[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]




 
                         TRANSITIONING HEROES:
                        NEW ERA, SAME PROBLEMS?

=======================================================================

                                HEARING

                               before the

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                            JANUARY 21, 2010

                               __________

                           Serial No. 111-55

                               __________

       Printed for the use of the Committee on Veterans' Affairs



                  U.S. GOVERNMENT PRINTING OFFICE
55-223                    WASHINGTON : 2010
-----------------------------------------------------------------------
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov  Phone: toll free (866) 512-1800; (202) 512ï¿½091800  
Fax: (202) 512ï¿½092104 Mail: Stop IDCC, Washington, DC 20402ï¿½090001


                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     HENRY E. BROWN, Jr., South 
Dakota                               Carolina
HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois       BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia      DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico             GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas             VERN BUCHANAN, Florida
JOE DONNELLY, Indiana                DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia

                   Malcom A. Shorter, Staff Director

                                 ______

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                  HARRY E. MITCHELL, Arizona, Chairman

ZACHARY T. SPACE, Ohio               DAVID P. ROE, Tennessee, Ranking
TIMOTHY J. WALZ, Minnesota           CLIFF STEARNS, Florida
JOHN H. ADLER, New Jersey            BRIAN P. BILBRAY, California
JOHN J. HALL, New York

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


                            C O N T E N T S

                               __________

                            January 21, 2010

                                                                   Page

Transitioning Heroes: New Era, Same Problems?....................     1

                           OPENING STATEMENTS

Chairman Harry E. Mitchell.......................................     1
    Prepared statement of Chairman Mitchell......................    39
Hon. David P. Roe, Ranking Republican Member.....................     2
    Prepared statement of Congressman Roe........................    39
Hon. Timothy J. Walz.............................................     3
Hon. John J. Hall, prepared statement of.........................    40

                               WITNESSES

U.S. Department of Defense, Hon. Noel Koch, Deputy Under 
  Secretary of Defense, Wounded Warrior Care and Transition 
  Policy.........................................................    27
    Prepared statement of Hon. Koch..............................    51
U.S. Department of Veterans Affairs, Madhulika Agarwal, M.D., 
  MPH, Chief Officer, Office of Patient Care Services, Veterans 
  Health Administration..........................................    29
    Prepared statement of Dr. Agarwal............................    53

                                 ______

American Legion, Joseph L. Wilson, Deputy Director, Health Care, 
  Veterans Affairs and Rehabilitation Commission.................     7
    Prepared statement of Mr. Wilson.............................    44
Iraq and Afghanistan Veterans of America, Tom Tarantino, 
  Legislative Associate..........................................     9
    Prepared statement of Mr. Tarantino..........................    47
Johnson, Staff Sergeant Sean D., USA, Aberdeen, SD...............     4
    Prepared statement of Sergeant Johnson.......................    41
Wounded Warrior Project, Captain Jonathan Pruden, USA (Ret.), 
  Area Outreach Coordinator......................................    11
    Prepared statement of Captain Pruden.........................    48


                         TRANSITIONING HEROES:
                        NEW ERA, SAME PROBLEMS?

                              ----------                              


                       THURSDAY, JANUARY 21, 2010

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
              Subcommittee on Oversight and Investigations,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 10:05 a.m., in 
Room 334, Cannon House Office Building, Hon. Harry E. Mitchell 
[Chairman of the Subcommittee] presiding.

    Present: Representatives Mitchell, Walz, Adler, Hall, Roe, 
and Stearns.

             OPENING STATEMENT OF CHAIRMAN MITCHELL

    Mr. Mitchell. Good morning, and welcome to the Subcommittee 
on Oversight Investigations hearing on ``Transitioning Heroes: 
New Era, Same Problems?'' This meeting will come to order.
    I ask unanimous consent that all Members have 5 legislative 
days to revise and extend their remarks and submit statements 
for the record. Hearing no objection so ordered.
    I would like to thank everyone for attending today's 
Oversight and Investigations Subcommittee hearing entitled, 
``Transitioning Heroes: New Era, Same Problems?'' Thank you 
especially to our witnesses for testifying today.
    We are here today to address what both the U.S. Department 
of Defense (DoD) and the U.S. Department of Veterans Affairs 
(VA) are doing to assist the men and women of our armed forces 
to seamlessly transition back to civilian life. Time and again 
we have heard from our returning servicemembers expecting a 
smooth transition back to the lives they once lived only to 
find themselves lost in a complex and frustrating bureaucracy.
    Today we will hear from a severely injured veteran, Staff 
Sergeant Sean Johnson who was hit by a mortar round in Iraq and 
is now completely blind. Although he has received excellent 
treatment at the Blind Rehabilitation Center in Chicago, he was 
never assigned a Federal Care Coordinator after contacting the 
VA almost a year ago.
    In addition, Staff Sergeant Johnson and his family are 
experiencing the hardships of navigating through both the DoD 
system and VA system at the same time.
    This is just one example of many. Staff Sergeant Johnson 
joins those veterans and their families who share the same 
concerns that our veterans service organizations (VSOs) will 
voice here today.
    Additionally, as I have said before, outreach to our 
Nation's veterans is an equally important task. Both the VA and 
DoD must ensure that veterans and their families are properly 
informed about the benefits and services they have earned when 
they return to civilian life.
    We need to proactively bring the VA to our veterans, as 
opposed to waiting for veterans to find the VA. This is a 
critical part of delivering the care they have earned in 
exchange for their brave service.
    The VA should be a place where veterans can easily, and 
with confidence, go for the help they seek, but the VA must 
also be willing to reach out to those veterans. Effective 
outreach will not only ensure better delivery of services for 
our veterans, but will also increase morale.
    I am hopeful that today both the VA and DoD will shed light 
on what they are doing to make certain our veterans are 
receiving the best possible care available; they are being 
provided with the services and resources they have earned; and 
most importantly, that the two Departments are working together 
to ensure that these benefits earned are seamlessly delivered.
    I believe that all my colleagues join me in being steadfast 
in our hopes that Secretary Shinseki, as he transforms the VA 
into a 21st century organization, will help eliminate the 
stigma that so many of our Nation's veterans have placed upon 
the VA. We must ensure that both the VA and DoD are working 
together and providing veterans the services that they 
rightfully deserve.
    Again, thanks to all our witnesses for testifying today, 
and we look forward to hearing your testimony.
    Before I recognize the Ranking Member for his remarks I 
would like to swear in our witnesses. I ask that all witnesses 
please stand and raise their right hand.
    [Witnesses sworn.]
    Thank you. I would like to now recognize Dr. Roe for 
opening remarks.
    [The prepared statement of Chairman Mitchell appears on p. 
39.]

             OPENING STATEMENT OF HON. DAVID P. ROE

    Mr. Roe. Thank you for yielding, Mr. Chairman.
    I would first like to thank the Members of the first panel 
for their service to this country. Not only their military 
service, but their continued service by appearing here today to 
share their testimony and help us work toward a better 
transition for our Nation's veterans.
    Prior to this hearing, my staff provided me with a list of 
the hearings held by the Committee on Veterans' Affairs over 
the past 10 years, totaling around 33 hearings. The topics have 
ranged from employment transition through the use of polytrauma 
centers, pre- and post-deployment heath assessments, sharing of 
electronic health records of our wounded servicemembers, 
transition assistance programs (TAPs) for Guard and Reserve 
forces, and the list goes on.
    As you can tell, helping our servicemembers move from the 
military to civilian life is of great importance to this 
Committee.
    Concern in Congress about helping our servicemembers 
transition to civilian life didn't start 10 years ago. During 
the 97th Congress, Congress codified this concept of DoD/VA 
sharing, now known as seamless transition in 1982 with passage 
of the Veterans Administration and the Department of Defense 
Health Resources Sharing and Emergency Operations Act. This act 
created the VA Care Committee to supervise and manage 
opportunities to share medical resources.
    Today's hearing will enable the Committee to review the 
various programs that have been instituted to assist our 
Nation's veterans and wounded warriors in their transition to 
civilian life. We will be looking forward not only at the 
medical record exchange between VA and DoD, but also at the 
various other transition services, the use of polytrauma 
centers across the country, and programs available to assist 
our veterans.
    This is not the first hearing to look at these items, and I 
am certain it will not be our last. We here in Congress must do 
everything we can to make certain that the transition our 
military personnel undergo is smooth, easy, and the programs 
available are truly helping our Nation's veterans.
    In the past it appears that any transition many 
servicemembers have encountered have not been exactly seamless, 
and certainly not easy or smooth.
    Mr. Chairman, I appreciate you holding this hearing today, 
and I believe we have much to learn from the witnesses today.
    Again, thank you, Mr. Chairman, and I yield back.
    [The prepared statement of Congressman Roe appears on p. 
39.]
    Mr. Mitchell. Thank you. Mr. Walz.

           OPENING STATEMENT OF HON. TIMOTHY J. WALZ

    Mr. Walz. Well thank you, Mr. Chairman and Ranking Member, 
and I will submit a statement to the record, but I want to 
thank both of you for holding this hearing and for our 
witnesses for being here. There is nothing more important that 
we do than to care for our veterans, and many of you in this 
room, and I know my colleagues up here, have heard me talk 
about seamless transition until I am blue in the face. There 
might be a reason for this. I just heard Dr. Roe talking about 
when we first started talking about this here, that is before I 
started basic training and did a 25-year career, and took some 
time off, and came to Congress, and here we sit today still 
talking about it.
    It is unacceptable, it is not getting the care for our 
veterans, it is costing this country money, and it is 
undermining the faith in what we do for them. We have the 
capability, we have the technology. I am absolutely convinced 
that this is the fundamental systemic issue on claims backlogs, 
on many other issues, and so I want to congratulate the 
Chairman and the Ranking Member once again for tackling this 
issue.
    It is complex and all of you who will testify today know 
that, but when we hear from Staff Sergeant Johnson, and I think 
you are going to hear some of the issues he faced is, no one in 
this country thinks that is acceptable. No one thinks it is 
acceptable. And the problem with it is, is that I think Tom 
Zampieri is out there somewhere from the Blinded Veterans of 
America, they can predict this every time what is going to 
happen, and they tell us exactly what the pitfalls are, exactly 
where the veteran is going to fall through the cracks, and then 
they give us suggestions on how to fix that.
    And I hope now that this is the time. It feels like the 
momentum is there, and so I look forward to hearing from our 
witnesses on ways we can correct this. I yield back.
    [No statement was submitted.]
    Mr. Mitchell. Thank you. At this time I would like to 
welcome Panel 1 to the witness table. Joining us on our first 
panel is Staff Sergeant Sean Johnson, an Operation Iraqi 
Freedom (OIF) veteran from South Dakota. Joseph Wilson, Deputy 
Director of Health Care, Veterans Affairs and Rehabilitation 
Commission, American Legion; Thomas Tarantino, Legislative 
Associate for Iraq and Afghanistan Veterans of America (IAVA); 
and Captain Jonathan Pruden, Area Outreach Coordinator for the 
Wounded Warrior Project (WWP). Each will have 5 minutes to make 
their presentation, but I also want them to know their complete 
statement will be entered into the record, but please keep it 
to 5 minutes. And I will ask in this order the speakers: Staff 
Sergeant Johnson, Mr. Wilson, Mr. Tarantino, and Captain 
Pruden.
    Thank you again for being here, and first Staff Sergeant 
Johnson, would you please begin.

STATEMENTS OF STAFF SERGEANT SEAN D. JOHNSON, USA, ABERDEEN, SD 
(OIF VETERAN); JOSEPH L. WILSON, DEPUTY DIRECTOR, HEALTH CARE, 
   VETERANS AFFAIRS AND REHABILITATION COMMISSION, AMERICAN 
    LEGION; TOM TARANTINO, LEGISLATIVE ASSOCIATE, IRAQ AND 
 AFGHANISTAN VETERANS OF AMERICA; AND CAPTAIN JONATHAN PRUDEN, 
 USA (RET.), AREA OUTREACH COORDINATOR, WOUNDED WARRIOR PROJECT

        STATEMENT OF STAFF SERGEANT SEAN D. JOHNSON, USA

    Sergeant Johnson. Chairman Mitchell, Ranking Member Roe, 
and the rest of the Committee. I thank you for giving me the 
invitation and the chance to give my testimony today. And I 
have to put in a disclaimer. I am not here in a military 
capacity, I am here as a veteran and a private citizen.
    My name is Sean Johnson and I am 38 years old. I am a 
three-time deployed vet, Persian Gulf, Bosnia, and Iraq. And I 
was deployed to Iraq on October 19th, 2005. And between October 
19th, 2005, and March 25th, 2006, I was exposed to four mortar 
blasts within 30 feet and a rocket blast, also within 30 feet. 
On March 25th, 2006, I was exposed to a mortar blast 10 feet 
away. I remember a bright light and a loud boom and that is it. 
It blew me 3 feet in the air and 7 feet back and I landed on my 
shoulders and my neck. I have received damage to my C-spine 
from C1 to C7. Before I got up, I was kind of paralyzed, I 
didn't know what was going on. As I looked through my feet 
another mortar hit 25 feet away. The other blast I was able to 
shake it off, this blast I couldn't. I didn't hear for almost a 
day. I was dizzy, confused, I couldn't see in the distance, I 
couldn't see at night, I had headaches and abdominal pain.
    And then I went into the hospital in May of 2006, and I was 
there for 7 days. A trauma surgeon was in charge of my case, 
and they concentrated on the abdominal pain. Sent me back and 
forth to Germany twice, and they couldn't figure it out. And 
they said it has got to be a gastrointestinal problem.
    Well, in between these trips to Germany they gave me 
antibiotics and stopped antibiotics, so I ended up with a 
serious infection. And I was sent back to the States to Fort 
Riley, Kansas. I was placed in the med hold there.
    There were all kinds of problems there. I had to launch 
seven Congressional complaints, and I was told at one time that 
if I stopped talking to my Congressmen, they would actually 
treat me.
    Fort Riley, the doctors there want to take care of their 
patients. They don't want to make referrals, they don't want 
Walter Reed or Brooke Army Medical Center (BAMC) to evaluate 
their patients, they want to treat them themselves. It is a 
type of an ego problem I believe.
    After the Congressional complaints, I did receive treatment 
at Walter Reed for pain, and at that time I got back to Fort 
Riley and they said we can't help you anymore. And at that time 
they sent me home, because the program, the Community Based 
Health Care Organization (CBHCO) that you guys created, they 
said my case was too complex and they couldn't help me anymore. 
And the Reserves, had hands tied.
    I have had an Medical Evaluation Board (MEB) waiting for 2 
years, and I just started it now. And they told me would take 
another 2 years to get through it. They are making me drill, 
and basically I go to drill and they pay me to sit in a small 
room to do nothing.
    I did not receive the transition of care. I wasn't 
contacted by a Federal Recovery Coordinator, I wasn't contacted 
by anybody. I had to copy my medical records on paper, take 
them to the VA, and at that point they entered them into their 
system, then they started all over again. Checking the 
abdominal pain. And then somebody referred me to the polytrauma 
doctors because of the blast injury. And they said, well you 
have a head injury, you have severe post-traumatic stress 
disorder (PTSD), and at that point I was treated, and then my 
vision loss came about a year later.
    I was seen by one optometrist and a couple of 
ophthalmologists. They said my eyes are fine. The VA spent 
thousands of dollars to send me to a neuro-ophthalmologist and 
she said my eyes are--my optic nerves are dead. When we came 
back the Compensation and Pension (C&P) panel said, no, that 
doesn't count. My question is, why did they spend thousands of 
dollars to get an expert opinion and they don't use it?
    So you are going through comp and pension exams 
unnecessarily over and over again before you get your benefits, 
and that just adds to the backlog. Not only that, but if they 
keep going back to a lower level of care, they won't be able to 
correct the problem.
    It really bothers me that it took 21 months to figure out a 
Traumatic Brain Injury (TBI). Twenty-one months. I went through 
all the Army treatment, I went through part of the VA 
treatment, and it took them 21 months to discern that it was a 
traumatic brain injury, and that is really scary. Because you 
can't get the treatment that you need timely enough to benefit 
you.
    The Federal Recovery Coordinators, we didn't even know 
about them. Nothing was ever said to us. And 4 years later I 
got a call from one the night before last. Two to 4 years 
later. There is no transition between case managers in the DoD 
side, and case managers in the VA side. None. There was no 
transition. If I wouldn't have brought my paperwork they 
wouldn't know what was going on. And there are a lot of younger 
soldiers that don't know that, don't know to copy their 
paperwork, or aren't given the opportunity to stay and get 
their disability. They are given a severance check and sent 
off. I know it has happened several times. I have talked to 
people in the med holds about it, and it is just shameful. You 
know, they put the burden on the VA instead of taking care of 
the soldier and then transferring him. There is no seamless 
transition, it is just not there.
    And one of the suggestions that I have, the Vision Center 
of Excellence needs to be staffed and needs to be--the building 
needs to be created at Bethesda and they need to get that done. 
They were given $6 million in the last round of money that was 
handed out and nothing has been done. They need to get that 
building up, they need to get the staff, because they are the 
ones who are going to do the trauma research and the eye 
research, which is what the injuries are coming out of Iraq and 
Afghanistan. The number of eye injuries is staggering, and it 
is happening 2 years after the injury. So it is not something 
that happens right away.
    And the scary part is, the benefits, Traumatic 
Servicemembers Group Life Insurance (TSGLI). If you are past 
730 days they don't pay out the money, and that is a 
legislative thing, the DoD put that disclaimer in there. Well 
if you have eye injuries and you go blind 2\1/2\ years later 
there is no help for you, and that is the money that is 
supposed to help you get started on getting your house done, 
getting your bills paid.
    The other thing that I would like to see, and I think it 
would help, is the Caregiver Bill, and I believe that was 
brought up and it is in the Senate and the House. My wife has 
given me tremendous care and looked out for me, and it is 
really a strain. A strain on my children, a strain on her work, 
and she may end up losing her job because she has to be gone 
all the time to take care of me. I can't go to doctor's 
appointments without her because I don't remember what goes on. 
And I suggest that that may be a fix.
    And there needs to be red flag system. There needs to be. 
For TBI and seriously injured soldiers. They need to be in 
polytrauma care, and they need to be taken care of. And not a 
year down the road. The Federal Recovery Coordinators, they 
need to be there right away to make sure that the patients are 
getting the care they need. Because up until now there are 
hundreds, maybe a thousand soldiers like me who get left 
behind. It is unacceptable.
    You have people that aren't getting the care they need, and 
they are getting left behind or slipped through the cracks, and 
you sit there for 4 years to get a med board that probably 
takes 3 days. Four years later. I was injured on the 
battlefield. Four years later. They still haven't given me a 
Purple Heart. You know, things like that, where soldiers are 
waiting, and there is no need for that. The care is there, it 
just needs to get the soldiers to the care. And the doctors are 
strained. The doctors are strained, the nurses are strained 
because of the overloaded system. And I understand they added 
four or five Federal Recovery Coordinators just recently this 
past week and they are overloaded. You have 100,000 people that 
are potentially patients and you have 20 Federal Recovery 
Coordinators. How effective is that?
    I guess the biggest thing I want you to know is that people 
are falling through the cracks and this needs to be addressed. 
And the Federal Recovery Coordinators, they need to have access 
to get this taken care of. The severely injured soldiers can't 
wait.
    You know, if you are blind in the VA, if you are not 
permanent and total they won't give you the benefits of a 
vehicle payment, or a house grant. They give a certain amount 
of money for your house to be structured. They won't give it to 
you unless you are permanent and total. Well blind soldiers 
need to have that money so that they can make their houses safe 
and their lives better, not to wait endlessly through exams and 
exams and exams to finally get permanent and total. That needs 
to be done right away.
    You know, there are five neuro-ophthalmologists in the 
country. If they say you are blind, you are not going to get 
better, then they need to accept that.
    And I hope that by my testifying today that some of the 
problems are out there, and you can come up with ways to help. 
And I hope that my testimony has helped bring things to light.
    And I speak not for myself today, but for all the soldiers 
that can't be here to speak, that are falling through the 
cracks and not getting the care they need, and not getting the 
care they need in a timely manner.
    And I want to thank you for the opportunity to be here 
today, and I will answer any questions that I can. And I 
appreciate you giving me a little extra time to give my 
testimony, as it is a little difficult to summarize when you 
have a vision problem. So that is all I have and I will answer 
any questions that I can. Thank you.
    [The prepared statement of Sergeant Johnson appears on p. 
41.]
    Mr. Mitchell. Thank you very much. Mr. Wilson?

                 STATEMENT OF JOSEPH L. WILSON

    Mr. Wilson. Chairman Mitchell and Members of the 
Subcommittee, thank you for the opportunity to present the 
American Legion's views on seamless transition issues. 
Currently, there are approximately 23.4 million veterans in the 
United States; of that total, 7.8 million are enrolled in the 
VA health care system. VA treats 5.8 million veterans at more 
than 150 hospitals and 800 plus clinics.
    As we examine the transition process, the American Legion, 
in its efforts to ensure transitioning servicemembers receive 
continuous/seamless care, has determined that veterans are 
facing various challenges, which may irrevocably deter any 
chance of a successful and smooth transition back into their 
local communities.
    An example of challenges include incomplete Post Deployment 
Health Reassessment questionnaires or PDHRA, inability to fully 
share medical records among the Department of Defense and VA 
health care facilities, lack of space at VA medical facilities, 
and shortage of staff, to include nurses and physicians.
    VA and DoD both play important roles in the transition 
process. As women and men return from Iraq and Afghanistan 
facing uncertainty with injuries and illnesses, the American 
Legion contends that closer oversight must be placed on various 
programs, such as the PDHRA and Federal Recovery Coordination 
Program, or FRCP, that have been implemented to ensure no one 
falls through the cracks. We ask Congress to assess these roles 
to ascertain the appropriateness of functional tools required 
to accommodate the Nation's veterans, their families, and the 
complex issues they are met with.
    DoD and VA have created and implemented various programs to 
support each servicemember and veterans as they transition from 
active duty to civilian life to include the PDHRA.
    The PDHRA program was established to identify and address 
servicemembers health concerns that emerge over time following 
deployments. To be in compliance with DoD's policy, each 
military service must electronically submit PDHRA 
questionnaires to DoD's central depository. However, a recent 
audit disclosed that the central depository did not contain 
questionnaires for approximately 23 percent of the 319,000 OEF/
OIF, Operation Enduring Freedom or Operation Iraqi Freedom, 
servicemembers who returned from theater. This means 
approximately 72,000 servicemembers were without questionnaires 
in the repository. The response to the absence of the 
questionnaires concluded that DoD does not have reasonable 
assurance that servicemembers, to whom the PDHRA requirement 
applies, were given the opportunity to fill out the 
questionnaire and identify as well as address health concerns 
that could emerge over time following deployment.
    The American Legion believes the administration of the 
PDHRA is essential to the success of the servicemembers 
transition, because the results would disclose telltale signs 
of debilitating illnesses, such as the disorders that plague 
many veterans who have gone undiagnosed at separation from 
active duty.
    Next the Federal Recovery Coordination program. The 
American Legion would also like to ensure that the FRCP is 
successfully assisting all recovering servicemembers and 
veterans suffering from severe wounds, illnesses, and injuries, 
as well as their families in accessing the care, services, and 
benefits provided through specifically, DoD and VA.
    There are more challenges transitioning servicemembers and 
veterans face. There have been various reports of critical 
challenges involving veterans who have recently departed from 
active-duty service. These challenges, as reported by RAND, 
includes barriers to mental health care access in community 
settings. More to specify it was discovered that military 
servicemembers and veterans are often reluctant to seek mental 
health care. The mental health workforce has insufficient 
capacity.
    The American Legion recently passed Resolution No. 29, 
Improvements to Implement a Seamless Transition, which 
recognized gaps in services, and has consistently advocated 
improvements be made to the process of servicemembers in their 
transition from active duty to civilian life. The American 
Legion continues to express that servicemembers and their 
families are easily overwhelmed when dealing with the 
bureaucracy of multiple departments. However, a more 
expeditious process that explicitly focuses on moving 
servicemembers from point A to point B, i.e., DoD to VA, 
respectively, would ensure timely and accessible care.
    The American Legion believes it is extremely vital that 
this Nation's servicemembers, before their departure, should be 
placed in a comparable or full duplex capable, fully 
compatible, DoD/VA database with appointment reminders to 
ensure their transition isn't stifled by the unknown; after 
all, active-duty servicemembers have been conditioned to be 
directed to all military appointments and events.
    Upon separation from service these newly transitioned 
veterans may continue to have the expectation that everything 
will be set up for them. Both DoD and VA are working to ensure 
servicemembers and veterans successfully receive information 
and treatment respectively.
    It is the American Legion's contention that the interaction 
between DoD and VA be heightened, most importantly, by complete 
shared access of medical records of servicemembers and 
veterans, as well as assessments of this relationship.
    Let us remember that there is no pause button for veterans. 
Every moment is critical and must be treated as such. Although 
the World War II veterans' population is diminishing at 
approximately 1,000 daily; other veterans, to include those 
from the Vietnam era to current OEF/OIF are presenting to VA 
with old and new issues. Complacency and communication between 
DoD and VA and implementation of programs can never be 
relative.
    The American Legion hereby reiterates its position and urge 
careful oversight of effective communication between DoD and VA 
to include verbal and written, as well as full implementation 
of programs to ensure no one is left behind during the 
transition process.
    Mr. Chairman and Members of the Subcommittee, the American 
Legion sincerely appreciates this opportunity to submit 
testimony, and looks forward to working with you and your 
colleagues to ensure all servicemembers are met with the best 
of health care upon transitioning into the community. Thank 
you.
    [The prepared statement of Mr. Wilson appears on p. 44.]
    Mr. Mitchell. Thank you. Mr. Tarantino.

                   STATEMENT OF TOM TARANTINO

    Mr. Tarantino. Mr. Chairman, Ranking Member, and Members of 
the Subcommittee, on behalf of Iraq and Afghanistan Veterans of 
America's 180,000 members and supporters, I would like to thank 
you for the opportunity to speak before you today.
    As an OIF veteran with 10 years of service in the Army, I 
have seen firsthand the difficulties that many veterans face 
when transitioning from servicemember to veteran for both the 
wounded warrior who is torn from service due to their 
extraordinary sacrifice or the young veteran who spent most of 
their formative years in uniform, the transition can be 
difficult.
    At a time when most of our civilian peers have begun to hit 
their professional stride, many of us now must start over, and 
this transition is felt by all, but none more acutely than the 
brave men and women who have sacrificed blood and limb for the 
country and who now must enter a world that does not fully 
understand their needs.
    Veterans of Iraq and Afghanistan may regularly receive 
excellent care in the ever-expanding polytrauma system. And 
while these centers can provide excellent care for 
servicemembers and veterans, there is a noticeable drop in the 
quality of care when transitioning to community-based 
institutions near the veterans home of record.
    Additionally, the quality of services for disabled veterans 
near their home generally does not match the standards of care 
that a veteran receives at a polytrauma center, and no where is 
this more true for veterans who are in the National Guard and 
Reserve component.
    Additionally, IAVA is concerned with the structure of some 
adaptive services benefits that many veterans use after leaving 
polytrauma care. Veterans are being forced into debt because of 
shortcomings in the benefits and the services that the VA 
provides.
    Currently, benefits for adaptive housing and automobiles 
are stuck at 1970's funding levels, and most are just one-time 
deals. With about 80 percent of OIF and OEF veterans under the 
age of 30, a veteran living with permanent disabilities will 
more than likely require more than one automobile in his or her 
life. The current rate may have bought a van equipped with 
adaptive modifications back in 1972. Today, that same amount 
might get you a mid size Kia with no adaptive technology.
    These veterans are left to pay the difference, and we 
cannot tolerate a benefits system that requires a veteran to 
incur debt just to perform everyday functions.
    Also, many veterans wounded in Iraq and Afghanistan are not 
homeowners and must return to their family homes to recover. 
They are then faced with the choice during their critical time 
in their recovery to choose between adapting the home that they 
are recovering in, or save that benefit for the home that they 
will eventually settle.
    The need for these services is obvious and the figures that 
require upgrading are absolutely known, so there is no excuse 
for leaving a veteran with substandard benefits.
    VA social workers play an indispensible role in the 
treatment of veterans recovering from multiple traumatic 
injuries, and the VA must rapidly expand their numbers. As more 
and more OIF and OEF veterans enter the VA health system, their 
overall needs will continue to inundate the overworked and 
understaffed cadre of social work professionals within the VA 
system. Private sector social workers, on an average, work on a 
caseworker to client ratio of 1 to 10 to 1 to 15. In 
comparison, in-house VA social workers operate at a ratio near 
1 to 35. The VA must address this issue before the ratios 
expand further, and these caseworkers cannot properly address 
the needs of our veterans and their families under these 
currently crushing workloads.
    For spouses and dependents of veterans who gave the last 
full measure of devotion to this country, the VA provides 
educational benefits under Chapter 35, the Survivors' and 
Dependents' Education Assistance Act or DEA. In 2008, the VA 
reported that over 80,000 family members took advantage of this 
program, more than the number of reservists using Chapter 1606, 
and unlike the generous Post-9/11 GI Bill or the recently 
increased Montgomery GI Bill, DEA provides a paltry sum of just 
over $900 a month, which will cover less than 60 percent of the 
cost of an education.
    IAVA believes that DEA benefit rates should be aligned with 
those of the new GI Bill, and if we don't what will end up 
happening is a two-tiered benefits system. One tier our family 
members were able to attend college because they qualified for 
the Gunnery Sergeant Fry Scholarship under the Post-9/11 GI 
Bill. The second tier are those forced to use DEA who take out 
student loans just to pay for a community college.
    Now since 2008, we have seen a noticeable shift in how the 
VA educates veterans about the benefits and services that we 
are talking about today. I have personally met with 
representatives from the Veterans Health Administration (VHA), 
the Veterans Benefits Administration (VBA), and the VA Business 
Office to discuss how they can better reach out to veterans of 
Iraq and Afghanistan. There has been a visible improvement with 
online and television advertisement, but there is a clear lack 
of coordination between VA departments. Within the VA, I firmly 
believe that there is talent, will, and desire to change the 
passive nature of VA communication; however, there are still 
substantial cultural and structural hurtles that must be 
overcome.
    IAVA believes that in order for the VA to conduct effective 
outreach to let these veterans know what is available to them 
it must centralize its efforts and speak as one Department of 
Veterans Affairs.
    See, the average veteran doesn't understand the difference 
between VHA and VBA. The average American certainly doesn't 
understand. When I wait an entire semester for my GI Bill check 
to come, I am not upset with the VBA, I am upset at the VA. 
When I wait 2 months to get a medical appointment, I am not 
upset at the VHA, I am upset at the VA. If the VA ever wants to 
effectively improve its communications, it must speak to the 
veteran population and the American people clearly and avoiding 
government jargon.
    Thank you once again for the chance to communicate our 
opinions on several of the issues facing veterans of Iraq and 
Afghanistan, and we look forward to continuing to work with the 
Committee, and I appreciate your time and attention. Thank you.
    [The prepared statement of Mr. Tarantino appears on p. 47.]
    Mr. Mitchell. Thank you. Mr. Pruden.

              STATEMENT OF CAPTAIN JONATHAN PRUDEN

    Captain Pruden. Mr. Chairman and Members of the 
Subcommittee, thank you for inviting Wounded Warrior Project to 
share its perspective on issues of seamless transition between 
the Departments of Defense and the VA.
    I was an Army captain who in 2003, became one of the first 
improvised explosive device casualties of Operation Iraqi 
Freedom. I have made that transition myself. Now after 20 
operations at seven different hospitals, including amputation 
of my right leg, I work as an Area Outreach Coordinator for the 
Wounded Warrior Project. I work with hundreds of warriors 
around the southeast covering Florida, Georgia, Alabama, and 
South Carolina.
    Over the past 6 years, I have witnessed DoD and VA making 
significant strides in care coordination and information 
sharing. This Subcommittee's steady focus on these issues has 
helped to achieve greater seamlessness for wounded warriors. 
But even the most well coordinated, seamless handoff from DoD 
to VA will not change the fact that for many wounded warriors 
this transition feels like they have been thrown off a cliff.
    While the two departments can take pride in certain areas 
of real progress, wounded warriors leaving the service continue 
to face programmatic, cultural, and structural barriers at the 
VA. It is critical, in our view, that those barriers be toppled 
and that key VA programs and service-delivery mechanisms be re-
engineered with the goal of having wounded warriors thrive 
physically, psychologically, and economically.
    Currently the VA does not provide wounded warriors 21st 
century help that they need. As you know, many are not only 
combating co-occurring PTSD and substance-use issues, but co-
occurring traumatic brain injuries, burns, amputations. Often, 
they are dealing with the constellation of issues which is 
pain, anger, depression, unemployment, lack of employment 
opportunity, and lack of permanent housing. In some cases these 
issues and behavioral health problems have resulted in run-ins 
with the law.
    VA has an array of programs targeted at specific problems, 
but little in the way of a holistic coordinated approach to 
turn these lives around. It must move in the direction of 
providing wraparound services that integrate the work of VA's 
Health and Benefits Administrations. Much work also needs to be 
done within those administrations to make existing programs 
more veteran centric.
    Let me cite a few examples. Too many veterans under VA care 
for PTSD or other mental health conditions are still simply 
being given pills to manage their symptoms despite a policy 
that emphasizes a goal of recovery and rehabilitation rather 
than just symptom management. This needs to change.
    OEF/OIF veterans who are struggling with PTSD need good 
clinical care, but they also need support and mentoring from 
peers who have made strides in battling the same demons. We 
urge the VA employ OEF/OIF veterans at every medical center to 
provide such peer support, as well as to do outreach to the 
many who have been reluctant to seek treatment.
    To offer another example, our own work with wounded 
warriors has highlighted the difficulties facing those who have 
PTSD and need in-patient treatment. VA's in-patient programs 
don't have uniform admission criteria. Each facility seems to 
set its own criteria. Too often warrior's circumstances don't 
fit those inflexible criteria for specialized PTSD care and 
they are denied admission to these programs they so vitally 
need.
    In short, rather than veteran-centered care this seems to 
be more like barrier-centered care. A veteran centric systems 
would not, as some facilities do, impose rigid requirements 
that a veteran must have had success in out-patient therapy for 
3 to 6 months to qualify for admission, must have had no 
suicidal attempts or suicidal ideation even for the past 6 
months, must first complete out-patient anger management before 
they can receive treatment, must first be substance abuse free 
for a certain amount of time, and must first be interviewed, 
and if accepted, may be admitted at a later date.
    Tragically many OEF/OIF veterans who are suffering with 
severe PTSD are hanging on by a fingernail, and they don't have 
months to wait to receive the in-patient care.
    Wounded Warrior Project field staff has considerable 
experience in helping OEF/OIF veterans get needed mental health 
care from VA facilities, but we have encountered great 
difficulty with placements when veteran's conditions pose a 
relatively urgent need for specialized in-patient treatment. 
The most pronounced of these cases have involved veterans who 
have been jailed because of behaviors linked to PTSD and 
substance abuse, and whose cases have come before a judge who 
is willing to having the veteran undergo treatment rather than 
incarceration.
    In several cases, however, VA medical center personnel who 
have attempted to facilitate such placements have been stymied 
by long waiting lists at specialized in-patient facilities 
inside their VISN. On numerous occasions, our field staff have 
inquired on behalf of our warriors about in-patient PTSD 
placement options beyond the confines of a particular VISN, 
only to learn that VA staff have no central repository of 
information or clearinghouse to turn to, to find out about 
programs that exist outside of their Veterans Integrated 
Services Network (VISN) or their immediate area.
    I am aware of one case where in Tuscaloosa, Alabama, there 
were 125 individual veterans on a waiting list for a dual 
diagnosis substance abuse PTSD program. One hundred eighty 
miles away in Jackson, Mississippi, was an analogous program 
with empty beds the next week. The two programs didn't know the 
other one exist because there was a VISN line between them, and 
this is unacceptable.
    We have urged the Department of Veterans Affairs to 
establish a clearinghouse on these programs to provide 
relatively real-time patient and placement information. To 
date; however, this recommendation has elicited no response.
    To cite another area, employment is certainly key to 
successful reintegration. Yet in programs targeted at helping 
veterans gain Federal employment, wounded warriors encounter 
troubling obstacles even at the VA, the one agency you would 
expect to go the extra mile in employing veterans.
    As you know, Mr. Chairman, service-connected disabled 
veterans are entitled to a ten-point preference in Federal 
hiring, but those extra points seem to give our warriors little 
or no practical help. Instead, the complex hurdles of the KSAOs 
(Knowledge, Skills, Abilities and Other characteristics) in 
demonstrating ones qualifications for a particular Federal job 
often knock qualified warriors out of contention, even in the 
VA. Surely the Department could establish some mechanisms to 
help overcome these hurdles.
    Mr. Mitchell. Captain, could you wrap this up?
    Captain Pruden. Yes, sir.
    Mr. Mitchell. Thank you.
    Captain Pruden. In short, Mr. Chairman, to achieve its 
ultimate goals of seamless transition it will not only require 
work to bring VA and DoD closer to fill the gaps, but a 
substantive transformation within the VA to insure that this is 
the most successful and well-adjusted generation of veterans 
ever.
    Thank you. That concludes my testimony.
    [The prepared statement of Captain Pruden appears on p. 
48.]
    Mr. Mitchell. Thank you very much. There are a couple 
questions I want to ask, and first to Staff Sergeant Johnson. 
Did I understand you correctly that you are still going to 
Reserve meetings?
    Sergeant Johnson. Yes. I was put in a transients, trainees, 
holdees and students (TTHS) holding cell, and they told me that 
until my MEB is over and they give me a disability rating that 
I have to go to monthly drills. And like I said, I go into a 
room, I sit there, that is it.
    Mr. Mitchell. How long after you returned home did you 
become blind?
    Sergeant Johnson. About a year.
    Mr. Mitchell. About a year?
    Sergeant Johnson. Year and a half.
    Mr. Mitchell. Could this have been prevented?
    Sergeant Johnson. No. From the blast injury my optic nerves 
already started to die, and the TBI had affected--my brain so 
it can't comprehend what my eyes are seeing, so according to 
what they told me it couldn't have been prevented, but the eye 
services would have helped tremendously.
    Mr. Mitchell. In that time period there could have been 
some transition to knowing what was going to happen, instead 
nothing happened until after you actually became blind?
    Sergeant Johnson. Yes.
    Mr. Mitchell. And did I hear you say that you have not even 
received your Purple Heart yet?
    Sergeant Johnson. Correct.
    Mr. Mitchell. And how many years has that been?
    Sergeant Johnson. Four years.
    Mr. Mitchell. Four years? Thank you.
    Let me ask Mr. Wilson something. What are the top two 
concerns for veterans that you hear from in your organization 
transitioning from DoD?
    Mr. Wilson. I actually heard those issues yesterday, during 
a site visit at one of the four Level 1 polytrauma centers in 
Tampa, transitioning, and screening.
    Mr. Mitchell. They what?
    Mr. Wilson. Servicemembers/veterans have no knowledge of 
the program. We have heard that some weren't screened 
extensively. So screening and pretty much ignorance of VA 
programs or even the transition from DoD to VA itself.
    Mr. Mitchell. So even if the VA comes--and they will 
testify I am sure--that they have all these programs, the 
problem is the veterans don't know about them.
    Mr. Wilson. The American Legion conducts site visits at 
VAMC's from January to June; we write that publication and we 
disseminate it to all 535 Congressional Members. If one 
evaluates the VA they are going to find very good programs. 
DoD, very good programs.
    Again, the problem is the transition from DoD to VA and/or 
the communication between the two, which begins also with 
medical records. Yesterday there was a doctor speaking on 
really good new patient programs, I asked him about challenges. 
He stated, ``The challenge is getting records from DoD.'' I 
asked, ``Well how do you do it? Do you do it the conventional 
way?'' He says, ``Exactly, the conventional way, and that takes 
lots of time.''
    Being an old computer guy I know there is such technology 
as duplex capability. There has to be more oversight on this. I 
mean it is frustrating now even to computer users who don't use 
computers that often, they know that there is a program that 
will allow both DoD and VA to communicate with one another.
    Mr. Mitchell. Thank you. Mr. Tarantino. What complaints do 
you hear most from veterans who are in the process of 
transitioning?
    Mr. Tarantino. Well, I think what we are hearing is 
definitely that there is a lack of communication, and this is 
not just for servicemembers leaving active duty, this is 
particularly for servicemembers in the National Guard and the 
Reserve. I know myself, I would have never gone to see the VA 
if an old sergeant major who was going through the Army Alumni 
Program with me hadn't grabbed me and said, ``You know, sir, 
right now you are young, you are macho, and you are stupid. 
When you get to be my age you are going to be old, you are 
going to be less macho, and you will probably still be stupid, 
but you are going to be in pain and you are going to need to 
know what is available to you.'' And the VA does not make 
itself known to active duty or to the Reserve component.
    And what we are seeing especially in the National Guard and 
the Reserve component, is that soldiers get these invisible 
injuries, they get discharged 48 to 72 hours after they leave 
Baghdad, and now they are home, they are drilling, and they 
need care, and they have to go to the VA. But there is no 
mechanism to bring them back into the fold of the DoD and say, 
okay, you are injured, you need a medical retirement, or we 
need to take care of you.
    In many cases we are seeing members, Iraq and Afghanistan 
veterans that are 70 to 80 percent VA disabled that are getting 
called up out of the IRR back onto active duty because the DoD 
has absolutely no idea that these guys were injured. And that 
is the big nightmare scenario that we are seeing with our 
membership.
    Mr. Mitchell. Thank you. And one last question to Captain 
Pruden. Do you think that the Office of Wounded Warrior Care 
and Transition Policy is on the right track? What improvements 
could be made?
    Captain Pruden. From what I know I think they are on the 
right track. I think they have made some very substantial 
improvements over the past several years here, and the addition 
of five more Federal Recovery Care Coordinators is certainly a 
step in the right direction.
    I would like to see again a more seamless handoff to the 
VA. I would like to see case managers who are--as Secretary 
Shinseki created the Seamless Transition Patient Advocate (TPA) 
Program doing the handoffs from the VA to DoD, unfortunately a 
lot of those slots were filled by social workers with no DoD 
experience, but a lot of experience in finding employment in 
the VA. And so I would like to see, again, TPAs be able to do 
their job and reach across and work directly with DoD to pull 
them into the new system.
    Mr. Mitchell. Thank you. Dr. Roe.
    Mr. Roe. Thank you, Mr. Chairman. Just a comment to Mr. 
Tarantino. In your testimony you had concerns raised over the 
seventies, and rightly so, funding level of the adaptive 
housing grants, and I want to make certain that you are aware 
that Congressman John Boozman who is on the Committee and 
Ranking Member of the Subcommittee on Economic Opportunity, 
introduced legislation that would increase funding, H.R. 1169, 
from the small housing grants of $12,000 to $36,000 and the 
larger housing grants from $60,000 to $180,000. The bill would 
also increase automobile grants up to $33,000.
    So I understand that there are some PAYGO issues with this 
obviously that have to be worked through, but I think all the 
Members on this Committee will look favorably toward that. So I 
just wanted to pass that along.
    You know, and the Chairman has been here one term, but you 
know you haven't been here a lot of terms when your group goes 
to Great Lakes, Illinois, in January, which is what we did. 
When other people are going to Hawaii, we went to Great Lakes.
    And what I keep hearing. I have been in the infantry, I 
have been to Afghanistan and spent a week there, been to Walter 
Reed and now to Great Lakes, and we have a VA in my hometown, 
so I have a pretty good idea, but I am still having a problem 
getting my arms around this. And after 33 hearings we are still 
hearing the same thing. And I think it is time to sit down. And 
I agree with you all, I see a VA at home that is trying to do 
the right thing. I go to a Walter Reed and I see them doing 
great work with the veterans there and the rehab with the 
wounded warriors. No doubt about it, as a physician I am amazed 
at the recovery that a lot of these wounded warriors are 
achieving now. But it is not coordinated where the left hand 
and the right hand knows what is going on. It is not because 
people are not trying. I absolutely believe that.
    But I am going to ask any one of you if you will take this 
pass and just tell us, is it beginning when the warrior--and I 
believe that what we need is, is when a soldier signs up that 
that soldier needs to have--be in the VA system that day, and I 
think they need to have one record. And I think, Mr. Wilson, 
you are absolutely right, you've got information here and 
information here and nobody can share the information. So I am 
beginning to get my arms around on what we need to do, but just 
to comment on my statement. Mr. Wilson you can start if you 
would like, or Mr. Tarantino.
    Mr. Wilson. Okay. You know, I had mentioned and it was in 
the testimony that the role of DoD and VA must be that of 
``safety net catalyst.'' Titled terminology epitomizes a 
respective program. For example, we notice that the term 
``seamless transition'' they pretty much shied away from; it's 
now called ``continuum of care.'' Seamless transition, I think 
the terminology holds us to a standard, and I will give you an 
analogy. VA's nursing home care facilities are now called 
community living centers. The American Legion has visited many, 
over 50 in this Nation, and they are holding to that standard, 
I think it's even better, because they are trying to pretty 
much help that veteran who is transitioning identify with their 
respective community by transforming the nursing home facility 
into a main street type community facility. So with VA, 
everything may be in a name. So seamless transition makes us 
aware of this process. Before it was called seamless transition 
as I said the name was changed to continuum of care, and I 
think we shied away from that level boost.
    Mr. Roe. Let me interrupt for just a second because I don't 
have much time left. But I know when I got out of the Army 
basically I gave myself my own physical to get out, because I 
wanted out, like most of us do. And I think that is what 
happens when you said we are young and stupid. I think you are 
right about that.
    Would it help when a veteran ETS's (Expiration of Term of 
Service) from the military if the VA were there at the time of 
separation and to prepare that veteran to move on? And I know I 
was given a physical, but is everybody given a physical on the 
way out the door? Do you have a record when you leave the 
military, are you examined by a physician or a physician 
assistant or whatever and get a complete physical exam before 
you leave so that you have that information when you leave? 
Because, see I think if you are injured, the best time to find 
out how bad your injury is, and it may change. As you pointed 
out, as you get older things change. But you at least at that 
point in time you would know exactly what was wrong with that 
soldier. And Captain Pruden or Mr. Tarantino. Either one. 
Captain?
    Captain Pruden. I think that having a pre-release physical 
is vital as part of this. But I will tell you that 
servicemembers who are coming off active duty currently because 
of enhanced oversight and programs that have been implemented 
in the last 6 years, do have a whole array of briefings about 
benefits that are available to them as they leave the service. 
Oftentimes there is a bit of information overload. They don't 
remember most of what is told them. They have 100 forms they 
have to sign. And so they leave the service having heard one 
time this thing that goes in one ear, out the other. They don't 
recognize that they will need that in the future.
    So I think again, it is critical the VA be there doing 
outreach as these guys are coming into the VA system. And you 
know, when the OEF/OIF folks are coming into the VA and 
enrolling in the VA, that they have the best primary care 
physicians around. As you guys know, the primary care managers 
at the VA are sort of the gatekeepers to all of their specialty 
care and will be the primary folks interacting with our wounded 
warriors and our veterans. And if nurse case managers--OEF/OIF 
nurse case managers could have override capabilities to put 
wounded warriors and veterans with appropriate primary care 
managers instead of sort of leftovers after--older veterans 
talk, and they know who the best doctors at the VA are.
    Mr. Roe. Not only veterans talk.
    Captain Pruden. Yeah. But they know who the best doctors 
are at the VA, and so there is a waiting list to get on with 
that primary care manager. The newest nurse case managers and 
the least experienced and perhaps maybe not the best physicians 
in the VA are the ones who have open slots typically, and 
oftentimes these warriors are assigned to folks who don't know 
about head or trophic ossification, a lot of the conditions 
that these guys are coming back from Iraq and Afghanistan with. 
You need a primary care manager who is familiar with these 
things, who is competent to serve as the gatekeeper to push 
them out to the appropriate services.
    Mr. Roe. Okay. Thank you, Mr. Chairman.
    Mr. Mitchell. Thank you. Mr. Hall.
    Mr. Hall. Thank you, Mr. Chairman and Ranking Member and 
other Members of the Committee for allowing me to go out of 
order. I have a meeting like most of us that I'm double booked 
on. But proud to say we have a member of the Wounded Warrior 
Project who has joined our staff in the 19th District in New 
York, and the meeting I am going to is for another veteran who 
we hope will join our staff here working on veterans' issues.
    It is disappointing to know that as we enter 2010, more 
than 9 years after we first entered Afghanistan, transitioning 
our troops is still such a challenge, and that we have to do 
better for all of our men and women in uniform, and our heroes 
like Staff Sergeant Johnson deserve better.
    I have visited the wounded warrior transition (WWT) unit at 
West Point, which is in my district, and commend the men and 
women who are working there. But even this success illustrates 
the shortcoming we have with only 35 WTUs in the whole country. 
We have servicemen and women from as far away as Vermont coming 
down to southern New York to Hudson Valley to come to the WTU 
in West Point to receive treatment.
    There is also a limited VA presence at West Point, and 
these are among the reasons that I plan to introduce 
legislation to improve this seamless transition by mandating 
that the VA have a permanent presence on all active-duty 
military facilities and require one-on-one consultations with 
active troops as they begin the transition process. There 
should be no improperly filled out enrollment forms, you know, 
it should cut down on processing time, and reduce the ever 
growing backlog, which is going to grow even more, as a result 
of the addition of three new Agent Orange connected diseases. 
Leukemia, Ischemic Heart Disease, and Parkinson's Disease, but 
I am sure you can fill me in.
    I wanted to ask you, Staff Sergeant Johnson, in your 
written testimony you said that you were told if you stopped 
contacting your Senators you would be given medical treatment. 
Can you tell us who told you that?
    Sergeant Johnson. The Reserve case manager at Fort Riley, 
Kansas. Shortly after that I was transferred to another case 
manager, because I stood up to her and said that this is not 
right, it is ridiculous, and I am not going to stand for it. 
And then I was transferred to another care manager.
    But like it was said before, the case managers are 
stretched thin. So instead of one-on-one or one-on-five it is 
one-on-ten or fifteen. So you get left behind.
    Mr. Hall. Well good for you for standing up like that, and 
I am not surprised, but many veterans get their problems solved 
or at least help getting their problems solved in part by 
coming to Members of Congress or Senators, and it is just 
shameful that somebody should tell you to stop contacting your 
elected representatives as if you gave up your rights as a 
citizen by being a soldier. That is very unfortunate.
    But I wanted to ask Captain Pruden, you mentioned the 
difficulty of some OEF/OIF veterans to get PTSD treatment. Do 
you believe that presumptive service connection for a PTSD will 
help this problem, such as the rule change that we are 
expecting from VA?
    Captain Pruden. Could you clarify the question as far as 
what a presumptive PTSD diagnosis would look like in your mind?
    Mr. Hall. Well there was a rule change proposed by the 
Department, the Secretary has testified before the full VA 
Committee about it, and the public comment period closed before 
Christmas, I think it was in November, and they are evaluating 
thousands of pages of testimony now before making the final 
announcement of what the rule change will be, but it would 
presume any PTSD to be service connected if that man or woman 
in question had served in a combat zone or an area of 
hostilities with the enemy so as to remove the need for a 
particular incident being proven.
    Captain Pruden. I think that is appropriate. I think that 
PTSD obviously is not necessarily caused by a certain focal 
instance where your own life is threatened, but it can be 
caused by the generalized fear of mortar attack or seeing dead 
bodies all around, seeing civilian casualties. So no, I think 
that is an appropriate step and would help facilitate more 
appropriate care for these guys as they are coming back. And 
unfortunately it is oftentimes when you have the burden of 
proof heaped on these guys, these warriors as they are 
returning it is a real challenge with the psychological issues 
they are dealing with to try to come up with the evidence they 
need. So I think a presumptive rating makes a lot of sense.
    Mr. Hall. Thank you very much. Thank you, Mr. Chairman. I 
will submit my statement in writing.
    [The prepared statement of Congressman Hall appears on p. 
40.]
    Mr. Mitchell. Thank you. Mr. Stearns.
    Mr. Stearns. Thank you, Mr. Chairman, and thank you very 
much for holding this hearing. Perhaps going along with what 
Mr. Hall said and the opening statement of Mr. Roe when he 
mentioned we had 33 hearings--I think Mr. Roe mentioned we had 
about 33 hearings on this topic the last 10 years. I asked 
staff to give me, going back to 2000 to the 106th Congress, the 
Subcommittee on Health had a VA hearing on health care sharing 
between DoD and the Veterans Administration. In 2002, there was 
a hearing in the Subcommittee on Benefits on the Transition 
Assistance Program and Disabled Transition Assistance Program. 
You can even go through this list and you can just see that in 
2005 we had an oversight hearing on the Transition Assistance 
and Disabled Transition Assistance Program. So this issue has 
not been without hearings.
    I think now, Mr. Chairman, what we need to do is, as a 
result of this hearing, come up with a bill, one perhaps that 
Mr. Hall mentioned and one that I think both Mr. Roe and I can 
work on to amend. I have several ideas, and Captain Pruden is 
in my Congressional district from Gainesville, Florida, and is 
working with the Wounded Warrior Project.
    So I think, Mr. Chairman, you have a unique opportunity, 
based upon what we heard today, and what the record shows, that 
we should try and solve this problem. And I know the second 
panel is going to mention veterans or the Veterans 
Administration, some of their personnel are here, but it 
appears to me there are two problems.
    One is when the veteran leaves, when he leaves the military 
active service, the coordination with the Veterans 
Administration has not been successful. Perhaps we should have 
some VA employees at the point of demobilization that are there 
when a veteran leaves the military, whether that is at the 
military base or at the country where he is just so that he 
gets it.
    The second thing is, I think we have to have enforced by 
the Veterans Administration the medical checks. Staff Sergeant 
Johnson, when you left the military did you actually have a 
medical screening, including an eye exam? I wasn't clear on 
that.
    Sergeant Johnson. Yes, when I was demobilized because the 
hospital could no longer do anything for me I was given an exit 
physical.
    Mr. Stearns. Including an eye exam?
    Sergeant Johnson. Yes.
    Mr. Stearns. Okay.
    Sergeant Johnson. Before I went back home to my unit.
    Mr. Stearns. Yes.
    Sergeant Johnson. The problem is the reservists have been 
deployed for a year. They come back and instead of debriefing 
them and keeping them for a little bit to see if they have the 
PTSD issues, they are in and out in 3 days.
    Mr. Stearns. I understand.
    Sergeant Johnson. Nobody wants to stay at the site, they 
want to go home and see their families.
    Mr. Stearns. Yes, I understand.
    Sergeant Johnson. So they are going to say whatever they 
want to hear----
    Mr. Stearns. To get out of there.
    Sergeant Johnson [continuing]. Or whatever they need to say 
so they can go home.
    Mr. Stearns. Did you have a mental health screening?
    Sergeant Johnson. Yes.
    Mr. Stearns. And you had a dental examination?
    Sergeant Johnson. Yes.
    Mr. Stearns. Captain Pruden, I think with all your injuries 
and everything, you obviously had a medical screening. Did you 
also have a mental health screening? Do you recollect when you 
left?
    Captain Pruden. There was a screening form that I filled 
out and a PTSD screening criteria form that I filled out, but 
did not have psychological evaluation.
    Mr. Stearns. Yes. So you were asked to sign something, but 
were you briefed on what you were signing and the meaning of it 
and so forth?
    Captain Pruden. I believe that I was. And again, I think 
the issue really is you are doing so much so fast, going 
through the NEBPB process----
    Mr. Stearns. You don't understand the significance of what 
you are doing.
    Captain Pruden. Exactly.
    Mr. Stearns. Yes. Based upon the conversations you and I 
have had in my office and based upon your testimony, what kind 
of changes, if you could wave a wand today, based upon your 
experience, would you like to see? Communication between the VA 
central office and the caseworkers working in the different 
VISNs? What would you do today at the Veterans Administration 
to help those that are suffering from traumatic brain injuries, 
PTSD, or other serious mental health issues and what we as 
members could follow up and do based upon your recommendation?
    Captain Pruden. You know, as I mentioned in the testimony, 
sir, I would recommend that there be a central clearinghouse of 
information that pulls in information about specialized PTSD, 
substance abuse, TBI programs across VISNs, and that that also 
would be pushed back out to the caseworkers who could use the 
information. Most caseworkers are overloaded, as the other 
witnesses have testified to, and they have a window of about 
this big, and when they get a warrior in front of them, a 
veteran in front of them that needs help they are going to send 
them to the place down the street, because it is the place down 
the street, it is the place they know. Not because it has 
available beds, not because it is necessarily the best facility 
for them, they send them to that facility because they don't 
know any better, and there is no information coming in, and the 
VISNs have become small feed centers. And so having a central 
clearinghouse for information would I think be a tangible way 
to make a difference with the case managers of these warriors.
    Mr. Stearns. Mr. Chairman, I think based upon his 
testimony, what we should do is write a letter to the Secretary 
of Veterans Affairs asking them if they have a central point of 
communication. I think they will say they do. What we would ask 
is for them to put in writing if it is systemwide. They might 
have it in different geographical locations, but what I think 
the captain is saying, is we need something that is systemwide 
so that everybody can go to that one person, not to separate 
geographic locations.
    Captain Pruden. Yes, sir. I talked to over two dozen OEF/
OIF caseworkers across the Nation about these programs, not a 
single one of them could tell me about programs outside of 
their VISN except occasional anecdotal things. So if the 
information exists it is not getting to the folks who need it.
    Mr. Stearns. So I think that would be appropriate. And then 
as a result of what he says we can follow up if necessary with 
legislation.
    The other big problem that I have heard over the years 
serving on the Veterans Affairs Committee is the effectiveness 
of peer-to-peer support and peer-to-peer mentoring amongst 
veterans. Captain Pruden, is that, in your opinion, being 
effectively done by the Veterans Administration?
    Captain Pruden. It is not at this point. I mean, that is 
something that the Wounded Warrior Project and other VSOs are 
working on laterally, but I think that the best shot the VA has 
taken was creating the transition patient advocate physicians, 
were supposed to be filled by OEF/OIF personnel, and 
unfortunately when that has been the case, I know of six 
personally who have filled those positions, OEF/OIF personnel, 
four of them are no longer working for the VA because they were 
so frustrated and a variety of issues that arose with that job. 
They thought they would have carte blanche to go out and do 
good and make sure the guys were taken care of as they came 
from DoD to the VA, and unfortunately that wasn't the way it 
worked out oftentimes.
    Mr. Stearns. Well let me just conclude, Mr. Chairman, by 
saying I think we have some very constructive ideas that have 
come from this panel. I think in addition to what Mr. Hall 
mentioned about having the VA representative there at the day 
they are discharged, that somehow we should have this 
mentoring, this peer-to-peer support and peer-to-peer 
mentoring, available for them in a consistent way so veterans 
before they sign up on these sheets can see these peer-to-peer 
mentor who can tell them what they are signing off and what it 
means. So if a fellow Marine, a fellow Army, a Navy, an Air 
Force personnel said to me, ``Cliff, before you sign off let me 
tell you what the situation is. I have had post-traumatic 
stress disorder and I signed off and I shouldn't have. This is 
serious.'' So this idea of being young, macho, and stupid would 
be balanced by having fellow soldiers who have been through it, 
who have lost their eyesight, lost their limbs--sitting here 
with shrapnel in their body--could say listen, let us not be 
stupid here. I want to tell you what my life story is, and then 
they would get their attention rather than just saying I want 
to get to Dayton, Ohio, I want to get back to West Virginia. 
This is really serious, and you are looking in the eyes of guys 
that are veterans who are wounded and have suffered and they 
can tell them about the experience that their spouses have also 
suffered. So that would make them more informed.
    So I appreciate all of your testimony and thank you for 
your time.
    Mr. Mitchell. Mr. Walz.
    Mr. Walz. Well thank you, Mr. Chairman, and thank each of 
you for your service. And Mr. Tarantino, I am that old sergeant 
major you talked to and I have sat through far too many of 
these. I think I am at a breaking point on this, along with 
many of you.
    Mr. Johnson and especially Mrs. Johnson, who I will be 
talking to most of the time, because that is a key here that we 
have missed and it hurts this Nation and it is the wrong thing 
to do. But to you, Mr. Johnson, on behalf of the people of 
southern Minnesota, and I think it is fair to say the people of 
this country apologize to you for what you have been through, 
but I also realize that and a yellow ribbon magnet don't even 
get you a cup of coffee. And I have had it with that type of 
rhetoric, I have had it with that type of support, if you would 
call it.
    And you want to hear a real sad story? In that very chair 
you are sitting in last year a young man named Travis Fugate 
sat in that same chair and went through the same thing. And we 
were warned about it, we were told about it, we lamented about 
it, we rang our hands, we gave--and you are going to hear Mr. 
Koch is going to come up, we will rail at DoD for not talking 
to VA, when those people are absolutely committed to our 
veterans and we are simply still not finding a fix.
    I find it absolutely appalling a caregiver bill--and Mrs. 
Johnson you will attest this when we hear what you have gone 
through and how your life has changed--passed this House, 
passed the Senate and sits there now. It took a week to pass 
the TARP bill, money sure moved quick to Wall Street. It took 3 
days to pass the money to re-build the bridge in Minneapolis 
after it fell. Well your bridge is falling every day. And the 
euphemism of that or the vision, I am just appalled that we 
can't see this.
    And I have to tell you, I have talked to Secretary Gates, I 
have talked to Secretary Shinseki, talked to Admiral Mullins, 
they are all committed. But you know if I was you, if I was 
asking today is, ask Members up here if they know their 
counterparts on the House Armed Services Committee. Why aren't 
they in here? Why can't we as a Congress talk together to 
figure it out? We keep talking about that. Oh no, we got our 
silo we got to protect. Go over and talk with who is on 
Representative Davis' Committee. If we can't name them shame on 
us. And you got them, and it is we that are handling that. We 
got it. It is our silo. It is our area of expertise. You know, 
I am the chairman there and all this.
    So I have to tell you, the time for the rest of the talk is 
done. We can scream and yell at DoD and at VA and all that. We 
are not setting the model here. We are not pushing the thing 
forward.
    And I want to just watch a few things. I think it is great. 
And Mr. Tarantino, a year or so ago we had VA in here and asked 
them about their outreach. We had to direct them, letter and 
spirit of the law to tell them that they could advertise. For 
every ad trying to get you in to be one of the few and the 
proud there ought to be one that say when you come home you are 
still few, you are still proud, and this country cares about 
you. But we had to tell them to do that. So then all of a 
sudden I saw a sign on the side of a bus. And then I go to the 
Web site and I can't even read it. My 9-year-old's club penguin 
site is more functional. And those are the things that how can 
we miss that? How can we get it wrong?
    So I ask Mrs. Johnson, as all of us talk about this if all 
those things happen or whatever and we debate the little things 
on this, could you just tell us on the Committee how has your 
life changed since your husband and our staff sergeant was 
wounded? How have things changed for you?
    Mrs. Johnson. Well we have three teenage children. We have 
been married for 15 years. And he came back to Fort Riley, and 
from the very beginning I knew things weren't right, but I 
didn't have the ability to be there with him. I had to be at 
work, I had a family to take care of, he was 12 hours away. 
Most of our conversations were by phone where, you know, my 
proud soldier would deceive me the best he could with oh, I am 
fine, it is great, I am feeling good today, I took my pills, it 
is all good. And so I had to do a lot of calling and 
complaining. And I used a lot of my time at work, asking a lot 
of favors from different people to, you know, can you cover my 
class for just a little bit while I go make this call? While I 
go call Senator Johnson's office back. I mean he would call and 
say, well maybe you shouldn't do that anymore because today 
they brought me in and said I need to quit making these phone 
calls, or I need to quit asking for this. And I knew he wasn't 
right.
    It took 9 months to get him home. He came home, was not 
able to be on the CBHCO Seal program. Was told that he was too 
severely injured, it is not a long-term program, we don't have 
the availability in your area, you need to just go home and go 
back to your regular job as a firefighter, as a lieutenant, in 
a position where he--first of all his physical stamina wasn't 
good, his confusion, he has memory loss, he can't make 
decisions. And to be able to say that he was going to come back 
and fill that capacity, I mean that was not good.
    It took about 6 months. They had him on a mostly paper 
shuffling job at the fire department. They worked very well 
with him. But within a year he had to take a medical 
retirement. He could not meet the demands of that job and the 
quick thinking and decision-making things that he needed to do.
    So we started with the VA when he got home. We did all of 
the legwork for that. He copied every one of his medical 
records from the military. At times we had to beg to get 
records of things. We had to search for things that didn't 
happen or didn't exist. We had to do all of the legwork on the 
VA end. And then throughout that process, while we have been 
very fortunate to have a great doctor in our polytrauma unit, 
prior to that there were no questions about blast injuries, 
about falls, about head injuries. They were focusing on the 
wrong problem. And I would say, ``Look, you know what, he 
doesn't remember conversations we had yesterday.'' And the kids 
and myself were saying dad's not right, this is wrong, there is 
something missing here.
    And so he returned home in May of 2007, and in December of 
2007 someone finally asked, ``Were you ever near a blast 
injury? Were you ever near an explosive device?'' That is what 
finally tipped them off that well maybe we better examine him 
for a brain injury.
    When we finally got that information--again, I really liked 
the doctor that we work with at the Sioux Falls VA, I think he 
does a great job--but the VA doesn't have any information on 
PTSD or TBI that they are handing out. They would sit us down, 
we would have our hour or half an hour appointment and then 
drive the 3 hours home and go home and Google everything. 
Everything that we know about every disability and injury and 
infection he has had is because we looked it up ourselves. And 
that is time consuming, it is difficult, it is hard to focus on 
your own position, focus on your children. We have to be at 
this or whatever appointment or activity, and fit in his 
appointments.
    I am very fortunate with my principal at my school that he 
does let me be gone as often as I need to be. I can go in and 
say, this is what is going to happen and I need a sub. But I 
know that there are so many more that aren't that fortunate to 
be able to go in and say hey, I have to be gone for 3 days and 
just have that be okay, have that be provided, and to be able 
to have that support system.
    I mean not a lot of your younger family members, especially 
if you are busy, you have young children, you don't know who to 
ask, you don't know where to go. And I think a lot of those 
younger soldiers don't know that it is okay to yell and scream 
and call and complain and keep looking for things. And I think 
the sad part is a lot of them believe what they are told. If 
you are told well if you do this, this will happen, or if you 
do this, you know, there is nothing more we can do, then that 
is what they accept.
    And that was part of our goal from the very beginning, was 
let us see what we can do to make it a little easier for 
someone else so that when you come home after serving your 
country, you don't have to fight and you don't have to search 
on your own and try and find your own answers.
    Mr. Walz. Well thank you, and I think we all need to be 
very, very clear, this chain of events for this family was put 
in place because someone raised their hands and choose to 
defend this Nation and do what they were asked. That is the 
only thing that put them in this position. And these people are 
not victims. And the idea that this mother, this wife, this 
American has to come back and spend that time fighting is just 
appalling.
    But I will tell you, everyone of us here better soul search 
a little bit. That seat will be occupied by another Travis 
Fugate, another Mr. Johnson, another down the road unless we 
determine at some point to stop it.
    So I appreciate all the advice that is getting here. You 
are all exactly right on. But I am convinced it is far more 
than just logistical fixes on this, it is systemic cultural 
change on how we view this. And if it doesn't happen that is 
the result.
    Mr. Stearns. Will the gentleman yield before you close?
    Mr. Walz. Yes.
    Mr. Stearns. I think it was very important that you asked 
Mrs. Johnson that I appreciate you taking the time, Mr. 
Chairman, I ask unanimous consent if there is anything she 
wanted to add.
    The question I have for her is, do you think that wives of 
veterans that are wounded like your husband should have an 
opportunity for counseling or some kind of support group for 
yourself?
    Mrs. Johnson. Yes.
    Mr. Stearns. Because in effect you are becoming not only 
his regular wife and the mother to the children and working, 
but the stress on you must be unbelievable too, and there must 
be a breaking point where you can't go on unless you have some 
kind of support.
    Mrs. Johnson. Yeah, I think that would be very beneficial. 
I mean, in our area we had the great family support with our 
unit when they were deployed, but everyone else's spouse came 
back, they went back to their normal lives with all their own 
little problems, but they didn't have injuries in our area. We 
don't have a lot of support for that. They don't have the 
family programs or the family counseling available.
    Most recently Sean came back from a PTSD program through 
the VA in St. Cloud and during that time I was not contacted by 
any member of that staff from that VA to ask about any input 
from the family or the home regarding his PTSD, regarding his 
behaviors at home. I was not contacted while he was there. I 
wasn't contacted when he came home. They sent home his medical 
record, which is over 300 pages, and said if your wife has any 
questions she can call us.
    Mr. Walz. Unbelievable.
    Mrs. Johnson. They did tell him that there are groups that 
are available for the wives and families if you live in that 
area. It is 4\1/2\ hours for us. The likelihood of me being 
able to take time off to go and go to these groups and get this 
support is not there.
    And at one point the VA had a V-tel capability where Sean 
could get some OEF/OIF group peer support. That is no longer 
available. So now if he is going to have that peer-on-peer 
support it will be if he can make the appointments 3 hours 
away.
    So yeah, I think there is a huge need to provide those 
things.
    Mr. Walz. The gentleman from Florida, that is a great point 
on that. And again, this is one of the issues, that portion is 
in the House version of the Caregivers Bill, but where is it 
at? It is setting. And he is exactly right.
    So I appreciate the comments and for us to keep focus on 
this. It is our responsibility to get it done. So I yield back.
    Mr. Mitchell. Thank you very much. And I want to before you 
all leave and I hope you stay around for the next panel, want 
to express my gratitude, and I think everyone's up here for the 
service and the sacrifices that you have all made. You know, we 
sit through a lot of these hearings, and I just wish other 
people could get the same feeling out of this that we do. And I 
just want to say thank you so much for everything you have 
done.
    Sergeant Johnson. I appreciate that. It was an honor.
    Mr. Mitchell. Thank you. And this panel is excused.
    I want to welcome panel number 2 to the witness table. And 
for our second panel we will hear from the Honorable Noel Koch, 
Deputy Under Secretary of Defense for the Office of Wounded 
Warrior Care and Transition Policy, U.S. Department of Defense, 
Dr. Madhulika Agarwal, Chief Officer of Patient Care Services, 
Veterans Health Administration. Dr. Agarwal is accompanied by 
Dr. Karen Guice, Executive Director of the Federal Recovery 
Coordination Program, and Paul Hutter, Chief Officer of 
Legislative, Regulatory, and Intergovernmental Affairs, 
Veterans Health Administration.
    And I would like to ask all of those who are making a 
presentation, Mr. Koch and Dr. Agarwal, if you would please 
keep your comments to 5 minutes, and your complete testimony 
will be put in the record. Mr. Koch.

    STATEMENTS OF HON. NOEL KOCH, DEPUTY UNDER SECRETARY OF 
   DEFENSE, WOUNDED WARRIOR CARE AND TRANSITION POLICY, U.S. 
DEPARTMENT OF DEFENSE; AND MADHULIKA AGARWAL, M.D., MPH, CHIEF 
   OFFICER, OFFICE OF PATIENT CARE SERVICES, VETERANS HEALTH 
     ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
  ACCOMPANIED BY KAREN GUICE, M.D., MPP, EXECUTIVE DIRECTOR, 
   FEDERAL RECOVERY COORDINATION PROGRAM, U.S. DEPARTMENT OF 
      VETERANS AFFAIRS; AND PAUL HUTTER, CHIEF OFFICER OF 
    LEGISLATIVE, REGULATORY, AND INTERGOVERNMENTAL AFFAIRS, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
                            AFFAIRS

                  STATEMENT OF HON. NOEL KOCH

    Mr. Koch. Thank you, Mr. Chairman, and thank all of the 
distinguished Members of this panel for the opportunity and the 
privilege to come before you this morning. You have already 
agreed that our written testimony would be submitted for the 
record, and so let me just make a few oral observations.
    The Members, the speakers in the last panel obviously leave 
all of us somewhat shaken. This panel didn't call us up here to 
listen to a litany of excuses for where we are and why we are 
where we are.
    But let me say before I proceed too far into this, that 
what we are attempting to do is novel. We have never done it 
before in our history. And if we go back 15 years we were 
reducing the size of our armed forces, that we were cutting all 
the talent, anybody that wanted to leave got to leave, and 
suddenly we find ourselves in a war--in two wars in which we 
are being presented with the kind of problems that we are being 
presented with today. Some of these problems are as old as 
history. Post-traumatic stress goes back to the Greeks. We 
still haven't figured it out, and it is the biggest problem 
that we have. When people look at our wounded veterans they 
look at traumatic amputations and their heart goes out to that, 
and all of ours do, but these people deal with these things 
very easily. The people who have difficulties are those who 
suffer from post-traumatic stress, and so that is one of the 
things we are wrestling with.
    Now it has been noted that we have a lot of effort behind 
this and we have a lot of programs, and that our biggest 
problem is a lack of ability to put this before the people who 
need it. We don't communicate well.
    I spend most of the time out of my office. I spend time at 
places like Fort Riley and Fort Drum and Fort Benning and Fort 
Bragg and Balboa and BAMC and the polytrauma centers and all 
these places that you are familiar with, and I spend hundreds 
of hours with these wounded warriors and ill and injured 
warriors, so I have a pretty good sense of what it is that we 
are trying to do for them, what they feel that we need.
    One of the things I want to say to you is that we are, you 
are, we all are dealing with something of a moving train here, 
and so while we take into account and take on board both 
emotionally and intellectually what we have heard here, a lot 
of these problems are legacy issues, and we are moving ahead, 
and I think we are doing a better job at addressing the kinds 
of problems that were brought up here today.
    Now having said that to the question of outreach, my 
office, The Wounded Warrior Care and Transition Policy Office 
has a number of programs to try to deal with this. One that I 
think most of the members are familiar with is the Transition 
Assistance Program. This was started back during the Gulf War, 
it is 20 years old, has never been updated, never been 
addressed, never been reformed. And in that period from the 
time that was back when we fought a war with most of our active 
components, now we are fighting two wars and chewing up our 
Reserve components, none of those changes in the realities that 
we were confronting were not addressed in the Transition 
Assistance Program. So in November we spend a week tearing this 
thing a part, putting it back together, and in the process of 
correcting that.
    And one of the things that Congressman Roe said resonates 
here, and that is that we need to start at the beginning. We 
need to start not when a youngster becomes a veteran, but when 
they become a soldier or a Marine or an airman or a sailor to 
deal with this. So we need to start the counseling process at 
reveille, and it ought to run all the way through to TAPs. It 
ought to begin from the time we recruit them until the time we 
intern them. And so we are looking at that. We are looking at 
that.
    And there are some very prosaic issues that come into this 
thing when you look at it. It is not the things that attract us 
emotionally such as a wounded soldier and his family. It is 
simpler things. It is like financial management. And when you 
are young, you know, you think the money just continues to 
flow. If you don't understand how to handle it by the time you 
get to be my age and you haven't learned to handle it you are 
going to be in an awful lot of trouble.
    And so we have these youngsters coming back from down 
range, they have no place for them to spend money down there, 
they've got their base pay, they got trigger time, hazardous 
duty pay, all these things. They come home with $100,000, 
$150,000, $200,000. And what do they do with it? Well they are 
home, they are happy, they want to buy mom something.
    One of my favorite stories is the young Marine that came 
home and bought himself a Porsche, which might have been 
reasonable enough, except that this young man is blind and the 
car is sitting in his living room.
    So we need to teach them how to handle their money. It is 
just one of the things that we need to deal with. But I agree 
with Congressman Roe, we need to start at the beginning, and 
that is part of the TAP program. And part of that program since 
the VA has brought to task for not doing their share of this 
thing, part of this involves pre-separation counseling, which 
is mandatory for all these people, but the VA provides an 
extensive briefing, at least 4 hours on what is going to be 
when they get out.
    Now the point is, at what point does that occur? And is it 
useful? And you have heard previous witnesses talk about what 
happens when people come home. They don't want to come home and 
listen to a lot of lectures. They want to come home and go 
home.
    And it becomes even more difficult with our Reserve 
components when these people are not coming back to a base 
where we sort of have our hands on them. Because they are going 
to disperse to all the places that we have brought them in 
from. The Reserves and the National Guards tend to be not 
centered around our major bases where our active components 
are. So these are some of the problems that we confront.
    And another one that was raised by one of the witnesses was 
a question of the effect of PTSD and people getting in trouble 
with the law. We are looking at veterans courts. We would like 
to nationalize this effort. We would like to have your help 
doing it. It is obvious these courts are not Federal courts 
that deal with these problems, but if there was a message that 
came out from this Congress, from this Committee saying that we 
need to treat people, or we at least need to take into account 
the fact that when they come back with difficulties, these 
difficulties may manifest themselves in going down the 405 at 
127 miles an hour on a motorcycle. And when they lose a leg 
people say, well that is not a combat wound. Oh yes, it is. It 
probably it is. And so we need to look at how these effects 
occur and we need to look at how the courts handle these 
issues.
    I think I am approaching the end of my 5 minutes, so I will 
defer the rest of my comments for questions and answers. But 
again, I want to thank you all for giving me the privilege of 
coming before you.
    [The prepared statement of Hon. Koch appears on p. 51.]
    Mr. Mitchell. Thank you. Dr. Agarwal.

              STATEMENT OF MADHULIKA AGARWAL, M.D.

    Dr. Agarwal. Good morning, Mr. Chairman and Members of the 
Subcommittee. Thank you for giving me the opportunity to be 
here today and to update you on various ways in which VA is 
improving the transition for returning servicemembers and 
veterans.
    I would like to begin by thanking Staff Sergeant Johnson 
and his family for their service to our country and apologize 
for the difficulties he has had to face.
    Together VA and DoD, as we just heard, are building a 
state-of-the-art post-combat care service for our returning 
servicemembers and veterans. We are continuing to refine these 
services, identify additional areas of need, and conduct wider 
research to improve outcomes.
    VA has made significant advances in several ways in very 
important areas, and I will list a few. First VA has increased 
its outreach efforts for the returning servicemembers, 
including Guard and Reserve component and veterans. We are 
collaborating with DoD in expanding the TAP and the Disabled 
Transition Assistance Program (DTAP) briefings, the yellow 
ribbon reintegration program events, PDHRA, and the Combat Call 
Center Initiative.
    VA is also aggressively pursuing the social media like 
Twitter, Facebook, YouTube, blogs. Also VA, DoD, and the 
Department of Labor support the National Resource Directory 
which has undergone significant revisions and is going to be 
relaunched in mid-February.
    Second, we have expanded the Federal Recovery Coordination 
Program. This is a joint VA/DoD program which helps coordinate 
and access Federal, State and local programs benefits and 
services for the seriously wounded ill and injured 
servicemembers and veterans through recovery rehabilitation and 
reintegration into the community.
    Third, our care management system begins at the military 
treatment facility where VA liaisons work in concert with the 
DoD case managers to facilitate a smooth transition of care 
from DoD to VA. Our OEF/OIF care management system is veteran 
and family centered. The case managers are actively involved in 
assisting our ill or injured veterans with reintegration into 
their home communities.
    Fourth, our polytrauma system of care provides coordinated 
in-patient transitional and out-patient rehab services. Each of 
our four polytrauma centers and the 21 network sites offer 
unique and highly specialized rehab services which help 
servicemembers and veterans achieve optimal function and 
independence in their communities.
    Fifth, VA has greatly enhanced its mental health services. 
We have hired more than 4,000 new mental health professionals 
in the last 3 years.
    Sixth, we continue to emphasize interdisciplinary care, 
which is veterans centered and requires the treating 
disciplines to coordinate and integrate care. And we are 
achieving this through new education initiatives and TBI, PTSD 
sleep disorders, and in pain management.
    Now a recent example is the joint VA/DoD clinical practice 
guideline on mild TBI that addresses the core conditions such a 
PTSD pain and sleep disorders.
    Another example of integrated care is the post-deployment 
integrated care clinic. These are primary case based clinics 
where specialists are integrated into interdisciplinary teams 
who address the special needs of combat veterans.
    We are also supporting more research for new treatments, 
and increasing the use of telehealth to reach those who live at 
great distances from our facilities and in rural areas.
    Finally VA does recognize and deeply appreciates the 
critical role of caregivers and families in supporting 
veterans. VA offers a variety of respite and home services to 
supplement the care that is provided by family members to 
improve the quality of life of veterans and their caregivers; 
however, much needs to be done in this arena, and we are 
grateful to Congress for its support.
    Secretary Shinseki is committed to transforming VA into a 
21st century organization. A 21st century VA will focus on 
results and make sure our services are timely, consistent, and 
of the highest quality, and adapt to the changing needs of 
veterans. We will leverage technology and educate our workforce 
to achieve results. It is our privilege to care for those who 
have borne the battle in Iraq and Afghanistan and our previous 
Nation's conflicts, and it is our solemn responsibility to do 
all we can to restore them to their highest and best level of 
functioning and support them in their journey home every step 
of the way.
    I thank the Subcommittee and you, Mr. Chairman. My 
colleagues and I are ready to answer your questions.
    [The prepared statement of Dr. Agarwal appears on p. 53.]
    Mr. Mitchell. Thank you. Let me just say that--and I know, 
Mr. Koch you have a specialty in the Wounded Warrior Care and 
Transition Policy of the Defense Department, but you are in the 
Defense Department. Can't you do something about getting the 
sergeant his Purple Heart? Four years. I think that is 
unacceptable. And I was just asking around here--he is required 
to go to Reserve meetings. If he didn't go to a Reserve meeting 
would he be classified as AWOL? I just don't understand.
    You know, Dr. Roe mentioned 33 hearings. We can have a 
hearing every week on this same issue, and we would hear the 
same things. And I know Dr. Agarwal and Dr. Guice and Mr. 
Hutter have all been here before, you hear these things. I 
don't leave these meetings very uplifted. It is a downer for a 
long time, and we have these continually. Because I know the 
people who spoke on the first panel, they are just the tip of 
the iceberg. They represent a lot of other people. And I just 
feel horrible that we have to have all this, and we hear the 
same thing over and over, different kinds of cases.
    But I think particularly since Staff Sergeant Johnson is 
still on the roles or in the Reserve, I don't know who takes 
care of him. I can see the problem here. He tries to get some 
VA benefits; he tries to get some DoD benefits. You know, we 
could have one, we probably could have a hearing like this 
every day, and we would hear the same response from DoD, the 
same response from VA.
    The point I think we are all trying to make is why can't we 
get it done?
    When I heard Mr. Tarantino talk about the reimbursement 
rates for automobiles, or to refit or retrofit a home because 
of disabilities, and we are using 1970 figures. And then I 
heard Dr. Roe say that Mr. Boozman has a bill in. I don't know 
if Mr. Wilson found this out on his own, but I would think that 
DoD or the VA would come and say, hey guys, we need to change 
this. I can't imagine why it would take somebody to introduce a 
piece of legislation unless that is what is required. And I 
would think that this piece of legislation should put in an 
inflation factor.
    Now and I also heard Dr. Roe said we are talking about 
PAYGO and so on. Let me tell you, we ought to pay for this the 
same way we paid for the war, the same way we got these people 
over there ought to be the same way we pay for it.
    And I am really kind of appalled also that no one has come 
forward to say to any of these Committees, we need to upgrade 
the amount of money we are giving to people to retrofit cars, 
houses, or any other kind--caregivers, the family givers.
    I used to teach government in high school, and I know that 
we used to teach them how important the legislative branch was 
and that the most important job is to legislate. But the longer 
I have been here I think the most important job we have is 
oversight. It is too bad that we have to continually hear over 
and over the same thing and we get the same responses back. You 
guys ought to feel bad. And somewhere you are in a better 
position than we are. If we need legislation, we will do it, 
just tell us what needs to be done.
    And I don't have any other questions, because I get the 
same answers over and over anyway. So, Dr. Roe.
    Mr. Roe. Thank you, Mr. Chairman and the rest of the 
Committee Members. I think we all share frustration. And I know 
that I have spent a career, when I see a problem, I fix it and 
work on fixing it, and if it takes more people than one, we try 
to get it together and fix it.
    And this is a huge problem when you are dealing with 
hundreds of thousands and millions of veterans as Mr. Wilson 
pointed out.
    Here is a bit of frustration. When we send a soldier to 
Afghanistan to war, it takes $1 million a year of support to 
keep that one soldier in theater. So this 30,000 troops that we 
are going to send to Afghanistan in the next several months is 
going to cost $30 billion. And yet we have a system here that 
when we bring soldiers back, that we nickel and dime on what we 
are doing to take care of them. And I think I share that 
frustration with everybody here. We spend $1 million per year 
to keep you in combat, to keep you in harms way, we get you 
home, we don't have that same commitment to you. And I believe 
being a Vietnam era veteran that we owe you a lifetimes worth 
of service. And I know Mr. Koch is a Vietnam veteran.
    And you know, we had a group of veterans that were left off 
the charts for about 20 years. We dropped the ball big time. 
And I think and I agree with Chairman Mitchell, I talked to him 
before the meeting and I am meeting with General Shinseki this 
afternoon, and I am going to share what we have said in this 
particular hearing today.
    And I think we just need to sit down now with a group at 
the table, not in a formal setting, and get this problem fixed. 
I mean, we will have 33 more hearings. I mean a year ago 
exactly, when Travis was here--and sergeant major you are 
absolutely right, I mean exactly sitting right over there where 
Sergeant Johnson was.
    We are having a meeting in Johnson City, Tennessee, for 
rural health. There is a sizeable sum of money, $250 million in 
rural health, and that is where I live, in a rural area, that 
is where Sergeant Johnson lives, in a rural area. And I am 
going to talk to the Secretary this afternoon, and hopefully he 
will visit Mountain Home VA in Johnson City, Tennessee, and I 
hopefully he will be there for this meeting, but it is a way 
how we provide support for these veterans who are a long way 
away.
    And I think developing these out-patient clinics is vital. 
And right now what happens in an out-patient clinic, a 
particular VA like ours at home gets a certain amount of money, 
but it comes out of their budget to put an out-patient center 
near where the veteran is. I think that is essential. And the 
more I think about this the more essential I believe it is--is 
to get the care that the veteran needs out to the veteran, 
instead of having to travel not 3 hours, 6 hours. You have to 
go and get back home once you start.
    And I also agree with Mrs. Johnson. I really appreciated 
your comments, I think to support the veterans. I remember very 
well that my scout master was killed in 1965 in Vietnam. He was 
a first sergeant in 101st airborne division. His family of four 
had a $10,000 insurance policy, and that was it. That is what 
we left him with, nothing.
    We not only can do better, we are going to do better. And 
if I seem a bit frustrated I am. I don't have any questions 
either, Mr. Chairman, I just want to now not sit here next year 
with our same group here. And I can assure you that one of the 
things that I have been most impressed with in this Committee 
is that this Committee is not Republican or Democrat, it is 
about veterans and about doing the right thing.
    Thank you, Mr. Chairman.
    Mr. Mitchell. Thank you. Mr. Walz.
    Mr. Walz. Thank you, Mr. Chairman, and thank each of you 
for your service. Your commitment to our veterans is never in 
question. We understand that. And Mr. Koch, your service to 
this Nation and as a veteran and CO I very much appreciate 
that.
    I just had a question for each of you to just take up as, 
how does a situation like Staff Sergeant Johnson's happen 
still? How does that happen with a chain of command? There is a 
first sergeant there somewhere, there is a sergeant major, and 
I am just at wits end to figure out how this still happens. I 
mean our hope is that it is the anomaly, but as I said, I see 
too many of these.
    Does anybody have like an insight into how we are losing? I 
understand this when you transition back home. When I came back 
from a deployment, it was 48 hours. If you said you had an 
injury, you had to stay over till the next Monday, and there 
was no way in heck with a 3-year-old at home I was going to do 
that, so they showed me the horse whisperer and told me to be 
nice to my wife and sent us home, and that was it. And I 
understand we are all learning, but how does this still happen 
today? How did the Johnsons end up in this situation, if you 
could? I know I am asking you a generality here, but I am 
trying to grasp it.
    Mr. Koch. Let me try to take a shot at this, sir. I have to 
say in the first place we have the benefit of coming here and 
listening to the frustrations of other panels, and we have the 
benefit of listening to your frustrations, but there is a 
separation of powers and there are certain political issues 
that make it difficult for us to share our frustrations with 
you, but I can assure you they will probably balance out, and I 
understand how great yours are. And I won't go on too much in 
that vain, but you can hear it from General Chiavelli and 
others who I am sure you can talk to behind closed doors.
    I would say I think first of all that Sergeant Johnson's 
situation is an anomaly. It is a tragic anomaly, but I think 
nevertheless that it is an anomaly. You don't generally bring 
folks up here to throw roses at you and bring Valentine's with 
you, I mean you are looking for the problems and not for all 
the things that are done right so that you can correct the 
problems and make sure that more things are done right. I don't 
know why he doesn't have his Purple Heart. I know a number of 
other people who have suffered wounds many years ago who don't 
have Purple Hearts, and they are usually administrative reasons 
or other reasons that the paper shufflers come up with. I will 
take this back and see what I can find out and see if I can get 
an answer to that and get back to you with it and see if we can 
expedite his receiving what he is entitled to receive.
    In the area of sharing what little frustration I can, I 
mean, I can give you an example, things take time, and 
sometimes you don't discover problems unless you actually go 
out and look for them. So I happened to be at one military 
treatment facility and it was a naval facility, but I was 
talking to all these people, and I was talking to them in a 
group, and a number of them were soldiers. And I said, ``How is 
the DES pilot going for you?'' And they said, ``We are not in 
it.'' And I said, ``Why not?'' ``Well, we can't. They want us 
to go up to Fort Irwin.''
    So we came back, we wrote new policy to universalize the 
MEB process, and that was probably 2 or 3 months ago, and it is 
slowly--we tried to do it procedurally because it has such a, 
you know, seemed to be congruent with common sense that maybe 
we can get this done and we tried to push it up, but no it got 
pushed back down, and so we have had to write a policy and we 
are walking that through the system, and ultimately we will 
have more people going through the desk pilot and they won't be 
disadvantaged because they are in a different service than the 
MTF.
    Mr. Walz. My question, I guess what I would ask, Mr. Koch, 
is in 2007, I was in Iraq and I witnessed as they had seven 
databases open on medical records, not even including VistA and 
the transition to that, and I made a comment in a hearing here 
now going on 3 years ago that wouldn't it make sense to record 
serial concussive blasts, because we were starting to see data 
at that point that those were going to add to long-term issues. 
Because mark my word on this, just like Agent Orange or 
whatever it will be, in 10 years we will have people here 
trying to come to us and say I was exposed to a blast, there 
was no record, I asked why we didn't have blast meters that are 
cheap and carried. You know, we put them on packages of milk so 
if it is shaken and the thing breaks, we know. How difficult 
would it be to attach it to a soldier and we would know that 
they have been in these, record them, and have that data. One, 
for the care. Two to make sure they don't come back and fight. 
That was 3 years ago.
    This virtual lifetime record we are talking about all of us 
agree with, is it going to happen? Is this an IT issue? I don't 
know how many platforms we operate. I heard somebody say people 
are frustrated with Windows 7, but you guys are using Windows 1 
or whatever. How do we get beyond that?
    Mr. Koch. Can I respond to that, sir?
    Mr. Walz. Sure.
    Mr. Koch. First of all with regard to registering blast 
effects that may produce traumatic brain injury, there is an 
awful lot of work going on, and we are working with the 
National Football League (NFL), I think probably some of you 
had talked to the NFL, because they have the same problems, and 
however well we are pushing toward that the Marines, you know, 
God love them, they had to keep it simple because they don't 
have as much to work with. And so while the rest of us are 
looking at helmets with sensors in them and things like this, 
which sound wonderful, but you are always looking for a 
technological solution, and the Marines, that is not the Marine 
way. So what they do is if you are in a blast situation and 
they bring you back and they ask you some simple questions. You 
get your bell rung? Yes. Okay. How long, you know, what do you 
think 30 seconds, 40 seconds? Okay. So you go through that 
three times, three strikes you are out of theater and there is 
a record of it. And that is simple, and it works, and it is 
smart.
    With regard to what comes under the broader umbrella of 
information technology, if I go too far down that road I am 
going to embarrass myself, but I know that the President 
himself is behind the virtual lifetime electronic record. When 
we started out with it, it was to look at medical records, and 
people who don't understand, including myself, who don't 
understand much about information technology, it is a kind of 
magical thing. So if we are going to do the medical records, as 
long as we are going to do that why don't we throw in personnel 
records and why don't we throw in the benefits records? And so 
we have done that. And the idea is that increases the 
complication arithmetically. Well it doesn't increase it 
arithmetically.
    Mr. Mitchell. Excuse me, Mr. Koch, we are about to be 
called for votes.
    Mr. Walz. Yes, I will yield back, but I thank you, and we 
will look into this more.
    Mr. Mitchell. And I would like Mr. Stearns to say something 
before we get called.
    Mr. Stearns. Thank you, Mr. Chairman. Dr. Agarwal, let me 
ask you a question. How long have you been an employee of 
Veterans Affairs?
    Dr. Agarwal. Sir, over----
    Mr. Stearns. How many years?
    Dr. Agarwal. Twenty plus years.
    Mr. Stearns. Twenty plus years?
    Dr. Agarwal. Yes, sir.
    Mr. Stearns. And how long have you been in your present 
position?
    Dr. Agarwal. Five years.
    Mr. Stearns. Five years. How many times have you had to 
testify before this Committee? Either the Subcommittee, full 
Committee, or any one of the Subcommittees?
    Dr. Agarwal. Sir, I would say at least three times.
    Mr. Stearns. My staff thinks it is between five and ten.
    Dr. Agarwal. Your staff is likely correct.
    Mr. Stearns. Also it appears to us that you have had to 
apologize in this area multiple times. Do you recollect that?
    Dr. Agarwal. Yes, sir.
    Mr. Stearns. Does it occur to you that your apology over 
these number of years--you have been in this position for 5 
years--is at the point where there should be action rather than 
apologies?
    Dr. Agarwal. Sir, if I may respond to that.
    Mr. Stearns. Oh, sure. Sure.
    Dr. Agarwal. Indeed. You know, we continually strive to 
improve our system, but when we make mistakes we do apologize 
for it. And in this instance, sir, and in the past also.
    Mr. Stearns. So you are saying in the future you will have 
to apologize again? I mean, do you have any confidence you can 
come up here and testify and not have to apologize?
    Dr. Agarwal. Sir, I would love to be here and never have to 
apologize.
    Mr. Stearns. And you are saying the reason you have to 
apologize is because you don't have the resources or you don't 
have the manpower or you don't have the--the job is too much 
for you? I mean, at what point can we get the assurance that 
you will come up here and you won't have to apologize? What do 
we have to do to help you?
    Dr. Agarwal. Sir, as I said previously, you know, we are a 
system that continually looks to improve the quality of care 
that we deliver across the board. We are a large system. And by 
and large we do very well. We have created a great network in 
this instance of how to take care of servicemembers who are 
returning to us.
    Mr. Stearns. Okay.
    Dr. Agarwal. And the instance when we do not step up and do 
what we think we should be achieving I feel that it is my 
responsibility to make sure that we take it back and then we of 
course correct.
    Mr. Stearns. Well if I were in your position, I would come 
to this Committee in a proactive way and say I don't want to 
come up here and apologize anymore. Here is what I want to do 
to solve the problem. You are on the clinical side, right?
    Dr. Agarwal. Yes, sir.
    Mr. Stearns. So I mean, I would just outline it in a letter 
to the Chairman here, Mr. Filner and Mr. Buyer, and say this is 
what I need to get the job done so I don't have to apologize 
anymore.
    Mr. Koch, let me ask you a question. The American Legion 
has testified that the Department--DoD has implemented a 
seamless transition to servicemembers, which includes medical 
screening, eye exam, dental examination, mental health 
screening. But we are under the understanding that these 
examinations for the Army and the Air Force are not being 
implemented. Is that true?
    Mr. Koch. I am not sure that that is true.
    Mr. Stearns. Well we have a fact here that the Army and the 
Air Force are not implementing separation physicals. It is done 
on a volunteer basis by them. And if they are doing it on a 
voluntary basis isn't that in violation of the law?
    Mr. Koch. The individual does have to agree to the 
examination. The individual as I understand it that is 
voluntary. Now let me refer to my notes here, because this is 
an area of some complication. There is a requirement that we do 
the things that are anticipated. Evaluate the health of the 
member at the time of separation and so on. If that person has 
been examined in the last 12 months then that may be waived. 
And that is one of the things that may be occurring here that 
gives the American Legion concern. And that is done with the 
consent of the member.
    Mr. Stearns. But let us say the person is injured and he 
doesn't want to do it? I think you have to have some kind of--
--
    Mr. Koch. I think, sir----
    Mr. Stearns. Or let us say he is injured and the injury 
doesn't appear until later. It seems to me that it should be 
sort of--I mean the law is saying that everyone should have a 
separation physical, but our understanding is the Army and the 
Air Force are not doing it, and that is in violation of the 
law. Does that sound right? Am I all wrong or not?
    Mr. Koch. If I take your example if he is injured, and I 
mean, you have offered two cases here.
    Mr. Stearns. Okay, sure. Okay.
    Mr. Koch. If he is injured then the probability is he is 
going to be in care and this issue is not going to arise 
because it is going to be a constant----
    Mr. Stearns. Well, it is an injury they don't detect 
though. Maybe it is an injury they don't detect.
    Mr. Koch. Well that is the second case you present.
    Mr. Stearns. Yeah, okay.
    Mr. Koch. And if he has been examined previously within the 
last 12 months, if that injury--if he is in an incident which 
is likely to produce an injury then he is going to be examined 
for it. So I don't know that we can give you a categorical case 
or you can give us a categorical case that right across the 
board these examination are not being performed.
    Mr. Stearns. Okay. Mr. Chairman, I just want to conclude by 
saying you had mentioned this, the purpose is oversight. I had 
a bill in Congress in which no more legislation would be 
proposed for 2 years, and all we did was implement oversight of 
the legislation that we have passed in previous years. Now this 
bill didn't go anywhere. But at some point you are exactly 
right, this Committee, any Committee, Energy and Commerce, Ways 
and Means, they pass--we vote 1,000 times a year, and there is 
no oversight on any of these bills, and we sit here and wonder 
why some of them don't work. Well you need oversight and you 
need support. So I think you are right about oversight being a 
big, big important part of our job.
    Mr. Mitchell. I just want to before we conclude thank all 
of you for your service and what you are doing and recognize 
that Mr. Adler is here, and any other question that he has we 
will submit them and it will be a part of the record.
    One last thing. I know, Mr. Koch, you said it takes time, 
and I understand that. But in the meantime people have house 
payments, they have bills. And it may be in the long run, but 
you have heard that phrase before, in the long run we are all 
dead. It is today that we live.
    There is one other thing that we may end up having another 
hearing on, which I think may be under your control or 
somebody, and that is the Vision Center of Excellence. Where is 
it? What is the status of it? You know, that is something I 
just don't understand. We have already had hearings on that, 
and as I understand right now it is really in disarray again.
    Mr. Koch. My understanding is that it is in limbo, Mr. 
Chairman. I can't give you a----
    Mr. Mitchell. I don't want an answer. I just want you to 
know that we will probably have to have another one.
    Mr. Koch. Right.
    Mr. Mitchell. And you will all come back and say, you know, 
we are trying, we are trying to hire people, you know, all 
those other things. If I understand there is about the only 
employee right now in that is part-time employee. That is not 
going to help. That is not going to do anything.
    We have to go. And I just would say that this hearing is 
adjourned, and if anybody has any questions please submit them 
for the record.
    [Whereupon, at 12:04 p.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

        Prepared Statement of Hon. Harry E. Mitchell, Chairman,
              Subcommittee on Oversight and Investigations

    I would like to thank everyone for attending today's Oversight and 
Investigations Subcommittee hearing entitled, Transitioning Heroes: New 
Era, Same Problems? Thank you especially to our witnesses for 
testifying today.
    We are here today to address what both the Department of Defense 
and the Department of Veterans Affairs are doing to assist the men and 
women of our armed forces to seamlessly transition back to civilian 
life. Time and again, we have heard from our returning servicemembers, 
expecting a smooth transition back to the lives they once lived, only 
to find themselves lost in a complex and frustrating bureaucracy.
    Today, we will hear from a severely injured veteran, Sergeant Sean 
Johnson, who was hit by a mortar round in Iraq and is now completely 
blind. Although he has received excellent treatment at the Blind 
Rehabilitation Center in Chicago, he was never assigned a Federal Care 
Coordinator, after contacting the VA almost a year ago. In addition, 
Sergeant Johnson has also found himself experiencing the hardships of 
navigating through both the DoD system and VA system at the same time.
    This is just one example of many. Sergeant Johnson joins those 
veterans and their families who share the same concerns that our 
Veterans Service Organizations will voice here today.
    Additionally, as I have said before, outreach to our Nation's 
veterans is an equally important task. Both the VA and DoD must ensure 
that veterans and their families are properly informed about the 
benefits and services they have earned when they return to civilian 
life.
    Proactively bringing the VA to our veterans, as opposed to waiting 
for veterans to find the VA, is a critical part of delivering the care 
they have earned in exchange for their brave service.
    The VA should be a place where veterans can easily, and with 
confidence, go for the help they seek, but the VA must also be willing 
to reach out to these veterans. Effective outreach will not only ensure 
better delivery of services for our veterans, but will also increase 
morale.
    I am hopeful that today, both the VA and DoD will shed light on 
what they are doing to make certain our veterans are receiving the best 
possible care available; they are being provided with the services and 
resources they have earned; and most importantly, that the two 
Departments are working together to ensure that these earned benefits 
are seamlessly delivered.
    I believe that all my colleagues join me in being steadfast in our 
hopes that Secretary Shinseki, as he transforms the VA into a 21st 
century organization, will help eliminate the stigma that so many of 
our Nation's veterans have placed upon the VA. We must ensure that both 
the VA and DoD are working together and providing veterans the services 
that they rightfully deserve.
    Again, thank you to all our witnesses for testifying today, and we 
look forward to hearing your testimony.

                                 
  Prepared Statement of Hon. David P. Roe, Ranking Republican Member, 
              Subcommittee on Oversight and Investigations

    Thank you for yielding, Mr. Chairman.
    I would first like to thank the members of the first panel for 
their service to this country, not only for their military service, but 
their continued service by appearing here today to share their 
testimony and help us work toward a better transition for our Nation's 
veterans.
    Prior to this hearing, my staff provided me with a list of the 
hearings held by the Committee on Veterans' Affairs over the past 10 
years. Totaling around 33 hearings, the topics have ranged from 
employment transition, through the use of the polytrauma centers, pre- 
and post-deployment health assessments, sharing of the electronic 
health record of our wounded servicemembers, transition assistance 
programs for guard and reserve forces, and the list goes on. As you can 
tell, helping our servicemembers move from military to civilian life is 
of great importance to this Committee.
    Concern in Congress about helping our servicemembers transition to 
civilian life didn't start 10 years ago. During the 97th Congress, 
Congress codified the concept of ``DoD/VA Sharing'', now known as 
``Seamless Transition'' in 1982, with passage of the Veterans 
Administration and the Department of Defense Health Resources Sharing 
and Emergency Operations Act (P.L. 97-174). This Act created the VA-
Care Committee to supervise and manage opportunities to share medical 
resources.
    Today's hearing will enable the Committee to review the various 
programs that have been instituted to assist our Nation's veterans, and 
wounded warriors in their transition to civilian life. We will be 
looking not only at the medical record exchange between VA and DoD, but 
also at the various other transition services, the use of the 
polytrauma centers across the country, and programs available to assist 
our veterans. This is not the first hearing to look at these issues, 
and I am certain that it will not be our last.
    We here in Congress must do everything we can to make certain that 
the transition our military personnel undergo is smooth, easy and the 
programs available are truly helping our Nation's veterans. In the 
past, it appears that the transition many servicemembers have 
encountered have not been exactly seamless and certainly not easy or 
smooth.
    Mr. Chairman I appreciate you holding this hearing today. I believe 
we have much to learn from the witnesses here today.
    Again, thank you Mr. Chairman, and I yield back.

                                 
                Prepared Statement of Hon. John J. Hall

    Thank you Mr. Chairman, and thank you to all the panelists here 
today to discuss the issue of a seamless transition for our disabled 
veterans.
    It is disappointing to know that as we enter 2010, more than 9 
years since we first entered Afghanistan, transitioning our troops to 
veteran life still remains a challenge.
    In particular, we must do better to care for those men and women 
injured in the line of duty. Heroes like Staff Sergeant Johnson deserve 
better.
    Both the Department of Defense and the VA have improved how they 
handle transitioning disabled veterans.
    The Wounded Warrior Program, and its Warrior Transition Units, has 
been a great success. The ability to care for our wounded soldiers 
while keeping them in an active-duty mindset has helped thousands of 
soldiers since 2007 who have experienced traumatic and life-altering 
events.
    I have visited the Warrior Transition Unit at West Point, and 
commend the men and women working there for their service.
    However, even this example of a success has its shortcomings. There 
are only 35 WTUs in the country. Servicemen and women from as far away 
as Vermont have to travel to the WTU in my district to receive 
treatment.
    Also, the VA has a limited presence at the West Point WTU, 
traveling from VA facilities in the area to give classes on TAP and 
other benefits programs.
    This is why I plan to introduce legislation that I believe will 
improve the seamless transition this hearing is addressing today.
    This legislation will mandate that the VA have a permanent presence 
on active-duty military facilities, and require one-on-one 
consultations with active troops as they begin the transition process.
    There should be no improperly filled out enrollment forms. This 
will cut down on processing times, and reduce the ever-growing backlog. 
Men and women separating from the service deserve to be fully informed 
of the benefits they have earned. An increased VA presence on these 
facilities is an important first-step toward a seamless transition for 
our wounded warriors.
    Thank you again, Mr. Chairman, and to the men and women testifying 
today. I yield back the balance of my time.

                                 
         Prepared Statement of Staff Sergeant Sean D. Johnson,
                    USA, Aberdeen, SD (OIF Veteran)

    Chairman Mitchell, Ranking Member Congressman Roe, and Subcommittee 
Members, I appreciate the invitation to testify today from my 
perspective as a severely injured soldier returning from Iraq. I want 
to speak for those veterans who cannot be here today.
    I am a Staff Sergeant with the 452nd Ordnance Co. of the United 
States Army Reserves. I am currently awaiting a medical review board so 
I can be medically retired from the military. Following a 15-year 
career as a Paramedic/Firefighter in my civilian life, I had to take a 
medical retirement in June 2008 due to my TBI, PTSD, and chronic health 
issues.
    I entered the military on June 22, 1988, and completed basic 
training at Ft. Leonardwood, MO. I attended the lab technician program 
in San Antonio, TX, in 1989. I was deployed to UAE during the Persian 
Gulf War from December 1990-March 1991 with the 311th EVAC Hospital 
from Minot, ND. I transferred to the 452nd ORD CO in Aberdeen, SD in 
1995. From March-November 1997 my unit was deployed to Taszar, Hungary 
in support of Operation Joint Guard during the Bosnian War. I was 
called to serve under Operation Iraqi Freedom from June 2005-August 
2006 in Balad, Iraq.
    Between October 2005 and March 2006, I was in close proximity to 
one rocket and five mortar attacks where I was within 30 feet of the 
impact. On March 25th, 2006, around 6:40 AM four mortars were marched 
in from the outer perimeter into our location with the third landing in 
the middle of our group and approximately 10 feet from me. The blast 
knocked me through the air and about 7 feet back. I landed on my neck 
and shoulders and was unconscious for 3 to 4 minutes. When I awoke I 
could not hear and was in shock. I looked up through my feet and 
another mortar hit about 25 feet away. My hearing wasn't right for 
several hours and I had a severe headache, dizziness, difficulty seeing 
distance, and light sensitivity throughout the next several days. I was 
seen in sick call on April 12, 2006, for abdominal pain, dizziness, and 
headache.
    I was hospitalized in 332 EDMGTH on May 11, 2006, for 7 days with 
extreme abdominal pain, nausea, vomiting, diarrhea, headache, neck 
pain, and dizziness. There was an initial diagnosis of salmonella 
poisoning and I was given high doses of antibiotics. During the next 
month the symptoms persisted and I lost almost 40 pounds. From June 21-
July 10, 2006, I was evaluated at Landstuhl Hospital in Germany. The 
doctors were unable to find the cause of the abdominal problems and I 
was returned to Iraq for regular duty. I was transported to Germany 
again on August 7, 2006 and this time was diagnosed with clostridium 
dificile (c-diff) infection. On August 25, 2006, I was sent back to the 
states with orders from my doctor that I be sent to Walter Reed Army 
Medical Center for further evaluation and treatment. Instead, the Army 
sent me to Ft. Riley, KS, where I was placed in the medical holdover 
barracks and was told by the physician that I would be treated for 
irritable bowel syndrome (IBS) as my records did not indicate c-diff 
infection or other health concerns.
    In October 2006, after much insistence on my part, I was seen by a 
GI doctor in Topeka, KS. After extensive testing he determined the c-
diff infection had cleared and that my persistent abdominal pain, 
nausea, diarrhea, dizziness, and headaches were not caused by anything 
related to my digestive system.
    I remained at Ft. Riley from August 2006 to May 2007 on medical 
holdover. During this time I had to file several Congressional 
complaints in order to be evaluated at WRAMC. My symptoms were not 
improving and the doctors were offering no explanations. I was told, 
``Just take your pain meds and you'll be fine.'' On several occasions I 
was told that if I stopped contacting my state Senators, I would be 
given medical treatment. The doctors admitted they didn't know exactly 
what was wrong with me, but were not willing to make the referral to 
WRAMC or BAMC where specialists might evaluate my case.
    In December 2006, I was sent to WRAMC for an evaluation at 
Deployment Health Clinical Center (DHCC). During this time I was 
diagnosed with Medically Unexplained Physical Symptoms (MUPS) and was 
scheduled for the 3-week Specialized Care Program for pain management 
in February 2007.
    In March 2007, with no definitive diagnosis or treatment plan, I 
began to push for a means to leave med hold and return home to my 
family. I applied for Community Based Health Care Organization (CBHCO) 
so I could go home and work at my local reserve center until my health 
improved or stabilized. My request was denied due to the severity of my 
symptoms. I was told that my condition was likely to be long-term or 
not improve and CBHCO is a short-term program for soldiers with less 
severe health problems. Ft. Riley decided to send me home as they had 
done all they could for me. I asked to be reconsidered for CBHCO as I 
would not be able to meet the physical demands of my civilian job at 
this time, and was told that my civilian job was not the concern of the 
Army. I was released from med hold and came home to return to my 
position as a Lieutenant at the Aberdeen Fire Department. I was placed 
on light duty within a month of my return home due to my weakened 
physical state and inability to make decisions and think quickly. I had 
to accept a medical retirement in June of 2008 after being diagnosed 
with a TBI.
    When I returned home, I contacted my local VA CBOC and began 
medical treatment in Aberdeen, SD. There was no contact between Ft. 
Riley and the VA regarding my case. I had to initiate all care and 
provide the VA with a complete ``paper copy'' of my military medical 
files. My wife and I spent many appointments going over my symptoms and 
the growing problems I was having with memory, concentration, decision-
making, confusion, dizziness, and episodes of staring/non-
responsiveness and now ask ``why were these not picked up'' as warning 
signs of a probable TBI? Also, I was still having daily headaches, 
persistent nausea, intermittent diarrhea with abdominal pain, and 
wonder if those were all related to the initial blast forces sustained 
from the injury in Iraq. The VA continued to search for a GI answer to 
the problems, despite the previous determination that it was not a 
digestive track problem. Finally, in December 2007, I was asked a 
series of questions at the VA concerning falls and blasts that I had 
encountered in Iraq. My profile was flagged for head injury, and I was 
referred to Dr. Hof at the Polytrauma Unit at the Sioux Falls, SD VA 
Hospital. This was the first time since my injury in March 2006 that I 
had been asked ANY questions about blast injuries. Dr. Hof and Dr. 
Muntz did a battery of tests and determined I had a mild TBI due to 
multiple blast exposures in Iraq.
    In June of 2008, my eye exam noted double vision in multiple fields 
and loss of peripheral vision at 60 degrees. I also had nystagmus and 
recurrent eye pain. By December of 2008 my double vision was in all 
visual fields and I had pain behind my eyes daily. On December 17, 
2008, I suffered stabbing eye pain and my vision was reduced to colors 
and shapes. I was treated for optic neuritis with IV steroids which 
brought some pain relief, but no change in vision loss. My vision was 
noted at 20/800. I was referred to the Visual Impairment Service Team 
(VIST) who provided me with some tools to help me magnify reading 
materials and protect my eyes from bright light. My VIST also made 
arrangements for me to be a patient at the Central Blind Rehabilitation 
Center at the Hines VA in Chicago, IL. I was at Hines from February 27, 
2009, to May 16, 2009. I learned to do things independently despite my 
vision loss, and how to use the vision I have left to the fullest. The 
Hines Blind Center did an excellent job of keeping my wife informed of 
my progress, and we both appreciated the family program at the end of 
my stay where my wife was able to experience my program, my blind 
training was reviewed, and skills learned were demonstrated.
    Most recently, I was an inpatient in the PTSD program at the St. 
Cloud, MN VA as my nightmares of my combat have grown worse. It saddens 
me that I had to wait 3 years for some of this treatment after hearing 
the doctor tell me I have an extreme case of PTSD. Think of all the 
time that I have wasted with my family and not being my best due to the 
combination of PTSD and TBI, and difficulties encountered in sorting 
this out since the time of my injury. I feel the program was very 
beneficial for my well-being; however, there was absolutely no contact 
between my family and staff members. I was told that if my wife wanted 
to read through my records (375 pages) she could do so and call with 
any questions. They did not ask for any input from my family regarding 
my behaviors at home, nor did they provide any feedback on my progress 
or treatment plan. At this time, there is a suggested treatment plan, 
but no programs available in my rural area, even if I am willing to 
travel 3 hours to the nearest VA Hospital. I am receiving 1:1 
counseling once per month.
    The impact on my family has been overwhelming. We have three 
teenage children receiving private counseling and all on anti-
depressant and/or anxiety medication. They struggle with the ``weird'' 
things dad does, the changes in my personality, the difficulty of 
helping take care of a blind dad when I should be taking care of them, 
driving me to and from appointments, helping me shop, explaining how to 
do things I used to know how to do, and the physical changes. My 
appointments take my wife and myself away from home, sometimes for days 
at a time. I have been at Hines and St. Cloud for a total of 5 months 
this year, which adds to the separation and reintegration problems 
similar to my deployment. My wife uses most of her sick leave to take 
me to appointments and like many wounded warriors' families is worried 
about loss of her job and meeting our financial needs. Although there 
is a DAV van available in our area that helps me with travel, my memory 
problems make it difficult to see the doctor on my own effectively. She 
is a full-time mother, caregiver to me, and works full-time as a 
teacher. My wife has spent countless hours researching my conditions, 
treatments, searching for strategies to help me or to help cope, and 
looking for information for our children and families.
    The most frustrating feeling is having a meeting with a doctor, 
caregiver, or social worker and being left with confusion and questions 
not receiving any information from the VA regarding my total care plan, 
both physical and the PTSD emotional injuries. Verbal descriptions are 
given, some theories, possible treatment plans, but I feel, probably 
like many others, that care managers are needed for more complex cases. 
When a servicemember is diagnosed with TBI or PTSD, the VA should 
immediately provide something tangible for the family to read and 
review. It is not right that we are names and case numbers; when we 
leave the office, the doctor goes on to the next case, but we live with 
this all day, every day. A wait-and-see approach does not feel very 
reassuring on the 3-hour drive home. We need tools we can use now for 
daily care. We need someone to check in and see how things are going. 
We need to know we are not in this alone.
    Again, in conclusion, I am concerned with the lack of continuity or 
``seamless transition'' between active duty, the return home, the VA 
health care system, and the family. It is unreasonable that an injured 
soldier who is not able to be rehabilitated for deployment must wait 
more than 2 years for his medical review board to be completed. As I 
look back, I find it shocking that it took 21 months for any medical 
personnel, be it military or VA, to diagnose my exposure to blasts with 
a TBI head injury while in Iraq then discern the PTSD. I am 
disheartened that soldiers are brushed aside in medical holding units 
or at home waiting for repeated exams and claims decisions. After years 
of work on electronic exchange of medical computer records, it doesn't 
seem to be any closer than before.
    Veterans should be introduced to one Primary Case Manager, then 
they should consult with one Primary Federal Recovery Coordinator 
(FRC), so difficult cases are jointly managed at the local level, and 
for special care programs like the VIST and Blind Rehabilitative 
Outpatient Specialists (BROS). While every injured servicemember might 
not need an FRC Coordinator immediately to enable them to make 
connections with those in charge of their case, there should be a red 
flag system for polytrauma cases. These people in turn must work with 
individuals, not numbers or files. Veterans need to be treated with 
dignity and respect. Many veterans do not know what to ask, what is 
available, and who can help them.
    The VA benefits system should use the experts' written records to 
make rating decisions permanent, instead of making veterans go through 
numerous evaluations and exams, as if to make the veteran prove his or 
her disability again. Providing veterans with certification of all 
benefits, like adaptive housing and other vehicle grants, would prevent 
repeated claims from being filed for the same case. These soldiers have 
paid the price in battle to serve their country selflessly, and they 
don't deserve the runaround when trying to get the benefits to which 
they are entitled. As of today, I still do not have my Purple Heart, 
and can only wonder how many others are ``pending reviews'' for theirs?
    Defense and VA Vision Center of Excellence need adequate funding, 
staffing today, and operational registry systems. The comprehensive 
system must include those with hearing, vision, and orthopedic problems 
along with the new TBI and Mental Health Defense Center of Excellence 
to ensure the care of the severely injured. More funding is necessary 
for adequate TBI and vision trauma research. The number of soldiers 
returning from battle with these combined injuries is staggering, and 
our country should not rest until we have provided for the needs of 
every one of them.
    The Veterans' Caregiver Bill, S. 1963, would be greatly 
advantageous to those families who are primarily responsible for the 
veterans' care, many finding it difficult to work while providing daily 
care for the veteran. Many have families to raise in addition to 
providing care, transporting to appointments (increasingly difficult in 
rural areas with fewer services), and trying to find their way around 
the VA system.
    I speak today not for myself, but for the thousands of veterans who 
do not have a voice, who are struggling in a faulty system where their 
concerns go unnoticed, where their specialized medical needs are 
sometimes delayed, where they are left waiting often months or years 
for a VA claims review. Timely and accurate diagnosis and treatment of 
conditions help the claims system. The burden of proof is put back on 
the veteran and should not be, it should be on the VA. I speak for 
families struggling with the changes and uncertainty of a future they 
never imagined when they proudly stood beside their soldier and 
professed their pride in America. I am but one example of thousands. I 
hope my story helps as you work on this Committee to find solutions and 
make the necessary changes. This concludes my testimony and I will try 
to answer any questions that you have for me.

          ``To care for him who shall have borne the battle.''
                            Abraham Lincoln
                                 

 Prepared Statement of Joseph L. Wilson, Deputy Director, Health Care, 
    Veterans Affairs and Rehabilitation Commission, American Legion

    Mr. Chairman and Members of the Subcommittee:
    Thank you for this opportunity to present the American Legion's 
views on seamless transition issues. Since 2001, the Department of 
Veterans Affairs (VA) Health Care system has undergone a major 
transformation in an attempt to accommodate the Nation's veterans; to 
include increasing outpatient and preventive care in its growing 
network of outpatient clinics. Currently, there are approximately 23.4 
million veterans in the United States; of that total, 7.8 million are 
enrolled in the VA Health Care system. VA treats 5.8 million veterans 
at more than 150 hospitals and 800 plus clinics.
    As we examine the transition process, the American Legion, in its 
efforts to ensure transitioning servicemembers receive continuous/
seamless care, has determined that veterans are facing various 
challenges, which may irrevocably deter any chance of a successful and 
smooth transition back into their local communities. An example of 
challenges include, incomplete Post Deployment Health Reassessment 
(PDHRA) questionnaires, inability to fully share medical records among 
the Department of Defense (DoD) and VA Health care facilities, lack of 
space at VA Medical Facilities, and shortage of staff, to include 
nurses and physicians.
    VA and DoD both play important roles in the transition process. As 
women and men return from Iraq and Afghanistan facing uncertainty with 
injuries and illnesses, the American Legion contends that closer 
oversight must be placed on various programs, such as the PDHRA and 
Federal Recovery Coordination (FRCP) programs that have been 
implemented to ensure no one falls through the cracks. We ask Congress 
to assess these roles to ascertain the appropriateness of functional 
tools required to accommodate the Nation's veterans, their families, 
and the complex issues they are met with.
    The transition period is very important because many conditions 
servicemembers are suffering from may go undiagnosed due to being in 
the emergent stage. The role of DoD and VA must be that of ``safety net 
catalysts'' that carefully guide servicemembers and veterans as they 
transition from active duty military treatment facilities to VA Medical 
Centers; thereby ensuring every servicemember or veteran is the 
recipient of adequate and continuous care.
    The following are some of the obligations DoD and VA have taken on 
to support each servicemember and veteran as they transition from 
active duty to civilian life:
Department of Defense and Seamless Transition:

    To ensure that each servicemember's transition is successful, DoD 
has implemented the following:

      When transitioning from active duty service to civilian 
life, servicemembers must undergo final physical examinations before 
separation which includes: Medical screening (including eye exam);
      dental examination; and
      mental health screening.

      They are offered a Medical Board Review for any unfitting 
conditions. This review is scheduled and performed at the request of 
the servicemember.

Post-Deployment Health Reassessment Program
    The PDHRA program was established to identify and address 
servicemembers' health concerns that emerge over time following 
deployments. To be in compliance with DoD's policy, each military 
service must electronically submit PDHRA questionnaires to DoD's 
central depository.
    However, a recent audit disclosed that the central depository did 
not contain questionnaires for approximately 23 percent of the 319,000 
(OEF/OIF) servicemembers who returned from theater. This means 
approximately 72,000 servicemembers were without questionnaires in the 
repository. The response to the absence of the questionnaires concluded 
that DoD does not have reasonable assurance that servicemembers, to 
whom the PDHRA requirement applies, were given the opportunity to fill 
out the questionnaire and identify as well as address health concerns 
that could emerge over time following deployment.
    The American Legion believes the administration of the PDHRA is 
essential to the success of the servicemember's transition, because the 
results would disclose telltale signs of debilitating illnesses, such 
as the disorders that plague many veterans who have gone undiagnosed at 
separation from active duty. These illnesses and injuries include 
Depression, Post-Traumatic Stress Disorder (PTSD), Mood Disorders and 
Traumatic Brain Injuries (TBI), Spinal Cord Injuries (SCI), Blind Eye 
Injuries, respectively.

Department of Veterans Affairs and Seamless Transition:

    Upon separation from active duty service, VA informs the veteran of 
the following:

          Eligibility to enroll for health care at any VA 
        Medical Center or clinic within 5 years following military 
        separation date. Upon enrollment, VA will administer health 
        care benefits to the veteran immediately.
          VA provides dental examinations and benefits to 
        veterans with service-related dental conditions. The veteran 
        may be eligible for one-time dental care; however, each veteran 
        must apply for a dental exam within the first 180 days 
        following the separation date.
          Every VA Medical Center (VAMC) has a team ready to 
        welcome Operation Enduring Freedom and Operation Iraqi Freedom 
        (OEF/OIF) servicemembers and help coordinate their care.
Federal Recovery Coordination Program:

    The American Legion would also like to ensure that the FRCP is 
successfully assisting all recovering servicemembers and veterans 
suffered from severe wounds, illnesses and injuries, as well as their 
families in accessing the care, services, and benefits provided through 
specifically, DoD and VA.
    According to recent VA reports, the greatest challenge for Federal 
Recovery Coordinators (FRCs) is the integration of Information 
Technology (IT) access within VA and the Military Training Facility 
(MTF). Although DoD and VA state that these challenges will be overcome 
with the implementation of more IT integration between VA and DoD, the 
American Legion would like to know the status of DoD and VA full IT 
integration and medical records sharing. Further, the American Legion 
recommends a strong emphasis by this Subcommittee for expediting the 
effort be made.

VA Polytrauma of Care, VA Social Worker and Seamless Transition:

    VA's Seamless Transition Social Worker, who is assigned to the MTF 
responsible for caring for the patient, makes contact with staff at the 
receiving Polytrauma System of Care facility. Vital clinical 
information is then transmitted to the Admission Case Manager at the 
Polytrauma Rehabilitation Center for review.
    The Admission Case Manager remains in contact with the Seamless 
Transition Social Worker and the clinical team at the Military 
Treatment Facility until the patient is transferred to the receiving VA 
Polytrauma facility. During the servicemember's stay, the VA Case 
Manager remains in contact with the patient's military branch to keep 
them informed of progress and/or changes in the patient's condition.
    VA and DoD, both ensure open communication and effective 
coordination through the following resources: phone calls, secure 
record transfers, and meetings. In addition, physicians in the VA 
Polytrauma System of Care and at Military Treatment Facilities contact 
each other directly through teleconferencing, videoconferencing, and 
through VA social workers assigned to each facility. Although the 
aforementioned duties are outlined and in place, VA continues to face 
challenges, such as screening and evaluating veterans for TBI.

More Challenges Transitioning Servicemembers and Veterans Face:

    There have been various reports of critical challenges involving 
veterans who had recently departed from active duty service. These 
challenges, as reported by RAND, includes barriers to mental health 
care access in community settings.
    More specifically, it was discovered that:

      Military servicemembers and veterans are often reluctant 
to seek mental health care. The following reasons being:

          Concern that admitting a mental health problem is a 
        sign of weakness
          Fear that use of mental health services will have 
        negative career repercussions (especially among active-duty 
        personnel, who are required to disclose treatment)
          Skepticism about the effectiveness of treatment and 
        concerns about the negative side effects of medication.

      The mental health workforce has insufficient capacity. 
The following reasons being:

          Mental health specialty care for conditions such as 
        Post-Traumatic Stress Disorder (PTSD) and Depression are not 
        readily available in many parts of the country.
          Studies also show that most mental health specialists 
        are concentrated in urban areas.
          Even where specialty care is available, limited 
        health plan coverage may reduce access for veterans seeking 
        care outside of the Veterans Health Administration (VHA).

The American Legion ``A System Worth Saving'' Site Visits:

    During the American Legion's 2009 Site Visits, it was discovered 
that challenges were systemwide when it comes to meeting the needs of 
OEF/OIF servicemembers turned veterans. Lack of sufficient and 
appropriate staff to meet increasing workloads, a lack of support for 
families caring for returning severely injured veterans, and difficulty 
reaching new veterans who recently separated from active duty military, 
especially significant number that may be possibly suffering from 
psychological disorders are among the critical issues. According to VA, 
during outreach, it was reported that the battlefield mindset may be 
preventing veterans from seeking health care from the VA by admitting 
that there is a problem.
    When women veterans' experiences include defragmentation of care, 
this cannot be deemed a successful transition. For example, 
approximately 49 percent of women veterans continue to split care 
between VA and the private sector. There continues to be a lack of 
space for a women veterans' clinic in some VA facilities. A common 
deterrent for women veterans include, the provision of day care for 
their children, and women veterans being uninformed of full service 
provided by VA which, at times, causes available clinics to be 
underutilized. Currently, an unknown number of veterans, men and women, 
are missing VA appointments due to childcare challenges.
    The American Legion recently passed Resolution No. 29, 
``Improvements to Implement a Seamless Transition,'' which recognized 
gaps in services, and has consistently advocated improvements be made 
to the process of servicemembers in their transition from active duty 
to civilian life. The American Legion continues to express that 
servicemembers and their families are easily overwhelmed when dealing 
with the bureaucracy of multiple departments. However, a more 
expeditious process that explicitly focuses on moving servicemembers 
from point A to point B, i.e., DoD to VA, respectively, would ensure 
timely and accessible care.
    The American Legion believes it is extremely vital that this 
Nation's servicemembers, before their departure, should be placed in a 
comparable or full duplex capable, fully compatible, DoD/VA database 
with appointment reminders to ensure their transition isn't stifled by 
the unknown; after all, active duty servicemembers have been 
conditioned to be directed to all military appointments and events.
    Upon separation from service, these newly transitioned veterans may 
continue to have the expectation that everything will be set up for 
them. Both DoD and VA are working to ensure servicemembers and veterans 
successfully receive information and treatment respectively. It is the 
American Legion's contention that the interaction between DoD and VA be 
heightened, most importantly, by complete shared access of the medical 
records of servicemembers and veterans, as well as assessments of this 
relationship.
    Let us remember that there is no pause button for veterans. Every 
moment is critical and must be treated as such. Although the World War 
II veterans' population is diminishing at approximately 1000 daily; 
other veterans, to include those from the Vietnam era to current OEF/
OIF are presenting to VA with old and new issues. Complacency in 
communication between DoD and VA and implementation of programs can 
never be relative.
    The American Legion hereby reiterates its position and urge careful 
oversight of effective communication between DoD and VA, to include, 
verbal and written, as well as full implementation of programs to 
ensure no one is left behind during the transition process.
    Mr. Chairman and Members of the Subcommittee, the American Legion 
sincerely appreciates this opportunity to submit testimony and looks 
forward to working with you and your colleagues to ensure all 
servicemembers are met with the best of health care upon transitioning 
into the community. Thank you.

                                 
      Prepared Statement of Tom Tarantino, Legislative Associate,
                Iraq and Afghanistan Veterans of America

    Mister Chairman, Ranking Member, and Members of the Subcommittee, 
on behalf of Iraq and Afghanistan Veterans of America (IAVA), I thank 
you for the opportunity to share our views and concerns on some very 
important issues facing veterans of Iraq and Afghanistan and their 
families.

Polytrauma and Adaptive Benefits
    Veterans of Iraq and Afghanistan regularly receive excellent care 
in the ever-expanding polytrauma system. However, the DoD and the VA 
must continue to innovate, develop, and improve methods of care that 
address the changing nature of injuries from Iraq and Afghanistan. 
While these centers provide excellent care for servicemembers and 
veterans, there is a noticeable drop in the quality of care when 
transferring to community based care near the veteran's home of record. 
Additionally, the quality of services for the disabled veteran near 
their home does not match the standards of care that a veteran receives 
while in a polytrauma center.
    Additionally, IAVA is concerned with the structure of the adaptive 
services benefits that many veterans will use after leaving polytrauma 
care. Veterans are being forced into debt because of shortcomings in 
their benefits and the services that the VA provides. Currently, 
benefits for adaptive housing and automobiles are stuck at 1970's 
funding levels; most are one-time deals. With about 80 percent of OIF 
and OEF veterans under the age of 30, a veteran living with permanent 
disabilities will require more than one automobile in his or her life. 
The current rate of $12,000 may have bought a van, equipped with 
adaptive modifications, back in 1972. Today, that might get you a mid 
size Kia with no adaptive technology. The veterans are left to pay the 
difference. We cannot tolerate a benefits system that requires a 
veteran to incur debt to perform everyday functions.
    Finally, many veterans, wounded in Iraq and Afghanistan, are not 
homeowners and must return to their family homes to recover. They are 
then faced with a choice during a critical time in their recovery. The 
must choose between adapting the home where they are recovering, or 
save that benefit for the home where they will eventually settle. The 
need for these services is obvious, and the figures that require 
upgrading are known. There is no excuse for leaving a veteran with 
substandard benefits.

Social Work Case Management
    VA Social Workers play an indispensible role in the treatment of 
veterans recovering from multiple traumatic injuries. The VA must 
rapidly expand their numbers. As more and more OIF and OEF veterans 
enter the VA health system their overall needs will continue to 
inundate the overworked and understaffed cadre of social work 
professionals within the VA system. Private sector social workers, on 
average, work on a caseworker to client ratio of 1:10 to 1:15. In 
comparison, in-house VA social workers operate near a ratio of 1:35. 
The VA must address this issue before the ratios expand further. These 
caseworkers cannot properly address the needs of our veterans and their 
families under these currently crushing workloads.

Dependent & Survivor Education Services
    To the spouses and dependents of veterans who gave their last full 
measure of devotion to this country the VA provides educational 
benefits under Chapter 35, the Survivors' and Dependents' Education 
Assistance Act (DEA). This benefit is limited to family members of 
veterans who died or became permanently and totally disabled due to a 
service-connected disability. In 2008, the VA reported that 80,191 
family members took advantage of this program. This is more than the 
number of reservists using Chapter 1606.
    Unlike the generous Post-9/11 GI Bill or the recently increased 
Montgomery GI Bill, DEA provides a paltry sum of $925/month, which will 
cover less than 60 percent of a public school education. The Post-9/11 
GI Bill has become a game changer for many spouses and dependents that 
can now utilize their veteran's unused education benefits to attend any 
public school in the country. IAVA believes that DEA benefits rates 
should be aligned with the generous benefits of the new GI Bill, to 
include tuition/fees, a living allowance and a book stipend. These 
changes will help prevent the creation of a two-tiered benefits system. 
The first tier being family members that can afford to go to school 
using the new GI Bill, because they meet the criteria under the Marine 
Gunnery Sergeant Fry Scholarship. The second tier being family members 
who are left to use DEA and will have to take out student loans just to 
attend a community college.
    Last, we believe that the definition of a ``child'' used under 
Chapter 35 and new Post-9/11 GI Bill, which requires dependents who 
have started college before the age of 23, unfairly excludes a number 
of dependents who simply got a late start attending college and should 
not be punished for doing so.

VA Outreach Efforts
    Since early 2008, we have seen a noticeable shift in how the VA 
educates veterans about the care and services that they offer. 
Beginning with the suicide prevention ads in the DC region, the VA has 
continued to rethink how it communicates with the veteran population at 
large. I have personally met with representatives from the VHA, VBA and 
the VA Business Office to discuss how the VA can better reach out to 
veterans of Iraq and Afghanistan. While there has been visible 
improvements with online and television advertisement, there is a clear 
lack of coordination between VA departments. Within the VA there is 
talent, will and desire to change the passive nature of VA 
communication, however there are still substantial cultural and 
structural hurtles that must be overcome.
    IAVA believes that in order for the VA to conduct effective 
outreach, it must centralize its efforts between VHA, VBA, and NCA and 
speak as one Department of Veterans Affairs. The average veteran (and 
the average American for that matter) does not understand the 
difference between the VHA and the VBA. When I wait an entire semester 
for my GI Bill check to come, I'm upset with the VA, not the VBA. When 
I wait 2 months for a medical appointment, I'm upset with the VA, not 
the VHA. If the VA wants to effectively improve communications, it must 
speak to the veteran population clearly, avoiding government jargon.
    Thank you once again for the chance to communicate our opinions on 
several of the issues facing veterans of Iraq and Afghanistan. We look 
forward to continuing to work with the Committee and I appreciate your 
time and attention.

                                 
       Prepared Statement of Captain Jonathan Pruden, USA (Ret.),
           Area Outreach Coordinator, Wounded Warrior Project

    Mr. Chairman and Members of the Subcommittee:
    Thank you for inviting Wounded Warrior Project to share its 
perspective on issues of ``Seamless Transition'' between the 
Departments of Defense and Veterans Affairs.
    I was an Army captain who in 2003 became one of the first IED 
casualties of Operation Iraqi Freedom, and have made that transition 
myself. Now, after 20 operations at 7 different hospitals including 
amputation of my right leg, I am an Area Outreach Coordinator with WWP, 
working with hundreds of wounded warriors and covering Florida, 
Georgia, South Carolina and Alabama.
    Over the past 6 years DoD and VA have made significant progress in 
care coordination and information sharing. I have seen firsthand real 
dedication to wounded warriors and their families. Certainly this 
Subcommittee's steady focus on these issues has helped achieve greater 
``seamlessness'' for wounded warriors in making a transition from the 
military to VA care and to receipt of VA benefits.

                    The Goal: That Warrior's Thrive

    Even the most well coordinated, ``seamless'' handoff to a welcoming 
VA will not change the fact, however, that for many wounded warriors 
this transition feels like having been thrown off a cliff. In short, 
more work needs to be done by the departments and by the Congress to 
achieve not only ``seamlessness'' but to ensure that our new veterans 
have a successful transition and reintegration into the community.
    Certainly much progress has been made in coordinating the clinical 
care of the severely injured servicemember. The DoD-VA Disability 
Evaluation System pilot program has also had success in expediting VA 
disability ratings. But while the departments can take pride in certain 
areas of real progress, wounded warriors leaving the service continue 
to face programmatic, cultural, and structural barriers at VA. It is 
critical, in our view, that those barriers be toppled and that key VA 
programs and service-delivery mechanisms be re-engineered, as 
necessary, to help wounded warriors not simply to recover from their 
injuries but to thrive physically, psychologically and economically.

                Meeting Warrior's ``Co-occurring'' Needs

    More specifically, critical VA programs, benefits, and service-
delivery models fall short in many instances of providing the array of 
21st century services wounded warriors need. We work with men and women 
who are not only combating co-occurring PTSD and substance-use 
problems, but ``co-occurring'' traumatic brain injury, burns and 
amputations. Often, they're also dealing with pain, anger, depression, 
unemployment and lack of employment opportunity, lack of permanent 
housing, and more. In some cases, behavioral health problems have 
resulted in difficulties with the law.
    VA has an array of programs targeted at specific problems, but 
little in the way of a holistic coordinated approach to turn these 
lives around. The goal of ``One VA'' a department that provides 
``wraparound'' services that seamlessly and effectively integrate 
Veterans Health Administration (VHA) services and Veterans Benefits 
Administration (VBA) benefits seems sadly remote. Yet, as a panel of 
the National Academy of Public Administration has observed, care and 
benefits to veterans could be improved if VA management, organization, 
coordination, and business practices were transformed with the aim of 
improving outcomes for veterans, rather than simply aiming to improve 
operational processes.\1\ Most importantly, that National Academy panel 
has provided VA detailed recommendations constituting a comprehensive 
blueprint for that needed transformation.\2\ At its core is its 
emphasis on the importance of leadership commitment to creating and 
maintaining veteran-centered systems, including a ``no wrong door'' 
policy to ensure receipt of appropriate guidance regardless of point of 
contact. The Academy has provided VA a vision, strategy and detailed 
recommendations for organizing and delivering veteran-centered 
services. We urge the Committee to press VA to implement these 
important recommendations.
---------------------------------------------------------------------------
    \1\ National Academy of Public Administration, ``After Yellow 
Ribbons: Providing Veteran-Centered Services,'' October 2008, p. ix.
    \2\ Ibid.
---------------------------------------------------------------------------
                       Bridging Programmatic Gaps

    The Academy report aptly cites the need to strengthen VA's system 
of care, including its care-management tools.\3\ The need for better 
coordination between VHA programs serving wounded warriors is aptly 
illustrated by reference to the separate development and separate 
administration of its specialized PTSD programs and its polytrauma 
system of care. As VA researchers observed in a recently published 
paper,\4\ the Department has not developed a systemwide program or set 
of guidelines for treating the many OEF/OIF veterans who may have both 
combat-related stress disorders and mild explosive-induced concussive 
injury. Researchers pursuing this important subject initiated 
interviews with VA clinicians who provide specialized PTSD or TBI 
services with the aim of helping to identify systemwide approaches to 
improve services offered to OEF/OIF veterans with mild TBI and PTSD. 
Highlighting just some of the findings, the interview data reportedly 
suggested considerable variation in the degree and type of 
collaboration between PTSD and polytrauma teams, and indicated that 
coordinating assessment and treatment depend on individual clinician 
initiative and can take considerable time, as well as entail potential 
problems in managing medications across teams and care-settings.\5\ Of 
particular note, many providers emphasized that TBI/PTSD can co-occur 
with other clinical problems, and expressed particular concern about 
the lack of adequate treatment availability for pain and sleep-related 
problems.\6\ To their credit, providers also cited a need for 
vocational services for these veterans, noting that employment 
difficulties are a significant problem for them.\7\
---------------------------------------------------------------------------
    \3\ Ibid, p. 51 et seq.
    \4\ Nina Sayer, Nancy Rettmann, Kathleen Carlson, Nancy Bernardy, 
Barbara Sigford, Jessica Hamblen, Matthew Friedman, ``Veterans with 
History of mild traumatic brain injury and posttraumatic stress 
disorder: Challenges from provider perspective,'' Journal of 
Rehabilitation Research & Development 46 (Nov. 6, 2009).
    \5\ Ibid., 710.
    \6\ Ibid., 711.
    \7\ Ibid.
---------------------------------------------------------------------------
    While it is encouraging that VA researchers are searching for best 
practices for treating these two, often co-occurring ``signature 
wounds'' of this war, what does this knowledge-gap say about care-
coordination for wounded warriors with even more complex co-occurring 
problems?
    In that regard, we applaud the Department for having initiated the 
Federal Recovery Coordination (FRC) program, which plays an important 
coordinating role for those it serves. But with only about 15 Federal 
Recovery Coordinators already carrying full workloads, many severely 
injured warriors, who are still struggling years after their injuries, 
are unable to benefit from such efforts. We see a real need to augment 
the number of FRC's assigned to help wounded warriors, but more 
profound system changes are also needed. To illustrate, the most able 
FRC or other case-manager cannot solve such problems as a systemwide 
lack of treatment capacity, whether in the area of treatment of pain or 
sleep-disorder, or of co-occurring PTSD and substance-use disorder. 
Individual case-management assistance afforded by an FRC is surely no 
substitute for the kind of delivery-system changes needed to most 
effectively help individuals who, for example, may be struggling with 
``co-occurring'' polytraumatic injury, behavioral health problems, and 
unemployment.
    The importance of VA's developing more holistic, integrated 
systems' approaches to help wounded warriors thrive should not, 
however, detract from improving targeted programs.

       Mental Health: An Example of Need for Programmatic Change

    Much more must be done, for example, to make VA mental health care 
more ``veteran-centric,'' a yet-to-be realized VA policy goal. VA 
mental health policy (articulated in a recent VHA publication 
establishing uniform mental health services requirements for VA 
facilities) is clear: ``Mental health services must be recovery-
oriented.'' \8\ The policy explains that ``recovery-oriented care'' is 
individualized, person-centered care; care that empowers the individual 
and builds on his or her strengths; and is aimed at enabling the person 
to live a meaningful life in the community.\9\ But too many veterans 
under VA care for PTSD or other mental health problems are still simply 
being given pills to manage their symptoms. That has to change.
---------------------------------------------------------------------------
    \8\ Department of Veterans Affairs, Veterans Health Administration, 
Uniform Mental Health Services in VA Medical Centers and Clinics, VHA 
Handbook 1160.01, September 11, 2008, 5.
    \9\ Ibid.
---------------------------------------------------------------------------
    One concrete step VA can take toward realizing a recovery-
orientation for returning veterans who need mental health care is to 
employ a cohort of OEF/OIF veterans to provide peer-outreach and peer-
support. VA policy recognizes that peer-support is one of the 
fundamental components of recovery,\10\ but only requires that that 
service be provided to veterans with ``serious mental illness.'' \11\ 
Peer-support and peer-mentoring, however, are as beneficial to veterans 
struggling with PTSD as to veterans with so-called ``serious mental 
illnesses,'' and should be a widely available, integral component of VA 
mental health care afforded OEF/OIF veterans.
---------------------------------------------------------------------------
    \10\ Ibid.
    \11\ Ibid., 30.
---------------------------------------------------------------------------
    To offer another example of a need for change, our own work with 
wounded warriors has highlighted the difficulties facing those who have 
severe PTSD (and often co-occurring substance use problems) and need 
residential treatment. Too often, those veterans' circumstances do not 
``fit'' VA placement criteria for specialized PTSD care. In essence, 
OEF/OIF veterans in the greatest need of mental health care too often 
confront barriers that effectively deny them access to the very care 
they need. In short, they seem to be experiencing ``barrier-centric 
care'' rather than ``veteran-centered care.'' Let me illustrate my 
point. VA inpatient PTSD programs lack systemwide uniformity in 
admissions policy; they appear instead to be governed by an array of 
differing rules that have barred warriors from needed specialized 
inpatient care based on such diverse requirements as that the veteran?

      have had success in outpatient group therapy for 3 to 6 
months to qualify for admission;
      must have no suicidal attempts or ideations in the past 6 
months;
      not be on benzodiazepines (a drug some physicians use for 
treating the anxiety that accompanies PTSD);
      must first complete outpatient anger management 
treatment;
      must be substance-free for a certain amount of time; and
      must first be interviewed and, if accepted, will be 
admitted at a later date.

    Tragically, many OEF/OIF veterans have suffered with severe PTSD 
for some time before VA encounters them. In such instances, an 
individual may be barely hanging on, and cannot wait for a residential 
PTSD program admission date which is anywhere from a few weeks to 
several months away. In such instances, the individual is generally too 
acutely ill to benefit from outpatient treatment, and due to 
unavailability of services are generally seen once every 2 to 6 weeks 
for ongoing therapy. During that time they often relapse, and may be 
readmitted to the psychiatric unit, become involved with the justice 
system or experience severe deterioration of their condition.
    Wounded Warrior Project field staff has considerable experience in 
helping OEF/OIF veterans get needed mental health care from VA 
facilities, but we have encountered great difficulty in attempting to 
facilitate needed placements under circumstances where a veteran's 
condition poses a relatively urgent need for specialized inpatient 
treatment for PTSD (or co-occurring PTSD and substance-use problems).
    The most pronounced of these cases have involved veterans who have 
been jailed because of behaviors linked to PTSD and substance use, and 
whose cases have come before a judge who is open to having the veteran 
undergo treatment rather than incarceration. In several such cases, 
however, VA medical center personnel who have attempted to help 
facilitate such placements have been stymied by long waiting lists at 
specialized inpatient facilities in their network (VISN). On numerous 
occasions, our field staff have inquired on behalf of our warriors 
about placement options for specialized inpatient PTSD care beyond the 
confines of the particular VISN, only to learn that VA staff have no 
national data base or centralized information source to which to turn 
to identify other potential VA placement sources. Yet I'm aware of an 
instance in which a VA facility's inpatient PTSD/substance-use 
treatment program had 125 veterans on its waiting list while a similar 
program 180 miles away in a neighboring VISN had open beds.
    In light of this troubling information-gap, we have urged the 
Department to establish a regularly updated ``clearinghouse'' on all 
specialized VA PTSD programs to provide relatively real-time placement 
information, to include nature of the program (such as whether the 
program provides treatment for dual-diagnosis patients; program 
requirements; length-of-stay limits; etc.); capacity; bed availability; 
length of any waiting list; OEF/OIF veteran census; and contact-
personnel. Such a resource should be available and accessible to VA 
personnel as well as to veterans' advocates. To date, however, our 
recommendation has elicited no response.

                     Employment: Programmatic Gaps

    We have highlighted some of the programmatic gaps relating to VA 
mental health, not because these programs are uniquely flawed, but 
because mental health is so important to overall health and to whether 
wounded warriors are thriving. To cite another area that cries out for 
programmatic improvement, employment is certainly key to successful 
reintegration. Yet even in programs targeted at helping disabled 
veterans gain Federal employment, wounded warriors encounter obstacles 
in gaining employment. It is particularly painful to find that warriors 
encounter problems in seeking employment with VA, the one Federal 
department one would expect to go the extra mile. VA certainly appears 
to have the needed legislative authority to be a leader in employing 
wounded warriors. As you know, Mr. Chairman, service-connected disabled 
veterans (and those retired from service on disability) are entitled to 
a ten-point preference in Federal hiring (in a system using 100 as the 
top score), and are entitled to hiring preference over other applicants 
with the same or lower scores. But those extra points seem to give 
veterans little or no practical help. Instead, the complex hurdles 
associated with demonstrating one's qualifications for a particular 
Federal job (in particular, demonstrating that one has the requisite 
``KSAO's,'' namely the Knowledge, Skills, Abilities, and Other 
Characteristics) often knock otherwise qualified wounded warrior 
applicants out of contention, even in VA. Surely the Department could 
establish mechanisms to help overcome such hurdles. But wounded 
warriors encounter frustration with VA even when they get jobs through 
a Veterans Recruitment Appointment (VRA), a special authority by which 
a Federal department or agency can employ a disabled veteran without 
competition. While the VRA authority has occasionally provided warriors 
jobs, such VA appointments seldom tap the leadership and other skills 
wounded warriors developed in service.
    In short, Mr. Chairman, to achieve its ultimate goals, ``seamless 
transition'' will not only require more work to close the remaining 
gaps between DoD and VA, but substantial transformation within VA in 
the area of mental health programming, vocational rehabilitation and 
employment, and many other areas to make warriors' transition an easier 
journey to successful community reintegration.
    That concludes my testimony; I would be happy to answer any 
questions you may have.

                                 
    Prepared Statement of Hon. Noel Koch, Deputy Under Secretary of
          Defense, Wounded Warrior Care and Transition Policy,
                       U.S. Department of Defense

    Mr. Chairman, thank you for inviting me to join you today to 
discuss how the Department of Defense (DoD) transitions our Wounded, 
Ill and Injured Servicemembers to the care of the Department of 
Veterans Affairs (VA). The Departments continue to work together to 
address these issues through the auspices of the DoD/VA Senior 
Oversight Committee and the Joint Executive Council.
    The Office of Wounded Warrior Care and Transition Policy's (WWCTP) 
mission is to ensure Wounded, Ill, Injured & transitioning Warriors 
receive the highest quality care and seamless transition support. Some 
of our Wounded, Ill or Injured Servicemembers may be able to return to 
active duty following their recovery, and may choose to do so, while 
others may leave military service. But while in the care of DoD, it is 
my office's job to develop policy and provide oversight of several 
parts of a Servicemember's care, recovery and transition.
    As you are aware, one of the most important efforts we have made 
was in response to the recommendations sent forth by the President's 
Commission on Care for America's Returning Wounded Warriors and 
required by the National Defense Authorization Act for Fiscal Year 2008 
(NDAA 2008) to provide a single point of contact for recovering 
Servicemembers and their families. In response to the NDAA requirement, 
we launched the Department of Defense Recovery Coordination Program 
(RCP).
    The RCP places Recovery Care Coordinators (RCCs) in each Military 
Department's Wounded Warrior Program. The RCCs support eligible 
Wounded, Ill and Injured Servicemembers, including members of the 
Reserve Component, and their families, by ensuring their non-medical 
needs are met along the road to recovery.
    With the Servicemember's Recovery Team, including the Commander, 
Non-medical Care Manager and Medical Care Case Manager, the Recovery 
Care Coordinator oversees the development and completion of a Recovery 
Plan. The patient-centered Recovery Plan identifies the Servicemember's 
and family's goals and action steps and points of contact to achieve 
them. Effectively, the plan is a roadmap guiding the recovering 
Servicemember and family along the process of recovery, rehabilitation, 
and reintegration. It may include information to assist the family 
member serving as the primary caregiver in receiving compensation, 
financial assistance, job placement services, support with child care, 
counseling, respite services, and other benefits and services available 
from Federal, state, and local governments, as well as our non-profit 
partners.
    The Recovery Coordination Program is guided by a new DoD 
Instruction (1300.24) on the Recovery Coordination Program, which was 
drafted by my office with input from a Policy Working Group composed of 
representatives from across the Military Departments, the Office of the 
Secretary of Defense and the Department of Veterans Affairs. The policy 
provides uniform guidelines and procedures for our Military Service 
Wounded Warrior Programs and assigns responsibilities for 
implementation of the Recovery Coordination Program. It establishes 
parameters for determining the type of care a Servicemember needs, 
provides the support of a Recovery Care Coordinator and lays out the 
process for developing a Recovery Plan. It also requires that the same 
support be provided to qualified Reserve Component Servicemembers. In 
addition to the Recovery Plan, the Recovery Care Coordinators bring to 
bear several other resources for our recovering Servicemembers and 
their families through a variety of Web sites and publications. Our 
Recovery Coordinators, Recovery Teams and providers, Servicemembers and 
their families all make use of these resources, including:

      The National Resource Directory (NRD): A successful tri-
agency initiative including DoD, VA, and the Department of Labor, the 
National Resource Directory is an online resource linking 
Servicemembers, care providers and family caregivers to information on 
more than 12,000 Federal, state and local support services. The NRD 
provides information on state-by-state resources and benefits.
      The Compensation and Benefits Handbook: This book 
includes a section dedicated exclusively to caregivers. It provides 
community options such as transportation services, respite care, 
financial assistance, and counseling resources.

    Surveys of our Recovery Care Coordinators and providers indicate 
over 90 percent utilize these resources as they develop and execute 
recovery plans.
    The Disability Evaluation System (DES) Pilot is another program 
that my office coordinates with VA. As of the first week of January, 
138 Servicemembers entered the DES Pilot from 21 Military Treatment 
Facilities (MTFs) during the reporting week for a cumulative enrollment 
of 6,408 Servicemembers since November 26, 2007, when the DES Pilot 
began. Of those, 1,164 Servicemembers completed the DES Pilot and 
returned to duty, separated from service, or retired, and 212 
Servicemembers were removed from the DES Pilot for reasons such as 
additional medical treatment or case terminated pending administrative 
discharge processing. 5,032 Servicemembers are currently enrolled in 
the DES Pilot.
    Active Component Servicemembers who completed the DES Pilot 
averaged 275 days from Pilot entry to a VA benefits decision, excluding 
pre-separation leave. Including pre-separation leave, Active Component 
Servicemembers completed the DES Pilot in an average of 291 days. This 
is 1 percent faster than the goal established for Active Component 
Servicemembers and is 46 percent faster than the current DES and VA 
claim process. Reserve Component Servicemembers who completed the DES 
Pilot averaged 279 days from Pilot entry to issuance of a VA Benefits 
Letter, which is 9 percent faster than the projected 305 day timeline.
    Survey results show that across all Servicemembers, Pilot 
participants were significantly more satisfied with DES Pilot Medical 
Evaluation Board (MEB), Physical Evaluation Board (PEB), and Transition 
processes than non-Pilot participants. Soldiers in the Pilot were 
significantly more satisfied with MEB, PEB, and Transition processes 
than Soldiers in the non-Pilot. Sailors and Marines were significantly 
more satisfied with the Pilot than non-Pilot MEB and PEB processes. 
Pilot participants reported DES Pilot MEB and PEB processes to be 
significantly fairer than did non-Pilot participants.
    In September 2009, six additional sites were approved for expansion 
of the DES Pilot between January and March 2010. The Departments of the 
Army and Navy completed initial site assessments and are currently 
conducting site visits to each of these locations. Upon expansion of 
the DES Pilot to these locations, approximately 46 percent of all new 
DES enrollees will be covered under the Pilot. We are conducting a 
joint DoD/VA evaluation of the Pilot that will help us determine the 
best way to expand the DES ``Pilot Model'' worldwide, the results of 
which will provide the basis for the final report on the Pilot due to 
Congress in May.
    But these programs notwithstanding, much remains to be done. Both 
DoD and VA are aware that we can improve how we care for our 
Servicemembers and Veterans, be it through further research, continuing 
to ease access to benefits for those who earned them, and better 
support for our Caregivers.
    Mr. Chairman, we are reminded daily of our obligation to our 
Servicemembers and their families, and particularly to the Wounded, Ill 
and Injured, and those who bear the greatest burden of caring for them. 
We are committed to providing the support they need to help ensure a 
successful transition through recovery and rehabilitation and back to 
active duty or reintegration into their communities.
    We appreciate the opportunity to come before you today to discuss a 
subject which the Secretary of Defense has said repeatedly is a 
Departmental priority second only to the wars in which we are engaged. 
I will be happy to answer your questions.
    Thank you.

                                 
   Prepared Statement of Madhulika Agarwal, M.D., MPH, Chief Officer,
    Office of Patient Care Services, Veterans Health Administration,
                  U.S. Department of Veterans Affairs

    Good morning, Mr. Chairman and Members of the Subcommittee. Thank 
you for the opportunity to discuss the Department of Veterans Affairs' 
(VA) efforts to help returning servicemembers transition back to 
civilian life. I am accompanied today by Dr. Karen Guice, Executive 
Director of the Federal Recovery Coordination Program, and Mr. Paul 
Hutter, Chief Officer, Office of Legislative, Regulatory and 
Intergovernmental Affairs.
    VA's primary mission is to care for those who have borne the 
battle. As science and technology have advanced, more and more of our 
brave heroes survive what would have been fatal wounds in previous 
conflicts. However, survival is only the immediate goal--our job is to 
restore Veterans to the greatest level of health, independence and 
quality of life that is medically possible. To facilitate a smooth 
transition from the Department of Defense (DoD), VA has stationed 33 
health care liaisons at 18 Military Treatment Facilities to facilitate 
the transfer of care to VA facilities. This program grew considerably 
during 2009 with six additional liaisons at five new sites. Altogether 
these liaisons have assisted more than 20,000 servicemembers in 
transitioning from DoD to VA since 2004. We continue to work with DoD 
to identify additional sites that have increasing numbers of wounded 
warriors who may benefit from these services.
    My testimony today will describe the advances made in VA's 
Polytrauma System of Care, which provides coordinated inpatient, 
transitional, and outpatient rehabilitation services; our care 
management system, which coordinates complex components of care for ill 
and injured servicemembers, Veterans and their families, as well as the 
education services VA provides to dependents and family members of 
injured Veterans; the Federal Recovery Coordination Program; and VA's 
outreach efforts to returning servicemembers and Veterans.

Polytrauma System of Care and Specialty Care
    Polytrauma refers to complex, multiple injuries occurring as a 
result of the same event. Some examples of polytrauma injuries include 
Traumatic Brain Injury (TBI), amputations, severe musculoskeletal 
injuries, burns, hearing loss or tinnitus, memory loss, visual 
impairment, cognitive impairment, pain, fatigue, or mental health 
conditions such as post-traumatic stress disorder (PTSD). Individuals 
with polytrauma require extraordinary levels of integrated and 
coordinated medical, rehabilitation and support services. To respond to 
these unique patient needs, VA developed a comprehensive model of care 
that includes interdisciplinary teams of health care providers that 
coordinate care as the patient moves from a Military Treatment Facility 
to a VA Polytrauma Rehabilitation Center, a local VA hospital, and 
reintegration into the Veteran's or servicemember's home community.
    Since the designation of VA's TBI Centers as Polytrauma 
Rehabilitation Centers in 2005, VA has continued to expand its 
Polytrauma System of Care by adding new specialized rehabilitation 
programs and teams of rehabilitation specialists at sites across the 
country. The VA Polytrauma System of Care has four levels of 
facilities: Polytrauma Rehabilitation Centers, Polytrauma Network 
Sites, Polytrauma Support Clinic Teams, and Polytrauma Points of 
Contact.
    The four Rehabilitation Centers (located in Minneapolis, MN; Tampa, 
FL; Richmond, VA; and Palo Alto, CA) provide comprehensive medical and 
rehabilitation services on both an inpatient and outpatient basis for 
Veterans and servicemembers with the most complex and severe injuries. 
These facilities typically have between 12 and 18 inpatient beds 
staffed by specialty rehabilitation teams that provide acute 
interdisciplinary evaluation, medical management and rehabilitation 
services. A fifth Rehabilitation Center is currently under construction 
in San Antonio, Texas and is expected to be completed in 2011.
    Occupancy rates at these centers fluctuate over time and location. 
The average length of stay is 30 days, but for the most severely 
injured the average is 67 days. Upon discharge from a VA Polytrauma 
Rehabilitation Center, patients may be transferred to another facility, 
although more than 70 percent are discharged to their home. From March 
2003 through fiscal year (FY) 2009, the Centers have treated 
approximately 1,500 inpatients with severe injuries; approximately 56 
percent of these patients have been active duty servicemembers. 
Slightly more than half of the patients treated in the Polytrauma 
Rehabilitation Centers were injured in non-combat, non-deployed 
incidents.
    Recent new specialized rehabilitation initiatives at the Polytrauma 
Rehabilitation Centers include:

      In July 2007, 10 bed residential Transitional 
Rehabilitation Programs were established at the four Centers to provide 
rehabilitation in a home-like environment to facilitate community 
reintegration for Veterans and their families.
      Beginning in 2007, VA implemented a specialized Emerging 
Consciousness care path at each of the four Polytrauma Rehabilitation 
Centers to serve those with severe TBI who are slow to recover 
consciousness. These patients require complex and intensive medical 
services and resources to improve their level of responsiveness and 
reduce medical complications. VA collaboratively developed this care 
path with subject matter experts from the Defense and Veterans Brain 
Injury Center (DVBIC) and the private sector. VA and DVBIC continue to 
collaborate on research in this area, and our models of care continue 
to be updated in response to scientific advances.
      In October 2008, all inpatients with TBI at VA Polytrauma 
Rehabilitation Centers began receiving special ocular health and visual 
function examinations. To date, 649 inpatients have received these 
examinations.
      In April 2009, VA began an advanced technology initiative 
to establish assistive technology laboratories at the four Polytrauma 
Rehabilitation Centers. These facilities will serve as a resource for 
VA health care and provide the most advanced technologies to Veterans 
and servicemembers with ongoing needs related to cognitive impairment, 
sensory impairment, computer access, communication deficits, wheeled 
mobility, self care, and home telehealth.
      VA continues to optimize its Polytrauma Telehealth 
Network to facilitate provider-to-provider and provider-to-family 
coordination, as well as consultation from Polytrauma Rehabilitation 
Centers and Network Sites to other providers and facilities. Currently, 
about 30 to 40 videoconference calls are made monthly across the 
Network Sites to VA and DoD facilities. New Polytrauma Telehealth 
Network initiatives in development include home buddy systems to 
maintain contact with patients with mild TBI or amputation, and remote 
delivery of speech therapy services to Veterans in rural areas.
      The Polytrauma Rehabilitation Centers have been renovated 
to optimize healing in an environment respectful of military service. 
Military liaisons located at the Centers support active duty patients 
and coordinate interdepartmental issues for patients and their 
families. Working with the Fisher House Foundation, we are also able to 
provide housing and other logistical support for family members staying 
with a Veteran or servicemember during his or her recovery at one of 
our facilities.

    The remaining components of the VA Polytrauma System of Care 
include 22 Polytrauma Network Sites, 82 Polytrauma Support Clinic 
Teams, and 48 Polytrauma Points of Contact. The Polytrauma Network 
Sites are available in each Veterans Integrated Service Network (VISN), 
as well as San Juan, Puerto Rico. These sites develop and support a 
patient's rehabilitation plan through comprehensive, interdisciplinary, 
specialized teams; provide both inpatient and outpatient care; and 
coordinate services for Veterans with TBI and polytrauma throughout the 
VISN.
    In 2008, the Polytrauma Support Clinic Teams expanded to 82 VA 
facilities. These interdisciplinary teams of rehabilitation specialists 
provide dedicated outpatient services closer to home and manage the 
long-term or changing rehabilitation needs of Veterans. These teams 
coordinate clinical and support services for patients and their 
families. They also conduct comprehensive evaluations of patients with 
positive TBI screens, and develop and implement rehabilitation and 
community reintegration plans.
    VA Polytrauma Points of Contact are available at 48 VA medical 
centers without specialized rehabilitation teams. These Points of 
Contact, established in 2007, are knowledgeable about the VA Polytrauma 
System of Care and coordinate case management and referrals throughout 
the system.
    In addition to enhancements to its Polytrauma System of Care, VA 
has implemented several other recent initiatives to improve care for 
Veterans and servicemembers with TBI:

      In 2009, VA developed clinical practice guidelines for 
mild TBI in collaboration with DoD and deployed them to VA health care 
providers. VA also developed recommendations in the areas of cognitive 
rehabilitation, drivers' training, and managing the co-occurrence of 
TBI, PTSD and pain.
      In 2009, VA began collaborating with the National 
Institute on Disability and Rehabilitation Research TBI Model Systems 
to collect rehabilitation outcomes data and establish a TBI Veterans 
Health Registry.
      Since April 2009, VA has developed an individualized 
rehabilitation and community reintegration plan for every outpatient 
Veteran with TBI who requires ongoing rehabilitation care. This 
national template is integrated into the electronic medical record and 
includes the results of a comprehensive assessment, measurable goals, 
and recommendations for specific rehabilitative treatments. The patient 
and family participate in crafting the treatment plan and receive a 
copy of the plan.
      VA regularly collaborates with private sector facilities 
to successfully meet the individualized needs of Veterans and 
complement VA care in cases when VA is not readily able to provide the 
needed services or the required care in geographically inaccessible 
areas. VA medical facilities have identified private sector resources 
within their catchment area that have expertise in neurobehavioral 
rehabilitation and recovery programs for TBI. In FY 2009, 3,708 
Veterans with TBI received inpatient and outpatient hospital care and 
medical services from public and private entities, with a total 
disbursement of over $21 million.
      Several educational materials for patients and families 
are in the final stages of being developed and distributed nationally 
including: TBI Family Education Manual, TBI Information Brochure, TBI 
Screening Brochure, and the Family Care Map. VA and DVBIC also 
collaborated to develop a training curriculum for family members in 
providing care and assistance to Servicemembers and Veterans with TBI.

    VA has also established an Amputation System of Care and the Blind 
Rehabilitation System of Care to provide specialty care for Veterans 
and servicemembers. The Amputation System of Care is composed of 7 
Regional Amputation Centers, 15 Polytrauma Amputation Network Sites, 
100 Amputation Clinic Teams, and 30 Amputation Points of Contact. These 
resources have been dedicated to reduce variance and improve access 
across VA to amputation rehabilitation care. More than 43,000 Veterans 
have major limb amputations, of which about 950 are Operation Enduring 
Freedom or Operation Iraqi Freedom (OEF/OIF) Veterans.
    Blind Rehabilitation Outpatient Specialists are assigned to 
Polytrauma Rehabilitation Centers and Network Sites, and patients with 
severe visual impairments receive further comprehensive services at any 
of our 10 inpatient Blind Rehabilitation Centers. In addition to these 
Centers, VA has 77 Blind Rehabilitation Outpatient Specialists and 137 
Visual Impairment Services Coordinators. VA has also assigned Blind 
Rehabilitation Outpatient Specialists to Walter Reed Army and Bethesda 
Naval Medical Centers to serve visually impaired servicemembers.
    VA works closely with DoD to support high quality integrated care 
for severely injured servicemembers and Veterans. The two Departments 
recently developed revisions to clinical codes to improve 
identification and tracking of TBI. In 2009, a 5 year pilot project to 
provide assisted living services for Veterans with severe TBI was 
initiated in collaboration with the DVBIC. We have placed three 
Veterans in Virginia, Florida and Wisconsin, and enrollment is pending 
for two Veterans in Texas and Kentucky.

VA Care Management and Education Services
    Care management refers to a patient- and family-centered approach 
to care by an interdisciplinary team of professionals with specialized 
knowledge in the management of patients with complex care needs. VA has 
developed a robust care management system for OEF/OIF Veterans. Each VA 
medical center has an OEF/OIF Program Manager, OEF/OIF Case Managers, 
and Transition Patient Advocates. The Program Manager coordinates 
clinical care and oversees the transition and care for this population. 
The Program Manager also serves as the primary point of contact for all 
referrals from the VA Liaisons for Health Care. OEF/OIF Case Managers 
coordinate patient care activities and ensure that all clinicians 
providing care to the patient are doing so in a cohesive and integrated 
manner. Transition Patient Advocates help Veterans navigate the VA 
system and Veterans Benefits Administration (VBA) team members assist 
Veterans with the benefit application process and education about VA 
benefits.
    All severely ill and injured OEF/OIF servicemembers and Veterans 
receiving care at VA facilities are provided a case manager. All others 
are screened for case management needs and, based upon the results of 
the assessment; a case manager may be assigned as indicated. In 
addition, OEF/OIF servicemembers and Veterans with special needs, 
including polytrauma, spinal cord injury, and blindness, are served by 
a specialty case manager. The patient and family serve as integral 
partners in the assessment and treatment care plan. Since many of the 
returning OEF/OIF Veterans connect to more than one specialty case 
manager, VA introduced a new concept of a ``lead'' case manager. The 
lead case manager serves as a central communication point for the 
patient and his or her family. Our case managers maintain regular 
contact with Veterans and their families to provide support and 
assistance to address any health care and psychosocial needs that may 
arise. As of December 31, 2009, 2,484 OEF/OIF severely ill and injured 
servicemembers and Veterans were receiving on-going case management 
services, an increase of 49 percent in 2009. Case managers collaborate 
with VA, DoD and community resources to address the needs of OEF/OIF 
Veterans.
    VA is training its staff and developing new models to support 
better care for severely injured and ill servicemembers and Veterans. 
We have implemented Web-based training to disseminate best practices 
and guidelines, and a mentoring program for OEF/OIF Program Managers to 
share expertise. VA updated policies for transitioning and care 
managing OEF/OIF Veterans and servicemembers with new handbooks 
published in October and November 2009. We will continue to integrate 
these services with our Post-Deployment Integrated Care Clinics and 
other specialty care such as mental health and polytrauma.
    VA has adopted the Care Management Tracking and Reporting 
Application (CMTRA), a Web-based tracking system that includes a care 
management schedule for each Veteran, identifies a lead case manager, 
produces management reports and creates data to assist VA in measuring 
performance. While CMTRA initially focused on the severely ill and 
injured, CMTRA has now been extended to track case management of non-
severely ill or injured OEF/OIF servicemembers and Veterans.
    VA works with family members and Veterans prior to discharge to 
train and educate them on specific health care needs and issues. For 
example, prior to discharge from a Polytrauma Rehabilitation Center, 
family members may be scheduled to stay with the Veteran in a family 
training apartment or the Veteran may participate in the Transitional 
Rehabilitation Program. This allows the family member to experience 
what the return home will be like for their loved one while still 
having rehabilitation staff and nursing staff available to answer 
questions, address unexpected problems, and provide the emotional 
support a family may need as they prepare for the next phase of 
rehabilitation.
    VA case managers are actively involved in assisting ill and injured 
Veteran's with re-integration into their home communities. VA provides 
skilled home care, homemaker/home health aide services, and a variety 
of respite care options to support Veterans and their families who 
require additional assistance at home. In FY 2009, VA Home-Based 
Primary Care interdisciplinary teams provided comprehensive primary 
care in the homes of 431 OEF/OIF Veterans. VA provides home 
modification grants and special adaptive equipment as needed to ensure 
a safe home environment. For OEF/OIF ill and injured Veterans who are 
unable to remain in their own homes, VA has developed an in-home 
alternative to nursing home care, the Medical Foster Home. VA is 
rapidly expanding its Medical Foster Home initiative, also known as 
``Support at Home: Where Heroes Meet Angels,'' across the Nation. There 
are several OEF/OIF Veterans who would otherwise have required nursing 
home placement that have been served in the Medical Foster Home program 
this year.
    VA recognizes the significant sacrifices made by family caregivers 
of severely ill and injured OEF/OIF Veterans. With support from 
Congress, VA was able to conduct eight caregiver support pilot programs 
at 39 VA medical centers across the country. The lessons learned from 
these pilot programs have provided us with the foundation to develop a 
comprehensive caregiver support program that will enhance caregiver 
education and training while providing a flexible menu of respite care 
options to reduce caregiver burden and improve the quality of life of 
Veterans and their caregivers.

Federal Recovery Coordination Program
    The Federal Recovery Coordination Program (FRCP), a joint VA/DoD 
program, helps coordinate and access Federal, state and local programs, 
benefits and services for seriously wounded, ill and injured 
servicemembers, Veterans, and their families through recovery, 
rehabilitation, and reintegration into the community. As of January 11, 
2010, 15 Federal Recovery Coordinators (FRCs) were coordinating care 
for 425 severely wounded, ill or injured servicemembers and Veterans; 
another 38 individuals were being evaluated for program enrollment. 
Five (5) new FRCs completed their orientation in early January, 
bringing the total number of FRCs to 20. FRCs are located at Walter 
Reed Army Medical Center, National Naval Medical Center, Naval Medical 
Center San Diego, Camp Pendleton Naval Hospital, San Antonio Military 
Medical Center, Eisenhower Army Medical Center, Houston VA Medical 
Center, and Providence VA Medical Center.
    Recovering servicemembers and Veterans are referred to the FRCP 
from a variety of sources, including from the servicemember's command, 
members of the multidisciplinary treatment team, case managers, 
families already in the program, Veterans Service Organizations and 
non-governmental organizations. Generally, those individuals whose 
recovery is likely to require a complex array of specialists, transfers 
to multiple facilities, and long periods of rehabilitation are referred 
to FRCP. After referral, an FRC conducts an evaluation that serves as 
the basis for problem identification and determination of needed 
services. After enrollment in FRCP, clients develop a Federal 
Individual Recovery Plan (FIRP) with their FRC.
    FRCs have the delegated authority for oversight and coordination of 
the clinical and non-clinical care identified in each client's FIRP. 
Working with a variety of case managers, FRCs assist their clients in 
reaching their goals as identified and tracked in the FIRP. The FRC and 
the relevant case manager determine responsibility and timeline for 
implementing the steps necessary to reach a goal. The FRC then monitors 
progress with the case manager and the client, providing support and 
additional resources to both, until the goal is reached. FRCs 
frequently organize meetings with providers, case managers and clients 
to make sure objectives and expectations are clear. The plan and goals 
change as a client progresses through the stages of recovery, 
rehabilitation and reintegration. The FRC provides a single, consistent 
point of coordination through this progression.

Outreach
    VA is continuously looking for ways to improve and achieve a smooth 
and seamless transition for servicemembers and their families. VA 
conducts numerous outreach activities to support this seamless 
transition. In FY 2009, VA conducted over 8,500 Transition Assistance 
Program and Disabled Transition Assistance Program briefings attended 
by over 356,800 servicemembers and their families. VA launched a pre-
discharge program home page (http://www.vba.va.gov/predischarge/) on 
June 9, 2009 to complement its Benefits Delivery at Discharge and Quick 
Start programs. In addition, VA launched the eBenefits portal on 
October 22, 2009 to streamline information to servicemembers, Veterans 
and families (www.ebenefits.va.gov/ebenefits-portal/).
    VA also conducts outreach to returning Reserve Component 
servicemembers through different approaches and settings, including: 61 
demobilization sites; the Yellow Ribbon Reintegration Program events at 
30, 60, and 90 days post-demobilization; Post-Deployment Health 
Reassessments, including those conducted at VA facilities; partnerships 
with the National Guard; Individual Ready Reserve musters, through the 
Combat Veteran Call Center Initiative; and for all servicemembers, the 
VA OEF/OIF Web site (http://www.oefoif.va.gov/).
    Additionally, VA establishes contact and provides assistance 
through annual focus groups held at VA medical centers, annual Welcome 
Home events held by each medical center, and community partnerships 
with providers, colleges and universities, job fairs, and other 
activities.
    Our outreach efforts have provided Veterans with knowledge and 
access to VA services and benefits. Of the 1,100,000 Veterans who have 
separated since 2002, 48 percent have used VA health care services. 
Between 2005 and September 2009, more than 86,000 referrals to VA were 
made through DoD's Post-Deployment Health Reassessment, and since 2008, 
more than 70,000 Veterans have enrolled in VA health care prior to 
leaving a demobilization site. We also are reaching and conversing with 
Veterans through social media, including Facebook, Twitter, YouTube, 
Flickr, and blogs. Currently, VA has the fastest growing Facebook page 
among cabinet-level agencies with over 11,000 fans, most of whom have 
been gained since Veterans Day (over 1,000 fans per week). VA 
participation on Facebook is expanding. Each Administration has its own 
page for topic-specific conversations, as do a dozen VA medical 
centers. VA has plans to launch a Facebook page for every VA medical 
center.
    VA now has four separate official Twitter feeds for the Department 
and each of the administrations. In the past 2 months, VA's primary 
Twitter feed has added followers at a higher growth rate than any other 
cabinet-level agency: nearly 2,000 have joined in that time. Half a 
dozen VA medical centers have active Twitter feeds. As with Facebook, 
VA plans to expand Twitter feeds to all medical centers beginning in 
2010. VA just launched the first official Twitter feed for a VA 
principal in January, with Assistant Secretary Tammy Duckworth now 
engaging regularly with the public via her own VA Twitter account.
    VA also has embraced video- and photo-sharing media with the use of 
YouTube (videos) and Flickr (photos). VA began posting each segment 
from its news magazine program The American Veteran on YouTube, while 
showcasing a selection of them on the VA homepage. At the same time, VA 
has a separate health care-related YouTube channel (administered by 
VHA) which has posted more than 90 videos, has 1,300 subscribers and 
more than 58,000 views.
    In terms of blogging, VA has thus far been spreading its message 
via other sites--with pieces published at the White House Blog, and 
others with messages posed by Secretary Shinseki and Assistant 
Secretary Duckworth at outlets like Military.com.
    VA's main Web site has also been rebuilt to make it more user-
friendly for Veterans. Up-to-date information about benefits and 
services is added daily. Reaching returning Veterans through their 
expected and familiar modes of communication is a priority. The OEF/OIF 
generation expects a communication style that allows conversation and 
engagement, and these resources help VA enhance information sharing 
with this group of Veterans, as well as other stakeholders.

Conclusion
    VA is focusing its resources and attention to meet the needs of 
Veterans and their families and to ensure that as servicemembers return 
home, they receive the care and support they have earned.
    Thank you again for the opportunity to speak about VA's efforts to 
support transitioning servicemembers and Veterans. My colleagues and I 
are prepared to answer your questions at this time.

                                 
