returned. My desire is that they
and those already here receive medical and benefit services in
a timely manner.
We ask that VA Health and Benefits Administrations be
adequately funded and staffed to provide medical care and
benefit services to all Hawaii's veterans. Hawaii received a VA
grant to build the Yukio Okutsu Veterans Home opening hopefully
this year. We envision that eventually we will have several
veterans' long-term care facilities, preferably one per county
with your aid, sir.
Presently, the per day veteran reimbursement rate is
$67.71. That amount is insufficient to maintain a veteran
without additional payments from the veteran and other
resources that are available. We request that the reimbursement
rate be raised to adequately cover long-term care services
provided to assist the state in meeting the medical care of
this frail group of older warriors. The cost is approximately
$300 a day.
As these veterans pass, many will utilize our state veteran
cemetery system. Presently, the state and county are reimbursed
$300 for each veteran burial. This is less than the cost to
open and close a gravesite and to provide for perpetual care.
The cost to bury and provide perpetual care is approximately
$1,000. The burial reimbursement rate has not changed in many
years, and we ask your Committee to look into increasing it to
more closely reflect the true cost of these interments.
We must continue to take care of those who have served.
They are our sons and our daughters, our Hawaii citizens, our
veterans. I thank the Committee and you for this opportunity,
and I will respond to any questions you may have.
[The prepared statement of Mr. Moses follows:]
Prepared Statement of Mark S. Moses, Director, Office of Veterans
Services, Department of Defense, State of Hawaii
Chairman Akaka and Members of the Senate Committee on Veterans'
Affairs, I am Mark Moses, Director of the Office of Veterans Services
(OVS). The office is the single State lead agency responsible for the
welfare of Veterans and their family members. We act as the Governor's
liaison to veterans, veterans groups and organizations, and serve as an
intermediary between the Department of Veterans Affairs and Hawaii's
veterans. The office serves in partnership with the VA to provide state
services and benefits. We provided services and information to nearly
33,000 veterans and eligible survivors this past fiscal year. I have
attached a summary sheet describing some services and activities made
available through the office for your review.
The final service we can provide a veteran is interment in a
veteran's cemetery with appropriate honors. The Veterans Administration
has consistently supported our efforts to expand Hawaii's cemetery
plots and columbarium space to keep pace with need. They are deserving
of our gratitude.
Additionally, it is important and proper to take this opportunity
to thank you, Senator Akaka for your unwavering support for our
veteran's cemetery program. We are particularly grateful for your
assistance in obtaining the new grant for the West Hawaii Veterans
Cemetery located in Kona. State veterans cemeteries are the only
cemeteries accepting full body burials on a consistent basis in Hawaii.
This VA grant will assure that West Hawaii will be the cemetery we all
have envisioned it to be.
Based on April 2000 data from the Office of the Actuary, Office of
Policy, Planning and Preparedness, Department of Veterans Affairs,
there are an estimated 120,000 veterans in Hawaii. The majority, about
72 percent live on Oahu, 13 percent reside on the island of Hawaii, 10
percent live on one of the three islands which comprise Maui County,
and approximately 5 percent live on Kauai. Hawaii, an island state
located in the middle of the Pacific Ocean, presents unique challenges
for the Department of Veterans Affairs.
Before I discuss some of these challenges, I want to share with you
comments that my staff and I hear from veterans about VA health care
and benefit services. These individuals speak to the excellence of VA
medical care; that VA's staff treats veterans with dignity and respect,
and that the services rendered by the dedicated health care
professionals are superior to the care they received on the mainland
United States. These comments are expressed by local veterans as well
as by veterans who visit Hawaii and have a need to seek services from
Spark M. Matsunaga medical staff. Similar types of comments are shared
about the VA Benefit staff.
This ``new'' VA exemplifies the well known phrase of ``supporting
our troops.'' Hawaii's VA supports our National Guard members and
Reservists prior to deployment and upon their return. They also offer
services to military members who are ending their military service. As
a disabled veteran, I can attest to the fact that the services provided
by the VA locally are top in the Nation. Nevertheless, given the proper
resource they are capable of doing better.
As mentioned earlier, Hawaii presents unique challenges to the VA.
We are an island state with one large population center on Oahu. Nearly
30 percent of Hawaii's veterans live on the neighbor islands. Presently
many of our veterans are referred for surgical services to mainland VA
medical centers, civilian medical centers on Oahu, or to Tripler Army
Medical Center. This can be very traumatic for neighbor island veterans
who are sent to other VA hospitals. They are booked on flights, sent to
a big city to find the VA facility, operated on and sent back to their
home in Hawaii. We ask that funding be provided so that those who
reside on neighbor islands be provided direct flights to the mainland.
We also propose that whenever possible, return flights fly directly to
the veteran's island of residence.
Another issue that affects Hawaii and Alaska involves changes that
were made to 38 U.S.C. 1151, Benefits for persons disabled by treatment
of vocational rehabilitation. With this change the only facilities
covered by the law are those over which the Secretary of Veterans
Affairs has direct jurisdiction, or Government Facilities contracted by
the Secretary. Tripler Army Medical Center and other medical facilities
in Hawaii, such as Straub, Kuakini, Queens, and St. Francis do not
qualify under the present law. Veterans suffering an unlikely event
causing any additional disability or worse are on their own and must
sue the medical facility for damages. For most, obtaining an attorney
to pursue this option is overwhelming.
We suggest that the definitions as listed in 38 U.S.C. 1701(3) and
38 U.S.C. 1151, be changed so that veterans in Hawaii treated outside
VA facilities are afforded the same protection as veterans who receive
VA medical care in VA facilities on the mainland. Hawaii's veterans
must have the same right to redress as veterans treated at mainland VA
facilities. At a minimum, veterans must be given the opportunity to
make informed consent about the benefits and shortfalls of choosing
between having surgeries or other medical procedures performed at a VA
facility on the mainland or in non-VA facilities locally.
Hawaii's neighbor islands must be offered the same level of medical
care and services as veterans located on Oahu. Presently neighbor
island Community Based Outreach Clinics place veterans on a wait list
where they are scheduled for specialty medical care. With the use of
Telemedicine and more frequent visits, this problem is being addressed;
however, backlogs still exist. Veterans have been known to wait several
months before they see a specialist. Additionally, VA has a difficult
time recruiting and maintaining competent medical staff in these rural
areas. To address these needs, the VA should be allowed to offer a
premium to rural medical service providers and consider contracting for
additional medical care in rural areas such as the neighbor islands.
As you are aware, Hawaii has received thousands of its returning
National Guardsmen and Reservists. As Director of the Office of
Veterans Services, my desire is that these returning military members
and those already here be able to access medical and benefit services
in a timely manner. We ask that VA Health and Benefits Administrations
be adequately funded and staffed to provide medical care and benefit
services to all veterans who make Hawaii their home.
Hawaii has received a grant from the VA to build its first
Veteran's Home. The Yukio Okutsu Veterans Home is scheduled to open
within a few months. Our concern is with the reimbursement rate that
the VA pays for veterans who will be residing at the home. The present
reimbursement is insufficient to maintain a veteran without payment of
additional funds. We in Hawaii are not alone in requesting that the per
day reimbursement rate be raised so that it adequately covers long-term
care services supplied by the facility. We envision that the Yukio
Okutsu Veterans Home will be the first of several veterans' long-term
care facilities, preferably at least on per county due to inherent
island produced isolation. Adequate per resident reimbursement will
assist the state in meeting the medical care needs of this frail group
of older warriors.
As these veterans pass, many will utilize our State Veteran's
Cemetery system. Presently the state and county are reimbursed $300 for
each veteran burial, but the cost to open and close the grave site and
provide perpetual care greatly exceeds this amount. This reimbursement
rate has not changed in many years. We ask that your Committee look
into increasing the present amount so that it more closely reflects the
true cost associated with full body and urn burials.
We must continue to take care of our veterans. We must support our
Soldiers, Sailors, Airmen, Marines, and Coast Guard members at home and
abroad. They are our veterans, our sons and daughters, our citizens of
Hawaii.
I thank the Committee for this opportunity to speak on this matter
and I will respond to any questions that you may have.
______
[Note: the following is a summary of services and activities being
offered by the Hawaii Office of Veterans Services.]
Hawaii Office of Veterans Services
MISSION
The Office of Veterans Services (OVS) is the principal state office
responsible for the development and management of policies and programs
related to veterans, their dependents, and/or survivors. The OVS acts
as a liaison between the Governor and veterans' organizations and also
between the Department of Veterans Affairs and individual veterans. Our
objectives are to assist veterans in obtaining State and Federal
entitlements, to supply the latest information on veterans' issues and
to provide advice and support to veterans making the transition back
into civilian life.
OVS is the State's primary advocate of veterans applying for and
receiving benefits and services. The OVS may take action on behalf of
veterans, their families and survivors to secure appropriate rights,
benefits and services. This process includes the reception,
investigation and resolution of disputes and complaints.
The OVS serves all eligible veterans, Reservists, National Guard
members, active-duty military personnel and their dependents (including
stepchildren). (See List of Services at end.)
STATE PROVIDED BENEFITS
Special Housing for Disabled Veterans
Payment by the State of up to $5,000 to each qualified, totally
disabled veteran for the purpose of purchasing or remodelling a home to
improve handicapped accessibility.
Burials
Burials for qualified veterans (including U.S. war allies) and
their dependents in Veterans Cemeteries on Oahu, Hawaii, Kauai, Maui,
Molokai, or Lanai.
Vital Statistics
Free certified copies of vital statistics forms when needed for
veterans' claims.
License Plates
For the same cost as regular license plates, qualified veterans can
acquire distinctive veterans' license plates for their car or
motorcycle. Currently available are: ``Veteran,'' ``Combat,'' ``Combat
Wounded,'' ``Pearl Harbor Survivor,'' ``Former POW,'' 'World War II
Veteran,'' ``Korean War Veteran,'' and Vietnam Veteran.''
Tax Exemptions
Applies to real property that is owned and occupied as a home by a
totally disabled veteran or their widow(er). Also applies to passenger
cars when they are owned by totally disabled veterans and subsidized by
the Department of Veterans Affairs.
Employment and Re-employment
Preference is given to veterans, Vietnam-era veterans, service-
connected, disabled veterans and their widow(er)s for civil service
positions, training programs, job counseling and referrals to civilian
jobs by the Workforce Development Division, Department of Labor and
Industrial Relations. Re-employment rights for veterans, Reservists or
National Guard members who leave a position within State or County
government for training or active military service.
We encourage you contact the Office of Veterans Services to have your
questions answered. The sooner we begin the process together, the
sooner you will see results. Please contact the OVS office nearest you.
Walk-ins are welcome, and appointments are recommended. Home, worksite
and hospital visits are available if necessary, as are Group
presentations.
Office of Veterans Services--Oahu
Office: Tripler Army Medical Center E-Wing
Address: Office of Veterans Services, 459 Patterson Road,
E-Wing, Room 1-A103, Honolulu HI 96819-1522.
Telephone: (808) 433-0420; Fax: (808) 433-0385.
E-mail: [email protected].
Hours: Monday-Friday, 7:45 a.m.-4:00 p.m.
Office of Veterans Services--Kauai
Address: 3215 Kapule Hwy., #2, Lihue, HI 96766.
Telephone: (808) 241-3346; Fax: (808) 241-3818.
E-mail: [email protected].
Hours: Monday-Friday, 7:30 a.m.-4:30 p.m.
Office of Veterans Services--Hawaii
Address: 101 Aupuni Street, Room 212, Hilo, HI 96720.
Telephone: (808) 933-0315; Fax: (808) 933-0317.
E-mail: [email protected].
Hours: Monday-Friday, 7:30 a.m.-4:30 p.m.
Office of Veterans Services--Maui
Address: 333 Dairy Road, Suite 201-A, Kahului, HI 96732.
Telephone: (808) 873-3145; Fax: (808) 243-5820.
E-mail: [email protected].
Hours: Monday-Friday, 7:30 a.m.-4:30 p.m.
list of services for veterans, active military,
spouses and dependents
Assist in preparation of VA claims.
Help individuals file VA Appeals.
Represent veterans at VA hearings.
Obtain veteran birth, marriage, divorce and death certificates
nationwide.
Assist with burial
Provide notary.
Assist indigents.
Maintain DD214s.
Refer individuals not qualified for VA benefits to other agencies.
Legal name change.
Review active service record.
Assist active medical boards.
Hawaii Veterans Newsletter.
Hawaii Veterans Roster.
Hawaii Veterans Website.
Governor's Liaison to veterans.
Legislative Advocate for veterans--State and Federal.
Yukio Okutsu Hilo Veterans Home--development and oversight.
State Veterans cemeteries statewide--grants and expansion.
Grant-in-Aid for all veteran related items--veterans' cemeteries,
Arizona Memorial, Aviation Museum, Veterans Centers
statewide, etc.
Tri-annual report for State Monuments.
Coordinate veterans organizations to clean the Korean and
Vietnam Memorials on Capitol grounds.
Coordinate Memorial and Veterans Day ceremonies annually
at Hawaii State Veterans Cemetery.
Assist with Memorial and Veterans Day ceremonies at National
Cemetery of the Pacific (Punchbowl).
Coordinate leis for veterans cemeteries on Memorial Day.
Staff the Advisory Board on Veterans Services.
Hawaii Veterans Memorial Fund.
Maintain presence on neighbor islands.
Validate Military Service for Employee Retirement System.
The Audience. (Applause.)
Senator Akaka. Thank you, Mark Moses.
I want to thank this panel. I want this panel to know that
I do have questions for you. But, in the interests of time, I
am going to submit the questions for the record. But I want to
express my appreciation for your testimonies.
To conclude, I thank all of our witnesses for their
participation today. We heard about what VA is doing well and
about what needs improvement. The Committee will continue its
oversight of VA to ensure that all veterans have access to
health care and benefits.
Following the end of this hearing, we will take a 5-minute
break, and then commence what we are calling the public comment
session. John Yoshimura, one of my staff, will provide further
information and instructions for participation in this session.
So those of you who are interested in this session, please
remain here.
And again, this has been a great hearing. It has taken
time, but we have heard from all these witnesses, which will
really help this Committee to work on improving care and
benefits for veterans throughout the country and in Hawaii. And
with that, I want to say aloha and this hearing is now
adjourned.
[Whereupon at 12:05 p.m., the Committee was adjourned.]
A P P E N D I X
------
Prepared Statement of WW II Fil-Am Veterans
Good morning to everyone, to our Comrades and fellow veterans, and
to our very own Senator Daniel K. Akaka. Aloha.
On this great opportunity, the Officers, Board of Directors and
Members of the WWII Fil-Am Veterans and Ladies Auxiliary, Hawaii
Chapter, extend our esteemed gratitude and sincere thank you to Senator
Daniel K. Akaka, as Chairman of the U.S. Senate Veterans' Affairs
Committee and to all Members of the same committee for approving on
June 27, 2007, legislation of the Filipino Veterans Equity Bill S.
1315.
Likewise, we extend our thanks to U.S. Senator Daniel K. Inouye for
consistently introduced the Filipino Veterans Equity bill since 1992
that will restore full veterans status and benefits to the WW II
Filipino veterans who were drafted into the U.S. Armed Forces and
bravely fought alongside the American troops under the American flag in
defense of freedom and democracy.
We understand that the bill S. 1315 passed by the U.S. Senate VA
Committee will soon, sometime in September 2007, be moved to the full
Senate floor, which we consider a major step toward realizing
legislation of the Filipino Veterans Equity bill S. 1315 after 15 years
since 1992.
While the Family Reunification bill is on hold, we propose an
alternative amendment to the bill H.R. 2642, the Military Construction
Veterans Affairs Budget bill approved to full Senate to incorporate as
RIDER for the Family Reunification Act of 2007 or an alternative RIDER
to the Filipino Veterans Equity bill S. 1315 without prejudice to pass
legislation of the mother bills.
We strongly APPEAL in the intent of HUMANITARIAN reason next to our
Constitutional rights the immediate need to pass legislation of S. 1315
so that the remaining elderly veterans now in their 80's of age and
over can enjoy at least their equity benefits and pension during the
rest of their twilight years.
Mahalo. God Bless Us All.
______
Prepared Statement of Luz N. Caleda, President, Ladies Auxiliary of the
WWII Fil-Am Veterans Hawaii Chapter
Good morning everyone, to our very own Senator Daniel K. Akaka.
Aloha.
My name is Luz N. Caleda. I am the President of the Ladies
Auxiliary of the WWII Fil-Am Veterans Hawaii Chapter with fifty six
members--all wives of the veterans residing in Hawaii. We were
organized to support and assist the veterans in carrying out their
plans and programs including other related activities and functions.
On behalf of the Officers and Members of the Ladies Auxiliary, I
extend our deepest gratitude and sincere thanks to U.S. Senator Daniel
K. Akaka and to all the Senate VA Committee Members for approving on
June 27, 2007 the legislation of the Filipino Veterans Equity Bill. On
April 11, 2007, I joined my husband, Art Caleda, who gave his testimony
during the Senate VA Committee hearing chaired by our beloved Senator
Daniel K. Akaka in Washington, DC.
We, the Ladies Auxiliary, all shared the 65 long years of injustice
suffering of our husband veterans in their fight for their equity
pension and other benefits rightfully deserved by them. We suffered
long enough. Many veterans already passed away and a number of wives
also passed away out of their frustrations. Believe it or not, we live
below the American living standard depending only on the SSI and Food
Stamps from the government. Think about it, some veterans frequent to
Food Banks to pick up free food stuffs and clothing. Some resort to
picking up empty soda cans and empty bottles and sell them to any
recycling outlets just to augment their meager SSI money.
We have been separated from our children and family when we came to
Hawaii with our husband-veterans. We cannot afford to go home to the
Philippines to visit our family and children once in a while because of
financial problem. We are now quite old, weak, and sickly and a number
are bedridden at home or in the hospitals. In many instances, when a
veteran dies, none of the children from the Philippines can come to see
or witness the burial or funeral. The bereaved family, on several
occasions, appeals for voluntary contributions from friends and mostly
from the veterans and Ladies Auxiliary members to help defray the
funeral and burial expenses of the deceased veteran.
We appeal and I urge all U.S. Senators to support legislation of
our very own U.S. Senator Daniel K. Akaka's bill, S. 1315, the Filipino
Veterans Equity Act of 2007, the much awaited Equity pension and
benefit for the Filipino veterans, who sacrificed their lives fighting
alongside with the American troops in defense of freedom and democracy;
and to include the family Reunification Act of 2007 which we urgently
need at this point in time.
Mahalo and God Bless.
______
Prepared Statement of Charles L. Clark,
President, Radiated Veterans of America
Chairman Akaka and Distinguished Panel Members:
My name is Charles L. Clark. I am a resident of Kailua.
I am a U.S. Navy Veteran of World War II and the Korean conflict. I
served in the Pacific and was one of the first Americans, not counting
on-site Prisoners of War, to enter Nagasaki after the August 9, 1945
atomic bombing.
I am currently the President of Radiated Veterans of America, the
only Internal Revenue Service recognized 501(c)(19) Veterans Service
Organization representing statutory war veterans exposed to ionizing
radiation during service to this Nation.
The United States, by and large, has treated Radiated Veterans
poorly. While laws have been passed, regulations created, and huge sums
of money have been spent addressing ionizing radiation, precious few
Veterans have been recognized, medically cared for, or compensated for
their losses.
This is, I believe, because there has been little continuity in
addressing the issues faced by Radiated Veterans. For example, Congress
has passed laws defining and addressing ``Atomic Veterans'' being those
potentially exposed to radiation during atmospheric, and a limited
number of underground ``tests'', and POWs and occupying troops at
Hiroshima and Nagasaki. Yet, the Veterans' Administration's Advisory
Committee on Environmental Hazards, in 1993, noted 11 categories of
Veterans, in addition to those statutorily listed as ``Atomic
Veterans'' who could have been exposed to ionizing radiation as a
result of their service.
Radiation is radiation, and the system, rather than treating all
Radiated Veterans equally demonstrably discriminates between Veterans
who have been exposed to ionizing radiation.
This is true even within the statutory ``Atomic Veteran''
classification where there is discrimination between those with so-
called ``presumptive'' cancers and ``non-presumptive'' diseases
recognized in the medical community as radiogenic in origin, for
purposes of compensation.
The non-presumptive diseases require the Veteran, or his/her
survivor to be subject to a Dose Reconstruction, admitted by government
as ``uncertain'', and expensive, before any compensation is awarded. .
. and much more often than not, the claim is denied.
Dose Reconstruction is flawed, yet it is kept alive by an unholy
alliance between the Veterans' Administration, the Defense Threat
Reduction Agency of the Department of Defense and its private
contractor, SAIC.
Even some members of the congressionally mandated Veterans Advisory
Board on Dose Reconstruction advocate that all ``Atomic Veterans'' be
treated as a Special Cohort.
I strongly suggest this Special Cohort classification be adopted to
law and expanded to include all Veterans whose military duties put them
at risk from ionizing radiation, including the 11 classification
recognized by the VA study group in 1993.
Further, I strongly urge that the Dose Reconstruction program,
which is fatally flawed, because the history of dose readings is itself
flawed, be scrapped. Too much time, and too much precious capital, has
been spent on this program.
The shortcomings of Dose Reconstruction, primarily based on
theoretical statistics, and in too few instances actual recorded
radiation readings, were recognized by the 2003 report issued by the
National Research Council. The report was titled ``A Review of the Dose
Reconstruction Program of the Defense Threat Reduction Agency''.
Further, I urge Congress to give more deference to the medical
community and less to the physical scientists, in recognizing the human
damage caused by ionizing radiation, which impacts not only those
subject to radiation, but even unto progeny affected by genetic changes
that occurred when a Veteran was exposed.
Also, I urge Congress to merge the various programs directed at
Veterans and Civilians such as ``Downwinders'', Uranium Miners, and
Defense Workers, so that the Nation can properly address the scourge
brought about by the uncontrolled introduction of atomic energy, and
the human experiments conducted to satisfy curiosities.
As an Atomic Veteran, who was damaged by residual radiation
following the bombing of Nagasaki (I have, for example, had 160 skin
cancers removed from my face and neck, and have other maladies the
medical community attributes to ionizing radiation) I can ask no less
of Congress, our elected representatives, for fellow Veterans and all
Humankind.
I understand your time to listen today is short, and that you have
many issues before you. I will, however be glad to respond, either
verbally, or to any questions you may have, either now, or as follow-
up, in writing if necessary .
The Internet Web Site for Radiated Veterans of America is
www.radvets.org. That site, which is continually updated, brings
together, in much more detail, much of what I have brought forth today.
Thank you for your time and attention.
FIELD HEARING ON HEALTH CARE FOR VETERANS ON MAUI
----------
THURSDAY, AUGUST 23, 2007
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:30 a.m., in
Maui County Council Chambers, Wailuku, Maui, Hawaii, Hon.
Daniel K. Akaka, Chairman of the Committee, presiding.
OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, U.S.
SENATOR FROM HAWAII
Senator Akaka. Aloha.
The Audience Members. Aloha.
Senator Akaka. I'll just start by making some preliminary
statements. And I want to say mahalo nui loa to all of you for
coming. I wanted to thank the Maui Counsel for giving us access
to this room. As you know, this is the counsel chambers. And
they've offered it to us for this hearing today. And I'm
extremely grateful to the counsel for that and to the people of
Maui for this as well. And to see all of you here is very
heartening for me. Because we want to hear from you and to see
what we can do to improve what the Department of Veterans
Affairs has been doing for our veterans.
And to begin with, I would like to ask Danny Kanahele to
lead us in the pledge and Rogelio Evangelista to lead us in
prayer. So at this moment, I ask all of you to please rise.
[Pledge of Allegiance and Prayer.]
Thank you very much. Danny Kanahele.
Mr. Kanahele. Sir.
[Pledge to Allegiance and Prayer.]
Senator Akaka. Aloha. I want to welcome all of you to
today's hearing. And this hearing will come to order.
This is the second hearing held by the Senate Committee on
Veterans' Affairs. The second of three hearings that I am
chairing here in the State of Hawaii this week and next week.
We held similar hearings at the start of 2006. Much has
improved since that time, for which I'm very, very grateful. It
took lots of work, teamwork with the Administration as well,
with the VSOs as well, and with Congress. But it is important
for the Committee to understand the remaining challenges.
Both the clinic and Vet Center on Maui are tremendously
busy and must be available to all of Maui's veterans and to
veterans living on Lanai and Molokai as well. It is my view
that both the clinic and the Vet Center are understaffed, and
we need some staff enhancements. This is something that I will
be exploring today.
I want to applaud the efforts of every VA employee on Maui.
These men and women work hard to help veterans who seek their
assistance. There are many things that VA does well in Hawaii.
However, there is always room for improvement. I want to hear
about how we can give VA the tools to make a difference in the
lives of Hawaii's veterans.
Back in Washington, we have worked hard to ensure that VA
has the resources to provide the best possible care.
The VA spending bill, which the Senate will take up early
in September, includes $43 billion for VA, $3.6 billion more
than was offered by the Administration. But we are looking
forward to taking it up when we reconvene in Washington in
September. We are finally on track for adequate funding for VA
mental health care and for those veterans with Traumatic Brain
Injuries.
Today and over this week and next, I will examine health
care and benefits in Hawaii. Given the State's unique features,
VA must specifically tailor its strategies that are successful
on the mainland, as they may not work as well here. And many of
you know what I mean.
It is vitally important that you share your thoughts with
us so that we know how to help VA help you and the rest of
Hawaii's veterans. VA officials are here to listen and to
respond to the concerns raised by the witnesses on the first
panel.
Finally, I note that there are many veterans here today,
and I'm happy to see all of you. And many veterans who would
like to testify as well. While we cannot possibly accommodate
everyone's request to speak, we do want to hear your views.
The Committee is accepting testimony which will be reviewed
and made part of the record of today's hearing. If you have
brought written testimony with you, please give it to the
Committee staff who are located in the back of the room. If you
do not have written testimony but would like to submit
something, Committee staff will also assist you in that.
In addition, the Committee staff is joined by VA staff who
can respond to questions, concerns and comments that you raise.
And when I say VA staff, I mean those who are on the Federal
level, as well as those who are on the State level here in
Hawaii.
Once again, mahalo nui loa to all of you who are in
attendance today. And I look forward to hearing from today's
witnesses.
Because of the last minute changes in witness availability,
we made a slight change in the hearing agenda. The first two
panels of individual witnesses have been combined into a single
panel. So we have them now in front of us. I want to welcome
this first panel to today's hearing. And I want to thank you
again, mahalo nui loa for your presence here and for your
testimony.
First, I welcome Rogelio Evangelista, President of the Maui
Veterans Counsel. I also welcome Clarence Kamai, Jr., a member
of the VA Advisory Counsel. I want to welcome Danny Kanahele,
another member of the VA Advisory Counsel.
I welcome Mitch Skaggerberg, President of Vietnam Veterans
of Maui County.
I welcome Karl Calleon. I understand that it is your la
hanau; that is, your birthday. So I want to say hauoli la hanau
to you at this time. I also welcome Carl Haupt, a Vietnam
Veteran. Next, I welcome Grant Steward, a Veteran of Operation
Iraqi Freedom. And finally, welcome William Stroud, a Vietnam
Veteran.
Again, I want to thank all of you for being here. Your full
statements will be included in the record of the Committee. We
would like to move this along as best we can. And because it is
important to do that and to keep things moving, please keep
your statement to no more than five minutes.
Here in front of me is a time clock. And you will see a
green light come on for 4 minutes. Then a yellow light to sum
up the last minute. And then a read light to stop.
So again, let me begin by asking Mr. Evangelista to begin
with your testimony.
STATEMENT OF ROGELIO EVANGELISTA,
PRESIDENT, MAUI VETERANS COUNCIL
Mr. Evangelista. Mr. Chairman, Senator Daniel Akaka, and
distinguished Members of the Senate Veterans' Affairs
Committee, greetings to you and your staff. And to the veterans
here today, thank you for giving me the opportunity to come
before you and discuss VA health care here on Maui, home to
about 100,000 veterans.
To the excellent efforts the staff of the Maui CBOC and
with the support of the (inaudible) and the Tripler Army
Medical Center have been extraordinary, especially due to the
unique nature of health care within the islands all divided by
the Pacific Ocean.
First of all, I would like to commend you and the Committee
for all your personal sacrifices and helping us veterans deal
with our everyday disabilities in our daily lives. All of you,
along with the medical staff in Hawaii that made great strives
in our support to overcome our hardship and disabilities.
I was even given the opportunity to address the panel on
January 10, 2006. And since then, there have been a lot of new
changes. We have lost our primary care doctor to CBOC in the
summer of 2006, and the position just got filled the beginning
of summer of 2007 by Dr. Chin.
As you know, the State of Hawaii is very unique in that
each county is divided by the Pacific Ocean, not like the
mainland where the veterans can drive to the clinics or
hospitals with his or her family support. And with less than 30
percent of service connected disability and the attending
physician at the clinic set you up for an appointment for a
condition that could be a plausible cause due to your
disability, but part of you must provide your own
transportation.
And this happened ever since the millennium, regarding
veteran's health care. To travel within the neighbor islands is
so costly for veterans because most of us are living with
limited income. And when we are referred to a VA doctor to see
a private practitioner here on Maui, after two months, we
receive a letter saying the visit was not authorized.
This has happened to me a few times. And since it takes so
long for VA to eventually get approval and pay the provider, it
ends up to collection agency, which gives you an appropriated
report. How many other veterans also have this problem?
Second, there are a lot of veterans here on Maui with
chronic health problems. And they just live with it from day-
to-day, hoping some day the problem will go away, which will be
when they die.
We have a primary care doctor and nurse practitioner that
you can get an appointment with. But when you try to call to
get an appointment that day, the appointments are usually full.
We need to have another doctor here at the CBOC. I think we
also need to access VA health care after-hours when the clinic
is closed, especially on weekends, so that we don't have to
deal the probability of our emergency bill not being paid,
especially here on neighbor islands.
On Oahu, they have Tripler Army Medical Center to go to for
emergency. They can drive there on weekends. We can't. There's
still so much red tape using VA as primary medical care,
especially after the clinic closed. And there would be a nurse
on-call or doctor on-call 24/7, to authorize emergency care
after clinic hours and during clinic hours if the clinic can
see you.
Third, our aging veterans are now more in need of acute
medical care. We need to provide them with 24/7 access to
health care. World War II, Korean and Vietnam Veterans are in
their 60's to past 80 years old, with some of them homebound.
With a staff of homecare nurses that can visit them at home to
provide some sort of respite care. Hopefully, there will be a
care home for veterans in the very near future.
There is also no contact with other veterans. Some of them
can no longer drive and some of them are without family
support. Some veterans are now only realizing their
disabilities that might have been caused by military service.
And when they apply, they are being asked for collaborating
evidence on something that happened over 30 years ago.
Why can't the Veterans' Administration get these records
for them? There are a lot of veterans here on Maui and
throughout the state and throughout our Nation that don't even
know certain benefits that they may be qualified to apply for
due to their physical and mental disabilities.
Four, let me share with you my personal experiences with
vocational rehab. At age 34, I was very fortunate to be
accepted in the VA Chapter 31 rehab program to secure various
computer certifications to pursue work as an electronic
technician. Somehow, however, I ended up with a shoulder injury
that ultimately led to me not being able to complete my
employment plan and resulting in my total disability from being
able to work.
As a result over time, I found myself to be increasingly
stuck at home dependent on others, depressed, frustrated, and
feeling useless. When Dr. Richard McDonald, my rehab counselor,
noticed my physical, psychological and social functioning was
dangerously spiraling downward, he referred me for an
independent living evaluation at my home.
Since I was aware that the independent living program has
already helped out so many other veterans through my long-
standing veteran advocacy, I agreed to undergo the evaluation.
Through Mr. McDonald's counseling and the helped of plan
development guideline, I began to see how I could use the
computer knowledge and skills that I gained through my rehab
training to help other veterans.
He completed it and we have since initiated my independent
living plan. Through this plan, I have received a riding lawn
mower so I can once again take care of my lawn. I also received
a laptop computer system so I can assist other veterans with
updating and operating their computers. It will also enable me
to help set up a Veterans Helping Veterans in our communities.
Veterans Helping Veterans is comprised of a growing number of
veterans who have also been empowered, and their independent
living plans are now helping others too disabled, too old, or
too poor to help themselves.
These veterans, like myself, are using their independent
living equipment skills, interest and time to help these people
by fixing their vehicles, repairing their homes, cleaning up
their yards, or whatever needs doing.
They're also fixing up their communities: school parks,
benches, and so forth. In the process of being empowered to
others, these veterans' lives are transforming from depression
and isolation to lives of renewed purpose, family, social and
community connection.
One of the main reasons this program is so effective with
these veterans on Maui, Molokai and Lanai, is because Dr.
McDonald works closely with the Maui Community Based Outpatient
Clinic staff: Dr. Kathleen McNamara, psychologist; Morey
Springer, psychiatrist; Sue Yin Chin, primary physician; and
our CBOC and veterans and support professionals throughout our
community.
It's disheartening to note, however, that this independent
living program is not being utilized in this critically
effective manner in many other regions in the Veterans'
Administration. This is why I asked Dr. McDonald to provide
more information on the independent living program.
The veterans now can be more independent through this
program to include full lives within their family and
communities.
Members of the Senate Veterans' Committee, we applaud you,
all that you do to help us veterans live better and fruitful
lives. Through this goal, we all ask that you do what you can
to improve both increased support for the use of this
independent living program, along with the increased medical
services for our most severely disabled veterans in Hawaii and
throughout our United Nation.
May God bless America's people and you, the Members of the
Senate Veterans' Affairs Committee, the Armed Forces, the
Veterans and their families. Thank you and aloha. I think I
went over the red light.
Senator Akaka. Thank you very much, Rogelio. And now we'll
hear from Clarence Kamai.
STATEMENT OF CLARENCE KAMAI, JR.,
MEMBER, VA ADVISORY COUNCIL
Mr. Kamai. Good morning, Mr. Senator, staff of Veterans'
Affairs, staff of Veterans' Administration, Maui CBOC staff.
Hello veterans, male and female.
I concur with what Mr. Roger Evangelista had to say
regarding our health care. It is important. It is needed.
We all know that. We all know that some of us have been
getting these bills from the collection agencies because of
nonpayment from times we've been in the hospital. So I do
concur with Mr. Evangelista.
I would also like to point out that maybe we could get back
into the system of fee basis. Get back into the fee basis
system where I think it would be easier for the staff and the
VA. Because what's happening now, as an example, I use myself.
Should my wheelchair break down, I have to call Maui CBOC, get
permission from the doctor. Now, there's a problem because it's
hard to get in touch with the doctor and sometimes it's hard to
get through the lines.
So what you have to do is follow the prompts and then just
leave your message and hope they'll call back. They do. Whether
it's the same day, the next day, it does not matter. But as
long as they call back. Now, I need my wheelchair fixed. This
is my mode of transportation. Now I'm down stuck in the water
until someone calls me back from Maui CBOC to let them now what
my situation is. Then there are three to four steps that will
follow after that.
First step would be for them to call a service provider.
The next step would be for Maui CBOC to get hold of a doctor to
get permission. And sometimes I have to get involved to call
Honolulu to see if prosthetics--and who knows what's happening
and what can happen before me.
The next step is about a week later, everything comes to a
head to say, yes, we're going to do this, yes, we're going to
do that. The last step is with the service provider. They will
give you an appointment. I need a wheelchair, you know, as soon
as possible, please. However, I won't get the service until a
week or maybe two weeks later.
So I'm saying that if we go with this simple fee basis and
we'll get the allocation of funds from our senators, then it
can be done. And this would solve a problem of too many
veterans going to the VA. This would really lessen the load, I
believe. It would take a lot of pressure off the Maui clinic
staff and doctors, and would enable them more time to serve
other veterans.
This is only one of many, Senator, that I would like to
speak about. And I shall let my constituents go ahead. Thank
you very much.
Senator Akaka. Mahalo. Thank you very much. I notice there
are some folks standing in the back and on the sides. I see
some seats that are empty. So feel free to please move and sit
down. Find a seat there and be comfortable.
At this time, I'd like to call on Danny Kanahele for his
testimony. Danny.
STATEMENT OF DANNY KANAHELE,
MEMBER, VA ADVISORY COUNCIL
Mr. Kanahele. Good morning. Thank you Mr. Chairman, staff
of Maui CBOC, Tripler Hospital, Dr. Hastings. Thanks for being
here. Mine is real simple.
Well, actually, what I do is public relation. Go out on the
street talk to people, see what's going on. The most important
thing I run across is the disability and the percentage that
people have. The 100 percenters, not bad.
Sometimes they get hard time, but not bad. But when you're
under 50 percent, you've got a real problem. You're either
going to be dead or you are mot going to make it. People call.
All they get is wait, I'll get to you. And they call back.
I see this done many times. I talk to friends. I run across
people. They say they are going to call me back.
Why did you not call me back? What is your percent? 30.
What's your percent? 50. It seems like anybody under 50
percent, they aren't going any place. I'd like to know who
checks on these guys that have been there for like 20 years; I
know two guys 20 years ago. Today, they are 50 percent. Who
checks on these guys to find out if they're getting any better?
They should get a note about they are not getting better.
There's a problem over there. And for myself, well, lucky for
me, I can take pain. But as long as you don't take too long, I
can be all right. So I hope somebody check on these guys way
behind in our percentage and check on why they are not moving
their percentage up to the par that they should have. I believe
something should be done about it. I think today would be a
good time.
Well, that's all I have for today.
Thank you very much, Committee, I appreciate it. Thank you.
Senator Akaka. Thank you very much Danny Kanahele.
And now we'll hear from Mitch Skaggerberg. Mitch.
STATEMENT OF MITCH SKAGGERBERG,
PRESIDENT, VIETNAM VETERANS OF MAUI COUNTY
Mr. Skaggerberg. Senator Akaka, good to have you here.
I am proud of the service you and your fellow Senator
Daniel Inouye have done for the veterans over the last 20 years
here. Twenty years ago, we didn't have any health care clinic
in Maui. And now we have a good health care clinic. And thank
you for this meeting so that we can even handle some of the big
problems that you're going to hear today.
I'd like to thank you for coming to our aid when we called
you in March with the problem that we all faced here, our
staff, our veterans, we lost both of our doctors and there were
no doctors in site. And I can't tell you how much it means to
us in what you did personally to make sure that we wouldn't sit
another year without doctors. Bless you. Thank you.
With that said, my main focus today is on long-term health
care. The veterans that formed a committee--Roger, how long has
it been now--to look into a long-term care facility here on
Maui. The need for this long-term care is evident in that 70
percent--we figure 70 percent of all the veterans that go into
the VA clinic are 60 years or older. 60 years or older, 70
percent. That's a staggering figure.
Now, what does that mean for long-term care? Well, the
urgent need for long-term care is already here. Kathy Haas is
one of the committee members, as well as Michael Covich, Bill
Staton, Roger Evangelista, and me.
Did I miss anybody?
We're proposing, Senator, like we did on the Big Island and
like we did on Oahu, that we start planning and generating the
funds necessary to build a 60-bed, long-term care facility
here. I've talked to Kathy Haas and some of the other medical
providers here in the VA Clinic.
They said that currently, they are handling anywhere from
20 to 35 VA disabled veterans who need long-term care in one
form or another. Either hospice care, respite care, where the
families are handling the job, but it's so overwhelming, that
they need rest. And they need a place to put our fellow
veterans for maybe a month or whatever it takes.
We have quite a few veterans with dementia now. And then,
of course, we have ambulatory care.
The way we handle that now is, I've seen it personally with
two of our close veterans, we put them in the hospital for two
months at Maui Memorial. They induce a coma for five or six
weeks to see if they can heal because there's no room on this
island right now for any long-term care facilities.
The one, Hale Makua, has a problem getting staff, Senator,
that their beds are empty right now. They can't even take the
veterans over there if we wanted to because there are no
qualified nurses right now to handle patients.
So I'm suggesting that on behalf of all the veterans and on
behalf of the VA medical staff, we begin to plan and implement
and construct a long-term care facility here. Not only for
Maui, but for Lanai and Molokai, knowing eventually there may
be new technology that allows those veterans from those two
islands to have home care at some point, long-term care.
But until that happens, at least they have an alternative
there on Oahu. The center for aging in Oahu, as you know, is
overbooked. Hilo's a long way to travel for those two veterans
and their families from those two islands. So we have started
studying possibilities of site locations. We have joined with
another group called a ``Maui Long-Term Partnership.''
We're looking at innovative ways of creating this, such as
integrating this long-term care facility for the veterans into
an overall community. A new community that is on the drawing
board where we would have transitional housing, i.e., a veteran
could move into one type of housing where he has, let's say, 50
percent disability, and needs adult care and some long-term
nursing care. And if he's not cured, then he can move into the
long-term care facility.
There could also be a branch of Kaunoa Senior Center. We'd
put a center in there so that they can try to keep many of us
more active and engaged. That would help us with our health and
perhaps delay the time where we had to go into the long-term
care facility.
So these are some of the things that our committee is
looking at. And we would be glad to work with you, Senator, and
the Veterans' Affairs Committee or anybody on your staff in
Honolulu to pursue this. We think the time is now.
So that concludes that.
The other thing I want to say is about the fee basis. You
were instrumental in arranging a meeting with Dr. Hastings and
Dr. Wiebe in Maui. I think that was in April. And one of the
things they had as a proposal was the same thing that Danny and
Clarence Kamai, Jr., said that we want to strengthen the fee
basis program here. Those were their words (Dr. Wiebe and Dr.
Hastings). So we have their support. At least, that's what they
told us.
I agree that anybody with 100 percent or 80 percent
disability rating, we usually get what we need in a timely
manner. But the veterans with 50 percent or lower, have a very
tough time. I think one of the bottlenecks for that is VA has a
department in Honolulu called the ``utilization board.'' I
think that all fee basis requests come from our doctor now, Dr.
Chin.
I believe request go through the ``utilization board.''
Then, staff in Honolulu takes sometime to process them because
they're overwhelmed with requests from the other islands; then
they've got to get back to us. Then they have budgetary
requirements. It seems to be a big bottleneck right now.
I know our new doctor is not familiar with this process. I
think she was in private practice. So I'm sure she's going to
say, well, gee, I'm the doctor, I know what's best. If we have
to wait three, four, five weeks for somebody in Honolulu--do
you understand what I'm saying, Senator?
Senator Akaka. Yes.
Mr. Skaggerberg. So that might be a key ,fee basis 24/7, to
have Dr. Wiebe and Dr. Hastings and all our needs met, in
looking where the bottlenecks are and expediting the process.
The third item I wanted to bring up is your Internet chat.
I'd never done an Internet chat. I said I'd never do an
Internet chat until you had one, Senator. I remember I asked
you for some help because we really need some help for Dr.
Springer and Dr. McNamara. You said, ``Mitch, I have good news
for you. We're getting a psychologist at the Vet Center.''
Well, thank you, Daniel. We've been interviewing for quite a
while. I understand our team leader has just found somebody
that he really likes. But again, we're concerned about the
length of time that it might take.
So, Senator, if you can just let same VA management people
know, it's not business as usual here. We have critical needs
and, you know, things can take forever sometimes. If Tom wants
to come here, he's been highly sought after by other people. I
think we need to expedite that process so he can be onboard
here in the next month or two.
Senator Akaka. I want to thank you very much, Mitch, for
all of this and for the gratitude you expressed.
I want to tell you, it's not only me. I mean, this is
teamwork. The VA people have been helpful in bringing this
about as well. But I really appreciate hearing from you.
Mr. Skaggerberg. Thank you.
Senator Akaka. Thank you.
Mr. Skaggerberg. Mahalo nui loa.
Senator Akaka. Thank you, Mitch.
Now we'll here from Carl Haupt for your testimony.
STATEMENT OF PRENTISS CARL HAUPT, VIETNAM VETERAN
Mr. Haupt. Thank you, Senator Akaka, for convening this
session. We are proud of our VA facility and staff here on
Maui, and grateful for your swift action when our clinic had no
doctors, and for the arrangements made for the veterans health
care on Lanai. We appreciate this opportunity to testify about
health care for veterans here on Maui.
I'd like to talk a little bit about Hawaii State Office of
Veterans Services. The State Office of Veterans Services, as
our testimony in front of you shows, now has a staff of ten
statewide allowed. We now have eight people.
We feel we need 12. Oahu has three counselors and one
clerical staff, with 2,275 people visiting last year. We have
2,288 people visiting--over 13 more than Oahu--with one
clerical staff and one counselor position, which is not filled
yet.
What we're saying now is, the state has 10 people allowed.
We now have 8. We feel we need 12. The Maui Office of Veterans
Services is a vital part of the infrastructure supporting Maui
that is in danger of being overwhelmed. The demand for their
services, like the Veterans' Administration, will only increase
after our soldiers come home from fighting in conflicts for far
too long.
We have two people now that are available for this position
that we feel are being--well, we don't know what to say--not
hired. Terry Garcia has been with the office for more than 10
years. She has an associate's degree.
The education requirement for the position is graduation
from an accredited college or university. Well, she has that.
She has 10 years experience. (Inaudible) machine gun in
Vietnam. Do I really want to go out with a gunnery sergeant who
has 10 years experience, or the new guy who has no experience?
Why don't we hire Terry for this position. It needs to get paid
right now, and get someone in there. Instead of Cass Russell
coming over one day a week. We really need Cass's support and
we appreciate all that he does and the time he spent traveling
to come to Maui. But we need someone in the office right now,
somebody hired in the very near future to take over the
position which is now not being filled.
We have someone in there right now who can fill the
position, who has the experience, who actually has 15 years
experience, not 10 years experience. We really feel that
Terry's health is also being affected because of stress at
work. Her office handles more patients than the Oahu office
which has four staff. We handle it with just one staff right
now. Totally unfair. Totally underpaid position. Totally
stressed out position.
This Office we feel, as a veterans community, we feel very
disenchanted and unable to get just about anything done
regarding the health measures that this Office puts out for our
veterans. We feel with an old hippie, antiwar protester,
antiveteran, by her political agenda and climate against
veterans, our Governor makes a bureaucratic nightmare for the
veterans to get their earned rights. So basically, that's what
I have to say about that issue.
One other issue I'd like to talk about is the DAV Van. The
DAV Van is not equipped for handicaps. We do not have the
support staff needed to drive patients either to Hana or to the
other side. With the traffic and everything, we actually need
someone in that van from 6 in the morning to 6 at night.
We wondered if there are any grants or scholarships
available, anything to help maybe fund this situation via MEO,
or whatever, to get what's needed 12 hours a day, to get the
people back and forth in all the tremendous traffic jams we
have on Maui so they can have their health care needs taken
care of.
[The prepared statement of Mr. Haupt and Mr. Skaggerberg
follows:]
Prepared Statement of Prentiss Carl Haupt and Mitch Skaggerberg, on
Behalf of the Vietnam Veterans of Maui County
Dear Chairman and Members of the Committee:
Thank you, Senator Akaka, for convening this session. We are proud
of our VA facilities and staff on Maui, and grateful for your swift
action when our clinic had no doctors, and arrangements were made for
the veterans' health care on Lanai. We appreciate this opportunity to
testify today about health care for veterans on Maui.
VA COMMUNITY BASED OUTPATIENT CLINIC
When Senator Inouye dedicated the Maui CBOC, he said this clinic
will be our model clinic for the Nation. Is our clinic still fulfilling
Senator Inouye's and Senator Akaka's vision? I don't think so. Two
issues, about quality of care have come to our attention. The first is
equipment and the second is staffing.
We are now losing our ophthalmologist because he is not provided
with even the most basic equipment to do his job. Where is the retina
machine Dr. Hastings said was in the warehouse back in March?
A VA cardiologist comes to Maui for examinations. He doesn't have
proper equipment at the clinic. Why are we wasting his time and our
money?
Why does our clinical staff continue to have to work evenings and
Saturdays, with no extra pay, just to get caught up on their paperwork?
The Washington Post brought attention to the problems with records
transfer between the Department of Defense and the Veterans'
Administration but VA staff in Hawaii have been coping with it ever
since the cooperative agreement with Tripler was signed, even before 9/
11. It is contributing heavily to staff burnout and turnover.
There are approximately 600 people on the CBOC waiting list who are
not yet able to get VA care. These people are paying as much as $600-
$800 per month for their maintenance prescriptions; their VA copayment
would be about $35. Many of these veterans are our oldest and most
distinguished World War II and Korean veterans.
According to a 2004 study sponsored by the VA Health Services
Research and Development Service, ``. . . about one in seven VA
pharmacy outpatients fit a definition of having only a small number of
outpatient visits annually with a relatively large pharmacy cost. This
number was 10 percent of VA patients. The budget impact of this 10
percent was only about 1 percent of medical care appropriations.'' \1\
---------------------------------------------------------------------------
\1\ Zhu, Gardner and Hendricks, ``Just How Many Enrollees Come to
VA Just for Pharmacy? '' HCFE Data Brief #2004-10, p. 2, VA Boston
Health Care System Research and Development, Health Care Financing and
Economics, funded by HSR&D SDR 97-001-01.
---------------------------------------------------------------------------
Many people seem to forget that because of these great men who
fought in World War II, Korea and many other conflicts, we have the
greatest democracy right now. What can be done right now to alleviate
this terrible financial burden on our oldest, most distinguished
heroes?
When will we get the necessary staff and equipment to properly
fulfill the Maui clinic's promise?
We have heard enough off-the-record comments about the quality of
care in Hawaii to believe that outside Congressional-level
investigators should interview past and present VA clinicians to get an
accurate picture of our veterans' care.
VET CENTER
We need the psychologist we've been promised. So far, no luck on
filling this gravely needed position. What can be done about incentives
to get the proper staff? We hear the same concerns about money from all
the applicants. Even with the 25 percent COLA, our housing, food and
gasoline are among the highest priced in the Nation, discouraging many
applicants who see themselves going financially backward if they come
to Maui.
HAWAII STATE OFFICE OF VETERANS SERVICES
The Office of Veterans Services, although it belongs to the State
of Hawaii and not the Federal Government, has long been instrumental in
helping our veterans receive the benefits and care to which they are
entitled. The Maui office no longer has a councilor and is being
covered one day a week by someone from Oahu.
As of June 30, 2007 the State councilors' offices had the following
number of office visits with the following level of staff:
------------------------------------------------------------------------
Visits Staff
------------------------------------------------------------------------
Oahu.......................... 2,275............ 3 councilors, 1
clerical.
Hawaii........................ 2,202............ 1 councilor, 1
clerical.
Kauai......................... 1,458............ 1 councilor, 1
(unfilled) clerical.
Maui.......................... 2,288............ 1 councilor
(unfilled), 1
clerical.
------------------------------------------------------------------------
Oahu has more telephone and outreach presentation contacts, which
of course is due to the large active duty population on the island. The
other islands have fewer active duty residents--in the case of Maui,
almost none. Their councilors work intensively with their clients on a
one-on-one basis, almost always on specific issues involving veteran's
benefits or health care.
With the departure of the Maui councilor, Mr. William Staton, and
the beginning of the new fiscal year, the office needs a permanent
full-time hire right away. We know 2 fine candidates now working full
time at other jobs. One of them would probably fill the position but
who would quit a permanent job for a temporary position?
The Maui Office of Veterans Services is a vital part of the
infrastructure supporting Maui veterans and is in danger of being
overwhelmed. The demand for their services, like the Veterans'
Administration's, will only increase as our soldiers come home after
fighting in conflicts for far too long.
We believe that Maui and the Big island each need 2 councilors and
2 clerical staff-instead of a multi-year supply of grave liners for the
state cemeteries. How do we get this changed and these very important
community positions filled as soon as possible?
DAV VAN
The VA needs to supplement volunteer staff to drive the van. Lack
of staff has led to clinic transportation difficulties for handicapped
and infirm veterans.
Mr. Chairman, we believe the problems we've recently encountered on
Maui are largely logistical and administrative, but magnified by cost
and distance. As such, they are a barometer of VA health care
efficiency in far flung, rural areas. Our clinicians are very
dedicated, but the weather is stormy.
Thank you for this opportunity to testify about veterans' health
care in Maui on behalf of the Vietnam Veterans of Maui County. We also
thank the Committee for its continuing support of the Nation's
veterans.
Senator Akaka. Is that your statement?
Mr. Haupt. Yes, sir.
Senator Akaka. Thank you. Thank you, Carl Haupt.
Now, we'll here from Karl Calleon.
STATEMENT OF KARL CALLEON, VIETNAM VETERAN
Mr. Calleon. Good morning, Mr. Chairman and Members of the
Committee. I'd like to thank you for the opportunity to testify
today.
I'll be talking about allowing private practice mental
health doctors to assist the veterans.
The VA office has become so thick that many vets are
discouraged from getting the mental and physical health care
they need. As a result, we have vets killing their families and
themselves.
It is a well-known fact that the VA does not have the
sufficient mental health resource throughout the system.
However, there are many qualified mental health providers who
would love to do their patriotic duty and help injured vets. I
don't understand why the VA would willingly outsource to
medical doctors and dentists, but not to mental health
specialists, who we need the most.
The VA does outsource the C&P evaluations to assist the VA
to process claims, but they do not outsource to private
practice mental health specialist to assist the vets. They only
outsource to assist the VA. It would be cost effective to
outsource to private practice mental health specialist because
they will only be paid on an as-needed basis. No extra money is
needed to be spent on facilities or employee benefits, making
this approach much more effective than maintaining the high
cost of clinics with their administration and maintenance
costs.
Now we can only get help during regular office hours.
However, most of our problems happen after office hours.
The expensive clinic is useless two-thirds of the time, but
the Government pays for it 24/7. I think most suicides occur on
nonoffice hours when the mental help is not available. Lack of
immediate attention has directly caused veterans suicides, like
it did recently at Tripler.
Maui has maintained a high-cost clinic. And much of the
time, there isn't even a doctor there to treat the vets. Please
remember, only the doctors provide life-saving treatment, not
the facilities which cost the most.
On Maui, after office hours and on weekends, we are told to
call 911 and go to the hospital emergency room. This is very
expensive and over triples the cost of our health care. And
there is no continuity of care. Why can't we just go directly
to a private doctor and not wait for clinic hours and face a
long waiting period, or go to the ER at extra expense to the
Government?
Lastly, we'd like to thank you for your kind consideration
and help you have provided us over the years. We are especially
impressed at how you jumped in and worked and help us when we
asked for help. You have a major role in resolving the problems
we were having in the C&P process. We offer our heartfelt
gratitude and appreciation.
Senator Akaka. Well, thank you. Thank you very much. We
really appreciate that. And now we'll here from Grant Steward.
Grant.
STATEMENT OF GRANT STEWARD,
OPERATION IRAQI FREEDOM VETERAN
Mr. Steward. Good morning. It is an honor to be allowed to
speak here today. After returning from the Middle East, I've
been to five different VAs. Although I generally feel
completely lost when I go there, the staff is always
professional and courteous.
Having spent two and a half years going to VA, here are a
few suggestions that may help veterans in the future. When VA
realizes that a vet will require counseling, it may benefit the
veteran if his or her family could get counselling as well, to
let them know what their veteran is going through.
An example would be, after a counseling appointment, the
counselor could call the veteran's spouse or family and offer
them some help. I find it difficult for myself to open up to
what's going on in my head. And, unfortunately, my family is
left in the dark.
My wife is very understanding. I do feel guilty for not
being able to communicate with her as much as I know I should.
Having a counselor that could explain things to her would
probably help bring some light to the situation.
There's nothing like being woken up in the middle of the
night with an elbow being jabbed into your side. According to
my wife, my teeth grinding is keeping her awake. Her elbow is
going to keep me awake. I don't have dental coverage because
it's only allowed for veterans who have 100 percent disability.
What I am having a difficult time understanding is, if I'm
going to have two service-connected problems with my head, why
can't VA take care of the whole head? So that is the whole
thing right there.
The following paragraph comes from a published study
released March 2001, where 40 veterans with PTSD and 40
veterans without PTSD had an oral examination to evaluate
toothwear.
Results showed significantly increased wear of tooth
services in the three dimensions near the gumline--
vertical, horizontal and depth--in those with PTSD
compared to controls. Erosion vertically was more than
three times greater, horizontally more than four times
greater, and more than ten times greater in depth than
controls.
The only reason I mentioned this is because, while I was in
Iraq and even when I came back, I wake up constantly with pain
in my jaw. And my dentist thinks it's from all this constant
teeth grinding. And I've already lost several teeth since I've
been back because of this. And VA can't do anything because of
all the red tape. So that's why I mentioned that today.
Lastly, I really hate missing appointments. This is a
result of several calls to the VA to make sure of my
appointment time, as I have a tendency to lose the paper I
write the appointment on. If the VA had a way of e-mailing
appointments or appointment cancellations, my memory loss
wouldn't cause a lot of overworked VA staff.
Thank you for your time. And I hope these suggestions
benefit everyone who has served and sacrificed for our country.
Thank you.
[The prepared statement of Mr. Steward follows:]
Prepared Statement of Grant Steward, Operation Iraqi Freedom Veteran
Good Morning. My name is Grant Steward and I am a U.S. Army
veteran. I feel honored to stand here before such prestigious
individuals.
Since returning from the Middle East, I've been to five different
VA's. Although I generally feel completely lost when I go there, the
staff is always professional and courteous. Of the five different
centers, the Maui clinic, in my opinion, is the best. The doctors and
staff all deserve a pat on the back for how attentive they are to their
patients' well being.
Having spent two and a half years going to the VA, here are a few
suggestions that may help veterans in the future.
When the VA realizes that a veteran will require counseling, it may
benefit the veteran if their family could get counseling as well; if
only to let them know what their veteran is going through.
I find it difficult to open up with what's going on in my head, so
unfortunately, my family can get left in the dark. My wife has been
very understanding, and I do feel guilty for not being able to
communicate with her as much as I know I should.
Recently, I had to deal with a rather messy landlord/tenant issue.
If the local VA had a list of lawyers who work with veterans, it would
have helped with the stress by pointing me in the right direction.
While in the Army, whenever a legal issue happened, JAG was full of
wonderful answers. These days, I call my counselor and have him tell me
to try not to stress out. Unfortunately, with a wife and 3 little
children, not having electricity in your house can bring on lots of
stress.
There's nothing like being woken up with an elbow jabbing into your
side. According to my loving wife, if my bruxism, teeth grinding, is
going to keep her awake, her elbow will keep me awake. I even find
myself clinching my teeth throughout the day. I don't have dental
coverage, so my teeth get worse every month. I understand the VA
wanting to cut costs, but when you have a service connection for two
problems with your head, the VA should include care for the whole head.
The following paragraph comes from a published study, released
March, 2001, (University at Buffalo, Buffalo VA Medical Center) where
40 veterans with PTSD and 40 patients without PTSD had an oral
examination and evaluation of tooth wear.
``Results showed significantly increased wear of tooth surfaces
in three dimensions near the gum line--vertical, horizontal and
depth--in those with PTSD compared to controls. Erosion
vertically was more than three times greater, horizontally more
than four times greater and more than 10 times greater in depth
than controls.'' \1\
\1\ http://www.buffalo.edu/news/fast-execute.cgi/article-
page.html?article=50630009.
I hate the idea of missing an appointment. This usually results in
several calls to the VA to make sure of my appointment times, as I have
the tendency to lose the paper I write my appointments on. If the VA
had a way of e-mailing appointments and appointment cancellations, my
memory loss won't continue to result in an overworked VA staff.
Thank you for your time and I hope these few suggestions benefit
all those who have served and sacrificed for our country.
Senator Akaka. Thank you very much, Grant. And now we'll
hear from William Stroud.
Mr. Stroud. Aloha.
Senator Akaka. Thank you.
STATEMENT OF WILLIAM FIELDING STROUD,
PAST PRESIDENT, VIETNAM VETERANS OF MAUI COUNTY
Mr. Stroud. Thank you for inviting me here to speak on
behalf of our veterans about health care system. Thanks mainly
to a 10-year effort of the Vietnam Veterans of Maui County to
obtain a clinic here on Maui for the veterans. There is now a
small facility here which has guaranteed a certain level of
stamp.
Because this clinic handles the 11,000 veterans here in
Maui County, it's crucial that minimum staffing level remain in
place. Earlier this year, all of our doctors had quit from
overwork and we were left without a staff. When I found this
out, I immediately e-mailed you, Senator Akaka, and you took
action by going to the VA director and presented him with this
information, received a promise of getting one doctor fast,
with another one coming up in a few months.
Sir, I applaud you, not only for your words concerning the
veterans, but of your willingness to take action. You are a
warrior of the highest caliber for taking such good care of
your men. In this case, the soldiers of our Nation.
We now have a critical situation of immense proportion. Not
only on Maui, but across our whole land.
We have hundreds of thousands of citizen soldier veterans
returning from combat and entering immediately back into what
can be called their normal lives. But their lives are not
longer normal. The reality of war can leave a person an
internal wreck.
One may look normal on the outside and try to fit in and do
what is right. But believe me, if you've been in combat, you
must agree with me that your internal world is forever changed
from the experience. Some deal with it. And others fall apart.
Now we hear statistics that 30 percent of the returning
combat veterans are seeking PTSD treatment and care. We're
talking hundreds of thousands of our men and women whom we sent
over there, coupled with the hundreds of thousands of
backlogged PTSD cases which we already had from Vietnam and
earlier conflicts. We have to admit that the VA is overwhelmed,
and very directly speaking, not up to the task. If it was, we
wouldn't be in the situation we're in.
VA medical care is among the best. This is not what
concerns me personally. I am more concerned that these
returning combat veterans get the PTSD care they need
immediately so we do not leave these kids and their families
hanging in the wind. But if the VA can't give them the care
that they need, what can be done, one might ask.
Well, I know from my personal experience that it really
takes a combat vet to relate to another combat vet.
For an intellectual person to address the subject of combat
without the empathetic or analogical experience themselves is
to make a mockery of the word treatment. Our veterans don't
need simple therapy. They need lasting positive change,
achieved through their experience not just words.
I propose that such a program be funded to be run on Maui
for these returning combat vets run by combat vets and
professionals who have been in combat situations. And having
returned, we're able to shed the negativity of their combat
experience and learn from it.
There is such a group here on Maui who can come together,
administer and implement an effective two-month program to run
combats through on a continual basis. There are such facilities
right now which can be rented or purchased if we acted in a
timely manner. These men and women returning from war need our
help.
Not dealing with PTSD issues is not an issue. With the Army
having the highest suicide rate in 26 years, we definitely have
a problem. If we fail to act now, we're looking at hundreds of
billions of dollars in lifetime care in benefits. And more
importantly, the utter failure of taking care of our sons and
daughters, whom we voted to put in harm's way.
Now, they say we are we going to pull out. Well, if the war
ended tomorrow, we'd have a rush of people who needed treatment
and care. Are we ready for this right now? I would say no. We
must be ready and get ready for the realities of PTSD in a
large way. And who better to deal with these imbalances other
than combat vets who know the way out of this internal hell.
Please give our returning combat vets the support they need
and do not be afraid to try something new. We don't want to
give these returning vets pills. We don't want to treat them on
the cheap. We want to give them the experience and the tools
they need to fight their internal war, coming out alive,
healthy and being a force of good in our lives.
The Maui Vietnam Veterans have proven their worth many
times over, both in combat and in peace. We have supported both
our country and our community. Our country once again needs
help and we're here, willing and able to continue our service.
Thank you.
[The prepared statement of Mr. Stroud follows:]
Prepared Statement of William Fielding Stroud, Past President,
Vietnam Veterans of Maui County
It has become public knowledge through the National News outlets
what Vietnam Veterans and Veterans from other previous wars know from
experience: The VA system for dealing with Veterans with PTSD issues is
pretty much broken. Our VA professionals really do not know how to deal
with these PTSD issues as 99 percent of them have never tasted combat
themselves; they can provide pills but are pretty ineffectual/slow/
inexperienced in combating active PTSD issues. With a backlog of over
250,000 cases even before the current mid-east crises' arose, and 100's
of thousands more current Veterans seeking relief from their PTSD
issues, our country is in a crises of unimaginable proportions.
Older Veterans know, from experience, that if PTSD issues are not
addressed early upon returning from a combat situation, these internal
conflicts will continue to solidify into patterns of behavior which are
destructive and can, and do, lead to a downward spiral of damaging
personal behavior, many types of family conflicts, large numbers of
homelessness and large numbers incarcerated in jails and prisons. And
now that there are many women veterans, we are looking at new areas of
concern for our society.
This situation is unacceptable to us who have fought in combat in
earlier theaters of operation. We cannot sit back and watch as our
younger brothers and sisters go through the years of physical,
emotional, mental and spiritual anguish which can be reduced and/or
eliminated if approached by people of like experience who have gone
through the process of re-integration themselves.
This correspondence is to inform you that there is a credible team
of peers, professionals and laymen living here on Maui consisting of
many combat veterans who have gone through the process of ``discharging
the negativity of the past'' and have the knowledge and expertise to
take on these veterans with PTSD issues and teach them how no part of
their life is so traumatic that they can't learn from it and become a
more mature person; using their experience to become a more balanced
person and not a conflicted one.
There is a first-rate facility here on Maui which can easily handle
a minimum of 75 PTSD claimants every 3-month cycle which can be
obtained (if we act in a timely manner) to provide a place to run this
professional operation; and the cost of putting one veteran through
this 3-month program is infinitely small compared to a lifetime of 100
percent disability payments. By running traumatized veterans through
this program on a continual basis we can pretty much guarantee that our
government (and thus our citizens) will save many Billions of Dollars
in actual out-of-pocket expenses in taking care of these brave soldiers
for the rest of their lives as well as the additional social costs of
their resulting behavior. More importantly though is the fact that we
will be helping these veterans turn their lives around after having
undergone such traumatic experiences in such hostile environments; all
at the request of our Country.
We stand ready to act--Now! The PTSD issues being experienced are
not so hard to deal with for people who have had similar experience and
have made it out through to the other side. Please do not hesitate to
act! Our only interest is in helping out our fellow combat veterans and
their families; their wars continue on internally.
Senator Akaka. Thank you, William. Thank you for your kind
expressions as well, and for your testimony. I have a few
questions here. Let me ask Rogelio Evangelista and Danny
Kanahele.
You both testified before this Committee in January of last
year, when we held the first series of field hearings across
the State. What has changed since then in terms of VA care? Has
progress been made on improving access to care on Maui?
Rogelio.
Mr. Evangelista. Well, I notice there have been some
progress being made. We ended up with more staff at the CBOC to
take care of us. One thing that I'd also like to question is,
at the last hearing, I think I mentioned that some of the staff
there are not full-time VA staff, they're only contract
workers. Is it possible to get them also to be on staff and not
just contract workers?
Senator Akaka. I will look into that. Danny?
Mr. Kanahele. You had some pretty good improvements with
health care. I really appreciate that because that was really
needed. But I still think that the disability rating of the
veterans has to be addressed. I'd like to know how they really
go about it and how they rate these people to find out and make
sure they get what they need. Because it's been a while. I know
a lot--it's been a while and they have never moved yet. They're
still there.
Senator Akaka. Well, thank you for that. And, of course,
what I'm reaching for is to find out what else is needed on
Maui. Plenty of you have testified to that. So let me call on
Carl Haupt.
Mr. Haupt. When Senator Inouye dedicated the Maui CBOC, he
said this clinic will be our model clinic for the Nation. Is
our clinic still fulfilling Senator Inouye's and Senator
Akaka's vision? I don't think so.
Two issues about quality care have come to our attention.
The first is equipment. The second is staffing. We are now
losing our ophthalmologist because he is not provided with even
the most basic equipment to do his job.
The Audience Members. We can't hear you.
Mr. Haupt. We are now losing our ophthalmologist because he
is not provided with even the most basic equipment to do his
job. I just went to see him the other day.
His hand was out here and my eyes were over here. And I
thought where is the retina machine Dr. Hastings said was in
the warehouse back in March?
A VA cardiologist comes for examinations on Maui. He
doesn't have the proper equipment at the clinic. Why are we
wasting his time and our money? Why does our clinical staff
continue to have to work evenings and Saturdays with no extra
pay just to get caught up with the paperwork?
The Washington Post brought attention to the problems with
records transfer between the Department of Defense and the
Veterans' Administration, but the VA staff in Hawaii has been
coping with it ever since the cooperative agreement with
Tripler was signed, even before 9/11. It is contributing
heavily to staff burnout and turnover.
As of two months ago, there were approximately 600 people
on the CBOC waiting list who were not able to get VA care.
Kathy Haas told us the other day that this is not so anymore,
that this list has been totally eliminated. We'd like to hear
her testimony today to straighten this out.
We can't believe that we have one doctor and one other
doctor come onboard on the first of this month, and now all of
a sudden, the 600 patients on waiting list are gone. That's
unbelievable. But if they said they'd done it, I don't want to
say anyone's a liar. I'd just like to hear the testimony on the
record to say it was done and how it was done.
These people are paying $600 to $800 a month for their
maintenance prescriptions. Their VA copayment will be about
$35. Many of these veterans are our oldest and most
distinguished World War II and Korean Veterans.
According to a 2004 study sponsored by the VA Health
Services Research and Development Service, only about one in
seven VA pharmacies fits the definition of having a small
number of outpatient visits annually with a relatively large
pharmaceutical cost. This number was 10 percent of the VA
patients, only 10 percent. The budget impact of this 10 percent
was only about 1 percent of the medical care appropriations.
Many of these people seem to forget that because of these
great men who fought in World War I and II and Korea, and many
other conflicts, we have the greatest democracy in the world
right now. What can be done right now to alleviate the terrible
financial burden on our oldest most distinguished heroes? When
will we get the necessary staff and equipment to properly
fulfill the Maui clinic's promise?
We have heard enough off-the-record comments about the
quality of care in Hawaii to believe that outside
Congressional-level investigators should interview past and
present VA clinicians in order to get an accurate and better
picture of our veterans' health care.
We felt these people will tell us off-the-record this,
that, and the other thing. But they will not say it to their
bosses because they're afraid to lose their job.
If you have an investigation, like we did before, and
deposition from people to get the right answers to the right
problems, I think a lot of these problems will be alleviated.
Senator Akaka. Thank you. Let me ask a final question. And
this is to all of you. What improvements do you believe could
be made to VA health care on Maui and in the State of Hawaii
overall?
As you've said, you have had all these experiences as
veterans and in dealing with the VA. And as I pointed out,
we're looking for what I call challenges that we need to deal
with to improve the services here on Maui. So let me give each
one of you a chance to respond to what improvements do you
believe could be made to VA health care on Maui and in the
State of Hawaii overall.
So let me begin with Rogelio.
Mr. Evangelista. Well, Senator, like all other health plans
in the State, I'm looking at 7/24 health care center to help
the veterans. Because they suffer 7 days, 24 hours. I think
that would, hopefully, be something that we could look forward
to in the near future.
Senator Akaka. Thank you. Clarence.
Mr. Kamai. Again, Senator, I would have to agree with
Roger. And I believe again that what Mr. Skaggerberg mentioned
about the fee basis as being a problem solver for this island,
and possibly for Kauai and the other outside islands. It would
solve, I believe, a lot of the problems that is happening now.
Senator Akaka. Mahalo. Danny.
Mr. Kanahele. I agree with these two guys, I think we're
all going to agree on the same subject. But I think--you've got
that equipment in Tripler. I think if we have one here, we'd
save a lot of money for our people traveling back and forth. If
we can get some equipment here for us--we have Maui, Lanai,
Molokai--that would save a lot of money from everybody flying
that far. I think that would do it also, sir. Thank you.
Senator Akaka. Mahalo. Mitch.
Mr. Skaggerberg. The mental health professionals we have
are some of the best in the country. But they're overwhelmed.
And we (those of us with 100 percent PTSD, and have had
numerous family problems) have to wait four or five weeks to
have follow-up appointments. Much too long!
As Roger and Danny said, a lot of our crisis comes during
off-hours, weekends. All of a sudden, our family are exposed to
us for three days and we're flashing back or we're about to do
harmful things to our families. A lot of it is verbal abuse.
But I think we need to look at how we are going to get a 24/7
mental health care.
We have hundreds and hundreds of disabled veterans with
PTSD here on Maui and on Kauai and on the Big Island. I don't
have answers. I mean, maybe we ``fee basis'' that too, to start
with. I know we need at least four or five full-time mental
health professionals right now. And I think we only have two.
But we understand that another one at the Vet Center is
thinking of accepting the job. But we need more than that, and
we need it 24/7.
Most of my episodes happen outside of clinic hours. And
it's amazing how a lot of them happen on the weekends, for
whatever reason. And we're sitting there for three days just to
be able to call the clinic and say we need help.
And then, of course, they want to help us, but they have
other critical things going on at the same time. So I would say
let's look at some ``fee basis.'' There are some outstanding
psychiatrists on the island in private practice that I think we
should look at as being able to handle that as well.
Senator Akaka. Thank you. Thank you very much, Mitch. Carl.
Mr. Haupt. I agree with Mitch about we need more mental
health professionals.
I'd also like to add that we need to offer them higher pay.
Money paid to employees on Maui is the number one reason for
lack of applicants. Even with 25 percent COLA, housing, food,
gasoline, we run the highest price in the Nation, discouraging
many applicants who see themselves going financially backward
if they come to Maui. Thank you.
Senator Akaka. Thank you. Karl Calleon.
Mr. Calleon. Same with me. I agree with everybody with what
they're stating. My testimony was about mental health problems.
If you cannot get the doctors here at our facilities to help us
out, why not attract the private practitioner and have them be,
you know--like these guys said, on a fee basis. That was my
main concern, too.
Senator Akaka. Mahalo, Karl.
Grant Steward.
Mr. Steward. I think they all hit it right on the head. The
24/7 care would be absolutely wonderful. Because life doesn't
exist between 8 to 5 only, Monday through Friday.
Mr. Skaggerberg. Can I interject something, Grant.
My understanding of the dental health care policy here is
that if you have a common injury or war injury, that even
indirectly affects your teeth, there is some time that you
should be able to get complete dental health care from the VA
system.
I can tell you a lot of our VA providers don't know this.
So I would ask you and the Senator to really look into that.
Because we have tremendous number of young soldiers coming back
and being denied. And yet, I believe-- if the last time I read
the regulations was if they can prove, you know. So to me,
that's a no-brainer, that his teeth should be getting fixed.
I'm sorry about that, Grant. I go crazy too sometimes. I
want to help you, and you deserve that. I would ask that
whoever is telling you that, ask them to look up the
regulations and go to Dr. Hastings, if necessary.
Mr. Kanahele. That's right.
Senator Akaka. Grant.
Mr. Steward. Every VA I've been to, I believe you have 6
months of care or 3 months of care, after which--until you're
100 percent. And I do believe it's one of the cost-saving
measures they have. And I've asked them here again because I
needed a dental guard. And they couldn't do it. So maybe if I
got a certain ache, they might fix it.
Senator Akaka. Thank you, Grant.
William. Bill.
Mr. Stroud. I've been using the clinic ever since it was
established here. But one thing I realized early on is that it
is small with only a few staff dealing with a lot of people. So
every time I needed an appointment, whether it's dental or
vision or dermatology or arthritis or whatever, I call the
specific department over at Oahu, because I know they have a
larger staff. I get appointments and I get airplane tickets I
need to get over there. And I get referred to a local dentist.
Like last year, I was running for Mayor and I didn't have
my false teeth, I lost them. So I needed like partials in a
hurry, and I explained this to them. They sent me over to a
dentist in Kihei, and I have it taken care of before my first
debate. So it was both necessary and very gratifying to get
that level of service.
So I would like to recommend that people here don't need to
swamp the clinic with their 800 phone calls. As past president
of Vietnam Veterans of Maui County, I used to mail out a list
of everybody over at Oahu, all the VA staff, the doctors and
the offices. And if you contact them directly, they're fast.
They get back to you fast. Thus, saving this clinic a little
bit of grief and angst for being overloaded with all of this
stuff.
I don't know if this defeats the purpose of not having
everything here. But I found a way in which I can get treated
much faster than try to go in and jam the line in the clinic,
which nobody wants to do.
Thank you, sir.
Senator Akaka. Mahalo nui loa, Bill. William.
Mr. Stroud. Bill is good.
Senator Akaka. I want to thank all of our witnesses for
your testimony, for your response, and for your comments.
Without question, it's going to be helpful to all of us, and
especially in our work on a different level of Government to
continue to help those on the State level, and as well as on
the Federal level.
The Committee will keep all of these as records, and we'll
be working on it. So I want to say mahalo nui loa to this
panel.
(Recess.)
Senator Akaka. Aloha. I wanted to say aloha to all of you
on the second panel. We'll go on with our second panel here. I
want to welcome our second panel. I want to welcome Dr. Michael
Kussman, who is the VA Under Secretary for Health. We're
grateful for you coming and attending our hearings here in
Hawaii. He is our top man for health at the VA. And so we are
grateful to have him here. He is accompanied by Dr. Jim
Hastings, who's the Director of the VA Pacific Islands Health
Care System here in Hawaii; and Dr. Robert Wiebe, who's the
Director of VISN 21.
I also want to welcome Mark Moses. He is the Director of
Office of Veterans Services for the entire State of Hawaii.
He's doing a tremendous job and we're delighted to have him
here today.
Finally, I want to welcome Dr. Michael Shepherd, Senior
Physician in the Office of Health Care Inspections of the
Office of the Inspector General. And we have here Julie Watrous
from the VA Inspector General's Office accompanying him. I want
to thank each of you for being here today and your full
statements will appear in the record of the Committee.
Now I'd like to call on Dr. Kussman. As I said earlier, I
can't say enough to welcome him and thank him for being
present, and also the others of you on this panel.
Dr. Kussman.
STATEMENT OF HON. MICHAEL J. KUSSMAN, M.D., MS., M.A.C.P, UNDER
SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY ROBERT L. WIEBE, M.D., DIRECTOR, VISN 21,
DEPARTMENT OF VETERANS AFFAIRS; JAMES HASTINGS, M.D., F.A.C.P.,
DIRECTOR, VA PACIFIC
ISLANDS HEALTH CARE SYSTEM, VETERANS HEALTH
ADMINISTRATION, DEPARTMENT OF VETERANS AFFAIRS
Dr. Kussman. Mr. Chairman, mahalo nui loa for the
opportunity to be here today to testify before you to discuss
the state of the VA care here on Maui.
Before I get to my prepared remarks, I'd like to express
from the VA in total, from the Secretary to the Deputy
Secretary, myself, and all our 230,000 people for the sorrow
and sadness of what happened in Iraq for the deaths in the
recent helicopter crash of the members of the 25th Infantry
Division, to all the members of the 25th Infantry Division,
particularly the family members of the deceased. This is
particularly poignant for me personally, having been a member
the 25th Infantry Division as a division surgeon. We send our
condolences and sorrow to all the people involved.
It's a privilege to be here in Maui, the Valley Isle, to
speak and answer questions about issues important to the
veterans residing in Maui County. Today I will describe our
current services and highlight issues of particular interest to
veterans residing in Maui, Molokai and Lanai. I would like, as
you mentioned already, to have the written testimony submitted
for the record. Thank you.
Senator Akaka. In the record.
Dr. Kussman. The Maui Community Based Outpatient Clinic
serves an estimated veteran population of almost 10,000
veterans. In FY 2006, 2,328 Maui veterans were enrolled for
care and 1,436 received VA care. The Maui CBOC recorded 9,217
clinic stops, a 46 percent increase from FY 2002. But market
penetration rates for enrollees and users suggest additional
demand is needed for the veterans' health care services here.
The past year has been difficult for the staff and patients
served by the Maui CBOC. That was mentioned already by the
previous panel. But the health care system provided coverage
with a combination of contract and VA staff traveling from
Honolulu. It wasn't what we would have liked, but we did the
best we could given the circumstances.
I am pleased to announce we have hired additional staff and
shortened waiting times for new patients for first primary care
appointments. By next month, the clinic should have two full-
time VA primary care physicians and one full-time primary care
and nurse practitioner. When the new staff is hired and
onboard, we will have sufficient capacity for over 2,000
primary care patients.
There is also significant demand for mental health care
services at the Maui Community Based Outpatient Clinic. About
32 percent of all patients currently seen at the clinic have a
documented mental health illness. The authorized mental health
providers include a psychiatrist, a psychologist, a social
worker, a clinical nurse specialist, and a substance abuse
counselor. We will soon have a telehealth psychologist and a
telehealth technician available as well. The Maui Vet Center is
also recruiting for another mental health care clinician.
Specialty care services are also available during scheduled
visits from physicians and clinicians from the Honolulu VA
Medical Center and other VA facilities in California. If a
veterans' needs service is not available at the clinic, the
health-care system arranges and pays for care in the local
community.
The islands of Molokai and Lanai are part of Maui County.
VA provides limited services on these islands, but is accessing
options to enhance care and access at both locations. VA
estimates that the veteran population on Molokai is 649, and
the VA provided care to 148 of them in FY 2006. The VA clinic
in Molokai is located in shared space near Molokai General
Hospital and operates two half-day primary care clinics per
week.
The clinic is staffed with a part-time VA physician and
contract support staff. The health care system plans to acquire
dedicated space on Molokai, telehealth care equipment, and to
add telemental health services when the staff at Maui CBOC is
available.
In FY 2006, the VA provided care to more than half of the
58 enrolled veterans on Lanai. We estimated there are
approximately 229 veterans on the island. For the past two
months, the VA has sent a primary care physician from Honolulu
to Lanai once a month to provide needed primary care services.
We will reassess the suitability of this monthly visit in about
6 months. The health care system is exploring options with a
nearby Straub Clinic, and we hope to relocate our services to
this location in the coming months.
In summary, with your support, Mr. Chairman, the VA is
providing an unprecedented level of health care service to
veterans residing in Hawaii and here on Maui. I am proud of the
improvements in VA services in Hawaii, but we recognize our job
is not done and there's more to do.
Again, Mr. Chairman and other members, mahalo nui loa for
opportunity to testify at this hearing. And my staff and I
would be delighted to answer any questions you might have.
Mahalo.
Senator Akaka. Thank you. Thank you, Dr. Kussman.
[The prepared statement of Dr. Kussman follows:]
Prepared Statement of Hon. Michael J. Kussman, M.D., M.S., M.A.C.P.,
Under Secretary for Health, Department of Veterans Affairs
Mr. Chairman and Members of the Committee, mahalo nui loa for the
opportunity to appear before you today to discuss the state of VA care
in Maui. It is a privilege to be here in Maui--the Valley Isle--to
speak and answer questions about issues important to veterans residing
in Maui County.
First, Mr. Chairman, I would like to thank you for your outstanding
leadership and advocacy on behalf of our Nation's veterans. During your
tenures as Chairman and Ranking Member of this Committee, you have
consistently demonstrated your commitment to veterans. As I will
highlight later, your vision and support have helped us provide an
unprecedented level of health care services for veterans throughout
Hawaii and the Pacific Region. In addition, I appreciate your interest
in and support of the Department of Veterans Affairs (VA).
Today, I will briefly review the VA Sierra Pacific Network that
includes Hawaii and the Pacific Region; provide an overview of the VA
Pacific Islands Health Care System (VAPIHCS) and the VA clinic here in
Maui; and highlight issues of particular interest to veterans residing
in Maui County, including capacity at the VA clinic in Maui and VA
services on the nearby islands of Molokai and Lanai. I also look
forward to addressing any questions you might have for me and my staff.
VA SIERRA PACIFIC NETWORK (VISN 21)
The VA Sierra Pacific Network (Veterans Integrated Service Network
[VISN] 21) is one of 21 integrated health care networks in the Veterans
Health Administration (VHA). The VA Sierra Pacific Network provides
services to veterans residing in Hawaii and the Pacific Region
(including the Philippines, Guam, American Samoa and Commonwealth of
the Northern Marianas Islands), northern Nevada and central/northern
California. There were an estimated 1.1 million veterans living within
the boundaries of the VA Sierra Pacific Network in Fiscal Year 2006 (FY
2006).
The VA Sierra Pacific Network includes six major health care
systems based in Honolulu, HI; Palo Alto, CA; San Francisco, CA;
Sacramento, CA; Fresno, CA; and Reno, NV. Dr. Robert Wiebe serves as
director and oversees clinical and administrative operations throughout
the Network. In FY 2006, the Network provided services to 235,000
veterans. There were about 2.9 million clinic stops and 24,500
inpatient discharges. The cumulative full-time employment equivalents
(FTEE) level was 8,400 and the operating budget was about $1.5 billion.
The VA Sierra Pacific Network is remarkable in several ways. In FY
2006, VISN 21 was the highest-ranked Network in overall performance
(based on an aggregation of quality, access, patient satisfaction and
business metrics). The Network hosts the highest number of Centers of
Excellence and also has the most highly funded research programs in
VHA. In the most recent all-employee survey, staffs in VISN 21 reported
the highest overall job satisfaction in VHA. Finally, VISN 21 operates
one of four Polytrauma units in VHA that are dedicated to addressing
the clinical needs of the most severely wounded Operation Iraqi
Freedom/Operation Enduring Freedom (OIF/OEF) veterans.
VA PACIFIC ISLANDS HEALTH CARE SYSTEM (VAPIHCS)
As noted above, VAPIHCS is one of six major health care systems in
VISN 21. Dr. James Hastings is the director and a practicing
cardiologist at VAPIHCS. VAPIHCS is unique in several important
aspects: its vast catchment area covering 2.6 million square-miles
(including Hawaii, Guam, American Samoa and Commonwealth of the
Northern Marianas); island topography and the challenges to access it
creates; richness of the culture of Pacific Islanders; and the ethnic
diversity of patients and staff. In FY 2006, there were an estimated
102,000 veterans living in Hawaii (representing 8 percent of the total
population in Hawaii and 9 percent of total veteran population in VISN
21).
VAPIHCS currently provides care in seven locations: the Ambulatory
Care Center (ACC) and Center for Aging (CFA) on the campus of the
Tripler AMC in Honolulu; and Community Based Outpatient Clinics (CBOCs)
in Lihue (Kauai), here in Kahului (Maui), Kailua-Kona (Hawaii), Hilo
(Hawaii), Hagatna (Guam) and Pago Pago (American Samoa). VAPIHCS also
has outreach clinics in Molokai and Lanai. The inpatient Post Traumatic
Stress Disorder (PTSD) unit is now also on the campus of Tripler AMC
(the unit was formerly in Hilo). In addition to VAPIHCS, VHA operates
five Readjustment Counseling Centers (Vet Centers) in Honolulu, Lihue,
Wailuku, Kailua-Kona and Hilo that provide counseling, psychosocial
support and outreach.
In FY 2006, VAPIHCS provided services to nearly 22,500 veterans,
19,000 of whom reside in Hawaii. There were 198,000 clinic stops in
Hawaii during FY 2006 (7 percent of Network total). The cumulative FTEE
in FY 2006 for the health care system was 502 employees. The operating
budget for VAPIHCS (i.e., General Purpose allocation from appropriated
funds) increased from $68.0 million in FY 2002 to $110 million in FY
2007--an increase of 62 percent. For comparison, during this same time
period, the operating budgets for VISN 21 increased 48 percent and VHA
increased 43 percent. (Please note these amounts do not include
Specific Purpose Funds and Medical Care Cost Funds [MCCF].)
VAPIHCS provides or contracts for a comprehensive array of health
care services. VAPIHCSdirectly provides primary care, including
preventive services and health screenings, and mental health services
at all locations. VAPIHCS does not operate its own acute medical-
surgical hospital and consequently, faces challenges in providing
specialty services. VAPIHCS recently hired specialists in orthopedics,
ophthalmology, nephrology and inpatient medicine (``hospitalist'') and
is providing selected specialty care in Honolulu and to a lesser
extent, in CBOCs. VAPIHCS is actively recruiting additional specialists
(e.g., Urology) and will continue to refer patients to DOD and
community facilities.
Inpatient long-term and acute rehabilitation care is available at
the CFA. Inpatient mental health services are provided by VA staff on a
20-bed ward within Tripler AMC and at the 16-bed PTSD Residential
Rehabilitation Program (PRRP). VAPIHCS contracts for care with DOD (at
Tripler AMC and Guam Naval Hospital) and community facilities for
inpatient medical-surgical care.
The current constellation of VA facilities and services represents
a remarkable transformation over the past several years. Previously,
the VAPIHCS (formerly known as the VA Medical and Regional Office
Center [VAMROC] Honolulu) operated primary care and mental health
clinics based in the Prince Kuhio Federal Building in downtown Honolulu
and CBOCs on the neighbor islands that were staffed primarily with
nurse practitioners. Congress approved $83 million in Major
Construction funds to build a state-of-the-art ambulatory care facility
(i.e., ACC) and a long-term care/rehabilitation unit (i.e., CFA) on the
Tripler AMC campus and these facilities were activated in 2000 and
1997, respectively. VISN 21 allocated nearly $17 million from FY 1998-
FY 20OO to activate these projects. VISN 21 also provided dedicated
funds to enhance care on the neighbor islands by expanding/renovating
clinic space and adding additional staff to ensure there are primary
care physicians and mental health providers at all CBOCs.
MAUI CBOC
VA operates a CBOC located in Kahului (203 Ho'ohana, Suite 303,
Kahului, HI, 96732). In FY 2002, VAPIHCS spent $208,000 to renovate the
clinic. The Maui Vet Center is located in nearby Wailuku.
The Maui CBOC serves an island veteran population estimated in FY
2006 to be 9,900. In FY 2006, 2,382 veterans residing in Maui were
enrolled for care and 1,436 veterans received VA care (``users''). The
market penetrations for enrollees and ``users'' are 24 percent and 14
percent, respectively. These are lower than rates elsewhere in Hawaii.
As I will discuss later, the Maui CBOC has recently increased its
staffing and currently is authorized to have 19 staff at the clinic.
For comparison, at the time of your last hearing here in January 2006,
the authorized staffing was 12.4 FTEE. The authorized primary care
providers include two physicians, a nurse practitioner and a social
worker. The authorized mental health providers include a psychiatrist,
psychologist, social worker, clinical nurse specialist and substance
abuse counselor. With this staff, the Maui CBOC provides a broad range
of primary care and mental health services. In addition, VAPIHCS
provides specialty care services at the clinic by sending VA staff from
Honolulu and other VA facilities in California. Services provided by
clinicians traveling to Maui include cardiology, gastroenterology,
geriatrics, nephrology, neurology, optometry, orthopedics and
rheumatology. If veterans need services not available at the clinic,
VAPIHCS arranges and pays for care in the local community (e.g., Maui
Memorial Hospital), Honolulu (including Tripler AMC) or VA facilities
in California. In FY 2006, VA spent nearly $3.6 million for non-VA care
in the private sector (i.e., not including costs at other VA or DOD
facilities) for residents of Maui.
In FY 2006, the Maui CBOC recorded 9,217 clinic stops, representing
a 46 percent increase from FY 2002 (i.e., 6,292 stops). The past year
has been difficult for the staff and patients served by the Maui CBOC.
Several staff, including a VA and a contract primary care provider,
left the clinic for a variety of personal and economic reasons (e.g.,
cost of housing on Maui). VAPIHCS provided coverage with a combination
of contract and VA staff traveling from Honolulu.
Some patients, like Mr. Richard Bond were pleased with the
arrangement. In a letter to an editor, he wrote, ``I want to thank the
Maui VA clinic. Out of the blue, staff phoned me with a lab appointment
and a few days later, a doctor's appointment. Dr. Wong [a VA physician
at the ACC in Honolulu] flew over from Honolulu and I received a
thorough physical and a flu shot to boot.'' However, VAPIHCS
understands that other patients were dissatisfied because continuity of
care was not optimal and waits for appointments lengthened. I am
pleased to report that with additional staff, the situation has
improved and the clinic currently has short waiting times for new
patients with very few veterans waiting more than 30 days for their
first primary care appointment.
SPECIAL ISSUES
Capacity at Maui CBOC
As noted earlier, in FY 2006 VA provided health care services to
1,436 veterans who reside in Maui. However, market penetration rates
for enrollees and ``users'' suggest there is additional demand for VA
health care. This was corroborated by veterans' advocates during a
meeting with Drs. Wiebe and Hastings earlier this year in Maui.
Consequently, VAPIHCS has significantly increased the authorized
staffing at the Maui CBOC. When the new VA primary care provider
arrives next month, the clinic will have two full-time VA primary care
physicians and one fulltime primary care nurse practitioner. Based on
VA primary care panel size criteria, this would give the clinic a
theoretical capacity for over 3,000 primary care patients (i.e., 1,200
patients for each full-time physician and 800 for each full-time nurse
practitioner). Even considering the special circumstances at the Maui
CBOC (e.g., lack of VA inpatient facility and limited community health
care resources on the island), the VA clinic will be able to provide
high quality and accessible primary care to more than 2,000 patients.
In addition, the Maui CBOC will soon begin Home Based Primary Care
(HBPC) services for veterans residing in Maui. HBPC is currently
available in Oahu, Kauai and the Big Island. HBPC is an important
component of VA's non-institutional long-term care program designed to
provide care in the least restrictive setting for veterans.
There is also a significant demand for mental health services at
the Maui CBOC. About 32 percent of all patients currently seen at the
clinic have a documented mental health illness (compared to 19 percent
for VHA), including a high prevalence of PTSD. In response, VA has
substantially increased its authorized mental health capacity at the
Maui CBOC. As you know, Mr. Chairman, Congress has provided several
hundred million dollars to VA over the past two fiscal years to
specifically enhance mental health services. In FY 2006 and FY 2007,
VAPIHCS received nearly $2 million of these funds. These funds are
being used to hire about 30 new mental health staff in VA facilities
across Hawaii and the Pacific Region, including five staff here at the
Maui CBOC. When all of these positions are filled, the Maui CBOC will
have a psychiatrist, psychologist, clinical nurse specialist, mental
health social worker, substance abuse counselor, telehealth
psychologist and telehealth technician. In addition, the Maui
Readjustment Counseling Center (``Vet Center'') is also recruiting for
another mental health clinician (i.e., psychologist or social worker).
The size of the veteran population and number of VA patients in
Maui limit the feasibility of having a large cadre of medical and
surgical specialists based in the Maui CBOC. Nonetheless, VA recognizes
that some veterans in Maui County have needs that go beyond primary
care and mental health. VA sends specialists from Honolulu and
California to the clinic on a regular basis. As noted earlier, services
provided by clinicians traveling to Maui include cardiology,
gastroenterology, geriatrics, nephrology, neurology, optometry,
orthopedics and rheumatology. VAPIHCS also refers patients to the local
community for care at VA expense (when eligibility criteria are met)
and transports (also at VA expense, when eligibility criteria are met)
to the VA facility in Honolulu. The Maui CBOC also utilizes telehealth
technologies to provide specialty services.
Molokai and Lanai
The islands of Molokai and Lanai are part of Maui County. VA
provides limited services on these islands with permanent staff (on
Molokai) and visiting VA staff (to both islands). However, VA is
assessing options to enhance services in both locations.
Molokai
VA estimates the veteran population on Molokai to be 649. In FY
2006, 211 veterans from Molokai were enrolled for VA care and 148
veterans received VA services. VA formerly established an outreach
clinic on Molokai in FY 2005. However, Mr. Chairman, with the
assistance of you and your staff, VA now has established a more formal
presence on the island. The VA clinic on Molokai is located in shared
space near Molokai General Hospital and operates two half-day primary
care clinics per week. The clinic is staffed with a part-time VA
physician and contract support staff. Although VA has not installed its
own telehealth equipment in Molokai, VA currently has access to
videoconferencing equipment. VAPIHCS is hoping to acquire dedicated
space in Molokai to enable the placement of permanent information
technology (IT) and telehealth equipment. VA also sends mental health
staff from the Maui CBOC to Molokai to provide care. Specifically, the
psychologist travels twice a month and the psychiatrist once a month.
VAPIHCS is also planning to add tele-mental health services when staff
(at the Maui CBOC) and equipment are on-board. In addition, VA
purchases non-VA care in the community (e.g., Molokai General Hospital)
for eligible veterans residing in Molokai, at a total cost of $280,000
in FY 2006. Veterans residing in Molokai also are seen at DOD and VA
facilities in other locations. VA pays for travel expenses for those
veterans eligible for beneficiary travel.
Lanai
VA estimates the veteran population on Lanai to be 229. In FY 2006,
58 veterans residing on Lanai were enrolled for VA care and 30 veterans
received VA services. VA currently sends a primary care physician from
Honolulu to Lanai once a month to provide needed primary care services.
This began in June 2007, and we will reassess the frequency in about 6
months. VA currently is using space adjacent to the Lanai Community
Hospital and is negotiating with the hospital to use its
videoconferencing equipment for telehealth. VAPIHCS is exploring
options with the nearby local medical clinic (i.e.,Straub Clinic) and
we hope to relocate our clinic to this space in the next couple of
months. In addition, VA purchases non-VA care in the community and pays
beneficiary travel for eligible veterans. VA is exploring other options
to improve access, including adding an automated pharmacy dispensing
device and/or telehealth capabilities. We are also having conversations
with local residents in Lanai City about a possible federally Qualified
Health Center (FQHC) and how VA might participate in and partner with
FQHC.
CONCLUSION
In summary, with your support, Mr. Chairman, and other Members of
Congress, VA is providing an unprecedented level of health care
services to veterans residing in Hawaii and here in Maui. Although VA
struggled earlier this year with staffing at the VA clinic in Maui, we
now have a robust cadre of primary care and mental health
practitioners. We look forward to a growth of new patients at the Maui
CBOC and will meet the expectations of veterans for quality and
timeliness.
VAPIHCS still faces several challenges, in part due to the
topography of its catchment area, lack of an acute medical-surgical
hospital, limited community resources in rural areas and difficulties
recruiting staff. VAPIHCS will meet these challenges by utilizing
telehealth technologies, hiring specialists, working with community
partners and developing new delivery models. I am proud of the
improvements in VA services in Hawaii, but recognize that our job is
not done.
Again, Mr. Chairman and other Members of the Committee, mahalo nui
loa for the opportunity to testify at this hearing. My staff and I
would be delighted to address any questions you might have for us.
And now may I call Mr. Moses, representing the State. Mark
Moses.
STATEMENT OF MARK MOSES, DIRECTOR, OFFICE OF
VETERANS SERVICES, DEPARTMENT OF DEFENSE, STATE OF HAWAII
Mr. Moses. Thank you, Mr. Chairman. It's a great privilege
to testify before your Committee today. I am Mark Moses,
Director of the Office of Veterans Services, OVS.
OVS is the state leading agency responsible for the welfare
of Hawaii's veterans and family members. We act as the
Governor's liaison to veterans and veterans groups. We serve as
an intermediary between the Department of Veterans' Affairs.
And we also provide the state services and benefits that our
legislature has authorized.
We have provided services and information to nearly 33,000
veterans and survivors this past fiscal year. I've attached the
summary sheet describing some of those services and activities
made available for your review.
Mr. Chairman, as you understand, the final service we can
provide a veteran is interment in a veterans' cemetery with
appropriate honors. We take this seriously.
The VA has consistently supported our efforts to expand
Hawaii's cemetery plots and columbarium space to keep pace with
need. They are deserving of our gratitude.
Makawao Veterans Cemetery has sufficient columbarium space,
and we are looking at the need to expand it for burials and
plots. It is important to take this opportunity to thank you
personally, Senator, for your unwavering support for our
veterans' cemetery program.
Thank you very much.
The April 2000 data from the VA Office of Actuary, Office
of Policy, Planning and Preparedness estimated that there are
120,000 veterans in Hawaii: about 72 percent on Oahu, 13
percent on the Big Island, 10 percent on one of the Maui County
islands, and approximately 5 percent on Kauai.
Our island state represents unique challenges for the
Department of Veterans Affairs, but also for our State Offices.
You heard the testimony this morning about vacancies. We have
had vacancies. We've had two vacancies we could not fill by law
because of workers' compensation problems. Both have been
resolved, and we're hiring right now as of about the last week.
Our island state presents unique challenges in other ways
because of our separation.
I want to share with you comments that we have heard from
veterans. Now, they speak of the excellence of the VA medical
care and how VA staff treats veterans with dignity and respect,
and that the services rendered by the dedicated health care
professionals are superior to that they received on the
mainland. These comments are from local veterans and those
visiting from neighbor islands, as well as from out of state.
Similar comments are shared about the benefits staff.
Hawaii VA supports National Guard and Reserves prior to
deployment and upon their return, as well as all those members
ending their active military service. As a disabled veteran, I
can attest to the fact that the services provided by the VA
locally are among the top in the Nation.
I've had many of my services here by choice when I could
have gone to other hospitals. Nevertheless, given the proper
resources, they are capable of doing better.
Nearly 30 percent of our veterans live on the neighbor
islands. Many of them are referred for surgical services on the
mainland in VA medical facilities or civilian medical
facilities on Oahu or Tripler Army Medical Center. For neighbor
island veterans sent to mainland VA hospitals, this can be very
traumatic.
They are booked on flights, sent to a big city where they
may not know their way around, and they're told to find the VA
facility. They're operated on. And then they're sent back to
their homes in Hawaii. We ask that sufficient funding be
provided for direct mainland flights from, and whenever
possible, back to their neighbor island of residence.
Changes to 38 U.S.C. 1151, Benefits for persons disabled by
treatment of vocational rehabilitation, means only facilities
covered by the law are those over which the VA Secretary has
direct jurisdiction or a government facility contracted by him.
Tripler, Straub, Kuakini, Queen's and St. Francis do not
qualify. A veteran who suffers any additional disability, or
worse, are on their own, and they must sue the medical facility
by themselves for damages. It is an overwhelming task for most
of our veterans.
We suggest the definitions, as listed in 38 U.S.C. 1701(3)
and 38 U.S.C. 1151 be changed, allowing Hawaii veterans the
same protection as veterans receiving care in VA facilities on
the mainland. At a minimum, veterans must be given the
opportunity to make informed consent about the benefits and
shortfalls between having medical procedures performed at a
mainland VA facility or locally at a non-VA facility.
Hawaii's neighbor islands must be offered the same level of
medical care and services as veterans located on Oahu. Neighbor
island Community Based Outpatient Clinics place veterans on a
wait list, where they are scheduled for specialty medical care.
With the use of telemedicine and more frequent visits, this
problem is being addressed. However, a backlog still exists
with some veterans waiting months to see a specialist.
VA has a difficult time recruiting and maintaining
competent medical staff in these rural areas. VA should be
allowed to offer a premium to rural medical service providers
and to contract for additional medical care in rural areas,
such as the neighbor island.
With our thousands of National Guardsmen and Reservists
returning, my desire is that they and those already here
receive medical and benefit services in a timely matter. We ask
that VA Health and Benefits Administration be adequately funded
and staffed to provide medical care and benefits services to
all of Hawaii's veterans.
We just received a VA grant to help us with the building
and now the opening of the Yukio Okutsu Veterans Home. And it's
supposed to open this year. There have been some delays, and
we're awaiting the final date of opening. We still don't have
eligibility criteria, though, for the hospital. And we're
trying to get that information.
Eventually, I envision that we will have several veteran
long-term facilities, preferably at least one per county, if
not one per island. The need is here. I personally pledge that
I will look into making use of the beds in other facilities
under the law that you have just passed. Thank you very much
for that.
The present per-day veteran reimbursement rate is only
$67.71. And that's very low and insufficient to maintain a
veteran without additional payments. We request the
reimbursement rate be raised to adequately cover the long-term
service provided to assist the state in meeting the medical
care of this very fragile and older group of warriors. The
actual cost is approximately $300 a day.
As these veterans pass, many will utilize our state
veterans' cemetery system. Presently, the state and county are
reimbursed $300 for each veteran burial. Less than the cost to
open and close the grave and to provide perpetual care. The
actual cost is approximately $1,000 per grave.
This reimbursement rate has not changed in many years. And
we ask your Committee to look into increasing it to more
closely reflect the true cost of interments.
We must continue to take care of those who served.
They are our sons and daughters. They are Hawaii citizens.
They are our veterans. I thank you and the Committee for
this opportunity to testify. And I will respond to any
questions.
[The prepared statement of Mr. Moses follows:]
Prepared Statement of Mark S. Moses, Director, Office of Veterans
Services, Department of Defense, State of Hawaii
Chairman Akaka and Members of the Senate Committee on Veterans'
Affairs, I am Mark Moses, Director of the Office of Veterans Services
(OVS). The office is the single State lead agency responsible for the
welfare of Veterans and their family members. We act as the Governor's
liaison to veterans, veterans groups and organizations, and serve as an
intermediary between the Department of Veterans Affairs and Hawaii's
veterans. The office serves in partnership with the VA to provide state
services and benefits. We provided services and information to nearly
33,000 veterans and eligible survivors this past fiscal year. I have
attached a summary sheet describing some services and activities made
available through the office for your review.
The final service we can provide a veteran is interment in a
veteran's cemetery with appropriate honors. The Veterans Administration
has consistently supported our efforts to expand Hawaii's cemetery
plots and columbarium space to keep pace with need. They are deserving
of our gratitude.
Additionally, it is important and proper to take this opportunity
to thank you, Senator Akaka for your unwavering support for our
veteran's cemetery program. We are particularly grateful for your
assistance in obtaining the new grant for the West Hawaii Veterans
Cemetery located in Kona. State veterans cemeteries are the only
cemeteries accepting full body burials on a consistent basis in Hawaii.
This VA grant will assure that West Hawaii will be the cemetery we all
have envisioned it to be.
Based on April 2000 data from the Office of the Actuary, Office of
Policy, Planning and Preparedness, Department of Veterans Affairs,
there are an estimated 120,000 veterans in Hawaii. The majority, about
72 percent live on Oahu, 13 percent reside on the island of Hawaii, 10
percent live on one of the three islands which comprise Maui County,
and approximately 5 percent live on Kauai. Hawaii, an island state
located in the middle of the Pacific Ocean, presents unique challenges
for the Department of Veterans Affairs.
Before I discuss some of these challenges, I want to share with you
comments that my staff and I hear from veterans about VA health care
and benefit services. These individuals speak to the excellence of VA
medical care; that VA's staff treats veterans with dignity and respect,
and that the services rendered by the dedicated health care
professionals are superior to the care they received on the mainland
United States. These comments are expressed by local veterans as well
as by veterans who visit Hawaii and have a need to seek services from
Spark M. Matsunaga medical staff. Similar types of comments are shared
about the VA Benefit staff.
This ``new'' VA exemplifies the well known phrase of ``supporting
our troops.'' Hawaii's VA supports our National Guard members and
Reservists prior to deployment and upon their return. They also offer
services to military members who are ending their military service. As
a disabled veteran, I can attest to the fact that the services provided
by the VA locally are top in the Nation. Nevertheless, given the proper
resource they are capable of doing better.
As mentioned earlier, Hawaii presents unique challenges to the VA.
We are an island state with one large population center on Oahu. Nearly
30 percent of Hawaii's veterans live on the neighbor islands. Presently
many of our veterans are referred for surgical services to mainland VA
medical centers, civilian medical centers on Oahu, or to Tripler Army
Medical Center. This can be very traumatic for neighbor island veterans
who are sent to other VA hospitals. They are booked on flights, sent to
a big city to find the VA facility, operated on and sent back to their
home in Hawaii. We ask that funding be provided so that those who
reside on neighbor islands be provided direct flights to the mainland.
We also propose that whenever possible, return flights fly directly to
the veteran's island of residence.
Another issue that affects Hawaii and Alaska involves changes that
were made to 38 U.S.C. 1151, Benefits for persons disabled by treatment
of vocational rehabilitation. With this change the only facilities
covered by the law are those over which the Secretary of Veterans
Affairs has direct jurisdiction, or Government Facilities contracted by
the Secretary. Tripler Army Medical Center and other medical facilities
in Hawaii, such as Straub, Kuakini, Queens, and St. Francis do not
qualify under the present law. Veterans suffering an unlikely event
causing any additional disability or worse are on their own and must
sue the medical facility for damages. For most, obtaining an attorney
to pursue this option is overwhelming.
We suggest that the definitions as listed in 38 U.S.C. 1701(3) and
38 U.S.C. 1151, be changed so that veterans in Hawaii treated outside
VA facilities are afforded the same protection as veterans who receive
VA medical care in VA facilities on the mainland. Hawaii's veterans
must have the same right to redress as veterans treated at mainland VA
facilities. At a minimum, veterans must be given the opportunity to
make informed consent about the benefits and shortfalls of choosing
between having surgeries or other medical procedures performed at a VA
facility on the mainland or in non-VA facilities locally.
Hawaii's neighbor islands must be offered the same level of medical
care and services as veterans located on Oahu. Presently neighbor
island Community Based Outreach Clinics place veterans on a wait list
where they are scheduled for specialty medical care. With the use of
Telemedicine and more frequent visits, this problem is being addressed;
however, backlogs still exist. Veterans have been known to wait several
months before they see a specialist. Additionally, VA has a difficult
time recruiting and maintaining competent medical staff in these rural
areas. To address these needs, the VA should be allowed to offer a
premium to rural medical service providers and consider contracting for
additional medical care in rural areas such as the neighbor islands.
As you are aware, Hawaii has received thousands of its returning
National Guardsmen and Reservists. As Director of the Office of
Veterans Services, my desire is that these returning military members
and those already here be able to access medical and benefit services
in a timely manner. We ask that VA Health and Benefits Administrations
be adequately funded and staffed to provide medical care and benefit
services to all veterans who make Hawaii their home.
Hawaii has received a grant from the VA to build its first
Veteran's Home. The Yukio Okutsu Veterans Home is scheduled to open
within a few months. Our concern is with the reimbursement rate that
the VA pays for veterans who will be residing at the home. The present
reimbursement is insufficient to maintain a veteran without payment of
additional funds. We in Hawaii are not alone in requesting that the per
day reimbursement rate be raised so that it adequately covers long-term
care services supplied by the facility. We envision that the Yukio
Okutsu Veterans Home will be the first of several veterans' long-term
care facilities, preferably at least on per county due to inherent
island produced isolation. Adequate per resident reimbursement will
assist the state in meeting the medical care needs of this frail group
of older warriors.
As these veterans pass, many will utilize our State Veteran's
Cemetery system. Presently the state and county are reimbursed $300 for
each veteran burial, but the cost to open and close the grave site and
provide perpetual care greatly exceeds this amount. This reimbursement
rate has not changed in many years. We ask that your Committee look
into increasing the present amount so that it more closely reflects the
true cost associated with full body and urn burials.
We must continue to take care of our veterans. We must support our
Soldiers, Sailors, Airmen, Marines, and Coast Guard members at home and
abroad. They are our veterans, our sons and daughters, our citizens of
Hawaii.
I thank the Committee for this opportunity to speak on this matter
and I will respond to any questions that you may have.
[The prepared statement of Mr. Moses follows:]
______
[Note: the following is a summary of services and activities being
offered by the Hawaii Office of Veterans Services.]
Hawaii Office of Veterans Services
MISSION
The Office of Veterans Services (OVS) is the principal state office
responsible for the development and management of policies and programs
related to veterans, their dependents, and/or survivors. The OVS acts
as a liaison between the Governor and veterans' organizations and also
between the Department of Veterans Affairs and individual veterans. Our
objectives are to assist veterans in obtaining State and Federal
entitlements, to supply the latest information on veterans' issues and
to provide advice and support to veterans making the transition back
into civilian life.
OVS is the State's primary advocate of veterans applying for and
receiving benefits and services. The OVS may take action on behalf of
veterans, their families and survivors to secure appropriate rights,
benefits and services. This process includes the reception,
investigation and resolution of disputes and complaints.
The OVS serves all eligible veterans, Reservists, National Guard
members, active-duty military personnel and their dependents (including
stepchildren). (See List of Services at end.)
STATE PROVIDED BENEFITS
Special Housing for Disabled Veterans
Payment by the State of up to $5,000 to each qualified, totally
disabled veteran for the purpose of purchasing or remodelling a home to
improve handicapped accessibility.
Burials
Burials for qualified veterans (including U.S. war allies) and
their dependents in Veterans Cemeteries on Oahu, Hawaii, Kauai, Maui,
Molokai, or Lanai.
Vital Statistics
Free certified copies of vital statistics forms when needed for
veterans' claims.
License Plates
For the same cost as regular license plates, qualified veterans can
acquire distinctive veterans' license plates for their car or
motorcycle. Currently available are: ``Veteran,'' ``Combat,'' ``Combat
Wounded,'' ``Pearl Harbor Survivor,'' ``Former POW,'' 'World War II
Veteran,'' ``Korean War Veteran,'' and Vietnam Veteran.''
Tax Exemptions
Applies to real property that is owned and occupied as a home by a
totally disabled veteran or their widow(er). Also applies to passenger
cars when they are owned by totally disabled veterans and subsidized by
the Department of Veterans Affairs.
Employment and Re-employment
Preference is given to veterans, Vietnam-era veterans, service-
connected, disabled veterans and their widow(er)s for civil service
positions, training programs, job counseling and referrals to civilian
jobs by the Workforce Development Division, Department of Labor and
Industrial Relations. Re-employment rights for veterans, Reservists or
National Guard members who leave a position within State or County
government for training or active military service.
We encourage you contact the Office of Veterans Services to have your
questions answered. The sooner we begin the process together, the
sooner you will see results. Please contact the OVS office nearest you.
Walk-ins are welcome, and appointments are recommended. Home, worksite
and hospital visits are available if necessary, as are Group
presentations.
Office of Veterans Services--Oahu
Office: Tripler Army Medical Center E-Wing
Address: Office of Veterans Services, 459 Patterson Road,
E-Wing, Room 1-A103, Honolulu HI 96819-1522.
Telephone: (808) 433-0420; Fax: (808) 433-0385.
E-mail: [email protected].
Hours: Monday-Friday, 7:45 a.m.-4:00 p.m.
Office of Veterans Services--Kauai
Address: 3215 Kapule Hwy., #2, Lihue, HI 96766.
Telephone: (808) 241-3346; Fax: (808) 241-3818.
E-mail: [email protected].
Hours: Monday-Friday, 7:30 a.m.-4:30 p.m.
Office of Veterans Services--Hawaii
Address: 101 Aupuni Street, Room 212, Hilo, HI 96720.
Telephone: (808) 933-0315; Fax: (808) 933-0317.
E-mail: [email protected].
Hours: Monday-Friday, 7:30 a.m.-4:30 p.m.
Office of Veterans Services--Maui
Address: 333 Dairy Road, Suite 201-A, Kahului, HI 96732.
Telephone: (808) 873-3145; Fax: (808) 243-5820.
E-mail: [email protected].
Hours: Monday-Friday, 7:30 a.m.-4:30 p.m.
list of services for veterans, active military,
spouses and dependents
Assist in preparation of VA claims.
Help individuals file VA Appeals.
Represent veterans at VA hearings.
Obtain veteran birth, marriage, divorce and death certificates
nationwide.
Assist with burial
Provide notary.
Assist indigents.
Maintain DD214s.
Refer individuals not qualified for VA benefits to other agencies.
Legal name change.
Review active service record.
Assist active medical boards.
Hawaii Veterans Newsletter.
Hawaii Veterans Roster.
Hawaii Veterans Website.
Governor's Liaison to veterans.
Legislative Advocate for veterans--State and Federal.
Yukio Okutsu Hilo Veterans Home--development and oversight.
State Veterans cemeteries statewide--grants and expansion.
Grant-in-Aid for all veteran related items--veterans' cemeteries,
Arizona Memorial, Aviation Museum, Veterans Centers
statewide, etc.
Tri-annual report for State Monuments.
Coordinate veterans organizations to clean the Korean and
Vietnam Memorials on Capitol grounds.
Coordinate Memorial and Veterans Day ceremonies annually
at Hawaii State Veterans Cemetery.
Assist with Memorial and Veterans Day ceremonies at National
Cemetery of the Pacific (Punchbowl).
Coordinate leis for veterans cemeteries on Memorial Day.
Staff the Advisory Board on Veterans Services.
Hawaii Veterans Memorial Fund.
Maintain presence on neighbor islands.
Validate Military Service for Employee Retirement System.
Senator Akaka. Thank you very much, Mark Moses.
Now we will receive the testimony of Dr. Michael Shepherd.
STATEMENT OF MICHAEL SHEPHERD, M.D., PHYSICIAN,
OFFICE OF HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR GENERAL,
DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY JULIE WATROUS, R.N., REGIONAL DIRECTOR, OFFICE
OF HEALTHCARE INSPECTIONS, OFFICE OF
INSPECTOR GENERAL, DEPARTMENT OF VETERANS
AFFAIRS
Dr. Shepherd. Mr. Chairman, mahalo. Thank you for the
privilege to testify on access to health care for the veterans
on Maui. I'm accompanied by Julie Watrous, Director of the
OIG's Office of Health Care Inspections, Los Angeles office.
Today I will briefly discuss challenges and opportunities for
providing health care to veterans on the island of Maui.
As have been mentioned by previous speakers, staffing with
primary care providers at the Maui CBOC has been a major
concern during the past year. Despite efforts at recruitment,
the Maui CBOC has been without a full-time VA primary care
physician for a 9-month period until May 2007. During this time
period, the clinic relied on the informal triage system for
scheduling patient appointments. Despite the efforts of
remaining staff, waiting lists accrued for nonurgent care
leading at times to frustration on the part of veterans and
impacting staff morale.
Although part-time contract providers were utilized,
continuity of care remained a significant issue. Currently,
there is a full-time VA physician day position, as well as a 3-
day per week contract position to see patients at the CBOC. In
the near term, a second contract physician reportedly will be
increasing hours in order to see walk-in patients and OEF/OIF
veterans.
A July 2004, VHA directive provides guidance on the maximum
number of active patients, or panel size, for whom a provider
should provide primary care. On Maui, primary care providers
have a greater reliance on fee basis and consult specialty care
in the absence of a full service VA, which impacts the real
time availability of medical information and may have bearing
on the appropriateness of panel size relative to a mainland
nonrural location.
Furthermore, replacing providers at rural facilities is
generally difficult and may be even more so in light of the
real estate market on the island. We found that despite
national VA panel size guidelines, the system has responded to
a recent gap in primary care continuity by hiring a second
full-time primary care physician for the Maui CBOC, who will
begin seeing patients within the next month.
During the past year, the Maui clinic has had a full-time
psychiatrist and psychologist, but has been experiencing an
ongoing increase in the number of patients seen for mental
health visits. Approximately 28 percent of visits in the last
year were for mental health. The system leadership is presently
recruiting for several clinical positions to augment mental
health and telemental health services.
In addition to serving veterans on Maui, the CBOC supports
veterans on the islands of Molokai and Lanai. Service to
veterans on Lanai was also significantly impacted during the 9-
month period in which the Maui CBOC was experiencing staffing
difficulties. In response, the system began sending providers
from Oahu to serve veterans residing on Lanai. System
leadership is subsequently considering permanently supporting
the VA services on Lanai from Oahu rather than from the Maui
CBOC. The system has also begun partnering with the local
hospital on the island.
Subsequent to your January 2006 field hearings, a part-time
VA physician residing on Molokai is available a few days per
week to see patients. The leadership reported having made
contractual arrangements for VA to use telehealth equipment
that is owned and located at a non-VA clinic on Molokai.
Telemental health equipment will be operational when the
recruited telehealth staff positions are filled at the Maui
CBOC.
The Veterans' Millennium Health Care and Benefits Act of
1999 directed VA to provide certain services to veterans in
their homes or in community settings, including the adult day
health care, homemaker and home health aids and home based
primary care, among others.
In 2006, at your request, the OIG was asked to determine
what restrictions placed on noninstitutional care services were
appropriate in light of the intent of the Millennium Act. We
reported that the system restricted contract adult day health
care and homemaker and home health aids to highly service
connected veterans, did not provide outpatient respite prior to
June 2005, and offered home based primary care only to veterans
living within a 50-mile radius to the system.
We specified the need for the VHA to make sure that
facilities eliminate local restrictions and where possible and
expand coverage to geographic areas that currently do not offer
noninstitutional care services. On Maui, VA clinicians reported
that homemaker and home health aids and contract adult care
services and purchased skilled home health services are
presently available to veterans without restrictions on service
connection or other non-medical eligibility.
Although there are no restrictions to home based primary
care, the system is still in the process of recruiting a nurse
practitioner to provide this service.
A gerontologist has resumed coming to the Maui CBOC every
other month to perform comprehensive geriatric evaluations and
management, and access is not restricted to this service as
long as patients have met program criteria. At present, respite
care is only available on Oahu and on an inpatient basis.
In summary, Mr. Chairman, over the past year, VA Pacific
Islands Healthcare System leadership has taken action to
improve access to care for veterans on Maui and to enhance the
consistency and continuity of care that will be provided.
Although recruitment and programming to enhance future access
are presently in progress, some obstacles to access still
remain for veterans on Maui.
Mr. Chairman, thank you again for this opportunity to
testify. Your leadership and service on behalf of our Nation's
veterans is inspiring. And I'm honored to testify before you
and the veterans present in this room today.
Thank you again.
[The prepared statement of Dr. Shepherd follows:]
Prepared Statement of Michael Shepherd, M.D., Physician, Office of
Healthcare Inspections, Office of the Inspector General, Department of
Veterans Affairs
Mr. Chairman and Members of the Committee, thank you for the
opportunity to testify today on access to health care for veterans on
Maui. I am accompanied by Julie Watrous, R.N., Director, Los Angeles
Regional Office, Office of Healthcare Inspections, Office of Inspector
General (OIG). Today I will discuss the challenges and opportunities
for providing health care to veterans on the island of Maui. These
challenges can be viewed as those concerns shared with Veterans Health
Administration (VHA) facilities nationwide, those in common with other
rural and/or remote areas, and those unique to Maui.
PRIMARY CARE STAFFING ISSUES AT THE MAUI
COMMUNITY BASED OUTPATIENT CLINIC (CBOC)
Staffing at the Maui CBOC has been a major concern since the
departure of the full-time nurse practitioner, relocation of the full-
time physician to the mainland, and the subsequent departure of a part-
time contract primary care provider in 2006. Despite efforts at
recruitment, the Maui CBOC was without a full-time VA primary care
physician for a 9-month period until May 2007. During this time period,
a full-time VA nurse practitioner who was hired in the summer of 2006
was the only consistent provider of primary care at the Maui CBOC.
During this period, the clinic relied on an informal triage system
for scheduling patient appointments, based on urgency of medical
complaint, service connection, Operation Enduring Freedom/Operation
Iraqi Freedom (OEF/OIF) service, and lack of veteran financial means to
access care elsewhere. Non-service connected veterans with private
insurance were encouraged to see providers in the private sector. Some
patients were co-managed by VA and non-VA providers depending on the
type of service or care needed. Wait lists accrued for non-urgent care
such as semiannual or annual physical examinations, leading at times to
frustration on the part of veterans and impacting, in turn, staff
morale. In the interim, part-time fee basis providers were utilized to
provide care that was helpful, though continuity of care remained a
significant issue. A fee basis primary care physician was hired as a
full-time VA employee at the CBOC in May 2007, and since then the wait
list has reportedly been improving. In addition to this now full-time
VA physician, a part-time fee basis physician continues to see patients
3 times per week, and a second fee basis physician has been seeing
patients twice a month. In the near term, this second fee basis
physician reportedly will be working weekly to see walk-in patients and
OEF/OIF veterans.
VHA Directive 2004-031, Guidance on Primary Care Panel Size, from
July, 6, 2004, provides guidance on the maximum number of active
patients (panel size) for whom a provider should deliver primary care
with the aim of establishing a primary care system that balances
productivity with quality, access, and patient service. The VHA
directive recognizes that expected panel sizes will vary from site to
site depending upon patient characteristics of the primary care
population and the level of system support. The directive also
recognizes that panel sizes for specialized panels may need to be
smaller than for undifferentiated primary care panels, and adjustments
to panel size should be made at a local level, incorporating guidance
from national programs where available.
On Maui, primary care providers have a greater reliance on fee
basis and consult specialty care in the absence of a full service VA,
which impacts the real time availability of medical information and
provider efficiency. In addition, the generation of paperwork and
arrangement of outside consultation, the absence of an in-house full
service pharmacy, and the need for outside referral for certain
radiology tests may also have a bearing on the appropriateness of panel
size relative to a suburban mainland location.
Replacing providers at rural facilities is generally difficult and
may lead to prolonged gaps in continuity. This challenge may be further
exacerbated by relative real estate prices on Maui compared to many
locations on the mainland. For these reasons, in addition to panel
size, in certain locations where there are unique geographic factors
that impact access and where a high percentage of complex patients are
in need of frequent appointments, expanded full-time primary care
provider staffing may be a salient consideration that might assure
greater continuity and minimize disruption to care in the event that a
full-time provider leaves VA employment. We found that the VA Pacific
Islands Health Care System has proactively responded to the recent gap
in primary care physician continuity by hiring a second full-time
primary care physician for the Maui CBOC. This physician will begin
seeing patients at the Maui CBOC within the next month.
ACCESS TO OUTPATIENT MENTAL HEALTH CARE ON MAUI
During the past year, the Maui clinic has had a full-time
psychiatrist and psychologist. The psychiatrist reported that the CBOC
has been experiencing an ongoing increase in the number of patients
seen for mental health visits. The VA Pacific Islands Health Care
System is presently recruiting applicants for several new positions at
the Maui CBOC including a telehealth clerk, an addictions therapist, a
psychology technician, and a psychologist to serve as a telehealth
coordinator. In addition, a clinical nurse specialist with a mental
health focus, who is presently assigned to the Kona CBOC, will
reportedly be assigned to the Maui CBOC to provide patient care.
Cognitive behavioral therapies including prolonged exposure therapy
are among the best evidence supported treatments for Post Traumatic
Stress Disorder. However, nationally, there is a relative shortage in
both the VA and private sector of clinicians trained in specific
cognitive behavioral techniques. The VA Pacific Islands Health Care
System reported having recently contracted with a psychologist from the
University of Pennsylvania to train VA psychologists in prolonged
exposure therapy.
ACCESS ON MOLAKAI AND LANAI
In addition to serving veterans on Maui, the CBOC supports veterans
on the islands of Molokai and Lanai. A part-time physician and a mental
health clinician are available a few days per week to see patients on
Molokai. At the U.S. Senate Committee on Veterans' Affairs field
hearings in Hawaii in January 2006, VA representatives committed to
funding for telehealth capabilities with non-VA providers and announced
that Molokai veterans would get telehealth equipment. VA Pacific
Islands Health Care System primary care leadership reported having made
contractual arrangements for veteran use of telehealth equipment that
is owned and located at a non-VA clinic on Molakai. The equipment will
be utilized when the telehealth positions are filled, and staff at the
non-VA clinic will assist veterans and VA staff with its use. Service
to veterans on Lanai was significantly impacted during the 9-month
period in which the Maui CBOC was experiencing primary care staffing
difficulties. In response, the VA Pacific Islands Health Care System
began sending providers from Honolulu to serve the 55 veterans residing
on Lanai. System leadership reports that subsequently a primary care
physician has been seeing patients in Lanai on a regular basis. System
leadership is subsequently considering permanently supporting VA
services on Lanai from the medical center in Oahu rather than via the
Maui CBOC. The VA Pacific Islands Health Care System has also recently
begun partnering with a local hospital.
ACCESS TO NON-INSTITUTIONAL SERVICES
PROVIDED TO VETERANS ON MAUI
The Veterans Millennium Health Care and Benefits Act of 1999
clarified requirements for VHA to provide non-institutional care for
veterans in response to the changing needs of aging veterans. The Act
directed VA to provide veterans eligible for medical services with
certain services that are provided to veterans in their own homes or in
community settings. VHA implemented policies requiring medical
facilities to provide non-institutional care services to all eligible
veterans and to include the services in the VHA medical benefits
package. These services include: home based primary care; purchased
skilled home health care; homemaker and home health aides (H/HHA);
adult day health care; geriatric evaluation and management; respite
care; and hospice and palliative care. In addition, VHA measures
facility use of care coordination and telehealth services (CCHT).
In 2006, at the request of Senator Akaka, the OIG was asked to
determine what restrictions were being placed on veterans for access to
certain non-institutional care services and whether these restrictions
were appropriate or were inconsistent with the intent of the Millennium
Act. The OIG report, Review of Access to Care in the Veterans Health
Administration, found that the VA Pacific Islands Health Care System
restricted contract adult day health care and H/HHA to highly service-
connected veterans, provided no outpatient respite prior to June 2005,
and offered home based primary care only to veterans living within a
50-mile radius of the VA Pacific Islands Health Care System or the Kona
and Hilo clinics. The OIG report specified the need for VHA to make
sure that facilities eliminate local restrictions limiting eligible
veteran access to non-institutional care and, where possible, expand
coverage to geographic areas that currently do not offer non-
institutional care services. VA clinicians reported that subsequent to
the time of the U.S. Senate Committee on Veterans' Affairs field
hearings in January 2006, both homemaker and home health aides and
contract adult day health care services no longer have restrictions on
service connection, and non-service connected veterans are eligible if
they meet the medical qualifications for these programs.
The VA Pacific Islands Health System primary care leadership
reported that contract adult day health care is available on Maui, and
additional funding has been allocated to bolster H/HHA services. There
are no restrictions to home based primary care, however, the VA Pacific
Islands Health Care system is presently recruiting for a nurse
practitioner to provide the home based primary care to medically
eligible veterans. CBOC staff report that purchased skilled home health
services are available on Maui. In addition, a gerontologist has
resumed working at the Maui CBOC every other month to perform
comprehensive geriatric evaluation and management, and there are no
restrictions to access as long as patients meet the program criteria.
VA Pacific Islands Health Care System primary care leadership reported
that they have begun consideration of ``health buddies'' and CCHT
services for incorporation in future programming once the nurse
practitioner to provide home based primary care is on board. At
present, respite care is only available on Oahu and on an inpatient
basis.
ACCESS FOR VETERANS TO NON-VA SPECIALTY
AND HOSPITAL CARE ON MAUI
Another challenge concerns veteran access to non-VA fee basis
specialty or sub-specialty care. Some specialty providers may have full
practices and are no longer taking new patients or may not accept the
reimbursement rate provided by VA fee basis. Additionally, though the
CBOC benefits from indirect access to specialty care through the
sharing agreement with the Tripler Army Medical Center, the Maui CBOC
does not derive the direct access benefit experienced from physical co-
location experienced by veterans at the Matsunaga Medical Center. To
address this issue, the VA Pacific Islands Health Care System primary
care leadership is examining possible future telehealth alternatives,
such as tele-optometry and tele-dermatology to provide certain
outpatient specialty care services.
A further challenge facing the VA Pacific Islands Health Care
System is the limited medical infrastructure on Maui. Maui Memorial
Hospital is presently the only hospital on the island. When veterans
are admitted to the hospital, which is a state run facility, they are
admitted on a rotational (on-call) basis to the service of local
physicians at Maui Memorial Hospital. VA staff reported that some non-
VA health care entities have hired hospitalists to care for their
patients admitted to Maui Memorial Hospital. A hospitalist is a doctor
who specializes in the care of hospitalized patients, whose focus is
treating health conditions for which patients are often hospitalized,
and whose office is usually located within the hospital. Whether or not
the number and medical complexity of veterans admitted to Maui Memorial
Hospital would justify hiring or contracting for the services of a
hospitalist is a question for further study by the VA Pacific Islands
Health Care System leadership.
SUMMARY
Over the past year, the VA Pacific Islands Healthcare System
leadership has taken actions to improve access to care for veterans on
Maui and to enhance the consistency and continuity of care that will be
provided. Although staff recruitment and programming to enhance future
access are in process, some obstacles to access remain for veterans on
Maui.
Mr. Chairman, thank you again for this opportunity to testify. I
would be pleased to answer any questions that you or other Members of
the Committee may have.
Senator Akaka. Thank you very much, Dr. Shepherd, for your
testimony. And now I have some questions for the witnesses.
Dr. Kussman, in recent years, VA has made significant
strides in telemedicine. And telemedicine capabilities in
Hawaii already have helped many people. When do you expect to
fully implement telemedicine capabilities of the neighbor
islands of Molokai and Lanai?
Dr. Kussman. Sir, as we discussed yesterday when we were
visiting Lanai, and you'll see tomorrow with Molokai, that this
is a work in progress. I think I'd have to refer to Dr.
Hastings on this specific dates. But as we're doing here in
Maui, the program in hiring the appropriate telemedicine
people, this is a very important program for us, as you know.
Because it allows us the leverage technology to get the
services to the veteran, rather than having to get the veteran
to the services.
And the VA has been a leader nationally in the
implementation of telemedicine. So we're very proud of what
we're doing. And we'll continue working very hard to increase
the capability on the island.
Senator Akaka. Dr. Hastings, will you comment further on
that.
Dr. Hastings. Yes. Thank you very much, Senator.
This is clearly an area that we have--that the VA has great
interest in, and, I think, is actually leading the country in
many areas in developing this technology to improve access and
quality care.
Of course, delivering care to more isolated places is the
challenge. And I can tell you that we have developed the
capability of delivering telemedicine to both of those islands.
And the challenge that we face right now is to educate our
providers in the best utilization of this technology. We have
it set up. We're ready to make the connections. Indeed, we've
made the connections. We've had very good cooperation from the
state and from Hawaii Health Systems Cooperation in allowing us
to work with them and use their equipment.
And so really the challenge that we face now is to have all
of our physicians make use of the technology, learn how to use
it, learn when to use it. And I think we ought to move ahead
smartly on this within the next year or two.
Thank you very much.
Senator Akaka. Thank you for that, Dr. Hastings.
Dr. Kussman or Dr. Wiebe, staffing at the Maui clinic is an
ongoing issue for veterans. While your testimony speaks to the
need for an additional providers of the clinic and the addition
of a home care program, when can we expect these changes to
take effect?
Dr. Kussman. Mr. Chairman, thank you for the question. As
was mentioned, the second full-time person will be here on the
7th of September, I believe. But the larger issue of
recruiting, as was mentioned by the first panel and ourselves,
has been a puzzle to me, actually. And we've had a chance to
talk about that.
This is such a wonderful place to live and such a wonderful
area that it's been strange that we haven't been able to get
people who wanted to come here. And there are a lot of issues
related to where you are in your stage of life and the housing,
and all of that. But even with offering enticements and things,
we've been challenged to do that.
And we're working hard to find out what are the issues that
don't allow us to hire people, or they don't want to come here.
This is not unique to Maui. It is a problem throughout the
islands. Even getting people to come to Oahu, for the cost of
living and things. So we're working they hard on that and
looking for innovative ways to encourage people to come.
I don't know. Bob, if you would like to add anything no
that.
Dr. Wiebe. I'll just add, in addition to the primary care
physician who will join us next month, we're currently
recruiting for the home-based primary care nurse. As Dr.
Kussman indicated in his testimony, we are recruiting to fill
the five mental health care providers that will be at the
clinic. And as noted by earlier witnesses, we will be hiring a
psychologist, hopefully, at the Vet Center very soon.
Senator Akaka. Dr. Wiebe, at the field hearing we held last
year on Maui, you and I discussed the fact that, in light of
network budget constraints, certain types of care were being--
let me use the word rationed. You stated at the time that you
would look into the situation and work to correct it. Is the
full VA benefit's package now available to all veterans on
Maui?
Dr. Wiebe. Thank you for the question, Mr. Chairman. As you
know, several years ago, the VA faced formidable resource
constraints and budget challenges. In response, we implemented
referral criteria for non-VA care, including noninstitutional
long-term care services.
Fortunately, and thanks to your leadership on this
Committee, VA funding has substantially increased since we last
met. And as we have noted, we've hired additional staff at the
Maui clinic for primary care, mental health and telehealth. In
addition, we have increased the number of patients we're
referring to the Maui community, and increased the amount of
money we're spending in the Maui community.
Specifically, as Dr. Shepherd noted, compared to
noninstitutional long-term care services last year, we have
increased over 30 percent the average daily census in
noninstitutional care in fiscal year 2007. And specifically, we
have doubled the average daily census for the homemaker health
aids.
So mahalo again for this question. But more importantly,
mahalo for your leadership on this Committee, as well as your
support for the Department of Veterans Affairs.
Senator Akaka. Thank you, Dr. Wiebe.
Dr. Shepherd, what is your assessment of the current status
of the access to both primary and specialty care on Maui?
Dr. Shepherd. Currently, the access to primary care is in a
stabilization phase. And hopefully, with Dr. Chin onboard and a
new physician coming, hopefully for patients over the next
three or four months, the clinic will move from a stabilization
phase to a more fluid phase of care.
Some of the veterans on the first panel have brought up
some issues, including those related to travel expense for
speciality appointments.
When veterans are admitted in Maui Memorial, there is a
discontinuity of care because there's not a VA provider caring
for them at the hospital. So I think there's still some access
to specialty care issues that the system needs to continue to
look at and evaluate.
Senator Akaka. On mental health care on Maui, do you
believe that it's up-to-par?
Dr. Shepherd. I believe it is with the addition of the five
new clinicians coming in. I think in the broader picture, one
of the major challenges the VA has is that surprisingly over
the past three, four years, about 75 percent of new mental
health patients for the system, as a whole, are the aging
Vietnam era veterans.
I think one of the challenges the system is going to face
as a whole and on Maui is tracking the rates of change in both
the returning OIF/OEF population that's going to need mental
health services and the aging Vietnam veteran population, and
really trying to stay ahead of those rates of change.
Senator Akaka. Dr. Shepherd, access to long-term care is
another issue that is of great concern to me and to many
veterans here as overall capacity in Hawaii, as we know, is
strained. What is your assessment of the current availability
of noninstitutional care on Maui?
Dr. Shepherd. Over the past year, access to
noninstitutional care has improved.
As mentioned by other panelists, once nurses are onboard to
provide a home-based primary care this will also lead to
further improvement in access.
Senator Akaka. Finally, I just want to ask if any of you
has any final statements to make before we adjourn.
Dr. Kussman?
Dr. Kussman. Mr. Chairman, again, thank you for the
opportunity to be here, to listen and to learn, and to continue
to partner with you. We're very fortunate to have you as the
Chairman of the Senate Committee on Veterans' Affairs. As you
know, we pledge to work with you regularly and the VSOs and
anyone who wants better care for veterans.
And again, mahalo.
Senator Akaka. Thank you. And thank you very much, all of
you, for your testimony. It's been very helpful. And we look
forward to working together to help the veterans of our
country. This hearing is adjourned.
[Whereupon, at 1:05 p.m., the Committee was adjourned.]
A P P E N D I X
----------
August 22, 2007.
Re: Allowing private mental health doctors to assist veterans.
The VA bureaucracy has become so thick that many Vets are
discouraged from getting the mental and physical help they need. As a
result we have Vets killing their families and themselves.
It is a well known fact that the VA does not have sufficient mental
health resources throughout the system. However, there are many
qualified mental health providers who would love to do their patriotic
duty and help injured vets. I don't understand why the VA will
willingly outsource to medical doctors and dentist but not to mental
health specialist, whom they need the most.
The VA does outsource their C&P evaluations to assist the VA to
process claims, but they do not out source to private mental health
specialist to assist vets, they only outsource to assist the VA.
It would be cost effective because the outsource doctor's will only
be paid on an as needed basis. No extra monies need to be spent on
facilities or employee benefits making this approach more cost
effective than maintaining the high cost of clinics with their
administration and maintenance cost.
Now we can only get help during regular office hours, however most
of our problems happen in the non-office hours. The expensive clinic is
useless 2/3's of the time, but the government pays for it 24/7. I think
most suicides occur in non -office hours when the mental help is not
available. Lack of immediate attention has directly caused veteran
suicides, like it did recently at Tripler.
Maui has maintained a high cost clinic and much of the time there
isn't even a doctor there to treat the vets. Please remember only the
doctor's provide the life saving treatment, not the facilities that
cost the most. On Maui after hours and on weekends we are told to call
911 and go to hospital emergency room. This is very expensive and over
triples the cost of our care, and there is no continuity of care. Why
can't we go directly to private doctors and not wait for clinic hours
and face a long wait period or go to the ER at extra expense to the
government.
Lastly, we would like to thank you for your kind consideration and
real help you have provided us over the years. We are especially
impressed at how you jump in and work to help us when we ask for your
help. You had a major role in correcting a problem we were having with
our C&P process. We offer our heartfelt gratitude and appreciation.
Concerned Maui Diabled Vets.
HEARING ON ACCESS TO VA HEALTH CARE AND BENEFITS IN KONA AND OUTREACH
TO THE GUARD AND RESERVE IN HAWAII
----------
MONDAY, AUGUST 27, 2007
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 1:00 p.m., in
Sheraton Keauhau Bay, Kailua Kona, Hawaii, Hon. Daniel K.
Akaka, Chairman of the Committee, presiding.
OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN,
U.S. SENATOR FROM HAWAII
Senator Akaka. The panel field hearings of Senate Committee
on Veterans' Affairs will come to order.
Aloha. Before I make my opening remarks, you've witnessed
the presentation of a check, and for those of you who may not
know and who may not have heard the news, the VA has approved a
grant to make significant improvements to the West Hawaii Vet
Center here in Kona. VA Under Secretary Bill Tuerk, who is Gene
Castagnetti's boss, advised the Committee of this development
during his testimony at our hearing in Honolulu. I could not be
more pleased that we're able to get this done for the veterans
here on the Big Island.
I'd like to welcome all of you to this hearing. This is our
third and final official hearing of the Senate Committee on
Veterans' Affairs that I'm chairing here in Hawaii.
We held similar hearings at the beginning of 2006. Much has
improved since that time for which I am very, very grateful.
However, it is important for the Committee to understand the
remaining challenges that we now face.
The focus of this hearing will be on access to VA health
care for veterans living in Kona, and on the effectiveness of
VA's outreach to redeploying and separating members of the
Guard and Reserve in Hawaii.
We are all aware that after Vietnam and other wars some
servicemembers who honorably served their Nation were not
provided with the care and services that they needed to
reintegrate into society. Caring for returning servicemembers
must be considered part of the continuing costs of war.
It is important that we look not only at the quality of
care that is provided, but also at the outreach process to
notify separating servicemembers of what they're entitled to
and what VA can do for them. We must ensure that adequate
levels of care and services are available to those that leave
the Armed Forces, including members of the Guard and Reserve.
We have learned that the earlier a veteran receives care after
separation from the military, the lower the risk of him or her
developing a long-term problem. An important part of the
Dignified Treatment of Wounded Warriors Act, which recently
passed the U.S. Senate is my provision to extend the period of
eligibility for VA health care for combat veterans of the
Persian Gulf War and subsequent wars from 2 years to 5 years
after discharge or release.
The Senate bill includes Veterans' Affairs Committee-
endorsed provisions that will improve access to mental health
care, extend the application period for dental benefits
following discharge, and designate the National Guard and
Reserves as integral components of VA's outreach program.
The Dignified Treatment of Wounded Warriors Act was truly a
collaborative effort between the Senate Veterans' Affairs
Committee and the Senate Armed Services Committee. I want to
tell you that this is the Hawaiian spirit and Hawaiian style of
doing business. I'm so delighted that this collaboration
between two Committees made that happen quickly.
Finally, I note that there are many veterans here today who
would like to testify. We cannot accommodate everyone's request
to speak. However, I do want to hear your views. The Committee
is accepting written testimony, which will be reviewed and made
part of the record of today's hearing. If you have brought
written testimony with you, please give it to Committee staff
who are seated at the table back there, or located also in
other places in the room, but we have a table on this side. If
you do not have written testimony but would like to submit
something, Committee staff will assist you. In addition, the
Committee staff is joined by VA staff who can respond to the
questions, concerns, and comments that you raise.
We are fortunate today that we have top people here from
Federal and state government. Coming from the Federal
Government we have VA staff. We also have Mark Moses from the
state here.
Once again, I want to say mahalo to all of those who are in
attendance today, and I look forward to hearing the testimony
of our witnesses today. I want to welcome the first panel to
today's hearing. Thank you for being here today. First, I want
to welcome David Ferreira. David Ferreira is the director of
the Hilo Family Assistance Center and retired member of the
National Guard. I also welcome First Sergeant Allison T. Yano,
who was deployed in Operation Iraqi Freedom. Your full
statements will appear in the record of the Committee.
So, Mr. Ferreira, will you begin with your testimony.
STATEMENT OF DAVID T. FERREIRA, FAMILY ASSISTANCE SPECIALIST,
HAWAII ARMY NATIONAL GUARD
Mr. Ferreira. Mr. Chairman, these are my comments based on
my experience as a family----
Senator Akaka. Let me interrupt. Can you folks hear him?
You can? Thank you.
Mr. Ferreira. Through my experiences as a family assistance
specialist on the Big Island. It takes too long for VA to
determine the disability to receive treatment and compensation.
Many Guard and Reserve soldiers that return from deployment are
anxious to go home, often do not disclose conditions that would
normally be treated during their out processing and delay their
return home. Once separated, they realize the condition has
worsened or requires treatment. This causes problems with their
civilian jobs and prevents them from seeking employment.
Both Hilo and Kona both lack services and specialty care in
the remote areas. The Community Based Outpatient Clinics in
Hilo and Kona provide much needed services, but at times they
lack the staffing or the specialist required. Members are
required to either wait for specialists to come in or travel to
Oahu.
Although VA has expended their services to families, the
Vet Caenters here lack the credentialed or licensed counselors
to provide services to family, and when it's available, it's
only for a limited time. This has been particularly true of
both centers here and in Kona. I've had several servicemembers
tell me that they went to the clinic and there were no
counselors there at that time, especially for family members.
The VA has done a good job in dealing with traditional
problems of active duty veterans, but they're not prepared for
the large influx of Guard and Reserve servicemembers that
return from deployment.
Our citizen soldiers and family members pose a unique set
of problems. Our active duty counterparts return to a
relatively stable environment, military environment, whereas
Guard and Reserve members deal with returning back to the
civilian sector. Returning Guard and Reserve servicemembers
have the same stresses of active duty members, but they also
have the additional stresses of returning to their civilian
jobs. Sometimes they require retraining, requalification. There
are different people working there. In some cases they have to
go into different positions. They also have to deal with their
families that were disrupted.
The families on the outside islands in remote areas become
instant military families when the Guard and Reserve members
get mobilized. We lack the military infrastructure of places
such as Oahu with large military installations. We have to rely
on the civilian sector, which is ill prepared to deal with
these requirements. Even our schools were unsure of how to deal
with children who have parents or family members and in some
cases multiple family members deploying.
The VA, the Guard, and Reserves needs to continue to expand
its outreach for our servicemembers and encourage them to
utilize the services provided. One of the problems in our Guard
and Reserve members is overcoming the stigma or perception of
going to the VA. Many worry that it will affect their civilian
jobs and are reluctant to come in.
On a final note, I feel that in the past several years the
VA's greatly improved and expanded its services and it's
largely due to the oversight of this Committee. Thank you.
[The prepared statement of Mr. Ferreira follows:]
Prepared Statement of David T. Ferreira,
Family Assistance Specialist, Hawaii Army National Guard
Dear Mr. Chairman:
My name is David T. Ferreira, I am a retired Sergeant First Class
with 30 years in the Hawaii Army National Guard, of which I served 24
years on Active Guard (AGR) as a Senior Human Resource Sergeant. I am
presently the Family Assistance Specialist, Hawaii Army National Guard
for the island of Hawaii. I am also a DEER/RAPIDS administrator and
issue I.D. Cards to Military Servicemembers of all branches, DOD
Civilians, Retirees, Disabled American Veterans (DAV) and their
dependents.
The following are comments/issues:
It takes too long to determine disability, to receive treatment and
compensation. Many Guard and Reserve soldiers that return from
deployment are anxious to go home, often do not disclosed conditions
that would normally be treated during their out-processing and delay
their return. Later once separated they realize the condition has
worsened, and requires treatment, this causes problems with their
civilian jobs or prevents them from seeking employment.
Lack of service and specialty care in remote areas, the Community
Based Outpatient Clinics in Hilo and Kona provide much needed services,
but many times they lack the staffing or specialist required. Services
members are required to either wait for a specialist to come in or
travel to Oahu.
Although the VA has expanded services to families, the Vet Centers
here lack credentialed/licensed counselors to provide that service to
families, and when available it is only for a limited time. This has
been particularly true of both Vet Centers here in Hilo, and Kona. I
have had several servicemembers and families tell me that they refuse
to see the counselor at the Hilo Vet Center, they were very critical of
the individual there.
The VA has done a good job in dealing with the traditional problems
of active duty veterans, such as physical injuries or PTSD. But they
were not prepared for the large influx of Guard and Reserve
servicemembers returning from deployments, our citizen soldiers/airmen
and family members posed a unique set of problems.
Our active duty counterparts return to a relatively stable military
environment versus Guard and Reserve members have to deal with
returning to the civilian sector. Returning Guard and Reserve
servicemembers have the same stresses as active duty members, but they
also have the additional stresses of returning to their civilian jobs
(some require retraining, qualification, different personnel, and in
some cases different positions), and disrupted families.
Families on the outside islands and remote areas became instant
military families, upon the mobilization of their Guard/ Reserve
members. They lack the military infrastructure (such ACS, etc.) of
places like Oahu with large military installations. They have to rely
on the civilian sector which was ill prepared to deal with the
deployments. Even our schools were unsure of how to deal with children
that had a parent or other family member (in some cases multiple family
members) deploying.
The VA, Guard and Reserve needs to continue to expand its outreach
to our servicemembers and encourage them to utilize the services
provided. One of the problems with our Guard and Reserve member is
overcoming the stigma or perception of going to the VA, many worry it
will affect their civilian jobs and are reluctant to come in.
On a final note, I feel that in past several years the VA has
greatly improved and expanded its services to our veterans and their
families largely due to the oversight and concern by Members of this
Committee.
Senator Akaka. Thank you. Thank you very much, Mr.
Ferreira.
And now, Mr. Yano.
STATEMENT OF FIRST SERGEANT ALLISON T. YANO, OPERATION IRAQI
FREEDOM VETERAN
1st Sgt. Yano. Mr. Chairman, thank you for this opportunity
to appear before you today to present my personal experiences
and observations with the VA as a Guardsman returning from
Operation Iraqi Freedom.
Streamlined access to VA health care benefits must get to
all combat veterans. The Iraq-Afghanistan Post-Deployment
Screen was initiated throughout the Department of Veterans'
Affairs in 2004 to identify OEF/OIF veterans who may have had
the need or clinical intervention for conditions such as PTSD,
depression, alcohol abuse, chronic and infectious diseases.
Early intervention was a goal to identify those who screened
positive for these conditions.
The inability to complete the post deployment survey with
the VA soon after their war experience hampered the opportunity
to prevent a quality transition and readjustment to civilian
life, as well as identify those with possible PTSD, depression,
alcohol/substance abuse, or other psychological issues as a
result of our National Guard service within the combat zone.
The screening is conducted only with OEF/OIF veterans who
have enrolled with the VA. As of two months ago, not all
soldiers who returned from our deployment enrolled, and only a
small number of combat veterans who signed up for VA benefits
were contacted and received the screening. A vast majority of
combat veterans failed to receive early intervention. We're
only now getting our soldiers enrolled.
This was due to a recent incident involving a fellow
soldier and the failure of qualitative counseling by the VA
after returning from a combat zone. Coupled with this is a lack
of streamline process of continued care with the VA, as well as
stressing the importance to the soldier in following up with
their recommended care. Only after this incident were we able
to put into perspective the importance in enrolling and
utilizing the services of the VA health care system.
Additionally, we had to make our own coordination for
readjustment counseling, educational briefings with the VA,
which should have been completed during the demobilization
process. Furthermore, the insufficient number of social workers
available to handle the large number of OEF/OIF veterans
prevented the screenings from being conducted.
A recommendation would be to make the enrollment to VA
health care system mandatory and part of our demobilization
process. This would allow VA to administer the Iraq-Afghanistan
Post-Deployment Screen to a greater number of returning
veterans at an earlier point after deployment.
Also, the lack of medical specialists in our geographical
location is another concern. The islands of Hawaii, Maui,
Molokai, Lanai, and Kauai do not have the same resources of
medical specialists as on Oahu; therefore, veterans who reside
on these islands are referred to see specialists on the island
of Oahu and are asked to pay for our transportation costs. This
is a deterrent to having soldiers get the necessary
examinations we need.
A recommendation is to have referred visits to specialists
paid for by the VA, or to have specialists flown to the outer
islands on a periodic schedule. I would like to acknowledge the
efforts of the staff of the VA Hilo Community Based Outpatient
Clinic in assisting myself and fellow combat veterans in
providing the best service they can with the minimal staffing
they have.
In closing, there are needed adjustment to ensure that
access to VA health care and benefits get to all combat
veterans. Although there are other concerns that are in the
minds of my fellow combat veterans, what is provided in this
testimony is of the greatest concern. It is hoped that this
testimony, along with others being given today, will expedite
necessary changes.
Mr. Chairman, this concludes my statement. I would be
pleased to answer any of your questions.
[The prepared statement of 1st Sgt. Yano follows:]
Prepared Statement of First Sergeant Allison T. Yano,
Operation Iraqi Freedom Veteran
Mr. Chairman, thank you for the opportunity to appear before you
today to present my personal experiences and observations with the VA
as a Hawaii Army National Guardsman returning from Operation Iraqi
Freedom III.
Streamlined access to VA health care and benefits must get to all
combat veterans. The Iraq-Afghanistan Post-Deployment Screen was
initiated throughout the Department of Veterans Affairs in 2004 to
identify OEF/OIF veterans who may have had the need for clinical
intervention for conditions such as PTSD, depression, alcohol abuse,
chronic and infectious diseases (ID). Early intervention was the goal
to identify those who screened positive for mental health conditions
and to refer others to specialty care for ID or chronic medical
conditions. The inability to complete the post deployment survey with
the VA, soon after their war experience hampered the opportunity to
prevent a quality transition and readjustment to civilian life as well
as identify those with possible PTSD, depression, alcohol/substance
abuse or other psychological issues as a result of our National
Guardsmen's and women's service within a combat zone. The screening is
conducted only with OEF/OIF veterans who have enrolled with the VA. As
of two months ago, not all soldiers who returned from our deployment
enrolled and only a small number of combat veterans who signed up for
VA benefits were contacted and received the screening. A vast majority
of combat veterans failed to receive early intervention. We are only
now getting our soldiers enrolled. This was due to the recent incident
involving a fellow soldier and the failure of qualitative counseling by
the VA after returning from a combat zone. Coupled with this is the
lack of a streamlined process of continued care with the VA as well as
stressing the importance to the soldier in following up with their
recommended care. Only after this incident were we able to put in
perspective the importance in enrolling and utilizing the services of
the VA health care system. Additionally, we had to make our own
coordination for readjustment counseling and educational briefings with
the VA, which should have been completed during the demobilization
process. Furthermore, the insufficient number of Social Workers
available to handle the large number of OEF/OIF veterans prevented the
screenings to be conducted.
A recommendation would be to make enrollment in the VA health care
system mandatory and part of the demobilization process. This would
allow the VA to administer the Iraq-Afghanistan Post-Deployment Screen
to a greater number of the returning veterans at an earlier point after
deployment.
The lack of medical specialists and our geographical location is
another concern. The islands of Hawaii, Maui, Molokai, Lanai, and Kauai
do not have the same resources of medical specialist as on Oahu,
therefore, veterans who reside on these islands and referred to see
specialists on the island of Oahu, are asked to pay for their
transportation cost. This is a deterrent to having soldiers get the
necessary examinations and help.
A recommendation is to have referred visits to specialist paid for
by the VA or to have specialist flown to the outer islands on a
periodic schedule.
I would like to acknowledge the efforts of the staff at the VA Hilo
Community Based Outpatient Clinic in assisting myself and other fellow
combat veterans in providing the best service they can with the minimal
staffing that they have.
In closing, there are needed adjustments to ensure that access to
VA health care and benefits get to all combat veterans. Although there
are other concerns that are in the minds of my fellow combat veterans,
what is provided in this testimony is of the greatest concern. It is
hoped that this testimony along with others being given today will
expedite necessary changes.
Mr. Chairman, this concludes my statement. I would be pleased to
answer any questions you or other Members of the Committee may have.
Senator Akaka. Thank you, Allison Yano, for your testimony.
I do have some questions for both of you. I'm so glad to
hear some of your concerns that will help us try to continue to
improve whatever has been improved already. My question to both
of you has to do with servicemembers and their families. I want
you to tell us what the challenge is, and if you have a
solution in mind, also mention that, because we are looking for
solutions.
So here is the question: Do you believe that servicemembers
and families are sufficiently informed about VA benefits and
services? Mr. Ferreira.
Mr. Ferreira. We try to make sure they're informed, both
families and soldiers. But like I said, a lot of them are
reluctant to go to the VA because they still have to go back to
their civilian jobs, and a lot of times I guess it's basically
a perception problem that, oh, you went to see the VA, that you
have some kind of disability, you know, where it may or may not
affect his job, but it's just a perception that it will.
On the family side, VA was not ready for families with
problems. We had instant military families, and when they went
to VA, the counselors there were more geared to deal with
soldiers with physical injuries and maybe PTSD-type problems,
not marital problems, separation anxiety problems, or even
children with problems dealing with the deployment of their
parents.
In some cases both parents were deployed. We've had several
people with both parents deployed and the kids were with the
grandparents or aunties and uncles and there really were not
enough counselors qualified to deal with them.
How would we fix the problem? That part I really don't
know, other than providing more trained counselors that would
be a great help.
Senator Akaka. Thank you very much, David.
Allison Yano.
1st Sgt. Yano. Sir, we did receive some briefings after
deployment, post-deployment process, and at that time I don't
think the briefings were standardized to all the different
units, and I don't think it was conducted at a time that was
right.
Everyone--again, like Mr. Ferreira stated in his testimony,
everyone is in a rush to get back to their families, so hearing
some of this information at that time was not a priority. What
I found in my experiences dealing with the VA is that the
perfect briefing I think was already there. The VA's
orientation briefing that you receive when you register with VA
would have been the ideal briefing to receive. However, again,
a lot of people just put registering with the VA on the side,
in the back of their minds because all they wanted to do is get
back into their civilian life.
Recently we held some briefings that brought out these
points and we had help from Helping Hands Hawaii, a nonprofit
association, that conducted briefing for us, and with those
briefings we were able to get a number of our combat veterans
registered with the VA. We're still in the process of
increasing the numbers, and also bringing that out to the
families.
So we're working with the FRGs to make this information
available to them as well, and that is our work toward the
solution to this problem. I think it's just a matter of getting
the right information out at the right time.
Senator Akaka. Thank you very much. You're not the first to
tell us that when a person is being separated, their priority
is to get home and get back to their family. This is something
we have to take into consideration. And as David mentioned, the
word reluctance, some of them are reluctant to seek the help.
I'm hoping these sessions that we have here, and with your help
and others, and Helping Hands' help, that we'll be able to get
veterans to feel easy enough to know that VA is there to help
them, and that they should be able to contact VA.
Here's another question to both of you, and this has to do
with families. And as you pointed out, VA really has not had a
focus on family, because they focus on veterans and not
veterans' families. But with this war and also with
deployments, and also with the fact that more veterans are now
married, about 38 percent of servicemembers have families. We
know how important families are to the troops, so we need to
help take care of families as well. We hope that in the future
programs we'll be able to put more focus on helping families.
You are aware that the well-being of families plays an
important role in the well-being of veterans. How can families
be more effectively included in the transition process and in
caring for veterans? David?
Mr. Ferreira. I guess both the VA, Guard, and Reserve would
have to, when they do their out processing, we actually have--
when the soldiers return back to their home islands, rather
than--you know, all the out process is done in a military
installation, and families are not physically present there.
They may have visited but they're not physically there, so they
don't really hear anything about the benefits available. I know
I myself is guilty of--a lot of times I get told stuff and I
would never go tell my wife, oh, yeah, we need to do this. So
maybe if they have a briefing back here again--we had
briefings, but, again, not with the family around, the soldier
is there. If part of out processing is at their home station,
that might help get the word out better.
Senator Akaka. Thank you. Allison.
1st Sgt. Yano. I think that's a good suggestion. A lot of
families were not even told about a lot of this from their
soldiers returning. Even ego issues or embarrassment issues,
those play a little part of it. But I think somewhere along the
line of the post employment period that we can have a period
where the families can come in and receive this briefing, that
will help the situation.
Senator Akaka. As I mentioned, improvements have been made
in services, but I repeat again, we are here to try to learn
more about what further improvements can be made. Helping
servicemembers adjust may take more than VA can provide. You
mentioned Helping Hands--I'm so glad that we're finding
veterans organizing to help themselves and their families,
which is really great here in Hawaii.
Are you aware of local groups partnering with VA and
military to enhance access to services for returning veterans?
David?
Mr. Ferreira. The National Guard have a retirees group that
work kind of closely with the VA, but that's the only group
that I know of that works closely with the VA. Part of their
members are part of the VA, the DAV, and they're both retired
Guardsmen and belong to the DAV, so they work pretty closely
with the VA to do outreach type of work.
Senator Akaka. Yes.
1st Sgt. Yano. I've been aware just recently with Mr. Park,
with Helping Hands Hawaii, and through working with him, along
with the VA, we've been able to get the education and
information out to the soldiers. But, again, this is just a
small amount.
We worked on a unit, because the individual that I
mentioned was within my unit as a co-worker, so it was a big
issue for us. But working with these other organizations helped
to get the information out, and I think if we can continue to
do this, you'll see greater improvements and involvement by our
families and so forth.
Senator Akaka. My final question to both of you. I am aware
that the Family Assistance Centers of the Hawaii Department of
Defense provide a broad range of services to families of the
Hawaii National Guard. What services do you offer to families
transitioning from active duty to civilian life, and which
services have been most important to families? David.
Mr. Ferreira. I normally provide a referral service.
Although I belong to the Hawaii Army Guard, we deal with all
services, even Coast Guard people come in. I also issue ID
cards for servicemembers and their dependants, also 100 percent
disabled veterans, and I normally do a referral service. If
they need legal-type counseling, we refer them to people we
have on the list, or specifically a lot of times we refer them
to the Military Family Life Consultants for counseling
services. They've been a real good resource on this island. And
we've recently lost that individual. For whatever reason, his
contract was terminated. I'm not really sure why. He was here
and he was willing to do counseling for the entire island. He's
actually out of--he actually works up in Waimea, but somehow he
lost the contract.
I'm not sure why he was taken off. A lot of the families
really liked that individual as far as going to see him for
counseling. He dealt with families and their children a lot of
times. And that was kind of a great loss for this island, I
know that.
Senator Akaka. Thank you. Mr. Yano.
1st Sgt. Yano. The big service that we've been using lately
is the Vet Center, which was instrumental in getting a lot of
other soldiers that we identified as having some issues,
resolution to the issues and helping them readjust and get back
into the civilian life and their families. Some family members
also took place in that conference, and that was key for us.
Other than that, Military OneSource was another route that we
sent people to.
Senator Akaka. Well, you know, I want to thank you so much
for your testimony and also your responses to the questions
I've asked. I want to tell you that you've been helpful to what
we're trying to do, and together we can continue to improve
services to veterans. So, again, I want to thank our first
panel very much.
[Applause.]
Senator Akaka. Now, I want to welcome our second panel of
witnesses. First, I welcome Brigadier General Gary Ishikawa,
who is the Deputy Adjutant General, Hawaii Army National Guard.
I also welcome Colonel Gerald Gibbons, Chief of Staff of the
9th Regional Readiness Command, he is accompanied by Colonel
Floresita Quarto. I want to thank both of you for being here.
Your full statement will appear in the record of this
Committee. We look forward to your testimony.
So will you please begin with your testimony, General
Ishikawa.
STATEMENT OF BRIGADIER GENERAL GARY ISHIKAWA,
DEPUTY ADJUTANT GENERAL, HAWAII ARMY NATIONAL GUARD
General Ishikawa. General Akaka, Members of the Committee,
aloha. Good afternoon.
Senator Akaka. Aloha.
General Ishikawa. Thank you for having us here. I have to
profess upfront that in my mad rush to get here, I have
misplaced my written testimony.
Fortunately, I've read it three or four times and I
remember the salient points, so I will forward to your staff my
official written testimony.
Senator Akaka. We'll make that part of the record.
General Ishikawa. Thank you, Senator Akaka.
I'm here on behalf of Major General Bob Lee, the Adjutant
General for the State of Hawaii, and he testified on August 21
on Oahu. And it's my distinct pleasure and honor to be here in
Kona representing the State Department of Defense.
I'm Gary Ishikawa. I'm the Deputy Adjutant General for the
State of Hawaii. Let me start off by saying the Department of
Defense is broken down or organized into four major divisions,
that's the Hawaii Army and the Hawaii Air National Guard, State
Civil Defense, and most important and relevant to these
hearings is the Office of Veterans Services, the State of
Hawaii office. Now, our new head person there is a retired
Major, Mark Moses. I believe he'll be testifying also as part
of the panels to follow. So I won't go into some of the areas
he's scheduled to talk about.
I will add that since the State Office of Veterans Services
is part of the State Department of Defense, it's been really my
privilege and honor to really work hard with that agency to
create a very effective newsletter, and that's something funded
by the State legislature and is growing more and more. I'm not
naive enough to believe that that's the only mechanism to
communicate, but I think it's a very important mechanism
besides, of course, the State Department of Defense web site,
has some important links with information. Again, it's not only
going to be one or two methodologies. It has to be many, many
efforts to communicate to our veterans the benefits as they are
available to them and the newer benefits that's becoming--
thanks to your great help becoming--made a state of law.
At this point in time, nine out of ten reservists, and I
include the Army Reserves and the Army National Guard, have
deployed to Iraq or Afghanistan. At one point in time part of
our total veterans population was decreasing, and that's
because a lot of them in large numbers were passing away each
day, especially from the Second World War and on into Korea.
But because of the recent deployments, we're staying fairly
level as far as the total number of veterans that we have, the
newest veterans being, of course, the recent deployments.
I bring two concerns, and, again, I'd like to in short form
capture what General Lee has shared. The two concerns I bring
to the table, you've heard it before and you're going to hear
it continuously, is access in remote areas, access to help.
I do want to share with the Chairman that last year I had
the honor of serving with the Chief of Staff of the Army for
funeral for a fallen warrior in American Samoa. I did have a
chance to go and visit with the 100th Battalion who deploys
with the 29th to Iraq, and in that time they were having a lot
of problems.
I want to thank VA for opening up a clinic in American
Samoa, and I think that will go a long way in at least
identifying some of the problems.
There are, however, other small islands in the Pacific that
probably need a good, strong look at, and at a minimum some
visiting teams to conduct assessments for some of the soldiers
of the 100th Battalion that deployed. I think this is going to
be a huge challenge, but I think that we as a Nation, it's
something that we can overcome if we put our minds to it.
The other issue that was brought up that I'd like to go
over real quickly is the classic need for paperwork, and the
recertification of some of our combat veterans when they
already were certified for combat awards or badges, and I refer
to it as a big check when they get awarded the CIB, the CAB,
Purple Heart, and things like that. It seems like you really
don't have to go through the paperwork again to recertify
something that's already been certified.
In a small way, when I look at this, it tells me that we
have some resources that perhaps would be better focused to
some of the harder problems that we face, especially in the
areas of mental health or brain damage.
That basically summarizes my testimony, and, Senator, I see
my testimony right there. I put it behind me when I received
the check, so I will be filing it with your Committee. Thank
you again very much for being here. I appreciate the
opportunity to testify.
Statement of Brigadier General Gary M. Ishikawa, Deputy Adjutant
General of the State of Hawaii before the Senate Committee on Veterans'
Affairs, Relating to State of VA Health Care in Hawaii
Chairman Akaka, Senator Craig and Members of the Senate Committee
on Veterans' Affairs, I am Brigadier General Gary Ishikawa, The Deputy
Adjutant General for the State of Hawaii.
Within the State Department of Defense, there are four major
divisions: the Hawaii Army and Air National Guard, State Civil Defense
and the Office of Veterans' Services (OVS). The Director of Office of
Veterans Service is Mr. Mark Moses, a retired Marine major and a former
state legislator.
The Office of Veterans' Services is the single office in the State
government responsible for the welfare of our veterans and their
families. OVS serves as the liaison between Governor Linda Lingle and
the veterans groups and organizations. They also act as an intermediary
between the Department of Veterans Affairs and Hawaii's veterans.
Veterans make up more that ten percent of Hawaii's total
population. The majority of them--about 72%--live on the island of
Oahu. About 13% reside on the island of Hawaii, 10% live on one of the
three islands that comprise Maui County, and about 5% live on the
island of Kauai.
Within this large veteran population are many World War II
veterans, many members of the famed 100th Battalion and the 442nd
Regimental Combat Team. Hawaii's overall numbers were declining because
many veterans of this era, most in their 80s, are passing on in large
numbers.
But since September 11, 2001, mobilizations have involved nine of
every ten Army National Guard and Reserve soldiers. They served
honorably in Iraq, Afghanistan and other locations; and have returned
to Hawaii after their 12-15 month activations. Air National Guard
members supported Operations Iraqi Freedom and Hawaii's overall veteran
population has increased.
We must insure these new veterans return to their civilian lives in
good health. The Office of Veterans Services partners with the Veterans
Administration here during the soldiers demobilization process. This
partnership works to insure no one or no benefit falls through the
crack.
The United States government has an obligation to our military
members from enlistment, through their service years, to veterans'
benefits and finally, death benefits. We must insure that all veterans
receive all entitled benefits now and in the years to come.
The National Guard Bureau recently issued a memorandum authorizing
both the Army and Air National Guard to release medical records to the
Department Veterans Affairs without the veteran's signature. This new
procedure speeds the Department of Veterans Affairs adjudication of
veterans' claims and provides medical care to Guard members.
I come to you with two concerns.
My first and most important concern is the Veterans Affairs
services to all our veterans, especially, on our neighbor islands and
our Pacific Islander veterans from Tinian, Rota and Saipan. In July
2007, a VA clinic opened in American Samoa that supports our veterans
there. However, veterans from other Pacific islands must pay the high
cost of airline and hotel accommodations to receive follow-on VA
medical treatment. In Hawaii, a similar situation occurs when neighbor
island veterans must come in to Tripler Army Medical Center or the
Matsunaga VA Hospital in Honolulu for treatment. We must work to find a
solution to this situation.
My next concern deals with the certification of a disability by the
Department of Veterans Affairs. Often a servicemember is awarded a
decoration recognizing the specific incident that is associated with an
injury or disability. However, when filing for a disability, the VA
requires a complete recertification of the incident causing the injury
or disability. Approval and certification of this letter of
determination is required prior to providing any services.
My final concern is the staff of VA hospitals. For example, the
Post Deployment Health Reassessment Program (PDHRA) requires an initial
appointment within 30 days of VA registration. On average, the VA
hospital schedules initial appointments as much as 90-120 days from the
registration date. Our local VA hospital staff has been doing their
best to provide services to all our veterans. They have stretched their
limited health care provider resources to their support mission
requirement to all the veterans in the Pacific Basin.
In closing, I want to thank the Committee for their continuing
support of our veterans. Thank you for coming to Hawaii to conduct
these hearings.
Are there any questions?
Senator Akaka. Thank you very much, General Ishikawa, for
your testimony.
Now we'll look to Colonel Gerald Gibbons.
STATEMENT OF COLONEL GERALD GIBBONS, CHIEF OF STAFF, 9TH
REGIONAL READINESS COMMAND, U.S. ARMY RESERVE
Colonel Gibbons. My name is Colonel Gerry Gibbons, and I'm
Chief of Staff for the 9th Regional Readiness Command. I'm here
representing Brigadier General Alexander Kozlov, Commander, 9th
Regional Readiness Command, who is off island. I have submitted
a copy of my written testimony for the record.
Senator Akaka. It will be included in the record.
Colonel Gibbons. This afternoon I'll limit my comments to
issues of returning 9th Regional Readiness Command Army Reserve
veterans and the necessity for collaboration between the
Department of Defense and the Veterans Health Administration to
prepare for and care for their future needs.
As you are probably aware, the 9th Regional Readiness
Command is responsible for Army Reserve units in American
Samoa, Guam, Saipan, Alaska, and Hawaii. Since 9/11,
approximately 2,400 9th Regional Readiness Command soldiers
have answered the call to duty and were mobilized in support of
Operation Iraqi Freedom and Operation Enduring Freedom. Within
the past two years over two-thirds of the Pacific based 9th
Regional Readiness Command soldiers will have served on active
duty in support of the Global War on Terrorism. Currently there
are 460 soldiers of the 9th Regional Readiness Command still
mobilized and deployed. Deployed soldiers are serving in Iraq,
Kuwait, and the Philippines.
As soldiers return from theater, they complete a Post-
Deployment Health Assessment before being released from active
duty. At 3 to 6 months after coming home from theater they are
then given a Post-Deployment Health Reassessment. Our findings
from these health reassessments show that 62 percent of the
soldiers are referred for additional assessment or care and
treatment. Almost without exception these referrals are all
evaluated by the VA.
If a soldier requires evaluation and/or treatment of mental
health or behavioral health problems, which have significant
impact on the performance of their duty, they may be brought
back on active duty status and assigned to an Army warrior
transition unit.
Currently, we have 23 Army Reserve soldiers in the warrior
transition unit at Tripler Army Medical Center. Initial
assignment to the warrior transition unit is for 179 days, but
that assignment can be extended until the soldier is found fit
for duty.
Soldiers diagnosed with Post Traumatic Stress Disorder
requiring inpatient care are enrolled in a 7-week VA PTSD
residential recovery program. In the last year, we have had 43
soldiers complete the program, and I should emphasize this
primarily happened because of the VA's constant support.
Currently, we have 12 soldiers programmed for the next PRRP
session scheduled to begin this week.
On July 21, 2007, the VA Pacific Islands Health Care System
held a dedication ceremony for a new Community Based Outpatient
Clinic in Pago-Pago, American Samoa. The opening of this clinic
is largely the result of a successful partnership between the
Army Reserve and the VA. With the opening of this clinic, we
know there will be an increase in efficiencies and more timely
access to health care and treatment for veterans in American
Samoa.
While it may not be possible to predict the specific number
of Army Reserve soldiers who will need to access Veterans
Health Administration Services in the future, it's critical
that we continue to work with the VA to ensure that we
understand the processes and procedures to enable our returning
soldiers to receive care through the current VA system in the
9th Regional Readiness Command's area of operations.
Thank you. I would be pleased to answer any questions you
have.
[The prepared statement of Colonel Gibbons follows:]
Prepared Statement of Colonel Gerald Gibbons, Chief of Staff,
9th Regional Readiness Command, U.S. Army Reserve
Good Morning. I appreciate being given the opportunity to speak
before the Senate Committee on Veterans' Affairs. I am Colonel Gerald
Gibbons and I am the Chief of Staff with the 9th Regional Readiness
Command (RRC). As you are probably aware, the 9th RRC is responsible
for Army Reserve units in American Samoa, Guam, Saipan, Alaska, and
Hawaii. Additionally, many of our members live and work in Japan,
Korea, other Pacific Rim countries, and CONUS. We are responsible for
3,400 soldiers serving proudly in the Pacific and other parts of the
world.
This morning I will limit my comments to the issues of returning
9th RRC Army Reserve veterans and the necessity for collaboration
between the Department of Defense and the Veterans Health
Administration to prepare and take care of their future needs.
Since 9/11, 9th RRC Reserve soldiers have answered the call and
were mobilized and deployed in support of Operation Iraqi Freedom (OIF)
and Operation Enduring Freedom (OEF).
There have been approximately 2,440 9th RRC Soldiers returned from
active duty and there are approximately 460 9th RRC Soldiers still
mobilized and deployed. Within the past 2 years, over \2/3\ of the
Pacific based 9th RRC Soldiers will have served on active duty in
support of the Global War on Terrorism.
As Soldiers returned from theater, they completed the Post
Deployment Health Assessment (PDHA) before being Release From Active
Duty (REFRAD) and approximately 838 soldiers have completed the
required Post Deployment Health Reassessment (PDHRA) at 3-6 months
after coming home from theater.
There are currently 23 Army Reserve Soldiers in the Warrior
Transition Unit (WTU) at Tripler Army Medical Center (TAMC). These
Soldiers are being continued or brought back on Active Duty status for
evaluation and/or treatment for medical, mental health or behavioral
health problems which have significant impact on their performance of
duty. Assignment to the WTU is for 179 days with a possibility of
extensions until they are found fit for duty.
Soldiers diagnosed with Post Traumatic Stress Disorder (PTSD)
requiring in-patient care are enrolled in the PTSD Residential Recovery
Program (PRRP), a VA Pacific Health Care System, at the TAMC Campus.
There are currently 6 Soldiers in the program.
The VA Pacific Islands Health Care System Community Based
Outpatient Clinic was recently dedicated on July 21, 2007 in Pago Pago,
American Samoa and is scheduled to be fully activated in the very near
future.
While it may not be possible to predict the specific number of Army
Reserve Soldiers who will need to access VHA services in the future, it
is critical that we continue to work with the VA to ensure that we
understand the processes and procedures to enable our returning
Soldiers to receive care through the current VHS system in the 9th
RRC's area of operations.
Thank you. I would be pleased to answer any questions you may have.
Senator Akaka. Thank you very much, Colonel. I do have
questions for both of you, but before I continue with the
questions, I just want to remind our veterans in the room that
if you have anything that you want to talk about that is a
problem for you and you need to talk to our staff, I just want
to remind you that they're seated in the back of the room. Even
as we talk here you should feel free to get up and seek their
help.
So to our witnesses, do you believe that there is a stigma
associated with seeking care for mental health disorders? If a
servicemember did come forward with mental health concerns, how
would his or her career be impacted? General.
General Ishikawa. There is a perceptional reality about
mental health. This is something not only in the military, but
in society overall, and we've done a lot of good things as far
as education. From my perspective, it should not impact a
soldier's career whatsoever, as long as they can get the proper
treatment, but there is that perception.
Senator Akaka. Thank you very much. Colonel.
Colonel Gibbons. I agree with General Ishikawa. There is a
perceived stigma associated with PTSD; however, our soldiers
are coming forward by somewhat significant numbers to attend
the VA's PTSD residential recovery program.
Additionally, we hear a consistent message from our
soldiers in remote areas that they would like greater access to
mental health practitioners. The point I would like to make is
that regardless if there is a stigma associated with PTSD, our
soldiers are seeking help.
Senator Akaka. General and Colonel, what is your best
estimate of number of Guard and Reserve members here on the Big
Island who have served in Iraq and Afghanistan? Your best
estimate.
General Ishikawa. Not to make light of it, Senator, but
over 90 percent of the Hawaii Army National Guard has deployed
to either Iraq or Afghanistan. The small percentage that did
not is on Oahu, and as once in a while we say, actually the
band is the only element or unit that is not. So all of the
soldiers or a huge majority of the Army National Guard on the
Big Island has in fact deployed.
Senator Akaka. Colonel Gibbons.
Colonel Gibbons. I would say the same thing. Both units we
have on this island, elements of the 411th Engineer Battalion
and the 100/442nd Infantry Battalion, have deployed. For
numbers I would estimate 20, 25 Infantry soldiers and
approximately 75 engineers have deployed. So, with the
exception of a few stay-behind folks, all USAR soldiers from
this island have deployed.
Senator Akaka. To both of you, last year DOD expanded the
post-deployment health assessment by including a breathing
assessment. How is the Hawaii National Guard conducting the
required post-deployment health assessments and reassessment?
Has this been an effective program, and does it reach all
members of the Guard in Hawaii as well? General?
General Ishikawa. Just overall it's three to six months,
and it's normally conducted on a unit level, and a lot of it is
done by our family support organizations. And keeping in mind
my original statements about perceptions of the stigma
attached, I think that it has, in fact, contributed to sharing
of information and the end result is more and more of the
soldiers are coming forward.
Senator Akaka. This is a follow-up question. Have the
soldiers experienced difficulty in getting follow-up medical
appointments?
General Ishikawa. Yes, that's still a huge problem. I think
when you made an employment it's supposed to be 30 days that
you're supposed to get. We're averaging anywhere from 90 to
120. I think there's going to be some testimony, I hope, today
with a lot of vacancies, and some of the ideas that may be when
you serve in a remote location there might be a premium
attached to that. I think when you look at rural medicine
overall that's a true statement.
Senator Akaka. Colonel.
Colonel Gibbons. I think the Post-Deployment Health
Reassessment has been a success story for the Army Reserve. At
the national level they have contracted with a medical
organization to come out and assist us in conducting these
reassessments. I know on Oahu the VA also participates, and
sometimes we get immediate care. On the remote islands, we do
get medical practitioners that come with this contracted
assessment team from the mainland. So, the PDHRA has been
helpful for us. And, as I mentioned in my opening remarks, 62
percent of the soldiers surveyed have been referred to VA for
further assessment and treatment.
Senator Akaka. To both of you, DOD recently launched a
Turbo TAP, a web-based program intended to assist separating
servicemembers with the transition process. Do you believe this
website meets the needs of transitioning servicemembers? What
can be done to improve the transition process? General
Ishikawa.
General Ishikawa. I need to pass on that one, Senator. I'm
not really familiar with that web site, so I'll pass.
Senator Akaka. Colonel.
Colonel Gibbons. I think that's an interesting question,
and I don't have the answer to that either. So I would like to
get back to the organization and we'll follow up on that.
Senator Akaka. Fine. Thank you. We'd like to have your
responses shortly.
General Ishikawa. We will respond.
Senator Akaka. General Ishikawa, as a result of problems at
Walter Reed Army Medical Center, much has been written about
care for members of the Guard and Reserves and medical holdover
detachments. Are you satisfied with the care for wounded
warriors from your units who are assigned to the Tripler
Medical holdover detachment and what improvements would you
recommend?
General Ishikawa. I think because of the incident at Walter
Reed it's been improved mightily, and I haven't had any recent
complaints, coming to me anyway, as far as the medical
holdover. I normally don't like to bring up problems where I do
have some idea of solutions, but let me just put it on the
table. In active duty you can return to your units and it's
kind of like a home. On our medical hold units, especially if
they're not from Oahu, it becomes a challenge. I think that--
and, again, I'm not sure how this can be solved, but if there's
a way where we can perhaps bring the families periodically.
We have Air National Guard aircraft, but I believe there's
regulations that won't let us do that. I think things like that
could help us get the families more involved. Short of that,
they have to go through this process to be cured, so I think
maybe some help getting the families there would be
appreciated.
Thank you.
Senator Akaka. To both of you, it has been recommended that
DOD and VA develop a joint separation physical. From your
perspectives, do you believe that all servicemembers separated
from active duty should receive a physical examination? Do you
believe it makes sense to combine VA and DOD separation exams?
General Ishikawa?
General Ishikawa. I would go one step further besides just
join. I know that Tripler use as lot of contract professional
doctors within the community. I think that all military leaving
the service should get a very thorough physical, and I think
that joint combined type of organization is very appropriate.
It's a matter of best resources doing the job.
Colonel Gibbons. Senator, during deployment, when soldiers
come off active duty, a physical is included as part of the out
processing procedures. I don't know the detail of the medical
review or how it differs from what VA provides. But, it would
seem to me that there is added value in a more detailed
composite physical.
Senator Akaka. General Ishikawa, we know the activated
members of the Guard and Reserve do not have access to TRICARE,
and in some cases have nowhere to turn for health cares besides
VA. What other issues do the Guard and Reserve face that are
not shared by their active duty counterparts?
General Ishikawa. That question is not overall Guard
differences, so I guess it's more in reference to benefits and
access. I think the Guard, by its nature, being a community-
based organization that really is in rural areas, I think that
adds a special challenge, as opposed to having a big military
base like Schofield where you have the capability of putting
more resources on base. I think our remoteness and the way
we're situated is the biggest difference as far as access to
support.
Senator Akaka. Colonel?
Colonel Gibbons. Another challenge for Guard and Reserve
soldiers is the transition back to their civilian job. We've
got the Employer's Support of the Guard and Reserve (ESGR), who
actively support our Guard and Reserve members when they get
off active duty. But, to list on issue in addition to the
change in the health care that is provided, I would add return
to civilian employment.
Senator Akaka. Well, you know with what we're doing today
we're very concerned about the Guard and the Reserves, because
there are so many things that we need to look at and try to
improve on what has been there, and part of that is they've
been deployed so many times. So there are some differences as
to how we need to deal with the National Guard and the Reserve
units. We look forward to any resolutions that you think might
help us.
I want to thank you so much Brigadier General Gary Ishikawa
and Colonel Gerald Gibbons, and Colonel Floresita Quarto also.
Thank you for being here with us. Thank you.
General Ishikawa. Thank you, Mr. Chairman.
[Applause.]
Senator Akaka. I want our audience to know that we have a
third panel that may be able to respond to some of the
challenges that were mentioned. I want to welcome a third panel
of witnesses, and the panel consists of representatives from
VA.
First, I welcome Dr. James Hastings. Dr. Hastings is the
Director VA Pacific Islands Health Care System. He is
accompanied by Felipe Sales, team leader of the Kona and Hilo
Vet Centers. I also welcome Mark Moses, who is the Hawaii State
Director of Office of Veterans Services. Finally, I want to
welcome Gregory Reed, Director of the Honolulu Regional Office
of the Veterans Benefits Administration.
I want to thank all the witnesses for being here today.
Your full statements will be included in the record of the
Committee.
Dr. Hastings, will you please begin with your testimony.
STATEMENT OF JAMES E. HASTINGS, M.D., F.A.C.P., DIRECTOR, VA
PACIFIC ISLANDS HEALTH CARE SYSTEM, VETERANS HEALTH
ADMINISTRATION, DEPARTMENT OF VETERANS
AFFAIRS
Dr. Hastings. Yes, thank you very much, Mr. Chairman.
Mahalo nui loa for the opportunity to appear before you today
to discuss the state of VA care in Hawaii. It is a privilege to
be here on the island of Hawaii, the Big Island, to speak and
answer questions about issues important to veterans residing in
Hawaii. I would like to request my written statement be
submitted for the record.
Senator Akaka. Without objection, it will be included in
the record.
Dr. Hastings. Thank you, sir. Before I begin, Mr. Chairman,
I would like to thank you personally for your leadership and
assistance in helping VA care for Hawaii veterans. Your vision
and commitment are truly noteworthy and deeply appreciated.
The VA operates CBOCs, Community Based Outpatient Clinics,
and Vet Centers in both Kailua-Kona and Hilo. The Big Island
CBOCs served an estimated island veteran population in fiscal
year 2006 of 14,291. Of these, 5,081 were enrolled for care,
and 2,936 received care. Since our last hearings in Hawaii, the
VA relocated the clinic here to Kailua-Kona. In fiscal year
2006 the Kailua-Kona CBOCs treated 1,055 patients and recorded
6,779 clinic stops.
The VAPIHCS, VA Pacific Islands Health Care System, now
leases about 5,000 square feet for the new clinic and spent
approximately $500,000 to renovate the existing facility.
Although the current configuration and size is a vast
improvement over the prior clinic location, parking at the new
clinic is very limited. Currently, we are working with an
outside firm to provide an additional 15 to 20 parking spaces.
Kailua-Kona CBOCs is actively recruiting for a psychiatry
position. In the interim, mental health coverage is provided by
a mental health clinical nurse specialist from the Maui CBOC
and a visiting psychiatrist and nurse from the Hilo CBOC. Our
clinics spent approximately $100,000 in fiscal year 2001 to
remodel the Hilo CBOC and further renovated it in fiscal year
2006. In fiscal year 2006 the Hilo CBOC treated 1,683 veterans
and recorded 8,843 clinic stops. The VA estimates that up to
15,000 Hawaiians have been deployed to serve in Operation
Enduring Freedom and Operation Iraqi Freedom as active duty
personnel, Reservists, or members of the Hawaii National Guard.
The VA Pacific Islands Health Care System has an active
outreach program to inform OIF and OEF veterans about the
availability and scope of VA health care services. A team of
clinical and non-clinical staff from our health care system
attend all Post-
Deployment Health Reassessment events. Those are the PDHRAs. At
these events the VA staff answers questions, enrolls veterans,
and schedules appointments for those who are interested.
The VA Pacific Islands Health Care System has a dedicated
OIF/OEF program manager who helps veterans receive the services
they need, and an OIF/OEF case manager. OIF/OEF veterans
requiring inpatient treatment for PTSD will be admitted to the
PTSD residential rehabilitation program in Honolulu.
In fiscal year 2006 the VA Pacific Islands Health Care
System provided care and services to 1,137 OIF/OEF veterans.
This group has special needs. For example, about 18 percent
have a diagnosis of PTSD, and women comprise a larger segment
of the population. A significant proportion of OIF/OEF veterans
have been exposed to blasts, placing them at risk for Traumatic
Brain Injury.
VA aggressively screens patients for TBI, Traumatic Brain
Injury, PTSD, and other conditions. We also are training staff
and hiring additional specialists to ensure we exceed the
expectations of these brave warriors.
The VA Pacific Islands Health Care System and the veterans
we proudly serve benefit from our relationship with academic
institutions. One of our most important partnerships is with
the John A. Burns School of Medicine, University of Hawaii.
Prior to my appointment as Director of VA Pacific Islands
Health Care System, I served as Chairman of the Department of
Medicine at the medical school. I've seen both sides of this
relationship and truly appreciate its value.
In summary, with support, Mr. Chairman, the VA is providing
an unprecedented level of health care services to veterans
residing in Hawaii and here on the Big Island. I am proud of
the improvements in VA services in Hawaii, but recognize that
our job is not done. We must continue providing exemplary care
to all veterans, including the brave soldiers of the Guard and
Reserve who proudly served in OIF and OEF.
Again, Mr. President, Mr. Chairman, mahalo nui loa for the
opportunity to testify at this hearing. I will be delighted to
address any questions you may have.
Prepared Statement of James E. Hastings, M.D., F.A.C.P., Director,
VA Pacific Islands Health Care System, Veterans Health Administration,
Department of Veterans Affairs
Mr. Chairman and Members of the Committee, mahalo nui loa for the
opportunity to appear before you today to discuss the state of VA care
in the Hawaii. It is a privilege to be here on the Island of Hawaii--
The Big Island--to speak and answer questions about issues important to
veterans residing in Hawaii.
First, Mr. Chairman, I would like to thank you for your outstanding
leadership and advocacy on behalf of our Nation's veterans. During your
tenures as Chairman and Ranking Member of this Committee, you have
consistently demonstrated your commitment to veterans. As I will
highlight later, your vision and support have helped us provide an
unprecedented level of health care services for veterans throughout
Hawaii and the Pacific Region. In addition, I appreciate your interest
in and support of the Department of Veterans Affairs (VA).
Today, I will briefly review the VA Sierra Pacific Network that
includes Hawaii and the Pacific Region; provide an overview of the VA
Pacific Islands Health Care System (VAPIHCS) and the VA clinics here on
the Big Island; highlight issues of particular interest to veterans
residing in Hawaii, including outreach to the National Guard and
Reserves, Compensation and Pension examinations, new State Veterans'
Home in Hilo and our important affiliations with our academic partners.
I also look forward to addressing any questions you might have for me.
VA SIERRA PACIFIC NETWORK (VISN 21)
The VA Sierra Pacific Network (Veterans Integrated Service Network
[VISN] 21) is one of 21 integrated health care networks in the Veterans
Health Administration (VHA). The VA Sierra Pacific Network provides
services to veterans residing in Hawaii and the Pacific Region
(including the Philippines, Guam, American Samoa and Commonwealth of
the Northern Marianas Islands), northern Nevada and central/northern
California. There were an estimated 1.1 million veterans living within
the boundaries of the VA Sierra Pacific Network in Fiscal Year 2006 (FY
2006).
The VA Sierra Pacific Network includes six major health care
systems based in Honolulu, HI; Palo Alto, CA; San Francisco, CA;
Sacramento, CA; Fresno, CA; and Reno, NV. Dr. Robert Wiebe serves as
director and oversees clinical and administrative operations throughout
the Network. In FY 2006, the Network provided services to 235,000
veterans. There were about 2.9 million clinic stops and 24,500
inpatient discharges. The cumulative full-time employment equivalents
(FTEE) level was 8,400 and the operating budget was about $1.5 billion.
The VA Sierra Pacific Network is remarkable in several ways. In FY
2006, VISN 21 was the highest-ranked Network in overall performance
(based on an aggregation of quality, access, patient satisfaction and
business metrics). The Network hosts the highest number of Centers of
Excellence and also has the most highly funded research programs in
VHA. In the most recent all-employee survey, staffs in VISN 21 reported
the highest overall job satisfaction in VHA. Finally, VISN 21 operates
one of four Polytrauma units in VHA that are dedicated to addressing
the clinical needs of the most severely wounded Operation Iraqi
Freedom/Operation Enduring Freedom (OIF/OEF) veterans.
VA PACIFIC ISLANDS HEALTH CARE SYSTEM (VAPIHCS)
As noted above, VAPIHCS is one of six major health care systems in
VISN 21. I am the director and a practicing cardiologist at VAPIHCS.
VAPIHCS is unique in several important aspects: its vast catchment area
covering 2.6 million square-miles (including Hawaii, Guam, American
Samoa and Commonwealth of the Northern Marianas); island topography and
the challenges to access it creates; richness of the culture of Pacific
Islanders; and the ethnic diversity of patients and staff. In FY 2006,
there were an estimated 102,000 veterans living in Hawaii (representing
8 percent of the total population in Hawaii and 9 percent of total
veteran population in VISN 21).
VAPIHCS currently provides care in seven locations: the Ambulatory
Care Center (ACC) and Center for Aging (CFA) on the campus of the
Tripler AMC in Honolulu; and Community Based Outpatient Clinics (CBOCs)
in Lihue (Kauai), here in Kahului (Maui), Kailua-Kona (Hawaii), Hilo
(Hawaii), Hagatna (Guam) and Pago Pago (American Samoa). VAPIHCS also
has outreach clinics in Molokai and Lanai. The inpatient Post-Traumatic
Stress Disorder (PTSD) unit is now also on the campus of Tripler AMC
(the unit was formerly in Hilo). In addition to VAPIHCS, VHA operates
five Readjustment Counseling Centers (Vet Centers) in Honolulu, Lihue,
Wailuku, Kailua-Kona and Hilo that provide counseling, psychosocial
support and outreach.
In FY 2006, VAPIHCS provided services to nearly 22,500 veterans,
19,000 of whom reside in Hawaii. There were 198,000 clinic stops in
Hawaii during FY 2006 (7 percent of Network total). The cumulative FTEE
in FY 2006 for the health care system was 502 employees. The operating
budget for VAPIHCS (i.e., General Purpose allocation from appropriated
funds) increased from $68.0 million in FY 2002 to $110 million in FY
2007--an increase of 62 percent. For comparison, during this same time
period, the operating budgets for VISN 21 increased 48 percent and VHA
increased 43 percent. (Please note these amounts do not include
Specific Purpose Funds and Medical Care Cost Funds [MCCF].)
VAPIHCS provides or contracts for a comprehensive array of health
care services. VAPIHCS directly provides primary care, including
preventive services and health screenings, and mental health services
at all locations. VAPIHCS does not operate its own acute medical-
surgical hospital and consequently, faces challenges in providing
specialty services. VAPIHCS recently hired additional specialists in
Orthopedics, Ophthalmology, Nephrology and inpatient Medicine
(``hospitalist'') and is providing selected specialty care in Honolulu
and to a lesser extent, CBOCs. VAPIHCS is actively recruiting
additional specialists (e.g., Urology) and will continue to refer
patients to DOD and community facilities.
Inpatient long-term and acute rehabilitation care is available at
the CFA. Inpatient mental health services are provided by VA staff on a
20-bed ward within Tripler AMC and at the 16-bed PTSD Residential
Rehabilitation Program (PRRP). VAPIHCS contracts for care with DOD (at
Tripler AMC and Guam Naval Hospital) and community facilities for
inpatient medical-surgical care.
The current constellation of VA facilities and services represents
a remarkable transformation over the past several years. Previously,
the VAPIHCS (formerly known as the VA Medical and Regional Office
Center [VAMROC] Honolulu) operated primary care and mental health
clinics based in the Prince Kuhio Federal Building in downtown Honolulu
and CBOCs on the neighbor islands that were staffed primarily with
nurse practitioners. Congress approved $83 million in Major
Construction funds to build a state-of-the-art ambulatory care facility
(i.e., ACC) and a long-term care/rehabilitation unit (i.e., CFA) on the
Tripler AMC campus and these facilities were activated in 2000 and
1997, respectively. VISN 21 allocated nearly $17 million from FY 1998-
FY 2000 to activate these projects. VISN 21 also provided dedicated
funds to enhance care on the neighbor islands by expanding/renovating
clinic space and adding additional staff to ensure there are primary
care physicians and mental health providers at all CBOCs.
BIG ISLAND CBOCS
VA operates CBOCs in both Kailua-Kona (75-377 Hualalai Road,
Kailua-Kona, HI 96740) and Hilo (1285 Waianuenue Avenue, Suite 211,
Hilo, HI 96720). VHA also operates Readjustment Counseling Centers
(``Vet Centers'') in Kailua-Kona (73-4976 Kamanu Street, Suite 207,
Kailua-Kona, HI 96740) and Hilo (126 Pu'uhonu Way, Suite 2, Hilo, HI
96720).
The Big Island CBOCs serve an estimated island veteran population
in FY 2006 of 14,291. In FY 2006, 5,081 veterans were enrolled for care
on the island and 2,936 received care (``users'') at Big Island VA
facilities. The market penetrations for enrollees and ``users'' are 36
percent and 21percent, respectively, and compare favorably with rates
within VISN 21 and VHA.
Kailua-Kona CBOC
Since the last time this Committee held hearings on the Big Island
(i.e., January 2006), VA relocated the clinic here in Kailua-Kona.
VAPIHCS now leases about 5,000 square-feet for the new clinic and spent
about $500,000 to renovate the existing facility. Although the current
configuration and size is a vast improvement over the prior clinic
location, parking at the new clinic is very limited. VAPIHCS is
currently working with an architect/engineering firm to provide an
additional 15-20 new parking spaces.
The current authorized FTEE level at the Kailua-Kona CBOC is 12.0,
including a full-time primary care physician, psychiatrist and nurse
practitioner. Currently, the psychiatry position is vacant and we are
actively recruiting to fill it. In the interim, mental health coverage
is provided by a mental health clinical nurse specialist (on ``loan''
from the Maui CBOC) and visiting psychiatrist for the Hilo CBOC. With
this staff, the Kailua-Kona CBOC provides a wide array of primary care
and mental health services. The Kailua-Kona CBOC also has a formal
home-based primary care (HBPC) program that provides clinical services
in the homes of veterans.
VAPIHCS provides specialty care services at the clinic by sending
VA staff to Kailua-Kona from Honolulu and other VA facilities in
California. Services provided by clinicians traveling to Kailua-Kona
include cardiology, gastroenterology, nephrology, neurology, optometry,
orthopedics and rheumatology. If veterans need services not available
at the clinic, VAPIHCS arranges and pays for care in the local
community (e.g., Kona Community Hospital) and Honolulu (including
Tripler AMC). In FY 2006, VA spent more than $7.8 million in non-VA
care in the private sector (i.e., not including costs at other VA or
DOD facilities) for residents of the Big Island.
In FY 2006, the Kailua-Kona CBOC treated 1,055 patients and
recorded 6,779 clinic stops. The clinic has short waiting times for new
patients with very few veterans waiting more than 30 days for their
first primary care appointment. The Kailua-Kona HBPC program recorded
598 clinic stops for providing home care to veterans residing on the
west side of the island.
Hilo CBOC
VAPIHCS spent about $100,000 in FY 2001 to remodel the Hilo CBOC
and spent additional funds in FY 2006 to further renovate the clinic.
The current authorized FTEE level at the Hilo CBOC is 15.0, including
two full-time primary care physicians and a psychiatrist. This is an
increase of four staff since January 2006 and reflects the reassignment
of staff from the PRRP that was relocated from Hilo to Honolulu. With
this staff, the Hilo CBOC provides a broad range of primary care and
mental health services. The Hilo CBOC also has a formal HBPC program
that provides clinical services in the homes of veterans.
VAPIHCS provides specialty care services at the clinic by sending
VA staff to Hilo from Honolulu and other VA facilities in California.
Services provided by clinicians traveling to Hilo include cardiology,
gastroenterology, nephrology, neurology, optometry, orthopedics and
rheumatology. If veterans need services not available at the clinic,
VAPIHCS arranges and pays for care in the local community (e.g., Hilo
Medical Center), Honolulu (including Tripler AMC) or VA facilities in
California. As noted before, in FY 2006, VA spent more than $7.8
million in non-VA care in the private sector (i.e., not including costs
at other VA or DOD facilities) for residents of the Big Island.
In FY 2006, the Hilo CBOC treated 1,683 veterans and recorded 8,843
clinic stops. The clinic has short waiting times for new patients with
very few veterans waiting more than 30 days for their first primary
care appointment. The Hilo HBPC program recorded 641 clinic stops for
providing home care to veterans residing on the east side of the
island.
SPECIAL ISSUES
OIF/OEF outreach
VA estimates up to 15,000 residents of Hawaii have been deployed to
Afghanistan and Iraq as active duty personnel, Reservists or Hawaii
National Guard. All VAPIHCS sites of care, including CBOCs, are
authorized to provide care to DOD beneficiaries as TRICARE providers
under the national ``Seamless Transition'' initiative between VA and
DOD.
VAPIHCS has an active outreach program to inform OIF/OEF veterans
about the availability and scope of VA health care services. As an
example, a team of clinical and non-clinical staff from VAPIHCS attend
all Post Deployment Health Reassessment (PDHRA) events. PDHRA is a
program managed by DOD and is designed to provide education, screening,
assessment and access to care for military personnel who have returned
from deployment. The assessment generally occurs 3 to 6 months after
returning from deployment. At the PDHRA events, VA staff is available
to answer questions and to enroll and make appointments for interested
veterans.
All VA health care systems, including VAPIHCS, have dedicated OIF/
OEF program managers, who help OIF/OEF veterans receive the services
they need. VAPIHCS also has an OIF/OEF case manager and support from a
Transition Patient Advocate in VISN 21. OIF/OEF veterans who need
inpatient treatment for PTSD will be admitted to the PRRP program in
Honolulu. Veterans residing in Hawaii also have access to the
Polytrauma Unit at the VA Palo Alto Health Care System. This is one of
four specialized units designed to meet the needs of the most severely
injured OIE/OEF veterans and active duty personnel.
The total number of OIF/OEF veterans seen in VA health care
facilities is a relatively small proportion of the total ``user''
population; however, the number is increasing. In FY 2002, VAPIHCS
treated 225 OIF/OEF veterans; in FY 2006, the number of OIF/OEF
veterans seen at VAPIHCS facilities increased to 1,137. Very few OIF/
OEF veterans are waiting more than 30 days for an appointment.
VA recognizes that our newest group of veterans has special needs.
About 18 percent of OIF/OEF veterans seen in VHA have a diagnosis of
PTSD. There are more women veterans in the OIF/OEF cohort than the
general veteran population. A significant proportion of OIF/OEF
veterans has been exposed to blasts and might suffer from Traumatic
Brain Injury (TBI). Musculo-skeletal problems (e.g., low back pain) are
common and constitute the most prevalent reason for seeking VA health
care. In response, VA is aggressively screening patients (e.g., for
TBI), training staff and hiring additional specialists (e.g., mental
health, rehabilitation) to ensure we will meet the needs and
expectations of these brave warriors.
Compensation and Pension (C&P) examinations
Veterans Benefits Administration (VBA) relies heavily on the
medical evidence and expert opinion provided by C&P examinations to
adjudicate veterans' claims. Consequently, the quality and timeliness
of C&P examination results provided by VHA is very important. The
quality of C&P examinations performed at VAPIHCS is very good, as
measured by Compensation and Pension Examination Program scores (an
external review of examination completeness and quality), insufficiency
rates and remand rates.
Regrettably, for the past several months, there is a backlog of
examination requests and the timeliness of examinations has not met VHA
standards of 35 days. The underlying causes of the delays include a
surge of requests from VBA, staffing vacancies coupled with recruitment
challenges (especially, in more remote locations such as Guam), and
space constraints in the ACC.
VAPIHCS is highly motivated to resolve these barriers and has
developed a credible plan. VAPIHCS now has made additional examiners
available to the C&P unit by reassigning staff, ``borrowing'' VA
physicians from mainland facilities and hiring contract staff. VAPICHS
is also conducting C&P clinics on some Saturdays and has plans to
renovate the ACC to relieve space constraints. Assuming the number of
requests from VBA remains stable (i.e., about 500 requests each month),
VAPIHCS is confident it can eliminate the backlog and maintain
timeliness standards by fall 2007.
State Veterans Home
The State of Hawaii is planning to open its first State Home in
Hilo later this year. This will be the first State of Hawaii facility
to provide nursing home and domiciliary care to eligible veterans. The
95-bed facility is on the site of the former Hilo Hospital on the Hilo
Medical Center campus. VA awarded a grant of about $20 million for the
project to complement state funding. VA is excited about this project
and looks forward to our continuing collaboration with the State of
Hawaii. I commend the State Advisory Board on Veterans Services for the
recommendation to name the facility in honor of Mr. Yukio Okutsu. As
you know, Mr. Chairman, Mr. Okutsu was a resident of Hilo and a
recipient of our Nation's highest award for valor, the Medal of Honor,
for his heroism during World War II.
Academic affiliations
VAPIHCS and the veterans we proudly serve benefit from an array of
balanced relationships with academic institutions. One of our most
important partnerships is with the John A. Burns School of Medicine,
University of Hawaii. Prior to my appointment as Director, VAPIHCS, I
was fortunate to have served as Chairman, Department of Medicine at the
Medical School. I have seen from both ``sides'' the value of a strong
relationship between VA and academic medicine. VAPIHCS serves as a
training site for medical students, post-graduate housestaff (i.e.,
interns, residents and fellows), dentists, nurses, pharmacists,
psychologists and social workers. We also work with the Medical School
in recruiting physicians and research investigators. Our patients and
staff also benefit from the training programs and other academic
programs at Tripler AMC.
CONCLUSION
In summary, with your support, Mr. Chairman, and other Members of
Congress, VA is providing an unprecedented level of health care
services to veterans residing in Hawaii and here on the Big Island. Our
goal is to provide safe, effective, efficient and compassionate care to
all veterans. We are committed to and active in our outreach efforts to
veterans, including the brave soldiers in the Guard and Reserve, who
proudly served in OIF/OEF.
However, VAPIHCS still faces several challenges, in part due to the
topography of its catchment area, lack of an acute medical-surgical
hospital, limited community resources in rural areas and difficulties
recruiting staff. VAPIHCS will meet these challenges by utilizing
telehealth technologies, hiring specialists, working with community
partners and developing new delivery models. I am proud of the
improvements in VA services in Hawaii, but recognize that our job is
not done.
Again, Mr. Chairman and other Members of the Committee, mahalo nui
loa for the opportunity to testify at this hearing. I would be
delighted to address any questions you might have for me.
Thank you.
Senator Akaka. Thank you very much, Dr. Hastings.
And now I call on Mark Moses for his testimony.
STATEMENT OF MARK MOSES, DIRECTOR, OFFICE OF
VETERANS SERVICES, DEPARTMENT OF DEFENSE, STATE OF
HAWAII
Mr. Moses. Thank you, Mr. Chairman. I'm very privileged to
testify before your Committee today. I am Mark Moses, the
Director of the Office of Veterans Services, OVS. OVS is the
State lead agency responsible for the welfare of veterans and
family members. We have a counselor stationed in each county
and we touch each island. We have counselors that have regular
appointments on every island in the state.
As the Governor's liaison to veterans and veteran groups we
serve as an intermediary between the Department of Veterans
Affairs and provide access to state services and benefits. We
have provided services and information to nearly 33,000
veterans and survivors this past fiscal year. I've attached a
summary sheet providing some services and activities made
available for your review.
The final service we can provide a veteran is interment in
a veteran cemetery with appropriate honors. The VA has
consistently supported our efforts to expand Hawaii's cemetery
plots and columbariums in order to keep pace with need. They're
deserving of our gratitude.
It is important and proper to take this opportunity to
personally thank you for your support of our veterans in
general and our cemetery system in particular. We are very
grateful for your assistance in obtaining a new grant for the
West Hawaii Veterans Cemetery. This VA grant ensures the
cemetery will have all that we have envisioned. The West Hawaii
Veterans Cemetery will be known as the most expensive cemetery
in the Nation, even with the personal sacrifices made by
veterans and community volunteers of time and energy. My
special thanks go to John Grogin and the West Hawaii Veterans
Cemetery Association. Thank you, gentlemen.
The effort of the volunteers were greatly enhanced through
material and financial support of the local business community.
Nurseries, construction firms, hotels, and the Carpenters
Union. Particularly noteworthy is our good neighbor Kukio.
Their individual contributions ensure the cemetery is the oasis
that it is today, and their commitment of water supply, which,
I understand, they have tripled, Mr. Chairman, ensure the
further expansion of the cemetery, as well as the ability to
have restroom facilities.
To all of you, thank you. We look forward to your
continuing participation as we work to expand the West Hawaii
Veterans Cemetery.
Mr. Chairman, the April 2000 data from the VA Office of the
Actuary Office of Policy, Planning, and Preparedness estimated
120,000 veterans in Hawaii. About 72 percent are on Oahu, 13
percent on the Big Island, 10 percent on one of the Maui County
islands, and approximately 5 percent on Kauai. Our island state
presents unique challenges for the Department of Veterans
Affairs. Despite these challenges, I want to share with you
comments that we hear from veterans.
They speak of the excellence of VA medical care, how VA
staff treats veterans with dignity and respect, and that the
services rendered by the dedicated health care professionals
are superior to that that they received on the mainland. These
comments are from local veterans and those visiting Hawaii that
seek care in the Spark M. Matsunaga Medical Center.
Similar comments are heard about the VA benefits staff.
Hawaii's VA supports the Guard and Reserve prior to deployment,
and upon their return, as well as their family members while
they're in military service. As a disabled veteran, I can
attest to the fact that the services provided here by the VA
are top in the Nation. Nevertheless, given the proper
resources, they're capable of doing better.
Recall that nearly 30 percent of the veterans live on the
neighbor islands. Many of them are referred for surgical
services to mainland VA medical centers, civilian medical
facilities on Oahu, or to Tripler Army Medical Center. For
neighbor island veterans sent to mainland VA hospitals, this
can be very traumatic. They're booked on flights, sent to a big
city, and they're told find a VA facility. They're operated on
and then they're sent back to their homes in Hawaii. We ask
that sufficient funding be provided for direct mainland flights
from and, whenever possible, return flights to the veteran's
island of residence.
Hawaii's neighbor islands must be offered the same level of
medical care and services as veterans located on Oahu. Neighbor
Island Community Based Outreach Centers place veterans on a
wait list where they are scheduled for specialty medical care.
With the use of telemedicine and more frequent visits, this
program is being addressed. However, backlogs still exist. With
some veterans waiting several months to see a specialist.
VA has a difficult time recruiting and maintaining
competent medical staff in these rural areas. VA should be
allowed to offer a premium to rural medical service providers
and to contract for additional medical care in rural areas such
as the neighborhood islands.
Thousands of National Guard and Reservists have returned.
My desire is that they, and those already here, receive medical
and benefit services in a timely manner. We ask that VA Health
Administration and VA Benefits Administration be adequately
funded and staffed to provide medical care and benefit services
to all Hawaii's veterans.
Hawaii received a VA grant to help build the Yukio Okutsu
Veterans Home, opening this year. I envision that eventually
we'll have several veterans long-term care facilities,
preferably at least one per county. This need is here now, and
I understand that you have legislation which offers bed spaces
in other hospitals, and that's greatly appreciated.
The present per day veteran reimbursement rate, however, in
the VA care home is $67.71 per day. It's insufficient to
maintain a veteran without additional payment. We request the
reimbursement rate be raised to adequately cover long-term care
services provided to assist the State in meeting the medical
care needs of this frail group of our older warriors. The
actual cost is approximately $300 per day.
As many veterans pass, many will utilize our State
veterans' cemetery system. Presently the State and County are
reimbursed $300 for each veteran burial, less than the cost to
open and close the grave site.
This reimbursement rate has not changed in many years, and
we ask your Committee look into increasing it to more closely
reflect the true cost of interments, which is approximately
$1,000. We must continue to care for those who served. They are
our sons and our daughters, our Hawaii citizens, our veterans.
I thank the Committee and you for this opportunity to testify,
and I'll respond to any questions.
[The prepared statement of Mr. Mark Moses follows:]
Prepared Statement of Mark S. Moses, Director, Office of Veterans
Services, Department of Defense, State of Hawaii
Chairman Akaka and Members of the Senate Committee on Veterans'
Affairs, I am Mark Moses, Director of the Office of Veterans Services
(OVS). The office is the single State lead agency responsible for the
welfare of Veterans and their family members. We act as the Governor's
liaison to veterans, veterans groups and organizations, and serve as an
intermediary between the Department of Veterans Affairs and Hawaii's
veterans. The office serves in partnership with the VA to provide state
services and benefits. We provided services and information to nearly
33,000 veterans and eligible survivors this past fiscal year. I have
attached a summary sheet describing some services and activities made
available through the office for your review.
The final service we can provide a veteran is interment in a
veteran's cemetery with appropriate honors. The Veterans Administration
has consistently supported our efforts to expand Hawaii's cemetery
plots and columbarium space to keep pace with need. They are deserving
of our gratitude.
Additionally, it is important and proper to take this opportunity
to thank you, Senator Akaka for your unwavering support for our
veteran's cemetery program. We are particularly grateful for your
assistance in obtaining the new grant for the West Hawaii Veterans
Cemetery located in Kona. State veterans cemeteries are the only
cemeteries accepting full body burials on a consistent basis in Hawaii.
This VA grant will assure that West Hawaii will be the cemetery we all
have envisioned it to be.
Based on April 2000 data from the Office of the Actuary, Office of
Policy, Planning and Preparedness, Department of Veterans Affairs,
there are an estimated 120,000 veterans in Hawaii. The majority, about
72 percent live on Oahu, 13 percent reside on the island of Hawaii, 10
percent live on one of the three islands which comprise Maui County,
and approximately 5 percent live on Kauai. Hawaii, an island state
located in the middle of the Pacific Ocean, presents unique challenges
for the Department of Veterans Affairs.
Before I discuss some of these challenges, I want to share with you
comments that my staff and I hear from veterans about VA health care
and benefit services. These individuals speak to the excellence of VA
medical care; that VA's staff treats veterans with dignity and respect,
and that the services rendered by the dedicated health care
professionals are superior to the care they received on the mainland
United States. These comments are expressed by local veterans as well
as by veterans who visit Hawaii and have a need to seek services from
Spark M. Matsunaga medical staff. Similar types of comments are shared
about the VA Benefit staff.
This ``new'' VA exemplifies the well known phrase of ``supporting
our troops.'' Hawaii's VA supports our National Guard members and
Reservists prior to deployment and upon their return. They also offer
services to military members who are ending their military service. As
a disabled veteran, I can attest to the fact that the services provided
by the VA locally are top in the Nation. Nevertheless, given the proper
resource they are capable of doing better.
As mentioned earlier, Hawaii presents unique challenges to the VA.
We are an island state with one large population center on Oahu. Nearly
30 percent of Hawaii's veterans live on the neighbor islands. Presently
many of our veterans are referred for surgical services to mainland VA
medical centers, civilian medical centers on Oahu, or to Tripler Army
Medical Center. This can be very traumatic for neighbor island veterans
who are sent to other VA hospitals. They are booked on flights, sent to
a big city to find the VA facility, operated on and sent back to their
home in Hawaii. We ask that funding be provided so that those who
reside on neighbor islands be provided direct flights to the mainland.
We also propose that whenever possible, return flights fly directly to
the veteran's island of residence.
Another issue that affects Hawaii and Alaska involves changes that
were made to 38 U.S.C. 1151, Benefits for persons disabled by treatment
of vocational rehabilitation. With this change the only facilities
covered by the law are those over which the Secretary of Veterans
Affairs has direct jurisdiction, or Government Facilities contracted by
the Secretary. Tripler Army Medical Center and other medical facilities
in Hawaii, such as Straub, Kuakini, Queens, and St. Francis do not
qualify under the present law. Veterans suffering an unlikely event
causing any additional disability or worse are on their own and must
sue the medical facility for damages. For most, obtaining an attorney
to pursue this option is overwhelming.
We suggest that the definitions as listed in 38 U.S.C. 1701(3) and
38 U.S.C. 1151, be changed so that veterans in Hawaii treated outside
VA facilities are afforded the same protection as veterans who receive
VA medical care in VA facilities on the mainland. Hawaii's veterans
must have the same right to redress as veterans treated at mainland VA
facilities. At a minimum, veterans must be given the opportunity to
make informed consent about the benefits and shortfalls of choosing
between having surgeries or other medical procedures performed at a VA
facility on the mainland or in non-VA facilities locally.
Hawaii's neighbor islands must be offered the same level of medical
care and services as veterans located on Oahu. Presently neighbor
island Community Based Outreach Clinics place veterans on a wait list
where they are scheduled for specialty medical care. With the use of
Telemedicine and more frequent visits, this problem is being addressed;
however, backlogs still exist. Veterans have been known to wait several
months before they see a specialist. Additionally, VA has a difficult
time recruiting and maintaining competent medical staff in these rural
areas. To address these needs, the VA should be allowed to offer a
premium to rural medical service providers and consider contracting for
additional medical care in rural areas such as the neighbor islands.
As you are aware, Hawaii has received thousands of its returning
National Guardsmen and Reservists. As Director of the Office of
Veterans Services, my desire is that these returning military members
and those already here be able to access medical and benefit services
in a timely manner. We ask that VA Health and Benefits Administrations
be adequately funded and staffed to provide medical care and benefit
services to all veterans who make Hawaii their home.
Hawaii has received a grant from the VA to build its first
Veteran's Home. The Yukio Okutsu Veterans Home is scheduled to open
within a few months. Our concern is with the reimbursement rate that
the VA pays for veterans who will be residing at the home. The present
reimbursement is insufficient to maintain a veteran without payment of
additional funds. We in Hawaii are not alone in requesting that the per
day reimbursement rate be raised so that it adequately covers long-term
care services supplied by the facility. We envision that the Yukio
Okutsu Veterans Home will be the first of several veterans' long-term
care facilities, preferably at least on per county due to inherent
island produced isolation. Adequate per resident reimbursement will
assist the state in meeting the medical care needs of this frail group
of older warriors.
As these veterans pass, many will utilize our State Veteran's
Cemetery system. Presently the state and county are reimbursed $300 for
each veteran burial, but the cost to open and close the grave site and
provide perpetual care greatly exceeds this amount. This reimbursement
rate has not changed in many years. We ask that your Committee look
into increasing the present amount so that it more closely reflects the
true cost associated with full body and urn burials.
We must continue to take care of our veterans. We must support our
Soldiers, Sailors, Airmen, Marines, and Coast Guard members at home and
abroad. They are our veterans, our sons and daughters, our citizens of
Hawaii.
I thank the Committee for this opportunity to speak on this matter
and I will respond to any questions that you may have.
______
[Note: the following is a summary of services and activities being
offered by the Hawaii Office of Veterans Services.]
Hawaii Office of Veterans Services
MISSION
The Office of Veterans Services (OVS) is the principal state office
responsible for the development and management of policies and programs
related to veterans, their dependents, and/or survivors. The OVS acts
as a liaison between the Governor and veterans' organizations and also
between the Department of Veterans Affairs and individual veterans. Our
objectives are to assist veterans in obtaining State and Federal
entitlements, to supply the latest information on veterans' issues and
to provide advice and support to veterans making the transition back
into civilian life.
OVS is the State's primary advocate of veterans applying for and
receiving benefits and services. The OVS may take action on behalf of
veterans, their families and survivors to secure appropriate rights,
benefits and services. This process includes the reception,
investigation and resolution of disputes and complaints.
The OVS serves all eligible veterans, Reservists, National Guard
members, active-duty military personnel and their dependents (including
stepchildren). (See List of Services at end.)
STATE PROVIDED BENEFITS
Special Housing for Disabled Veterans
Payment by the State of up to $5,000 to each qualified, totally
disabled veteran for the purpose of purchasing or remodelling a home to
improve handicapped accessibility.
Burials
Burials for qualified veterans (including U.S. war allies) and
their dependents in Veterans Cemeteries on Oahu, Hawaii, Kauai, Maui,
Molokai, or Lanai.
Vital Statistics
Free certified copies of vital statistics forms when needed for
veterans' claims.
License Plates
For the same cost as regular license plates, qualified veterans can
acquire distinctive veterans' license plates for their car or
motorcycle. Currently available are: ``Veteran,'' ``Combat,'' ``Combat
Wounded,'' ``Pearl Harbor Survivor,'' ``Former POW,'' 'World War II
Veteran,'' ``Korean War Veteran,'' and Vietnam Veteran.''
Tax Exemptions
Applies to real property that is owned and occupied as a home by a
totally disabled veteran or their widow(er). Also applies to passenger
cars when they are owned by totally disabled veterans and subsidized by
the Department of Veterans Affairs.
Employment and Re-employment
Preference is given to veterans, Vietnam-era veterans, service-
connected, disabled veterans and their widow(er)s for civil service
positions, training programs, job counseling and referrals to civilian
jobs by the Workforce Development Division, Department of Labor and
Industrial Relations. Re-employment rights for veterans, Reservists or
National Guard members who leave a position within State or County
government for training or active military service.
We encourage you contact the Office of Veterans Services to have your
questions answered. The sooner we begin the process together, the
sooner you will see results. Please contact the OVS office nearest you.
Walk-ins are welcome, and appointments are recommended. Home, worksite
and hospital visits are available if necessary, as are Group
presentations.
Office of Veterans Services--Oahu
Office: Tripler Army Medical Center E-Wing
Address: Office of Veterans Services, 459 Patterson Road,
E-Wing, Room 1-A103, Honolulu HI 96819-1522.
Telephone: (808) 433-0420; Fax: (808) 433-0385.
E-mail: [email protected].
Hours: Monday-Friday, 7:45 a.m.-4:00 p.m.
Office of Veterans Services--Kauai
Address: 3215 Kapule Hwy., #2, Lihue, HI 96766.
Telephone: (808) 241-3346; Fax: (808) 241-3818.
E-mail: [email protected].
Hours: Monday-Friday, 7:30 a.m.-4:30 p.m.
Office of Veterans Services--Hawaii
Address: 101 Aupuni Street, Room 212, Hilo, HI 96720.
Telephone: (808) 933-0315; Fax: (808) 933-0317.
E-mail: [email protected].
Hours: Monday-Friday, 7:30 a.m.-4:30 p.m.
Office of Veterans Services--Maui
Address: 333 Dairy Road, Suite 201-A, Kahului, HI 96732.
Telephone: (808) 873-3145; Fax: (808) 243-5820.
E-mail: [email protected].
Hours: Monday-Friday, 7:30 a.m.-4:30 p.m.
LIST OF SERVICES FOR VETERANS, ACTIVE MILITARY,
SPOUSES AND DEPENDENTS
Assist in preparation of VA claims.
Help individuals file VA Appeals.
Represent veterans at VA hearings.
Obtain veteran birth, marriage, divorce and death certificates
nationwide.
Assist with burial
Provide notary.
Assist indigents.
Maintain DD214s.
Refer individuals not qualified for VA benefits to other agencies.
Legal name change.
Review active service record.
Assist active medical boards.
Hawaii Veterans Newsletter.
Hawaii Veterans Roster.
Hawaii Veterans Website.
Governor's Liaison to veterans.
Legislative Advocate for veterans--State and Federal.
Yukio Okutsu Hilo Veterans Home--development and oversight.
State Veterans cemeteries statewide--grants and expansion.
Grant-in-Aid for all veteran related items--veterans' cemeteries,
Arizona Memorial, Aviation Museum, Veterans Centers
statewide, etc.
Tri-annual report for State Monuments.
Coordinate veterans organizations to clean the Korean and
Vietnam Memorials on Capitol grounds.
Coordinate Memorial and Veterans Day ceremonies annually
at Hawaii State Veterans Cemetery.
Assist with Memorial and Veterans Day ceremonies at National
Cemetery of the Pacific (Punchbowl).
Coordinate leis for veterans cemeteries on Memorial Day.
Staff the Advisory Board on Veterans Services.
Hawaii Veterans Memorial Fund.
Maintain presence on neighbor islands.
Validate Military Service for Employee Retirement System.
Senator Akaka. Thank you very much, Mr. Moses. Now we'll
receive testimony of Gregory Reed.
STATEMENT OF GREGORY REED, DIRECTOR, HONOLULU
REGIONAL OFFICE, VETERANS BENEFITS ADMINISTRATION, DEPARTMENT
OF VETERANS AFFAIRS
Mr. Reed. Chairman Akaka, it is my pleasure to be here
today to discuss our efforts to meet the needs of veterans
residing in the Pacific Region. The Veterans Benefits
Administration, VBA, is responsible for administering a wide
range of benefits and services for veterans, their families,
and their survivors.
Today I will discuss the important services we provide at
the Honolulu Regional Office. I will also discuss actions VA is
taking to expedite the processing of claims from our Operations
Iraqi and Enduring Freedom veterans and VBA's national hiring
initiative that will improve Honolulu's ability to provide more
timely, accurate, and consistent determinations on veterans'
claims.
The Honolulu Regional Office is responsible for delivering
VA benefits and services to veterans residing in the Pacific
Region, including Hawaii, Guam, American Samoa, and the
Commonwealth of the Northern Marianas. We provide disability
compensation, dependency and indemnity compensation, disability
and death pension, and burial benefits to eligible veterans,
dependents, and survivors. In addition, we offer vocational
rehabilitation employment services, home loan guarantees, and
Native American direct loans.
The Regional Office also provides extensive outreach to
veterans and dependents throughout the Pacific Region. One of
our most successful benefit packages is the Native American
Direct Loan Program. Initially a pilot program, which you,
Senator, helped to make permanent in 2006 by way of Public Law
109-233, the Native American Direct Loan Program. This has
effectively provided quality homes in the U.S. territories and
Hawaii homelands. At present, the Honolulu Regional Office
holds 75 percent of all Native American direct loans
nationwide.
More than 107,000 veterans are served by the dedicated
employees of the Honolulu Regional Office. Approximately 16,700
of these veterans are receiving disability compensation. This
fiscal year, through July, the Honolulu Regional Office
provided approximately 4,314 veterans with decisions on their
disability claims. Through aggressive outreach and public
contact activities, Regional Office employees have conducted
nearly 9,000 personal interviews and over 2,300 telephone
interviews, and briefed 850 separating servicemembers so far
this year.
We recently extended telephone service, benefits
counseling, and other interisland itinerate services to the
South Pacific area encompassing the Federated States of
Micronesia. Telephone service is also provided to veterans
residing in the Republic of Palau and the Marshall Islands. Our
Veterans Service Center at the RO has a designated Military
Service Coordinator, who performs many of the outreach
functions provided to returning servicemembers. The Military
Service Coordinator conducts regular briefings covering the
full range of VA benefits as part of the Military Transition
Assistance Program, better known as TAP. A Veterans Service
Representative is also out based in Guam to provide TAP
briefings there. In addition, the Military Service Coordinator
conducts briefings for members of the Army or Navy being
discharged for medical disabilities.
Our Vocational Rehabilitation and Employment employees work
very closely with military facilities in Hawaii to ensure that
outreach is extended to as many returning servicemembers as
possible. A VA employment specialist from the Honolulu Regional
Office is staffed at the Tripler Army Medical Center's
Deployment Health Center to assist returning Reservists and
National Guard members.
In addition to providing information about VA services, the
employment specialist sometimes refers recuperating soldiers to
the local Disabled Veteran Outreach person for employment
briefings offered by the Department of Labor.
We also provide monthly briefings at the TAP sessions at
Pearl Harbor Naval Hospital and Schofield Barracks. Our
vocation rehabilitation division also provides over 1,000
servicemembers and recently discharged veterans vocational and
educational counseling. We are the third highest in the country
providing that service.
The Honolulu Regional Office has been a major player in the
success of the Native American Direct Loan Program. Since 1993
VA has made almost 600 loans to Native American veterans for
the purchase, construction, or improvement of homes on Federal
trust land under this program. Over 75 percent of all loans
made in this program have been to Native American veterans
living on the homeland territories of American Samoa, Guam,
Hawaii, and the Commonwealth of the Northern Marianas. Much of
the credit for this achievement is due to our ongoing
partnerships with the Department of Hawaiian Homelands, the
Community Development Bank of American Samoa, the Territorial
Government of Guam, and the Commonwealth of the Northern
Marianas Cultural Affairs Office.
With the ongoing activation of Reserves and National Guard
members in support of the military operation in Iraq and
Afghanistan, servicemembers are becoming eligible for VA home
loan benefits faster and in greater numbers. Instead of the
time and service requirement of 6 years for members of the
Reserves or National Guard, eligibility is established under
the loan guarantee and Native American Veteran Direct Loan
Program after 90 days or more of active wartime service.
Further, as a result of Public Law 108-454, veterans are
eligible for VA guaranteed and direct loans equal to the
Freddie Mac conforming loan limit. As of January 2006, that
rate increased to 625,000 for high cost areas such as Hawaii
and Guam.
Mr. Chairman, I will now discuss two VA-wide initiatives
which the Honolulu Regional Office is actively participating.
The first of these is priority processing of claims submitted
by veterans of Operation Iraqi Freedom and Operation Enduring
Freedom.
Since the onset of the combat operations in Afghanistan and
Iraq, VA has provided expedited and case management services
for all seriously injured OIF and OEF veterans and their
families. Records show that the Honolulu staff has assisted a
total of 57 OIF/OEF seriously injured veterans. This
individualized service begins at the military medical
facilities where the injured servicemembers, separating under
the VA medical care and benefit system, are streamlined into
our benefits system overall, as well as the VA health care
system.
Beginning in February 2007, VA has provided priority
processing for all OIF/OEF veterans' disability claims. This
initiative covers all active duty, National Guard, and Reserve
veterans who were deployed in the OIF/OEF theaters or in
support of these combat operations, as identified by the
Department of Defense, DOD. As a result, all the brave men and
women returning from the OIF/OEF theaters who were not
seriously injured in combat, but who, nevertheless, have a
disability incurred or aggravated during their military service
enter the VA system and begin receiving disability benefits as
soon as possible after separation.
I am especially pleased today to be able to discuss VA's
national hiring initiative. VA has already added more than 800
new employees since April, and plans call for adding a total of
3,100 new employees by the end of next year. These employees
will be placed in critically needed positions in VA regional
offices throughout our Nation. In order to have these new
employees online and productive within a few months, VA is
providing them with accelerated training that focuses on
specialized areas of claims processing. This initial training
will be followed by ongoing, carefully structured, and
progressively complex training until full journeymen expertise
is achieved.
The Honolulu Regional Office been authorized to increase
its staffing level by over 10 percent as a result of this
hiring initiative. A number of the new employees are already on
board, and the regional office is in the process of filling
another five vacancies. The training of our new employees is
going well. We sought the assistance of the San Diego Regional
Office and temporarily detailed one of their senior specialists
for about 6 weeks to assist with training in forming a nucleus
of expertise. Our employees were tremendously helped by this
expertise and continue to thrive on it. These additional
resources will enable Honolulu Regional Office employees to
make great strides in improving the delivery of benefits and
conducting more outreach in the Pacific Region.
We thank you for your assistance, and with your continued
support we intend to deliver best service possible to veterans
who reside in the Pacific Region.
Mr. Chairman, this concludes my testimony. I greatly
appreciate being invited to testify here today and look forward
to any questions you may have, sir.
[The prepared statement of Mr. Reed follows:]
Prepared Statement of Gregory C. Reed, Director, Honolulu Regional
Office, Veterans Benefits Administration, Department of Veterans
Affairs
Chairman Akaka, it is my pleasure to be here today to discuss our
efforts to meet the needs of veterans residing in the Pacific Region.
The Veterans Benefits Administration (VBA) is responsible for
administering a wide range of benefits and services for veterans, their
families, and their survivors. Today I will discuss the important
services we provide at the Honolulu Regional Office. I will also
discuss actions VA is taking to expedite the processing of claims from
Operations Iraqi and Enduring Freedom (OIF/OEF) veterans and VBA's
national hiring initiative that will improve Honolulu's ability to
provide more timely, accurate, and consistent determinations on
veterans' claims.
HONOLULU REGIONAL OFFICE
The Honolulu Regional Office is responsible for delivering VA
benefits and services to veterans residing in the Pacific Region,
including Hawaii, Guam, American Samoa, and the Commonwealth of the
Northern Marianas. We provide disability compensation, dependency and
Indemnity compensation, disability and death pension, and burial
benefits to eligible veterans, dependents, and survivors. In addition,
we offer vocational rehabilitation and employment assistance, home loan
guaranties, and Native American direct home loans. The regional office
also provides extensive outreach to veterans and dependents throughout
the Pacific Region.
One of our most successful benefit packages is the Native American
Direct Loan Program. Initially a pilot program, which you helped to
make permanent in 2006 by way of Public Law 109-233, the Native
American Direct Loan Program has effectively provided quality homes on
in the U.S. Territories and Hawaiian Home Lands. Currently, the
Regional Office has closed 315 loans, and refinanced 161 loans,
totaling $30,557,365 and $13,716,700, respectively. Our Loan Guaranty
division has an additional 33 homes under construction with loan
obligations totaling $6,686,919. At present, Honolulu holds 95 percent
of all Native American Direct Loans, nationwide.
More than 107,000 veterans are served by the dedicated employees of
the Honolulu Regional Office. Approximately 16,700 of these veterans
are receiving disability compensation. This fiscal year through July,
the Honolulu Regional Office provided approximately 4,314 veterans with
decisions on their disability claims.
OUTREACH AND COMMUNICATION
Through aggressive outreach and public contact activities, regional
office employees have conducted nearly 1,350 personal interviews and
2,250 telephone interviews, and briefed approximately 850 separating
servicemembers so far this year. We recently extended telephone
service, benefits counseling, and other inter-island itinerant services
to the South Pacific area encompassing the Federated States of
Micronesia. Telephone service is also provided to veterans residing in
the Republic of Palau and the Marshall Islands.
The Veterans Service Center at the RO has a designated Military
Services Coordinator who performs many of the outreach functions
provided to returning servicemembers. The Military Services Coordinator
conducts regular briefings, covering the full range of VA benefits, as
part of the military Transition Assistance Program (TAP) at various
military installations in Hawaii. A Veterans Service Representative is
also outbased in Guam to provide TAP briefings there. In addition, the
Military Services Coordinator conducts briefings for members of the
Army or Navy being discharged for medical disabilities. These
briefings, which are part of the Physical Evaluation Board
orientations, are conducted at Pearl Harbor Naval Regional Medical
Center and Tripler Army Medical Center.
VOCATIONAL REHABILITATION AND EMPLOYMENT ACTIVITIES
Our Vocational Rehabilitation and Employment (VR&E) employees work
very closely with military facilities in Hawaii to ensure that outreach
is extended to as many returning servicemembers as possible. A VA
Employment Specialist from the Honolulu Regional Office is staffed to
the Tripler Army Medical Center's Deployment Health Center to assist
returning Reservists and National Guard members. In addition to
providing information about VA services, the Employment Specialist
sometimes refers recuperating soldiers to the local Disabled Veteran
Outreach Program for employment briefings offered by the Department of
Labor. VR&E employees participate in a program at the Schofield
Barracks Army Base's Soldier and Family Assistance Center, which
provides one-stop service for returning servicemembers and their
families. We also provide monthly briefings at Disabled Transition
Assistance Program (DTAP) sessions at Pearl Harbor Naval Base and
Schofield Barracks.
Our Vocational Rehabilitation Division also provides over 1,000
servicemen and recently discharged veterans vocational/educational
counseling, the third highest in the country.
HOME LOAN GUARANTY SERVICES
The Honolulu Regional Office has been a major player in the success
of the Native American Veteran Direct Loan Program. Since 1993 VA has
made almost 600 loans to Native American veterans for the purchase,
construction, or improvement of homes on Federal Trust lands under this
program. Over 75 percent of all loans made under this program have been
to Native American veterans living on the homeland territories of
American Samoa, Guam, Hawaii, and the Commonwealth of the Northern
Marianas.
Much of the credit for this achievement is due to our ongoing
partnerships with the Department of Hawaiian Homelands, the Community
Development Bank of American Samoa, the Territorial Government of Guam,
the Commonwealth of the Northern Marianas (CNMI), the CNMI Department
of Community and Cultural Affairs Veterans Affairs Office, and the
Mariana Islands Housing Authority. These offices have played crucial
roles in assisting with outreach and delivery of the VA home loan
benefit to veterans located throughout the South Pacific. They have
acted as our partners in assisting with loan packaging, appraisals, and
construction-related inspections, and have provided crucial
communication links between our staff and the veterans we serve.
With the ongoing activation of Reserve and National Guard members
in support of the military operations in Iraq and Afghanistan,
servicemembers are becoming eligible for VA home loan benefits faster
and in greater numbers. Instead of the time-in-service requirement of 6
years for members of the Reserves or National Guard, eligibility is
established under the Loan Guaranty and Native American Veteran Direct
Loan Programs after 90 days or more of active wartime service. Further,
as a result of P.L. 108-454, veterans are eligible for VA-guaranteed
and direct loans equal to the Freddie Mac conforming loan limit. As of
January 2006, that rate increased to $625,500 for high cost areas such
as Hawaii and Guam. We think this will make VA guaranteed home loans
much more attractive to veterans served by the Honolulu Regional
Office, and we anticipate continued growth in the Loan Guaranty Program
and Native American Direct Loan Program in the Pacific Region as a
result.
PRIORITY PROCESSING FOR OIF/OEF VETERANS
Mr. Chairman, I will now discuss two VA-wide initiatives in which
the Honolulu Regional Office actively participates. The first of these
is priority processing of claims submitted by veterans of Operation
Iraqi Freedom and Operation Enduring Freedom (OIF/OEF).
Since the onset of the combat operations in Afghanistan and Iraq,
VA has provided expedited and case-managed services for all seriously
injured OIF/OEF veterans and their families. Records show the Honolulu
staff has assisted a total of 57 OEF/OIF seriously injured veterans.
This individualized service begins at the military medical facilities
where the injured servicemembers return for treatment, and continues as
these servicemembers are medically separated and enter the VA medical
care and benefits systems. VA assigns special benefits counselors,
social workers, and case-managers to work with these servicemembers and
their families throughout the transition to VA care and benefits
systems, and to ensure expedited delivery of all benefits.
Beginning in February 2007, VA has provided priority processing for
all OIF/OEF veterans' disability claims. This initiative covers all
active duty, National Guard, and Reserve veterans who were deployed in
the OIF/OEF theatres or in support of these combat operations, as
identified by the Department of Defense (DOD). As a result, all the
brave men and women returning from the OIF/OEF theaters who were not
seriously injured in combat, but who nevertheless have a disability
incurred or aggravated during their military service, enter the VA
system and begin receiving disability benefits as soon as possible
after separation.
The Honolulu Regional Office is currently processing 74 OEF/OIF
veteran claims. None are designated as seriously injured. Currently,
our average time to process these claims is less than 180 days. On
occasion, specialty exams or add on conditions will necessarily extend
the time required to process a claim.
VA expanded outreach programs for National Guard and Reserve
components and its participation in OIF/OEF community events and other
information dissemination activities. An OIF/OEF team at VBA
Headquarters addresses OIF/OEF operational and outreach issues at the
national level and provides support to the newly designated OIF/OEF
managers at each regional office, including Honolulu.
To ensure that VA benefits information is provided to all
separating servicemembers, including Reserve and Guard members, VA
works with DOD to expand its role in DOD's military pre-separation
process. Specifically, VA now 5 provides ``Claims Workshops'' in
conjunction with many VA benefits briefings for separating
servicemembers. At these workshops, groups of servicemembers are
instructed on how to complete the VA application forms. Personal
interviews are also conducted with those applying for VA disability
benefits.
In addition to providing ongoing TAP/DTAP briefings at the major
military bases on Oahu, the Regional Office OIF/OEF Manager
collaborates with the Veterans Health Administration on special
outreach events. Most recently, on August 7, 2007, a multi-disciplinary
``New Patient Orientation'' was conducted for OEF/OIF veterans.
Approximately 30 veterans participated and our staff reported it was a
very successful event. Our OEF/OIF Coordinator and Manager are working
on sponsoring ``Claims Workshops'' in collaboration with the Warrior
Transition Units at TAMC, Schofield, and MCBH. I would also like to
point out that our out based satellite office in Guam is also actively
engaged in services such as these, serving the veterans who reside on
Guam and the Commonwealth of the Northern Marianas Islands. Our Guam
staff has also been responsible for providing benefits counseling
services to veterans in Micronesia, at the special ``request of the
Ambassador of the Federated States of Micronesia.
NATIONAL HIRING INITIATIVE
I am especially pleased today to be able to discuss VA's national
hiring initiative, VA has already added more than 800 new employees
since April, and plans call for adding a total of 3,100 new employees
by the end of next year. These employees will be placed in critically
needed positions in VA regional offices throughout the Nation.
In order to have these new employees ``on-line'' and productive
within a few months, VA is providing them with accelerated training
that focuses on specialized areas of claims processing. This initial
training will be followed by ongoing, carefully structured, and
progressively complex training until full journey expertise is
achieved.
The Honolulu Regional Office has been authorized to increase its
staffing level by over ten percent as a result of this hiring
initiative. A number of the new employees are already on board, and the
regional office is in the process of filling another five vacancies.
The training of our new employees is going well. We sought the
assistance of the San Diego Regional Office and temporarily detailed
one of their senior specialists for about six weeks to assist with
training and forming a nucleus of expertise. Our employees were
tremendously helped and have ongoing access to this expertise.
These additional resources will enable Honolulu Regional Office
employees to make great strides in improving the delivery of benefits
and conducting more outreach in the Pacific Region. We thank you for
your assistance, and with your continued support, we intend to deliver
the best service Possible to Veterans who reside in the Pacific Region.
Mr. Chairman, this concludes my testimony. I greatly appreciate
being invited to testify here today and look forward to answering your
questions.
Senator Akaka. Thank you very much, Director Reed.
Again, I want to remind you, if you have any messages to
pass on, any written statements, please take it to the staff
who are here, even as we talk. Before I ask questions of the
witnesses, I'd like to ask Felipe Sales, who is accompanying
Dr. Hastings, if he wants to say something about the Vet
Centers?
Mr. Sales. Thank you, Mr. Chairman, for allowing me to be
here. Yes, I need to, in a sense, clarify some of the things
that I think often get misconstrued in terms of what we do at
the Vet Centers. The Vet Center is the outreach center of the
VA. We do outreach, where the VA usually doesn't go out and
talk to or get to veterans, especially those from the combat
theater. We are mandated to provide counseling to combat
veterans and their families. And in the instance of the units
on the Big Island that were deployed, we in fact went to and
their units and talked to them prior to deployment, explaining
to them and letting them know what were the benefits and
resources available for them and their families who were
remaining behind, and then what may be available to them on
their return.
Also, on their return, we also went and made contact with
the units, letting them know what was available in terms of
counseling for the veteran and their families. There's also a
family support group that the Guard units and the Reservists
have. We have gone out to them and talked to their families in
terms of the resources and benefits that are available for
them. Hilo Vet Center was involved with both the deployment
health survey, and we conducted--I think we saw about 135
veterans that came back. And since then, the follow up we've
done in terms of counseling--veterans that have come in for
counseling and their families--we've seen approximately 20
families now.
So we let them know that we're available. We even had
extended hours for those that work. The only thing we ask is
that they call. I don't think we've turned down any one of them
that have applied or called for counseling. Thank you.
Senator Akaka. Thank you very much, Felipe. Now, questions
to each one of the panelists. It has been recommended, and
you've heard this question before today, that DOD and VA
develop a joint separation physical. From your perspective, do
you believe that it makes sense to combine VA and DOD
separation exams?
Dr. Hastings.
Dr. Hastings. Thank you, Mr. Chairman. I saw this one
coming when you had asked the previous group.
It's a complicated question because the DOD and the VA are
looking at different things when those exams are done. But as I
think about it, to have one very complete and comprehensive
evaluation done on somebody that's separating from the
military, I think would be a good thing.
The DOD separation physical is traditionally quite brief.
The VA physical examination for rating purposes is
extraordinarily detailed. And we need to train our people
extensively in order to meet the high standards that the VA
maintains for those physical exams.
So this would be a significant investment, I think, for the
system, combined DOD/VA system, in order to meet this
requirement. It's an investment in the future. If you look, as
I do, at the VA as being the health care provider for these
people who are separating for the rest of their lives, I think
to have a benchmark as to what their issues were is a
worthwhile investment for the country. Thank you.
Senator Akaka. Thank you, Dr. Hastings. Mr. Moses.
Mr. Moses. Thank you, Mr. Chairman. Of course I'm not in
the medical field myself. I think it would be beneficial to
have some of the issues identified at the time of discharge,
but I know out of just observations and personal history all
the issues don't show themselves immediately upon discharge.
Post Traumatic Stress Disorder is one that might not appear
for a few years. That doesn't mean you can't at the time of
discharge try to indicate the types of combat or other
situations that you were involved with. I don't know if we can
get those listed, though, at the time of a medical examination.
They should more appropriately be in the active duty records.
If they could come up, that would be good.
I can see one other problem. We have the luxury here in
Hawaii with having the VA and Tripler co-located. You don't
have that in all instances in other states, but also we have
Makalapa and we have facilities at the Marine Corps Base
Kaneohe. We don't have that co-located with VA. So I can see a
lot of logistics problems in just getting everybody together at
the appropriate time. When a VA doctor travels to one of these
other facilities, he's not serving VA patients. This is a
complicated issue.
Senator Akaka. Gregory Reed, I know you're not a doctor,
but you're the director of the Regional Office. Let me ask you
for your comments on this.
Mr. Reed. No, Senator. I believe it would help us expedite
the claims if we could do this. As Mark pointed out, it may
not, you know, pick up PTSD and things of that nature, but as
far as physical, I think it would be very beneficial for us.
Senator Akaka. As I mentioned earlier, this has been
recommended. I'm just asking our witnesses to comment on this.
And this is part of a whole move to try to have seamless
transition between active and civilian life. We are thinking
seriously about this and looking for comments from all of you.
Mr. Moses, what is the State of Hawaii doing to assist
members of the Guard and Reserves as they transition to
civilian life?
Mr. Moses. Well, briefly, Mr. Chairman, I have to go a step
further. We help active duty while they're still active duty.
We have active duty veterans coming in regularly into the
office from all branches of the service, but that includes the
Guard and the Reserve. We try to attend the returning
ceremonies, the post-deployment gatherings of all the veterans,
we try to have a counselor available. We also are getting more
involved in actually providing the information, as you've seen
attached to the testimony, the list of the services that we
provide, we find that not all members understand that those
services are available.
And I can go back to my own history. When I was active
duty, I never thought of going to a state Office of Veterans
Services for anything, let alone the VA. There was active and
there was my command and that's who took care of me. We're
trying to break through that, and this goes toward your
seamless idea, to make them understand that we are there. We're
there for many things that can be done while they're still in
service, and at the time of their discharge or release we need
to get out to them more and more and tell them what's
available.
We do try this through newsletter, web site, and, as I
said, we have counselors go to their post-deployment
gatherings, whether it's formal or informal, there are
debriefings and there are regular--I don't know what word to
use for it other than gatherings, but the National Guard and
the Reserves do talk to all of their returning soldiers and
airmen about what's going on and what they should expect. We're
trying to be there as part of it.
I think it's fortunate that we are part of the National
Guard. We're directly under the National Guard in this state,
and that helps us because we know the events that are happening
and we know when units are returning, and even as individuals
return we have access to that information and we can be there.
Senator Akaka. Thank you, Mark Moses.
Mr. Reed, VA's timely access to veteran's DD-214 and
medical records continues to be a serious problem.
Please explain the process by which the Veterans Benefits
Administration obtains these records. And does delayed access
slow claims processing at the Honolulu Regional Office?
Mr. Reed. In reference to that accessing the DD-214s, are
you speaking about from the Records Maintenance Center in St.
Louis? That's where we normally access the 214s from. Is that
what you're referring to?
Senator Akaka. No.
Mr. Reed. I'm unaware of younger veterans having difficulty
obtaining their 214s for VA.
Senator Akaka. Let me rephrase my question. Are they
bringing in their DD-214s to you as they come in?
Mr. Reed. Yes, they are, sir, when they're filing original
claims.
Senator Akaka. One of the things that we're going with this
idea of seamless transition is to try to eliminate some of the
problems that develop into problems of access and getting
records----
Mr. Reed. Yes.
Senator Akaka [continuing].--from the active duty.
Mr. Reed. Sir, we've had a problem or a challenge in
getting records from the National Guard, but we have recently
become signatories, or I have, and I believe everybody else on
this panel has with the Hawaii National Guard. We had one of
the representatives come over and meet with Susan Bauman, and
we signed off on that and we looked to that to be improved
greatly.
Senator Akaka. Dr. Hastings, a key provision of the
Senate's Dignified Treatment of Wounded Warriors Act is the
extension of automatic access to care for separating combat
veterans from two to five years after separation. How will this
affect health care for veterans in Hawaii?
Dr. Hastings. Senator, first of all, I applaud this idea,
because as we are identifying problems with the individuals
that are coming back, some of them are not picked up initially.
The classic one of course that you've heard about is the PTSD,
but this is also true of the TBI, and there are others as well.
So it's very clear to us that there are problems that are not
being identified initially, and also it's taking us a while to
work through the natural history of these diseases in carrying
for these veterans. I applaud the efforts of the Senate to
extend that eligibility for a period of three more years.
My organization is growing. We have been growing at 5 to 6
percent per year, and as a result we're improving access, we're
adding staff, we're improving specialty care, and of course
adding--this is an additional workload to us. My guess is that
this will increase our workload by probably 6 or 7 percent,
which on the aggregate would increase my growth rate probably
the equivalent of 1 or 2 percent per year, which is in line
with the growth that we're sustaining right now.
I think this is something that we will handle in the normal
course of events, as long as we continue on the growth curve
that we have experienced in the past few years, and I don't see
any reason why we shouldn't. You have provided and the Senate
has provided increased resources to us, and we are offering
more care today to the veterans in our area of operation. I
would expect that will--or I hope that ends up continuing, with
your support. Thank you, sir.
Senator Akaka. Thank you, Dr. Hastings.
Dr. Hastings and Mr. Reed, what measures have you
undertaken to educate separating servicemembers about the VA
benefits and services available to them? Let me call on Mr.
Reed first.
Mr. Reed. Senator, as I mentioned in my testimony, we are
actively engaged with separating the servicemembers at all the
military facilities on Oahu, as well as out on Guam, in getting
them TAP sessions and also we're involved in the DTAP sessions.
I think we're doing a very good job there.
Dr. Hastings. Senator, we're involved also at the TAP
sessions and at the DTAP sessions, and in addition, we are
actively involved with the PDHRAs.
Of course, the other thing we have done is once we have
veterans that have signed up with us, we have begun inviting
them in to orient them again. Now, the issue there is if they
didn't sign up with us at one of these original events, then
they may not be picked up. But when we have gone out to
advertise with these sessions where we sort of have an
orientation for them once they've signed up, we sort of open it
up and say, please bring your friends, it's not an exclusive
thing, and indeed when we've done that--we actually signed up
some more veterans that we had missed in our first rounds. But
there's no doubt that outreach for us is a continuing effort,
and it's going on both here and on Oahu.
It's going on at our CBOCs. It's going on throughout our--
you know, throughout our organization, and of course we're
getting help from the Vet Centers. A lot of veterans are coming
in through the Vet Centers, and we have very good close working
relationships between our Vet Centers and our CBOCs, and so
they will refer back patients--or refer back and forth when
they identify individuals.
Senator Akaka. I have one more question to ask Dr.
Hastings. Before I do that, I just want to tell the panelists
that following that question I'm going to ask each member of
the panel to make any final comments.
I want also those of you who are here to know that although
we continue to talk about challenges and looking for
improvements. We all know that many improvements have been made
over the few years back, but we still want to improve what is
happening. We still have people that have concerns as well.
This is what we're trying to do with these hearings and
meetings that we're holding. As I asked the first panel, as you
remember, if they had any solutions or recommendations, to
mention it.
We are looking, because you folks are the ones that have
these concerns and we may have a simple answer to whatever your
concern is. You can leave it with some of the staff that are in
the back of the room. I just want to mention it because I was
talking to Jim Asing, who is sitting in the first row here, who
is a Vietnam veteran and a musician who set up a foundation.
And this is, again, about people who are trying to help
veterans. He set up a foundation, and their approach is to help
veterans through music therapy. That's the kind of solution
that we may be able to use in the future.
I'd like for you to think about these innovative ideas, and
if you have any, we would be glad to hear them. And of course
if we can work it in the system, you know, we certainly would
like to look at that.
Dr. Hastings, I am aware that members of the National Guard
and Reserve are not eligible for TRICARE, and if I'm wrong,
correct me, must turn to VA for health care. Are members of the
Guard and Reserve who come to be soldiers in Hawaii receiving
the care they need?
Dr. Hastings. You're talking about the OIF/OEF veterans, is
that it? I believe that the OIF and OEF veterans that are
coming to us, once they've been identified, are being seen, are
being taken care of. We monitor this. We monitor the waiting
times. We try to keep them under 30 days, and I think we're
succeeding in that the majority of the time.
We are challenged when we're dealing with some of the outer
islands and some of the more distant locations in the Pacific.
There's no doubt about that. That's a continual challenge for
us, and that has been mentioned by some of the earlier
testimony today, and that's the challenge that we face in
building a health care system in an area of the world that is
the geographically separated by oceans. And so that's--that's
our challenge. It's what we're doing.
We have been able to improve using all the tools available
to us. We have been able to improve specialty consultation to
our--to our beneficiaries. So am I totally satisfied with how
well we're doing today? No, I'm not. Do I think we can do
better? Yes, I do. Is it a matter of money and resources? No.
You have provided for me the money necessary.
The problem is building complex systems, and that's the
challenge that I face is building complex health care systems
to work in this kind of harsh environment we live in.
Senator Akaka. Thank you, Dr. Hastings. I would like to ask
Felipe about the Vet Centers.
Are Vet Centers staff meeting regularly with demobilized
Guard and Reserve members as they come together for drills or
otherwise get together? And do you have sufficient resources to
do such outreach?
Mr. Sales. No, we don't do it regularly. It's been offered.
We've talked to the point of contacts at the Guard units,
letting them know of our availability and our willingness to go
in and talk with them. Our regular hours are 8 to 4:30, with
extended hours in the evening to take care of anyone who works,
but we have gone down to the Guard units on the weekends also
to do talks for them. Like the previous incident that occurred
with one of their members, we went down and helped debrief and
talked with them and got some of them to come in for counseling
services. So we're readily available.
We'll go there, or if they call, more than willing to see
them in the office.
Senator Akaka. Felipe, what is your assessment of how the
Guard and Reserve members and their families are learning about
their benefits?
Mr. Sales. Aside from the briefings, just from how they
either call either our office or the CBOC or the visit, we have
a benefits counselor that now comes into our office once a
month, and we take sign-ups and if they have questions they can
ask there, but we've gone out to them and talked to them about
the benefits that are available and allow them to know that.
We're a resource, and we're a resource that can attach them
to other resources in the VA that can help them with any other
problems that they might be having.
Senator Akaka. Well, thank you very much. I'm asking all of
this because you know that I feel that Vet Centers are
important to veterans. I thank you so much for what you're
doing.
Let me ask for each of the witnesses to make their final
comments and for any responses they may have. I'm going to
start Greg Reed, the Director of the Regional Office.
Mr. Reed. Thank you, Senator. I just wanted to once again
thank you for all the support you've given the Honolulu VA
Region Office. You know, sir, without your intervention,
without your support, we would not be where we are today with
the additional hires, as well as doing the itinerate visits to
the outer islands. That was put on hold because of travel fund
constraints, and we also an opportunity to go out to Micronesia
and do two town hall meetings out there, which were very
successful. We have a representative that works for us in Guam.
He went to the islands of Micronesia, and he has also has done
briefings for National Guard units on Saipan and also on Guam.
Thank you very much.
Senator Akaka. Thank you. Mark Moses.
Mr. Moses. Thank you, Mr. Chairman. Some of the problems I
heard at the beginning , was lack of outreach, lack of
outreach, lack of knowledge and where to get help. We do
outreach, as I mentioned, in the newsletter. There's 8 veterans
organizations registered with us. We send them regular
briefings.
We send them newsletters, what's going on. We have the
website. As I said, we have counselors located in each county
and they make trips to each of the islands within the county,
or like on the Big Island, my counselor Keith there makes trips
over to Kona regularly. We also attend all the transition
assistance programs.
And more than just outreach, we try to tell them to come
into us we'll help you prepare documents. We'll help brief you
in detail on your particular case, and we do help prepare their
actual documents before they submit them to the VA. I think we
do a very good job of getting it right the first time, which
helps the VA, because it cuts down on repeats. And if they do
have an appeal, we represent the veterans at the appeal.
The question about the DD-214s, as each veteran separates,
he's asked what state are you going to, and the DD-214 is sent
to that state. And the state offices are called various things,
but in Hawaii it's the Office of Veterans Services. The DD-214s
are sent to us. And if the veteran comes in, of course he has
one, but if he needs another one, he can come to us and we'll
give him a copy. And the veteran service organizations, we can
do the same thing. So we can provide that DD-214. If he didn't
put down Hawaii, put down some other state, we will get it from
the other state and we'll provide them with a certified copy
that can be used by the VA.
Senator Akaka. Thank you very much, Mr. Moses.
Dr. Hastings.
Dr. Hastings. Thank you, Mr. Chairman. We are faced with
many challenges, and I mentioned to you the obvious one that
you know very well, and that is that we live in this very
challenging geographic area. My area of interest covers million
square miles and encompasses a number of different cultures
that we must figure out how to deliver health care in.
At the same time, we're faced with an evolving system
that's evolving very, very fast. Health care is changing. The
science of health care is changing. The sociology of health
care is changing. And then the very nature of warfare is
changing, and so the new veterans that we are seeing today have
different challenges from the veterans we saw from each of the
encounters that our country has had to deal with in the past 50
or 75 years, and the VA must change in order to meet those
challenges.
An example is women veterans. We recently, as you know, had
the opportunities to open a new clinic in American Samoa, and
we've heard about that today. And I was at a town hall down
there and a woman came up to me and asked me what are you
providing for women veterans in American Samoa? I must admit, I
was a little embarrassed. I didn't realize how many we had. And
I asked her, how many women veterans do we have down here? And
she said between 300 and 400. I didn't know that. And that's a
challenge for me. How do I build a system to take care of that
group of veterans that I didn't even really recognize I had
responsibility for.
This whole area of Traumatic Brain Injury, this is the
signature illness of this war. We are just learning about it.
We really are. I'm actually a little embarrassed to tell you
that also. And in saying that, I'm reflecting on the science of
medicine and where we stand and how much information we have.
And we are rapidly trying to understand this and integrate
it into our health care system. What are the long-term
implications of this--of this traumatic process that our
soldiers are coming back with. And it's hard for us to know
exactly how to do this. So we're building the system to do
these things.
We're living in a rapidly evolving system on many realms. I
think--I think we're doing pretty well, all things considered,
but there's no doubt that we have a lot of challenges ahead of
us in the next few years to build a health care system that's
going to meet the needs of our veterans into the future. We're
going to continue to need to be resourced and supported as we
go forward from this point on. And I want to thank you very
much for the support that you've given to our veterans with
your leadership and support over the past several years, and I
look forward to working with you into the future.
Senator Akaka. Thank you very much, Dr. Hastings.
You've heard from our person in charge of benefits for
Hawaii. And you've heard from the person who represents the
State of Hawaii, Office of Veterans Services. I want to tell
you that the State of Hawaii has really been instrumental in
helping veterans. Mark Moses now is in charge of the veterans
affairs for Hawaii, so remember him. As he was pointing out,
they want to do all they can to help Hawaii's veterans. And, of
course, Dr. Hastings is our health person, and Felipe is our
Vet Center person.
In closing, I again want to thank all of our witnesses for
appearing today. I'm always so pleased to hear directly from
Hawaii's veterans on issues affecting the veterans of this
State. I truly appreciate your taking the time to share your
perspectives on the issues that our service men and service
women are facing, and on ways to support them. My hope is that
today's hearing will promote more thoughtful and focused
assistance for the veterans of our State.
I'm so happy to have all of you here. I want to wish you
well, and thank you so much for your service to our great
country. And of course we are grateful for all of those who are
now serving us in harm's way, and we have so much aloha for
those families who have lost loved ones who were serving our
country.
And so with that, I want to say aloha to all of you. God
bless you. God bless America. This hearing is adjourned.
[Whereupon, at 3:05 p.m., the Committee was adjourned.]
A P P E N D I X
------
Prepared Statement of Michael Kilpatrick, M.D., Deputy Director, Force
Health Protection and Readiness, Office of the Assistant Secretary of
Defense for Health Affairs, 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 satisfaction with medical care that a Servicemember has after
becoming ill or injured in the combat theater will be the measure of
success of cooperation between the Department of Defense (DOD) and the
Department of Veterans Affairs (VA) in providing facilities, treatment,
rehabilitation and support for Servicemembers and their families.
Today I will highlight some of the significant programs that our
two Departments have together put in place to provide the world-class
medical care that our men and women in uniform deserve. The medical
innovations such as body armor, buddy care, far-forward surgical care,
and medical air transportation with intensive care in the air have
saved American lives. However, the severity of wounds, the rapidity of
movement between medical care locations, and the necessity for long-
term rehabilitation have created new challenges for the medical systems
and for the systems that support our Servicemembers and veterans when
they have medical problems. As needed changes are instituted to meet
these challenges, we must always keep the focus on the patient and the
family.
DOD and VA have had many independent and internal groups evaluate
our abilities to support and care for our ill and injured
Servicemembers and veterans, culminating in almost 400 recommendations.
Even as these groups were preparing those recommendations, the
Secretary of Defense and the Secretary of Veterans Affairs chartered a
Senior Oversight Committee (SOC) to systematically address concerns
about the treatment of wounded, ill, and injured Servicemembers and
veterans. DOD and VA are already working toward the prompt
implementation of the recommendations of the President's Commission on
Care for America's Returning Wounded Warriors. In addition, the SOC
will ensure that the recommendations of the Secretary of Defense's
Independent Review Group, DOD's Mental Health Task Force, and the VA's
Task Force on Returning Global War on Terror Heroes, and others, are
promptly consolidated and properly aligned, integrated, coordinated,
resourced, and implemented.
To do this, the SOC will collect all recommendations, evaluate
feasibility, break down the recommendations into actionable parts,
associate those actionable parts with timelines and milestones,
establish priorities, and apply resources to support rapid
implementation. The Deputy Secretary of Defense and the Deputy
Secretary of Veterans Affairs chair the SOC. Reporting to the SOC is an
Overarching Integrated Product Team (OIPT), chaired by the Principal
Deputy Under Secretary of Defense for Personnel and Readiness and the
Principal Under Secretary for Benefits (VA). The OIPT has chartered
eight discrete lines of action (LoA), each tasked with analysis and
improvement of a specific part of both Departments' integrated programs
for treatment and support of wounded, ill, or injured Servicemembers,
veterans, and their families.
DOD's collective focus is centered on LoAs that leverage the
experience and capabilities of both the DOD and the VA to enable each
to more effectively serve its beneficiary populations. We are convinced
the continued cooperation of both Departments will greatly improve the
quality of health care provided to all beneficiaries.
LoA 1 has DOD and VA working closely to provide a seamless and
transparent disability process that is jointly administered by both
organizations. The Departments will support one Disability Evaluation
System that will be flexible enough to evolve as trends in injuries and
supporting medical documentation and treatment necessitate.
For LoA 2, DOD and VA are working together to respond to a myriad
of recommendations about the identification, treatment, recovery, and
follow-up for Traumatic Brain Injury (TBI) and post-traumatic stress
disorder (PTSD) and other psychological health (PH) issues. A group of
DOD and VA subject matter experts were temporarily assigned to a ``Red
Cell'' to develop a comprehensive program to address all aspects of
recommendations and concerns about these issues, including establishing
Centers of Excellence for both PH and TBI. Through this collaborative
effort, we are focusing on clinical research, prevention, education and
patient/family support. The Red Cell will involve the Services in
assessing their TBI and PH/PTSD plans and programs for responsiveness
to the SOC-approved planned and prioritized actions of LoA 2.
LoA 3 addresses recommendations to improve coordination and
collaboration of DOD/VA health care delivery and support to all
Servicemembers and their families through the continuum of care. The
LoA 3 team is assessing optimal approaches for delivery of an
integrated, comprehensive DOD/VA case management program that will
provide timely, proactive, longitudinal, seamless, collaborative
coordination of quality health care and social services to the
individual Servicemembers and their families in a manner that promotes
positive outcomes and quality of life throughout the continuum from
active duty to veteran status.
The goal of this program is to provide individualized, integrated,
interagency and intergovernmental support for the wounded, injured, or
ill Servicemember and his/her family throughout the process of
treatment, rehabilitation, and renewal. These efforts will strive to
minimize fragmentation of Federal services, improve coordination of
medical and rehabilitative care provided by DOD and VA and enhance
access to needed support.
LoA 4 focuses on the DOD and VA commitment to full, bidirectional
exchange of each Department's electronic medical records. The goal is
to ensure the Departments' vast array of shared beneficiary data,
medical records, and other health care information is visible,
accessible, and readily understandable through secure and interoperable
information systems, essential in supporting a seamless continuum of
care.
Our current focus is building a common inpatient application for
both Departments to further enhance patient-centric health care
delivery. DOD and VA have recently contracted a study to identify
common processes and requirements for a joint inpatient electronic
health record. Currently, the requirements are being assessed and a
recommendation will be made on how to create a joint inpatient system.
In the meantime, further integration of the current systems is taking
place.
LoA 5 addresses concerns and recommendations associated with
adequacy of facilities to support medical hold and holdover
Servicemembers at DOD installations.
LoA 6 will provide Departmental leadership recommendations for a
redesign of policies, regulations and laws, processes, and course
directions. The philosophy behind this LoA is holistic, beginning with
a blank sheet of paper, and setting aside all limitations presented by
existing public law, departmental policy and organizational lines to
deliver and implement a seamless continuum of care for Servicemembers
and their families from the battlefield to return to productive life.
LoA 7 develops the public affairs strategies necessary to
successfully implement changes through legislative proposals approved
by the Administration and submitted to Congress. The primary goal is to
ensure that the Departments have the authority and capability to
provide the world's best medical care for our Servicemembers, veterans,
and their families.
LoA 8 seeks to provide solutions to ensure compassionate, timely,
accurate and standardized personnel, pay, and financial support
practices for wounded, injured, or ill personnel. Ensuring appropriate
data sharing, quality control, and support benefits will further
support these objectives. Together with the Small Business
Administration, we are working to provide more timely and accurate
personnel and fiscal support at all critical patient flow locations and
points of Service support to include reintegration.
OVERALL DOD-VA SHARING EFFORTS
Over the last several years, the DOD and VA have made significant
strides in coordinating and developing common health care and support
services along the entire continuum of care. Both agencies are making
concerted efforts to work closely to maintain and foster a more
effective, aligned Federal health care partnership.
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. Progress on the Joint Strategic Plan
objectives is tracked on a monthly basis and reported to the co-chairs
of the JEC, and the plan is revised annually.
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.
Section 721 of the National Defense Authorization Act for FY 2003,
required the Departments to 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. There are now 48 JIF projects underway or
completed, accounting for $88.9 million of the $90 million in the fund.
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.
Augusta--coordinated staffing and assignment to hire,
train, and share staff.
Integrated DOD/VA operations at eight locations: 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 FY 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 the
VA for reservists entitled to VA care after returning from combat
operations.
This year, both Departments plan to integrate services within
market areas, not just facility operations, in major population
centers.
COORDINATED TRANSITION
For Servicemembers who transition directly from DOD military
treatment facilities to VA medical centers (436 individuals as of June
2007), DOD and the VA implemented the Army Liaison/VA Polytrauma
Rehabilitation Center Collaboration program--also called ``Boots on the
Ground''--in March 2005. This program ensures that severely injured
Servicemembers who are transferred directly from a military medical
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 worked as well when
Servicemembers were transferred to other locations around the country.
In response, the VA opened 17 additional Polytrauma Network Sites
to improve continuity of care to injured Servicemembers. The Department
deeply values the sacrifices that these veterans and their families
have made. Through the efforts of the LoAs, we are actively doing all
we can to improve the coordination and care management plan for
Servicemembers transitioning to any VA facility.
The VA also is placing personnel in our medical facilities. The
Joint Seamless Transition Program, established by the VA in
coordination with the military Services, facilitates more timely
receipt of benefits for severely injured Servicemembers while they are
still on active duty. 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 June 29, 2007, VA
social worker liaisons had processed 7,760 new patient transfers to the
Veterans Health Administration from participating military hospitals.
Finally, the 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.
Mental Health
Although the Mental Health Task Force's findings indicate that we
have work to do in expanding our Mental Health programs, we have in
place several programs that already make a difference. 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 health care are available in-theater. In addition,
before they return 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
the 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. DOD provides 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 members 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 by Traumatic Brain
Injury (TBI). For example, in August 2006, a clinical practice
guideline for management of mild TBI in-theater was developed and
fielded for the Services. Detailed guidance was provided to Army and
Marine Corps line medical personnel in the field to advise them on ways
to assess, diagnose, and treat TBI. The clinical practice guideline
includes 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.
As part of the LoA 2 effort, DOD has 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. In April, VA began
TBI screening of OEF/OIF veterans seeking care in the VA. While there
is no currently validated clinical screening instrument for TBI, the VA
is screening for events that increase risk for TBI, immediate symptoms
at the time, new or worsening symptoms after the event, and current
symptoms.
HEALTH INFORMATION TECHNOLOGY AND DATA SHARING
Although LoA 4 actions will improve DOD and VA data sharing, we
have already 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 the VA.
The work of capturing and sharing relevant clinical information
between the DOD and VA begins on the battlefield. Data is being
captured and sent to the DOD electronic health record, AHLTA. By
December 2007, theater clinical data will be accessible by VA providers
for patients presenting to VA for care.
In September 2005, DOD began monthly transmission of the electronic
Pre- and Post-Deployment Health Assessment information to the 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 to be referred to the VA for care or evaluation
started in December 2006. As of June 2007, VA has access to more than
1.7 million assessment forms on more than 706,000 separated
Servicemembers and demobilized Reserve and National Guard members.
The Bidirectional Health Information Exchange (BHIE) enables the
real-time sharing of allergy, outpatient pharmacy, demographic,
laboratory, and radiology data between all DOD and all VA treatment
facilities for patients treated in both DOD and VA facilities. Today,
all DOD sites and all VA sites can view allergy information, outpatient
pharmacy data, radiology reports, and laboratory results (chemistry and
hematology) on shared patients, as well as computable data in the
Clinical Data Repository/Health Data Repository.
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. Our
greatest mission is to honor our Servicemembers by providing the best
quality care and ensuring a compassionate, fair, and timely disability
adjudication process to enable them to return to the fullest, most
productive and complete quality of life possible.