[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
HEALING THE PHYSICAL INJURIES OF WAR
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
July 22, 2010
__________
Serial No. 111-93
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
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 HEALTH
MICHAEL H. MICHAUD, Maine, Chairman
CORRINE BROWN, Florida HENRY E. BROWN, Jr., South
VIC SNYDER, Arkansas Carolina, Ranking
HARRY TEAGUE, New Mexico CLIFF STEARNS, Florida
CIRO D. RODRIGUEZ, Texas JERRY MORAN, Kansas
JOE DONNELLY, Indiana JOHN BOOZMAN, Arkansas
JERRY MCNERNEY, California GUS M. BILIRAKIS, Florida
GLENN C. NYE, Virginia VERN BUCHANAN, Florida
DEBORAH L. HALVORSON, Illinois
THOMAS S.P. PERRIELLO, Virginia
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
__________
July 22, 2010
Page
Healing the Physical Injuries of War............................. 1
OPENING STATEMENTS
Chairman Michael H. Michaud...................................... 1
Prepared statement of Chairman Michaud....................... 35
Hon. Henry E. Brown, Jr., Ranking Republican Member.............. 2
Prepared statement of Congressman Brown...................... 35
WITNESSES
U.S. Department of Defense, Jack Smith, M.D., MMM, Acting Deputy
Assistant Secretary for Clinical and Program Policy............ 27
Prepared statement of Dr. Smith.............................. 55
U.S. Department of Veterans Affairs, Lucille B. Beck, Ph.D.,
Chief Consultant, Rehabilitation Services, Office of Patient
Care Services, and Director, Audiology and Speech Pathology
Service, Veterans Health Administration........................ 29
Prepared statement of Dr. Beck............................... 58
______
American Legion, Denise A. Williams, Assistant Director for
Health Policy, Veterans Affairs and Rehabilitation Commission.. 10
Prepared statement of Ms. Williams........................... 53
Blinded Veterans Association, Thomas Zampieri, Ph.D., Director of
Government Relations........................................... 3
Prepared statement of Dr. Zampieri........................... 36
Disabled American Veterans, Joy J. Ilem, Deputy National
Legislative Director........................................... 6
Prepared statement of Ms. Ilem............................... 42
Iraq and Afghanistan Veterans of America, Tom Tarantino,
Legislative Associate.......................................... 8
Prepared statement of Mr. Tarantino.......................... 49
Paralyzed Veterans of America, Carl Blake, National Legislative
Director....................................................... 4
Prepared statement of Mr. Blake.............................. 40
MATERIAL SUBMITTED FOR THE RECORD
Post-Hearing Questions and Responses for the Record:
Hon. Michael Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs to Thomas Zampieri, Ph.D.,
Director of Government Relations, Blinded Veterans
Association, letter dated July 27, 2010, and response
letter dated August 13, 2010............................. 66
Hon. Michael Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs to Carl Blake, National
Legislative Director, Paralyzed Veterans of America,
letter dated July 27, 2010, and response letter dated
August 31, 2010.......................................... 68
Hon. Michael Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs to Joy J. Ilem, Deputy
National Legislative Director, Disabled American
Veterans, letter dated July 27, 2010, and Ms. Ilem's
responses................................................ 71
Hon. Michael Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs to Tom Tarantino,
Legislative Associate, Iraq and Afghanistan Veterans of
America, letter dated July 27, 2010, and Mr. Tarantino's
responses................................................ 75
Hon. Michael Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs to Denise A. Williams,
Assistant Director for Health Policy, Veterans Affairs
and Rehabilitation Commission, American Legion, letter
dated July 27, 2010, and response from Tim Tetz,
Director, National Legislative Commission, letter dated
September 8, 2010........................................ 77
Hon. Michael Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs to Hon. Robert M. Gates,
Secretary, U.S. Department of Defense, letter dated July
27, 2010, and DoD's responses............................ 79
Hon. Michael Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs to Hon. Eric K. Shinseki,
Secretary, U.S. Department of Veterans Affairs, letter
dated July 27, 2010, and VA responses.................... 82
HEALING THE PHYSICAL INJURIES OF WAR
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THURSDAY, JULY 22, 2010
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 9:59 a.m., in
Room 334, Cannon House Office Building, Hon. Michael H. Michaud
[Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Donnelly, McNerney,
Halvorson, Perriello, Brown of South Carolina, and Bilirakis.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. I will call the Subcommittee on Health to
order, and I would like to thank everyone for coming this
morning.
The purpose of today's hearing is to explore how we can
best serve our veterans who have sustained severe physical
wounds from the wars in Iraq and Afghanistan.
Today we will closely examine the U.S. Department of
Veterans Affairs' (VA's) specialized service for the severely
injured, which include blind rehabilitation, spinal cord injury
(SCI) centers, polytrauma centers, and prosthetic and sensory
aids services.
With advances in protective body armor and combat medicine,
our servicemembers are surviving war wounds which otherwise
would have resulted in casualties. Many servicemembers who are
severely injured in Operation Enduring Freedom (OEF) and
Operation Iraqi Freedom (OIF) will require sophisticated,
comprehensive, and often lifelong care.
We know that the blast injuries from improvised explosive
devices (IEDs) are the most common cause of injuries and death
among our OEF/OIF servicemembers. Blast injuries often include
combinations of traumatic brain injury (TBI), blindness, spinal
cord injuries, burns, and damage to the limbs, which results in
amputations.
Today, we will examine whether VA is meeting the needs of
our severely injured, and whether the veterans have access to
the most current therapies for treating their physical war
injuries. We will identify what VA is doing well and what areas
they need improvement in. We will also explore how VA ensures
that the quality of care is consistent and standardized across
the VA health care system so that veterans receive the same
high quality care regardless of which VA facility they visit.
Finally, we will review VA's current efforts to coordinate
specialized services for the severely injured with the U.S.
Department of Defense (DoD) and how we can achieve improved
coordination between the two Departments.
I look forward to hearing the panels this morning, and I
would turn it over to my good friend Ranking Member Mr. Brown
for any opening statement he may have.
[The prepared statement of Chairman Michaud appears on
p. 35.]
OPENING STATEMENT OF HON. HENRY E. BROWN, JR.
Mr. Brown. Thank you, Mr. Chairman, and good morning all.
Yesterday we reached a milestone. It was 80 years ago on
July the 21st, 1930, that President Herbert Hoover first
established what we now know as the Department of Veterans
Affairs. Since that day, VA has endeavored to fulfill their
mission to care for those who have borne the battle and for
those who return carrying the very worst wounds of war,
including spinal cord injury, traumatic brain injury,
amputations, and blindness.
The VA has developed specialized services to meet the
unique rehabilitative needs of our veteran population.
Providing these types of services to our very highest priority
veterans is the backbone of the Department.
Since 1996, Congress has mandated that the VA maintain
capacity for these specialized rehabilitative services, and in
2004, Congress enacted legislation to provide comprehensive
services for severely injured servicemembers suffering with
complex injuries resulting from blast injuries. This came to be
called VA's Polytrauma System of Care.
More than 2.1 million servicemembers have been deployed
since October 2001. As of April the 3rd, 1,552 had suffered
amputations in Iraq or Afghanistan. Countless others have
suffered TBI, SCI, eye trauma, hearing loss, or other severe
combat wounds.
These young heroes are going to require a lifetime of
rehabilitation and highly skilled medical services and support.
They have risked life and limb in our name, and in return, it
is our responsibility to provide them with the care they
require and so dearly deserve.
As the battles in Iraq and Afghanistan persist, the
specialized caregiver in VA medical, polytrauma, spinal cord
injury, and blind rehabilitation centers continue to take on
increasing importance.
We must diligently prioritize investments in specialized
services, medical research, and recruitment to have all the
tools necessary to provide all veterans, and especially our
most severely wounded veterans, with an active and full life
characterized by independence, functionality, and achievement.
I am grateful to our panelists and audience members for
being here this morning, and I yield back.
Thank you, Mr. Chairman.
[The prepared statement of Mr. Brown appears on p. 35.]
Mr. Michaud. Thank you very much, Mr. Brown.
I would like to call the first panel forward, and while
they are coming forward I will introduce them. We first have
Dr. Thomas Zampieri who represents the Blinded Veterans
Association (BVA), Carl Blake, of the Paralyzed Veterans of
America (PVA), Joy Ilem, from the Disabled American Veterans
(DAV), Tom Tarantino who is with Iraq and Afghanistan Veterans
of America (IAVA), and Denise Williams who is from the American
Legion.
I want to thank all of you for coming this morning and look
forward to hearing your testimony today. We will start with Dr.
Zampieri.
STATEMENTS OF THOMAS ZAMPIERI, PH.D., DIRECTOR OF GOVERNMENT
RELATIONS, BLINDED VETERANS ASSOCIATION; CARL BLAKE, NATIONAL
LEGISLATIVE DIRECTOR, PARALYZED VETERANS OF AMERICA; JOY J.
ILEM, DEPUTY NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN
VETERANS; TOM TARANTINO, LEGISLATIVE ASSOCIATE, IRAQ AND
AFGHANISTAN VETERANS OF AMERICA; AND DENISE A. WILLIAMS,
ASSISTANT DIRECTOR OF HEALTH POLICY, VETERANS AFFAIRS AND
REHABILITATION COMMISSION, AMERICAN LEGION
STATEMENT OF THOMAS ZAMPIERI, PH.D.
Dr. Zampieri. Mr. Chairman, Members of the Subcommittee,
the Blinded Veterans Association appreciates this opportunity
to present our testimony today, and I appreciate that the
Committee is taking a look at the specialized programs in
regards to the returning servicemembers with a variety of
injuries.
I also appreciate the fact that that you highlighted that
oftentimes in this town we don't hear a lot about the other
injuries. Most of the research papers and scientific papers on
these types of wounded coming back clearly demonstrate that
they all have multiple injuries. It is rare you ever just have
somebody that comes back with just quote ``TBI.'' They have a
variety of injuries. Burns, fractures, amputations,
psychosocial problems associated with the multi-trauma that
they have sustained, and so it is just good that this is being
done today.
The VA, I want to start off on some good news, you know,
the blind rehab service has expanded services throughout the
system. Ironically back in 2004, they developed the plans for a
continuum of care based on the idea that the aging population
of veterans would need a lot of low-vision and blind
rehabilitative services. Little, I think did they realize back
then, that the plans that they were making to expand services
would suddenly be immediately useful for the returning
servicemembers with eye trauma and traumatic brain injuries
with vision impairments associated with the TBIs.
And so what we have is now the VA has expanded, they have
had ten in-patient blind centers, which offer comprehensive
rehabilitative services for those with blindness, but they also
have all the specialized staff in those centers such as
consultants with the general surgeons, neurologists,
psychiatrists, pharmacologists, occupational therapists,
physical therapists, speech pathologists. The list goes on and
on.
So those individuals referred into the ten blind centers
get, I think, excellent care, but the VA has also expanded and
they now have 55 sites where they have either low vision
specialists or advanced blind rehabilitative centers, and those
centers have specialized staff. They have actually hired about
250 staff, including about 60 low-vision optometrists, and they
are screening these patients with vision problems and visual
impairments. And so that is the good news.
I want to compliment the Chairman, because actually the
number of blind rehabilitative outpatient specialists (BROS)
that you helped sponsor and Congressman Brown helped support,
doubled the number of blind rehab specialists that were in the
system. Again, it is just good timing. So we went from about 25
blind rehabilitation specialists to 75 in the system. They are
at all of the VA polytrauma centers. And so that is the good
news this morning I guess.
The other thing that I want to touch on is there is a
problem. The BROS that are assigned to the military treatment
facilities have a problem in getting credentialed and
privileged. It is something that has been worked on by the VA
and they have had meetings with DoD representatives, but the
problem is DoD has never had the credential or privilege.
Anyone who is a BROS, an orientation mobility specialist, who
has a master's degree, that category of occupation doesn't
exist and it is been a problem, because the BROS are unable to
actually do the training inside the military treatment centers,
even though they can visit the patients, explain the training
that they need, they are restricted, and that is an issue that
I wanted to include in my testimony today.
Last, I want to talk about--there is problems, though, with
the Vision Centers of Excellence. It is been slow to get it
started to say the least. It is been slow in getting the
staffing. It is been difficult to get any accurate budgets in
the last couple years. Budget requests that come over from the
Pentagon rarely have included any special request for funding,
even though it has been identified as an area where there is a
shortage of funding. It has taken a long time to get the
staffing for the Vision Centers of Excellence, and also the
electronic registry, which is important for tracking all of the
eye injured has been not operational yet. The VA Information
Technology (IT) Department and Department of Defense IT people
have done a lot of work on the registry, but again, I hear
stories about problems with finding the funding for the
registry.
With that I will try to end this by thanking you again for
having this hearing, and be glad to answer any questions you
have on my testimony that I have submitted.
Thank you.
[The prepared statement of Dr. Zampieri appears on p. 36.]
Mr. Michaud. Thank you very much, Doctor.
Mr. Blake.
STATEMENT OF CARL BLAKE
Mr. Blake. Thank you Chairman Michaud and Members of the
Subcommittee, on behalf of Paralyzed Veterans of America I
would like to thank you for the opportunity to be here today to
present our views on how the Department of Veterans Affairs is
doing in caring for severely injured veterans, including
Operation Enduring Freedom and Operation Iraqi Freedom
veterans.
My comments will be limited primarily to veterans who have
incurred spinal cord injury or dysfunction while on active
duty.
It is important to emphasize that specialized services are
part of the core mission and responsibility of the VA. For a
long time, this has included spinal cord injury care, blinded
rehabilitation, treatment for mental health conditions,
including post-traumatic stress disorder, and similar
conditions. Today, traumatic brain injury and polytrauma
injuries are new areas that the VA has had to focus its
attention on as part of their specialized care programs.
The VA's specialized services are incomparable resources
that often cannot be duplicated in the private sector.
For PVA there is an ongoing issue that has not received a
great deal of focus. Some active-duty soldiers with a new
spinal cord injury or dysfunction are being transferred
directly to civilian hospitals in the community and bypassing
the VA health care system. This is particularly true of newly
injured servicemembers who incur their spinal cord injury in
places other than the combat theaters of Iraq and Afghanistan.
This violates the Memorandum of Agreement between the VA and
DoD that was effective January 1, 2007, requiring that care
management services will be provided by the Military Medical
Support Office, the appropriate Military Treatment Facility,
and the admitting VA Medical Center as a joint collaboration,
and that whenever possible the VA health care facility closest
to the active-duty member's home of record should be contacted
first.
In addition, it requires that to ensure optimal care,
active-duty patients are to go directly to a VA medical
facility without passing through a transit military hospital,
clearly indicating the critical nature of rapidly integrating
these veterans into an SCI health care system.
This is not happening. For example, PVA found that some
servicemembers who incurred a spinal cord injury while serving
in Afghanistan and Iraq were being transferred to Sheppard
Spinal Center, a private facility located in Atlanta, when VA
facilities are available in Augusta. When we raised our
concerns with the VA regarding Augusta in a recent site visit
report, the VA responded by conducting an information meeting
at Sheppard to present information and increase referrals.
However, reactionary measures such as this should not be the
standard for addressing these types of concerns.
Of additional concern to PVA it was reported that some of
these newly injured soldiers receiving treatment in private
facilities are being discharged to community nursing homes
after a period of time in these private rehabilitation
facilities. In fact, some of these men and women have received
sub-optimal rehabilitation and some are being discharged
without proper equipment.
PVA is greatly concerned with this type of process and
treatment. There is a serious need to reinforce compliance by
DoD regarding the Memorandum of Agreement toward the treatment
of soldiers with new spinal cord injury and disease (SCI/D) at
VA SCI centers.
Ensuring that these men and women gain quick access to VA
care in spinal cord injury centers is critically important
because it begins what will become a lifelong treatment
process.
SCI/D care in the VA is unique from private care for spinal
cord injury rehabilitation because of the care coordination
that the veteran receives for the remainder of his or her life.
We ask that the Subcommittee work with your colleagues of
the House Committee on Armed Services to ensure that our SCI/D
veterans are getting the complete, proper, and appropriate care
they have earned and deserve.
PVA also remains concerned that the VA must maintain its
capacity for the provision of SCI/D care as mandated by Public
Law 104-262, the Veterans Health Care Eligibility Reform Act of
1996. This law required the VA to maintain its capacity to
provide for the special treatment and rehabilitative needs of
veterans with spinal cord injury, blindness, amputations, and
mental illness.
The baseline of capacity for spinal cord injury was
established based on the number of staffed beds and the number
of full-time equivalent employees assigned to provide care on
the date of enactment of the law.
Unfortunately, the single biggest accountability measure,
an annual capacity reporting requirement, expired in April
2004. This allows the VA to make changes to its SCI/D capacity
in a less than transparent manner.
In accordance with the recommendations of The Independent
Budget for fiscal year 2011, PVA calls on this Subcommittee to
approve legislation to reinstate this vitally important
reporting requirement.
Lastly, Mr. Chairman, the SCI/D programs of the VA face a
common challenge with the larger health care system, a shortage
of qualified nurse staffing. In order to meet this challenge
head on, some SCI centers in the VA have offered recruitment
and retention bonuses to enhance their nurse staffs,
unfortunately, this is not a uniform national policy and these
actions are subject to the budget decisions of local VA medical
center and Veterans Integrated Service Network directors.
In accordance with recommendations of The Independent
Budget, we believe it is time for the Veterans Health
Administration (VHA) to centralize policies and funding for
systemwide recruitment and retention of SCI nurse staffing.
Additionally, we believe Congress should establish a
specialty pay provision for nurses working in the SCI service,
and should consider extending similar provisions to the other
VA specialized services.
Once again, Mr. Chairman, Ranking Member Brown, I would
like to thank you for the opportunity to testify. I would be
happy to answer any questions that you or the Members of the
Subcommittee might have.
Thank you.
[The prepared statement of Mr. Blake appears on p. 40.]
Mr. Michaud. Thank you very much.
Ms. Ilem.
STATEMENT OF JOY J. ILEM
Ms. Ilem. Thank you. Mr. Chairman and Members of the
Subcommittee, thank you for inviting DAV to testify at this
important hearing about VA specialty rehabilitation services
for severely injured Iraq and Afghanistan war veterans. My
remarks are focused on VA's polytrauma and traumatic brain
injury system of care.
According to VA, over the past 7 years, a total of 1,792
in-patients with severe injuries have been treated at VA's
Polytrauma Rehabilitation Centers, also known as PRCs.
Early on in the wars, VA received little information about
the treatment that wounded servicemembers had received before
arriving at a VA facility; however, in late 2009, a team of VA
polytrauma specialists visited the Landstuhl Army Medical
Center in Germany to establish a regular information exchange
on these transfer cases between the military and VA PRCs.
We are pleased with this relatively new development and
believe it has begun to address the gaps in care that were
clearly evident early on in the wars.
Recently, DAV's National Commander visited the Tampa VA
PRC. He met with injured patients and families and received
very positive feedback about the level and coordination of care
provided, and the high regard these families held for the
dedicated VA and DoD staff.
Also in preparing for this hearing, I had the opportunity
to interview with a father of a severely brain injured
servicemember now at the Tampa PRC. I was very pleased to learn
that from the date of his son's injury to present, the
communication and care coordination provided between DoD and VA
in his opinion was seamless.
We acknowledge and commend the report of improved
collaboration between the Departments, and we value the
dedicated staffs that created and sustained this critical
system to better coordinate and optimize care for the severely
injured.
According to the Institute of Medicine (IOM), VA has
established a comprehensive system for polytrauma and severe
TBI care for acute and chronic needs that arise in the initial
months and years post injury, but IOM also reported that
protocols and programs to manage the lifetime effects of these
conditions are not in place and have not been fully studied.
In this connection, DAV is aware of an extraordinary
proposal called the Heroes Ranch. We understand that property
is available for a proposed Tampa area facility to service a VA
post-acute long-term residential brain injury model for the
most severely injured.
According to the proposal, a three-tiered program would
include post-acute long-term care for patients in a vegetative
state or a state of emerging consciousness, subacute
residential rehabilitation in a safe environment to treat
patients with neurobehavioral deficits, and an outpatient day
rehabilitation services program, a specialized form of adult
day health care.
We understand this proposal is pending within VA, however,
we are not clear if it has been approved or funded, therefore,
we ask the Subcommittee to inquire about the status of this
unique initiative.
For the severely impaired, in many cases, VA may need to
provide permanent living arrangements in an age appropriate
therapeutic environment, thus we are very pleased to see at
least one PRC is planning for these unique facilities and we
urge VA to move forward in establishing this type residential
rehab model.
As highlighted in prior hearings, DAV also remains
concerned about the problems that exist in the Federal Recovery
Coordinator Program in social work case management system that
are initial to coordinating complex components of care for
polytrauma patients and their families. We believe these issues
warrant continued oversight and evaluation by the Subcommittee.
Mr. Chairman, although not defined in the severely injured
category, we would like to bring to the Subcommittee's
attention our concerns about treatment and care for veterans
with mild to moderate TBI residuals.
Multiple sources indicate that in the near future VA will
likely be confronted with a significant OEF/OIF injured
population with these problems. We believe VA level two PRC
sites may struggle to provide the specialized or individualized
interdisciplinary care and support this particular population
will need.
We ask the Subcommittee to provide oversight to ensure
sufficient resources and staff are available for VA to also
accomplish this mission.
Additionally, VA TBI specialists with whom we have
consulted believe a new specialized dual track program is
necessary to meet the individualized needs of veterans with
mild to moderate TBI residuals accompanied by post-traumatic
stress disorder.
Mr. Chairman, for these reasons we hope VA will now turn
its attention to the needs of thousands of veterans with less
life threatening, but still troubling brain injuries, caused by
war that are little understood but in need of significant
attention.
Mr. Chairman, this concludes my statement and I will be
able to take any questions you may have.
Thank you.
[The prepared statement of Ms. Ilem appears on p. 42.]
Mr. Michaud. Thank you very much.
Mr. Tarantino.
STATEMENT OF TOM TARANTINO
Mr. Tarantino. Thank you, Mr. Chairman, Ranking Member, and
Members of the Subcommittee, on behalf of Iraq and Afghanistan
Veterans of America's 190,000 members and supporters, I would
like to thank you for allowing us to testify before the
Subcommittee.
My name is Tom Tarantino and I am a Legislative Associate
with IAVA. I proudly served in the Army for 10 years, and
during these 10 years, my most significant and important duty
was to take care of other soldiers. In the military, they teach
us to have each other's backs. And although my uniform is now a
suit and tie, I am proud to work with Congress to continue to
have the backs now and in the future.
Over the past few years, the Committee has secured
impressive improvements to the VA health care system. IAVA
applauds the work this Committee has done and will continue to
do in the months and years to come.
Now we have asked our members what they thought of
treatment they are receiving at the VA and we received a wide
range of opinions, both complimentary and critical. However,
several common themes appeared. Long waits for appointments,
frequent interaction with rude administrative staff, a growing
distrust of VA health care, and long drives to VA facilities.
Fortunately, we received very few complaints about the actual
quality of care at VA medical centers. But in addition to the
concerns listed above, our members have expressed concern with
how the VA deals with traumatic brain injury.
To properly treat returning combat veterans with mild to
severe TBI, the VA must completely rethink and adapt their
medical rehabilitation practices. IAVA is concerned that the VA
has limited or denied access to some veterans seeking recovery
services for TBI, because current statute requires that the VA
provide services to restore function to wounded veterans. And
while full recovery should always be the desired outcome for
rehabilitation, sustaining current function or just preventing
future harm should also warrant access to VA services.
And I have no doubt that Members of this Committee agree
that the VA's role isn't just to help those who might get
better, but also to help and support those who might get worse.
IAVA recommends adjusting these statutes to embrace the
realities of injuries like TBI. Veterans should be able to
focus on maintenance and recovery not fighting with the VA.
Among our members seeking services at the VA, the single
most common complaint is how long it takes just to schedule an
appointment. Despite improvements of wait times for primary
care and specialty care, many veterans have experienced
unacceptably long waits just to speak to someone who can get
them an appointment that is 4 to 6 weeks away. Unfortunately, I
have experienced this myself. After spending 45 minutes
attempting to get my primary care team on the phone I gave up
and vented by frustration on Twitter. Fortunately somebody at
the VA follows my Twitter feed and I actually received a call
from the Medical Director's Office at DC a day later. I was
able to get an appointment because of the magic in new media,
but the point is that no veteran should wait 45 minutes
listening to a phone ring.
In addition to the long wait times, some veterans have to
drive almost an entire day to get to their local VA facility,
and IAVA is concerned that the VA has yet to develop a
consistent and humane policy for answering that age old
question of how far is too far to make a veteran drive to the
VA?
Now we acknowledge that the VA can't always be a short
drive for every veteran, these veterans however should be given
a choice to continue using VA care or access more convenient
local medical care.
We also believe the VA should assist veterans who need to
drive to their appointments. They should provide a lodging
stipend and mileage reimbursement for veterans forced to travel
long distances for VA medical care, and it should be comparable
to the stipend paid to VA employees when they travel.
Now those of us in this room know that the VA provides good
care and services; however, the reality is that some of our
members openly fear going to the VA. Recent media reports about
HIV (human immunodeficiency virus) and hepatitis exposure only
served to fuel that fire. A veteran who reads about his or her
battle buddies being exposed to infectious diseases while being
treated at a VA medical center will likely think twice before
they try to seek the care and services they need.
Now whether or not those fears are actually warranted is a
topic for another hearing, but the end result is the same, that
if the VA and VA health has a massive public relations problem,
and until the VA adequately addresses this issue, many combat
veterans will be weary to seek treatment.
IAVA believes that in order for the VA to conduct effective
outreach, it must centralize its efforts and aggressively re-
brand itself to the American people as one Department of
Veterans Affairs.
Now the VA provides great health care, it has sent
generations of Americans to college, it is enabled millions of
veterans to own their own home, and regularly contributes to
the advancement of medical science. It is absolutely astounding
to me that only a handful of Americans actually know that.
In addition to re-branding itself to America. the VA has to
develop a relationship with servicemembers while they are still
in service. Like many successful college alumni associations
that greet students at orientation and put on student programs
throughout their entire time in college, the VA must shed its
passive persona and start recruiting veterans and their
families more aggressively into VA programs.
Now overall, the VA continues to provide good care to our
Nation's veterans; however, we must continue to strive for
better. In the military they taught us to never stop improving
our fights positions and always be forever vigilant. It is this
proactive ethos that continues to lead to victory on the battle
field. And if we are to honor the service and sacrifice of
American's warriors, we must instill this spirit in all the
services that we develop to care for them.
I want to thank you for your time and attention and I would
happy to answer any questions.
[The prepared statement of Mr. Tarantino appears on p. 49.]
Mr. Michaud. Thank you very much.
Ms. Williams.
STATEMENT OF DENISE A. WILLIAMS
Ms. Williams. Mr. Chairman and Members of the Subcommittee,
thank you for this opportunity to present the American Legion's
views on the Department of Veterans Affairs efforts to care for
severely injured servicemembers from OIF and OEF.
The United States military operations in Iraq and
Afghanistan has produced a significant number of servicemen and
women with amputations. According to the DoD, as of April 3rd,
2010, there has been a total of 1,552 members that suffered
amputations. This unique population of younger servicemembers
requires extraordinary medical care and rehabilitation. Walter
Reed Army Medical Center, among many DoD facilities dedicated
to assisting wounded warriors, has highly advanced programs to
care for warriors with amputations.
In response to the large number of veterans with
prosthetics and rehabilitative needs, VA established the
Polytrauma Rehabilitation Centers, however, the American Legion
is concerned about VA's ability to consistently meet the long-
term needs of these young veterans.
As stated by the Military Medicine Journal, rehabilitation
is a crucial step in optimizing long-term function and quality
of life after amputation.
Although returning veterans with combat-related amputations
may be getting the best in rehabilitative care and technology
available, their expected long-term health care outcomes are
considerably less clear.
It is imperative that both DoD and VA clinicians seriously
consider the issues associated with combat-related amputees and
try to alleviate any foreseeable problems that OIF/OEF amputees
may face in the future.
The VA has made great strides in addressing the increased
influx of young veterans with amputations; however, it has been
reported that VA does not have the state-of-art prostheses
available in comparison to the DoD. That is why it is of utmost
importance that VA receives the adequate funding to ensure that
all VA medical facilities are fully equipped to address these
veterans' prosthetic needs.
This is especially vital for the veterans that reside in
rural and highly rural areas. It would be a grave disservice to
these veterans if they have to bear the burden of traveling
hundreds of miles in order to receive care in addition to
enduring their debilitating condition.
The American Legion applauds VA on the establishment of the
Prosthetics Women's Workgroup to enhance the care of female
veterans in regard to their prosthetics requirement. Despite
this implementation, there are still cases where the fitting of
the prostheses for women veterans has presented problems due to
their smaller physique.
The American Legion urges VA to increase their focus on
amputation and prosthetics research programs in order to
enhance and create innovative means to address this population
of veterans' health care needs.
During our ``System Worth Saving'' site visits to the
polytrauma centers, some facilities reported that there were
staffing shortages in certain specialty areas such as physical
medicine and rehabilitation, speech and language pathology,
physical therapy, and certified rehabilitation nursing. This
was attributed to the competitive salaries being offered for
these positions in the private sector.
Considering the complex nature of these severely wounded
veterans, the American Legion finds this unacceptable. The
Department of Veterans Affairs needs to step up their
recruiting efforts in these areas so that in the future these
veterans are not faced with the dilemma of going outside of the
VA for care.
There are currently 49,460 blind veterans enrolled in the
VA health care system and that number is expected to increase
because of the number of eye injuries in Iraq and Afghanistan.
DoD reports that in the current conflict, eye injuries account
for 13 percent of all injuries. The American Academy of
Ophthalmology reports that eye injuries are a very common form
of morbidity in a combat environment.
DoD does not provide rehabilitation for blindness. Unlike
other injuries where after rehabilitation warriors may be
retained and continue service, blinded warriors are medically
discharged and relegated to utilize the VA for their
rehabilitative needs.
Section 1623 of the National Defense Authorization Act of
2008 requires DoD to establish a Center of Excellence in the
prevention, diagnosis, treatment, and rehabilitation of eye
injuries, and for DoD to collaborate with VA on matters
pertaining to the Center.
In addition, Section 1623 directs DoD and VA to implement a
joint program on traumatic brain injury post-traumatic visual
syndrome, including vision screening, diagnosis, rehabilitative
management, and vision research. Unfortunately, the Center has
yet to be fully established because of constant funding delays
and bureaucratic hurdles.
The American Legion calls for immediate action from the
Secretary of Defense and the Secretary of VA to rectify this
important issue.
Mr. Chairman and Members of the Subcommittee, the American
Legion sincerely appreciates the opportunity to submit
testimony and looks forward to working with you and your
colleagues on these important issues.
This concludes my written statement and I would welcome any
questions you may have.
[The prepared statement of Ms. Williams appears on p. 53.]
Mr. Michaud. Thank you very much, Ms. Williams. And once
again, I would like to thank all the panelists for your
testimony and also for the recommendations included within your
testimony, which will be very helpful.
This question is for all the panelists. I have heard
anecdotes from veterans who applaud the prosthetic services
that they receive at the Department of Defense, but are very
leery of the care that they might receive through the VA
system. Do you believe that DoD provides better overall
prosthetic services compared to the VA, or do you believe that
these anecdotes that I am hearing represent just a few,
isolated cases?
Ms. Ilem. I will go ahead and take a stab at that.
I think early on, you know, we heard reports, I mean, I
remember from hearing even with Tammy Duckworth, you know, one
of the situations is--that is very unique is DoD and Walter
Reed obviously have had, you know, the focus has been on them
for really doing much of the prosthetics and rehab there on
site.
I know that VA, from attending their prosthetic meetings,
you know, have integrated their people to go out there and see,
you know, what is going on as these people start to transfer
back to VA, but the complaints were, you know, when they return
to the VA to have either their item serviced or to continue
their rehabilitation, they ran into sort of a disconnect from,
you know, anyone at the facility where they had been working
with the prosthetist and had very much attention to and access
to all the newest items and options, you know, at the DoD site.
You know, it seemed very different within the VA.
I think that, you know, VA's prosthetic services tried to
really improve that and make, you know, good strides in trying
to make sure that they are ready to accept these veterans as
they transition back into VA to prepare--to repair their
equipment, to have--I know that they have access to all of the
vendors that are working out there, and they have done this
liaison work.
I am hoping that, you know, that that perception as Tom as
mentioned, you know, it lingers when you hear so much about DoD
and then people want to return there because it is a very
sensitive issue in terms of the people that they are working
with and the items that they are working with, and then to have
to go to a new system where people that haven't seem the high-
tech equipment, you know, you don't have a lot of confidence. I
am sure, if they are saying that is the first time I have seen
that. But the truth is they are getting access to some of the
most high quality equipment that nobody has seen.
So I am hoping it is changing, but it still may be the case
in some situations.
Mr. Blake. Mr. Chairman, I just sort of want to piggyback a
little bit on what Joy had to say and also make another comment
first.
Representing a membership that is probably one of the
highest in users of prosthetic devices and equipment from the
VA, I would say that our members generally never--I won't say
never--generally do not have problems getting the most state-
of-the-art wheelchairs and other types of equipment that they
need. In the occasion where maybe there is some difficulty
getting a piece of prosthetic equipment or whatever it may be,
it is usually just a matter of working with the prosthetics
department through our service officers or what have you to
make sure that the right steps are taken. But our members are
not experiencing a lot of problems getting what they need. And
believe me when it comes to state-of-the-art wheelchairs, you
would be surprised at what is out there.
I want to sort of tag along with what Joy had to say. I
think you would find that DoD is not unlike VA in sort of the
prosthetic structure, and some of the VA's prosthetic services,
not unlike the rest of its health care, has become adaptable to
changing needs of this generation. Prosthetics is no exception.
I think a lot of focus is put on the--we talk about these
advanced prosthetics that the servicemembers are getting from
DoD, but it really boils down to them getting them through
Walter Reed, Bethesda, Brooke or some of the major military
check points. But if they went back to a lot of home stations,
I think you would find that a lot of these military treatment
facilities, they don't exactly have the capacity to meet their
needs when it comes to prosthetics or the maintenance required
for that equipment either.
So DoD is not unlike VA in this respect. And I think VA is
probably trying to address it more than DoD would in that
respect. And we have heard time and again from Mr. Downs, who
oversees the VA's prosthetics, that I think he recognizes the
need for them to become more adaptable and get it to the field
so that as these men and women ultimately are going to come to
their local facilities the VA can meet their needs,
particularly on the maintenance of this high-end equipment.
I mean, they are intimately involved in what is going on
out at Walter Reed in particular, because that is sort of where
everything begins when it comes to these advanced prosthetics.
So you can beat up on the VA for it, but in fairness to the
VA, I mean they are seeing demands on their system that they
never could have imagined before now also.
Mr. Michaud. Thank you very much.
My last question, for all the panelists is, in talking to
your membership, do you believe that specialty care within the
VA system is provided equally among all VA facilities?
Mr. Blake. I will speak to the SCI side of it. I think
because of the model that has been established we feel pretty
confident that it is sort of a uniform policy in the way all
SCI care is provided across the system. That again is a
function of the way the entire SCI service has been set up
through the hub and spoke model.
We are encouraged to see that the VA is sort of moving that
way in the polytrauma aspect, and yet there are a lot of
challenges as it relates to TBI that Joy raised and going
forward that the VA is going to have to figure out how to deal
with along the way.
But I feel pretty confident that they do the right think
across the board when it comes to SCI service in particular.
Ms. Ilem. I would add onto that.
Some of the complaints that we have heard from veterans
contacting us about mild to moderate TBI is that, you know,
their families sort of recognized they had an issue, they had
been using the VA system for other things, went to the VA,
weren't satisfied in areas of the country.
I mean, I had received calls sort of from different
locations saying, you know, I ended up in the private sector
with VA fee basing me into an outpatient program that really
offered a range of things that I have learned so much in the
last 6 months in terms of, you know, mild TBI, how to deal with
it from my family center care addressing, you know, a range of
issues and opportunities for them to have this wide range of
outpatient care. And in those cases, you know, I have contacted
the VA directly and tried to find out is it, you know, just
this location that they are having this problem or is this a
systemic problem? It is hard to say unless, you know, somewhere
like PVA, you know, really has people on the ground that are
doing site visits in the region. Within that specific area, you
know, that is a concern of ours.
We are hoping that in certain areas they have the
interdisciplinary teams that are needed to provide that care
and that they have developed a wide range of services and a
good type of program for that, but I am not convinced of that
that it is everywhere yet.
I think at certain locations, you know, with the--obviously
with the major polytrauma centers, but as you go further out
and then obviously in the rural areas where those services are
not available, you know, and they have to connect them with the
nearest private-sector facilities, you know, we would like to
see some continuity of care and make sure that care is
available everywhere.
Mr. Michaud. All right.
Ms. Williams. I would like to add that during our site
visit that was a main issue, staffing shortages as Joy just
mentioned. In the areas where they have the polytrauma centers
you will see where they have a lot of specialty care available,
but as you go out to the other facilities there is definitely a
shortage for specialty care, and we hear that from the veterans
and we have also heard that from VA staff themselves at the
facilities that there is a shortage.
Dr. Zampieri. The same thing. The major centers, both the
military polytrauma centers, Walter Reed, Bethesda, Brooke Army
Medical Center, Balboa in San Diego, or you go to any of the
four VA polytrauma centers, it is amazing. I think everybody
gets seen by everybody. I mean it is not unusual to have a team
of 30 different specialists seeing a patient.
And the hand off has improved dramatically from back in
2005 when I was sitting in this room I think with a couple
things. One is we always are concerned that, you know,
everybody focuses I think on, you know, the famous beat up in
this town is Walter Reed when something goes wrong, and the
universe focuses there, but the patients who are evacuated back
through Landstuhl come back into the United States, I think
there is a misperception that well everybody goes through
Bethesda or Walter Reed, and in actuality, some people will
admit that about 30 percent of all the wounded and walking
wounded actually go back to the original home platform base of
deployment.
So if you go to Fort Drum or Fort Carson, Colorado, or Fort
Gordon, Georgia, or just name a base, Fort Hood, Texas, you
will find individuals who were evacuated back through the
system that didn't get seen in one of these highly specialized
centers, and some of those are the ones that we find that have
a vision problem that, you know, they didn't have a lot of
other severe injuries so they were evacked back and then they
sort of get lost. Somebody on one side doesn't notify the VA
blind rehab services or the local Visual Impairment Services
Team (VIST) coordinator that they have somebody that is
experiencing vision problems, and that there is treatment
available, that there is specialized devices from prosthetics
that are available to help them in their recovery and
treatment.
And so that is why the Vision Centers of Excellence is
important, because it isn't just the major trauma severe cases
that need to be tracked, it is all of the types of injuries,
mild, moderate, severe, as far as vision goes, that need to be
carefully tracked and followed, and the providers need to be
able to exchange the information between them--between the VA
providers, the ophthalmologist and the military, their
colleagues in the military treatment facilities. Because again,
a person at Fort Drum, New York, may suddenly have somebody
come in that was evacuated back from Landstuhl with injuries
and that is where one of the problems is.
Thank you.
Mr. Michaud. Thank you. Mr. Bilirakis.
Mr. Bilirakis. Thank you, Mr. Chairman, I appreciate it.
Mr. Zampieri, on that point again, I understand your
frustration with the delays in the planned construction and
operation of the Vision Center of Excellence. How confident are
you that your timeline will be met?
Dr. Zampieri. Thank you very much.
Wow. I have been chasing the ghost of timelines for quite a
while, and I am not sure. You know, in fact someone said that
what was originally--you know, the Vision Centers of Excellence
by the way is not a clinical surgical center, it is an
administrative headquarters to coordinate and facilitate
information flow of connectivity between all of these patients
and the providers, and so you are not building a surgical rehab
center or whatever, it is like 4,000 square feet of office
space, and here we are, the money was provided in the war
supplemental last August and originally it was hoped that the
construction would start this summer, then I was told it
wouldn't start until this fall, and now I am being told that
instead of January, February, or March, that it won't get done
until next May or June.
I mean this is really phenomenally incompetent. I mean, I
don't know how else to put it. You know, they open up a 72,000
square foot National Intrepid Center of Excellence for
traumatic brain injuries and mental health, which cost $68
million, has all the state-of-the-art equipment in it, over 100
employees, those are clinicians and providers and counselors
and therapists, and they do that and a grand opening, at the
same time they can't renovate 3,800 square feet of just office
cubicles so that we can get this thing up and running and
people all collocated instead of temporary office spaces where
they have been moved like three times in the last year and a
half?
And so yeah, I am a little frustrated, and I don't believe
any of the timelines.
And also I might as well, since you asked, there is never a
budget anywhere in anybody's testimony, and I am frankly very
frustrated about that.
Thank you.
Mr. Bilirakis. Thank you.
Mr. Blake, I appreciate your interest in reinstating what
we call the capacity report; however, I am concerned that the
requirements for that report need to be reevaluated and updated
to ensure that the information contained in the report is
relevant and functional. Would you be willing to work with us
on that?
Mr. Blake. Absolutely, and we have already discussed this
with the staff. There was some discussion about why the
capacity report even expired in the first place, and I have
already talked to our staff at PVA as well about the
willingness to try to figure out what would be a more useful
report, what kind of information should it include, and how
could it be used once these reports were to be processed again?
So the short answer is, yes, sir, very much.
Mr. Bilirakis. Thanks so much, I appreciate it.
Ms. Ilem, I hope I didn't mispronounce your name. In your
testimony you mentioned the proposed facility in Tampa called
the Heroes Ranch, which is in my Congressional district. I
think this is a wonderful concept. I have some background here
and I have talked to the James A. Haley VA Medical Center about
this and I believe it could be a viable solution to the problem
of how to treat our catastrophically wounded warriors.
Can you tell me more? Give me your thoughts on this, and if
you can elaborate a little bit I would really appreciate it
because it is something that I would like to pursue.
Ms. Ilem. Sure. As I noted in my statement our National
Commander was able to visit the facility and came back and told
me about this proposal that he had seen.
One of the things we have been hearing from different
people actually starting a couple a years ago is the concern
about a number of patients, you know, probably not a
significant number, but still those that may not be able to go
home, they may not have someone to care for them at home, and
it really wouldn't be a--you know, a really appropriate place
to put them that was within a Federal system to make sure that
they have continued rehabilitation throughout, and obviously
these would be the most severely impaired.
So my understanding of the overview of the project was to
really have this residential facility that would be for these
very specific group of people.
And I asked some folks there, you know, why a place away
from a clinical setting? And they mentioned to me that, you
know, when they have taken people out, some of the severely
wounded, when they get them out of the clinical setting they
really start to see some progress and a responsiveness in some
of these people, and so it is so important to be in an
environment that is not perhaps just a clinical, you know, the
clinical setting.
Also, you know, this would be a very highly specialized
type of care setting and model, and so I am really hoping to
hear from VA if they are able to comment on it.
DAV would certainly support, as we have talked about it in
The Independent Budget, we have talked about it in the
testimony, that there is probably going to be a need for maybe
a couple of these centers in the country to make sure that
these people aren't forgotten after, you know, time goes by and
that we really provide them with the state-of-the-art care that
they need, even those that perhaps aren't going to be able to
be reintegrated with their families or into society in any real
way, but they need a setting too that continues the care for
them.
So we would love to collaborate with your staff and you on
this project, and hopefully VA can shed some light on this and
let us know what the status of the initiative may be.
Mr. Bilirakis. Thank you very much. Thank you for your
willingness to work with me on that.
Mr. Chairman, I have one last question, is that okay? All
right. Again for Ms. Ilem.
You mention in your testimony that the Institute of
Medicine March 2010 report said, and I quote, ``Although VA has
established a comprehensive system of rehabilitation services
for polytrauma and severe TBI patients that addresses acute and
chronic needs that arise in the initial months and years after
injury, protocols, and programs to manage the devastating
lifetime effects that many of these veterans must live with are
not in place.'' That is a real shame.
Can you tell me where the VA is failing and what can we do
about it?
Ms. Ilem. I don't know if I would use the word failing,
because I mean, I was impressed that VA has developed these
post-acute facilities, the residential facilities that are
attached with the polytrauma centers that are almost apartment
like that is staffed with clinical staff so when veterans are
getting ready to discharge from the facility but not quite
ready to go home to make sure they are going to be safe and
really be able to care for themselves or be in an assisted
living situation. And I think there is that component.
And they are looking at some of these things right after
the post acute. I mean obviously the focus has been on this,
you know, the long period that it takes to rehabilitation.
Oftentimes many surgeries, transferring back between DoD and
VA. And I think VA has developed these programs right outside
of that.
The concern is about this lifetime of care for some of
these folks who just may not have the support or the ability to
really function on their own and may need, you know, continued
support, as well as their family members who are dealing with
this traumatic injury along with them.
So I think this proposal was so exciting about the Heroes
Ranch because it also mentioned this integration of family
centered, an opportunity--you could see people being able to go
there that were with the veteran and perhaps have their own
track of information and being able to deal with this sort of a
respite for them as well, but also learning environment of all
the pressures that they deal with as long term caregivers.
And so I think it is good news that we are starting to see
this come up within the VA, because obviously we think they are
going to be the folks that are going to have the lifetime care,
you know, responsibility for these folks.
And so, you know, I think that was the concern and IOM sort
of fleshed that out to say they are doing a good job for this,
you know, immediate time in maybe the first couple years, but
after that what are we going to do and how are we going to
follow them?
Mr. Bilirakis. Great. Thank you very much, I appreciate it.
Let us get it done together.
Mr. Michaud. Mr. Perriello.
Mr. Perriello. Thank you, Mr. Chairman, just two questions.
First, you know, the Chairman was kind enough to come down
to my district and do a field hearing this week in Bedford,
Virginia, and one of the things that I think was most powerful
was hearing the story of Lynn Tucker who has three sons who are
all marines who face different health issues, and her son Ben
has had severe brain injury and requires 24/7 care actually
from a dirt bike accident, it was not service related.
But one of the things that she talked about most in her
story was given that it is highly specialized care how often
she is bounced between different facilities, different VA
hospitals, different clinics without a lot of coordination and
effort.
And so I guess--and we have heard some of that today. While
the quality of care is often very strong, once its gotten to it
is the barrier of getting there and particularly when it may
involve multiple locations over time and some use of civilian
as well as VA facilities.
So I guess the question is with some sense of urgency, what
are the immediate steps that can be taken within the VA to help
coordinate the--when it comes to specialized care, and
particularly in rural communities?
Dr. Zampieri. I guess just one thought is, you know, it is
important that the military case managers, social workers are
aware--exactly aware of the resources there are in the VA
system for specialized care.
You know, it seems like an easy quote ``thing to do,'' but
you know, really you are dealing with hundreds of people at
hundreds of different sites making sure that they are aware
that their counterparts in the VA system like in case of vision
impaired servicemembers, that there are VIST coordinators at
every VA hospital. You know, and so it doesn't matter if you
are in Montana or southern Virginia or up in Maine, you know,
there is a VIST there, and that person can help facilitate
getting that person all the specialized things that they need
whether it is prosthetics or eye appointments or whatever.
But if that side of the fence doesn't have their staff
aware--and I am sure it is the same with the other specialties
with regards to those kind of problems.
Mr. Perriello. But your general sense is the program is
working we simply don't have enough people or that it is just
given the complexity this is the best we are going to be able
to do?
Dr. Zampieri. Communications between those people. I don't
know if you can--maybe in smaller facilities make the argument
there isn't enough staff, it is more the sense of the staff
that are there are they informed, and also do they have the
links that they have to communicate with the VA people that
they need?
You know, it is actually sort of scary if you go out to
Walter Reed there are so many case managers that you actually
have to figure out who is not a family member, you know,
because they are there everywhere. It is whether or not, you
know, somebody is picking up the phone and contacting the right
person back at the local clinic, VA hospital, whatever.
Mr. Blake. Well, Mr. Perriello, first let me say I had the
opportunity to sit in on the field hearing in the back of the
room on Monday and Ms. Tucker's testimony was very powerful, I
will say that.
I think Tom hit on--from my perspective there were two
things that stood out to me. One was an obvious break down in
communication in her son's particular case. She talked about
going to Durham and Danville and Salem and all these different
places, nobody ever seemed to talk to each other and nobody
knew what was going on with her son's case. And so I think the
structures are in place to meet her son's needs, but they were
obviously not being met.
The other thing that sort of stood out to me was I would
say her son would probably be--would fall under the
classification of polytrauma even though seemingly his biggest
concern was just immediately TBI, but I think that is the area
where we would sort of be caught in. And yet, very little did
she talk about his treatment at Richmond where the polytrauma
center actually is and the care coordination that should go on
for her son.
I thought that it sounded like to me she said she had a
couple people that were her go to people, but that wasn't care
coordination, these are sort of her contacts in the VA to help
her get things done, but that screams to me that who is the
person who ultimately has responsibility for ensuring that his
care is being met across the spectrum?
So I think there is an obvious--maybe some evaluation needs
to be done to go back and look at how is the VA doing care
management of these individuals? And I think the rule setting
is the challenge. You know, when you have individuals who are--
who live within even 100 miles--you know, SCI veterans are a
unique example, because there aren't a lot of SCI centers
around the country. I mean they are fairly well geographically
placed, but there are some areas where it is hundreds of miles
to an SCI center, and yet our members have sort of grown
accustom to what they can get and where they can get it.
Through the model that the SCI uses they go to the nearest SCI
center to their acute care, but they can also go to local
facilities where there is sort of a step down, and we sort of
developed this hub and spoke model to ensure that they can get
some form of care, even some degree of the specialized care at
the local level as best as possible. And I think the TBI aspect
is something that the VA is still trying to get its arms
around.
So I hate to say that is sort of the unfortunate situation
she was in, but the things from her case in particular I think
that stood out were care management and communication, and it
is obviously important in the rural setting because of the
break down that goes on between the VA sort of putting the word
out there and what is available and how they can get you around
to certain places.
But the fact that that young man was taken to four or five
different facilities, plus she went to a couple of private
facilities, I mean that was just--made me cringe just thinking
about it, so.
Mr. Perriello. Yeah.
Ms. Ilem. I would just have one thing to add to that. I
think that the Office of Rural Health, we have been somewhat
disappointed in that program--that office getting really stood
up and that could help with a lot of these types of situations,
so.
Mr. Perriello. If I can do one more quick question just for
Mr. Tarantino. And thank you for coming down to the hearing,
Mr. Blake, we really appreciate that, and thank you for your
service.
One of the things you talked about was re-branding the VA.
So going out of the weeds for a second and into kind of the big
picture, you know, there is nothing worse in that experience
than being on the phone, I have to deal with it with my cable
company all the time, because you know--and I give up because
it is not worth it to get my DVR fixed, but that really doesn't
matter at the end of the day. We are talking about life and
death issues of people just getting turned off in the system.
So one of the questions I have in terms of the branding
work that needs to be done is how much is that a matter of this
younger generation coming back, the OEF/OIF men and women, what
is their perception of both the quality of care at the VA which
you have spoken to and the ease of accessing it? Where do we
stand right now in terms of what you hear on that?
Mr. Tarantino. Well, Congressman, I think for those who are
actually able to get into the VA and receive care the quality
is very good, and we hear that from our membership, they
provide very good care.
The problem is that there is this negative perception, and
this is partly structural within the VA and it is also partly a
public perception.
You know, VA, as I don't have to tell you, we know that the
VA is three separate agencies that largely work independent of
each other, but when they communicate to the American people
that is the way that they communicate. The VHA communicates,
the Veterans Benefits Administration (VBA) communicates, the
National Cemetery Administration, you know, talks to the
American people. But as a veteran, someone who doesn't live in
DC and is not in the veterans affairs world, I don't understand
that.
When my GI Bill check is late I am not upset with the VBA.
When I, you know, can't get an appointment I am not upset with
the VHA, I am upset with the VA, and that is the mind set, but
the VA doesn't communicate to people the way people perceive
them.
So I think that is something they really need to start
changing.
And I think when you are talking about just the younger
generation you need to start looking at how Iraq and
Afghanistan veterans communicate with the world. The VA is
starting this. They are building up their new media strategy,
but they really need to start breaking down those barriers.
Every time I talk to someone at the VA to talk about
outreach the big question they ask is, how do I reach out to
veterans? Well first of all you have not to stop reaching out
to veterans, because we are ten percent of the--less than ten
percent of the population, we don't all live in one place, we
don't all watch the same movies or read the same newspapers, we
are everywhere. You need to start reaching out to America.
Because quite often you are not going to catch the veteran. You
are not going to go catch the veteran and say hey, I need to go
get in services. You are going to catch their mother, their
brother, their girlfriend, their buddies who are going to say
hey man, you need help, go, and I know, because I see this, I
can see the VA, and maybe you should go talk to the VA because
they are there for you.
Right now if you are not a veteran, the VA basically just
ignores you, and that is the wrong answer.
Mr. Perriello. Thank you.
Mr. Michaud. Mrs. Halvorson.
Mrs. Halvorson. Thank you, Mr. Chairman. And thank you all
so much for being here. And I know we are preaching to the
choir and vice versa, you guys are great, and I know I have
more questions than I have time for, so I will probably be
submitting them for the record and we will get some answers
back. Again, I don't know where to start.
First of all, can I just start with Tom here. You do a
phenomenal job with what you have, and I know that I don't want
to put you on the spot, but later on I want you to tell me who
told you that you are not going to get your 4,000 square feet
of space until next summer. I want to know, because that is
ridiculous.
And I also want to point out that maybe the public doesn't
know that you take people's mileage that they have extra and
don't you help people to fly places so that you can help them?
Because you don't have very many centers and people don't have
very much money and you don't get much help from the VA. So I
want everybody to know that, you know, they can donate their
mileage, right, to help you and the people that you help get to
places, because that is a very important thing.
Also somebody was talking about, you know, being
understaffed, and I want to just piggyback on what Mr.
Perriello said. This is about communication. I have a master's
degree in communication, and I don't say that just to pat
myself on the back, but I got that later in life, and maybe it
is something a little more, but when I became a Congressperson
I had just been through the fact that my husband and I had a
son that was seriously injured in Afghanistan, and I knew that
if I were lucky enough to become a Congressperson that I was
going to make it my mission to help families who had gone
through the same thing. My husband spent the night with Jay and
I went back and forth on the shuttle bus listening to families
and what they were going through.
So when I became the Congressperson, I hired a full-time
caseworker that just did veterans' issues, because the problem
is communication. We have so many people that are so busy doing
all their different things, but everybody is trying to reinvent
the wheel. So I have a caseworker who just does veteran case
work, and she goes out every night doing her outreach. I hate
to say it, but she is now the one that spends all day long
doing all the things that maybe the VA or the different people
should be doing, but that one person doing all the outreach can
help. And if we do more communication and outreach, maybe we
wouldn't have these kind of problems that we have.
So I am just trying to find out from all of you how we can
do a better job or how the VA can do a better job on that
communication between each other.
Now the other thing that we are trying to do in our
district is have that central location. We have a hospital that
is soon to be empty that I am insisting on, I am not going to
take no for an answer, that we change into a VA medical
facility that we have all those different specialties at so
that it is a one-stop shop, that people don't have to drive to
far.
What I am trying to figure out is what we have been talking
about since I became a Member of Congress that we have a
seamless transition. I don't see it. And I think it was Mr.
Blake that said that DoD isn't keeping track and they aren't
doing the reporting that they need to. How do we do that
reporting, and is the VA ready to get the report that if we do
are we ready for that? Mr. Blake.
Mr. Blake. I didn't say that comment, but I am going to try
to address the question.
Mrs. Halvorson. Okay, I apologize if it wasn't you.
Mr. Blake. I think the problem is ensuring that there is
the transition to VA from DoD and that DoD doesn't necessarily
have that as their top priority.
Mrs. Halvorson. Uh-huh.
Mr. Blake. I mean they are still going to do their best to
take care of them whether it be at Landstuhl or Walter Reed or
what have you, but I don't think that the first consideration
in their mind is to immediately coordinate with the VA for
their care. It depends on what type of injury I think the
servicemember has incurred about.
Also I talked about the SCI side, and the DoD generally
does a pretty good job with that, but you know, I can't speak
for blinded veterans. I think you would have a much more----
Mrs. Halvorson. And I think I said it wrong. What is
happening, I believe, is that DoD doesn't publicly track the
data on the seriously injured, but if they did and then once
they are out of theater is the VA ready to get at that data?
Because the Department of Defense, when they are done with
being in that budget, they are happily ready to get rid of them
to put them in the VA budget. I am trying to----
Mr. Blake. I am going to try to answer for Tom here again.
Mrs. Halvorson. Okay.
Mr. Blake. I don't know that it is a matter of not publicly
tracking the data, it is just that they're not even necessarily
tracking the right data.
Mrs. Halvorson. Okay.
Mr. Blake. I think--and Tom can probably speak better to
this for the blinded side--I think that there are a lot of
folks who are not being captured in their evaluation for what
are their problems that they are experiencing when they go.
Mrs. Halvorson. Right.
Mr. Blake. So you know, in the case of blinded veterans
they are finding all these individuals who escaped the system
and were never identified as having a problem.
We have seen this with TBI in particular where Joy
mentioned the mild to moderate side. A lot of these folks are
escaping--I hate to say escaping--they are leaving the service
and then later things start to crop up and those things were
never identified while they were in service.
So a lot of things go missed when they are trying to ensure
that these individuals are going to get the care down the road.
Dr. Zampieri. Yeah, the electronic registries are an issue.
I think what you are getting at is that.
You know, it is interesting bureaucracy is Ph.D. is
political science but I spent 25 years as a clinical person. I
did surgery and so I throw that out there because I was also an
aero medical flight surgeon in the Army and retired as a major,
so I think I know a little bit about the system as a medical
provider.
Mrs. Halvorson. Sure.
Dr. Zampieri. And what happens is bureaucracies look at
these electronic registries as repetitive duplication efforts,
unnecessary expenses, et cetera, et cetera. What they don't
understand from a clinical point of view is that the
registries, whether it is amputees, spinal cord, vision
impaired, whatever the registry is, there is key clinical
information that needs to be seen by the other providers.
Whether it is a DoD provider that had a person that has come
back from a VA polytrauma center or whether it is a VA provider
who is an ophthalmologist that is at Kansas City who has a
veteran who shows up that has had surgery in Landstuhl, surgery
at Walter Reed, surgery down at Richmond, Virginia, at the
polytrauma center and he ends up back out there. Those surgical
records that are unique to what is important to that
ophthalmologist is what is important in the registry.
Also it is important for all these registries for outcomes.
You know, a little stunning fact that I told Secretary
Shinseki a year ago when I met with him was that we have
outcome studies from Vietnam eye trauma cases, 50 percent of
them went blind 10 years after. Somebody ought to be worried
about, you know, if there are several thousand serious
penetrating eye injured are we going to have that same rate in
2020 that they had in 1978 when they did 10 year follow up of
injured servicemembers in Vietnam in 1968?
So any way, the bureaucracies love to say well, you know,
we are going to eventually have a fully interoperable exchange
of health care electronic records and so you don't need all
these registries. And I have been told that, and again from the
research standpoint, it is important that you have those
registries because of the coordination of research. If somebody
starts on a research program on the DoD side and ends up in the
VA, whether it is clinical outcomes, whether it is development
of certain policies, whether it is, you know, just being able
to answer how many are certain types of retinal injuries,
whatever, optic nerve injuries there are.
Any way, sorry. I am really frustrated when people say
well, you know it is going to cost $8 million for that eye
trauma registry, and that is just going to be repetitive of all
these other registries. Well guess what, there is a reason for
that. And again, you know, you look at the Vietnam experiences
or the Korean War experiences or World War II experiences, you
know, you want to improve things.
Mr. Michaud. Mr. McNerney.
Dr. Zampieri. Thank you.
Mr. Michaud. We will be called for votes shortly, so if we
can try to finish up this panel.
Mr. McNerney. Okay, thank you, Mr. Chairman.
Yesterday I was in here in the same room and we had a
hearing on some of the new treatments that are available for
post-traumatic stress and for traumatic brain injury, and I
couldn't help but think that some of the treatments and
methodologies are transferable to the physical injuries that
are not in the same category. And so I just ask that you
consider coordinating your efforts.
There is a lot going on out there. And today I have seen a
tremendous transformation of American society from the 1970s to
now when so many groups, so many individuals are reaching out
and trying to do what they can to help veterans and to make
veterans welcome. So it is a great feeling to see that
happening out there, and I welcome everyone here and thank you
for your hard work. I can see you are all dedicated to what you
are trying to achieve.
I have some specific questions. Mr. Blake, you noted that
many servicemembers with mild traumatic brain injury leave the
service without having the proper diagnosis and consequently
that they are unaware that they need or should be looking for
treatment.
How do you recommend that we move forward in either
preventing that from happening, making sure that we get the
proper diagnosis before they leave or reach them when they are
having the problems that make them aware that they need service
or help?
Mr. Blake. Well, I would say it is not as simple as just
saying they are just being diagnosed because oftentimes it is
not that easy, but one of the things we have put a lot of
emphasis on over the--for many years, not just in recent past--
is the need for really comprehensive medical examinations of
these servicemembers both post-deployment and when they are
preparing to leave the service.
There has been a lot of grousing over the years about
medical screening and things like that that are done to exit
servicemembers either from theaters or from the service
altogether and I am not sure that goes far enough. It doesn't
benefit the servicemember in the long run, because a lot of
times this is self-reporting and that is not going to help them
out, and you know, it has an outcome for them both of the
benefit side and the health care side in the future.
Ms. Ilem. I would just like to add, you know, sometimes we
hear one step forward but then two steps back.
We recently had heard that theater they were going, you
know, very quick examinations following if someone was near a
blast, perhaps doesn't physically know that they have had a
injury, but definitely want to measure, you know, how close
they were to the blast, and you know, we have heard a couple of
different things and it certainly starts right there in being
able to track.
Then we started to hear that because servicemembers wanted
to return with their unit and didn't want to be pulled out that
they would try to, you know, answer the questions in a way or
were familiar with, you know, how to answer them so that they
wouldn't be pulled out.
But if we really don't have an accurate tracking that, you
know, over a period of time they have been exposed to this
number of blasts, and then you know, be able to follow that
along, you know, it is very difficult later on and oftentimes
it is the family who are the first ones who recognize it that
there is a change in this person, all be it subtle, you know,
they have problems holding a job, you know temper issues, a
variety of things.
So again, it is a DoD, VA collaboration where you really
want to see this great hand off, but right from the start being
able to have accurate information so down line you can say hey,
you know, this person was exposed to this number of blasts, let
us really do a good, you know, cognitive assessment on this
person and see if we have some, you know, minor or you know,
mild deficit, but still, you know.
Mr. McNerney. I mean ultimately I think we will develop--
well not we, but somebody is going to develop a way to diagnose
this relatively early, but right now we have to depend on
recordkeeping and so on to do that.
I have two more questions, I hope I have enough time.
Mr. Tarantino, you raised some concerns about the VA
limiting or denying access to some veterans who need services
with traumatic brain injury. Can you expand on that point a
little bit and give some examples of the type of care that is
being limited or denied?
Mr. Tarantino. Yes, Congressman. Basically, we have been
hearing a lot from our members who have tried to receive care
at local medical centers, and this is kind of a theme that has
come up over and over where members who have sought traumatic
TBI care are being denied because they are not--their
rehabilitation land essentially they are not going to get
consistently better, they are going to need to just maintain
their services.
I am actually looking for, there is actually in our written
testimony we do have a story of--I am trying to find it, excuse
me--of a vet who was denied care. She was denied services.
Basically, they said well, you don't qualify for the services
we provide because you are looking for long-term maintenance
and that is not what we are providing.
Mr. McNerney. Well, probably also because they don't
recognize that she has that sort of injury I am guessing, but
that seems to be what you are getting at.
Mr. Tarantino. Right. I mean this is a larger issue of we
need to start restructuring the way we look at these wounds.
You know, we are not just looking at wounds that, you know, you
are going to get care and you are going to recover and
ultimately you will get better--fully better. A lot of these
wounds are going to be either just maintaining that basic level
of functioning, which is going to require a lot of time and
money and patience, and frankly a structure that isn't built at
the VA to where we need it, but it is also going to be some of
this can be degenerative, and we are going to need to double
our efforts in making sure that these veterans' quality of life
can at least be maintained and that the VA is going to be able
to provide services to them whether it be 24-hour care, whether
it, you know, just be continual adaptive services.
I mean this speaks to that larger issue, our entire range
of adaptive services is horribly, horribly out of date.
Mr. McNerney. Okay, thank you.
Ms. Williams, in your testimony you applauded the VA for
efforts in the area of prosthetics for women veterans, and that
is a great achievement.
My question is, are there gender differences where the
needs of women are not being met whether it is for blind
rehabilitation, spinal cord injuries, or so on and polytrauma
that are not as well met for women as they are for the men
veterans?
Ms. Williams. In terms of the spinal cord injury there was
a part that I found during my research that was not included in
the testimony, and I wanted to--I can bring that to your
attention regarding women with spinal cord injuries and the
difficulties that they face in receiving their medical care,
specifically their Pap smear and what they have to go through
in order to receive the care because of if they are in a
wheelchair and if they have lost use of their legs.
There are certain--I am having a brain cramp--but it is the
debilitating condition that the females face with the spinal
cord injury compared to their males having to receive their
breast exam, what they have to go through to receive a
mammogram and their Pap smear as a spinal cord injury.
Mr. McNerney. Okay, those are good specific topics. And if
you could keep us informed about the progress of that sort of
treatment, it would be beneficial I think for the VA.
Ms. Williams. Sure.
Mr. McNerney. Thank you, Mr. Chairman.
Mr. Michaud. Thank you. Once again, I would like to thank
the panel for coming this morning. Your testimony has been very
helpful and I look forward to working with you as we provide
services for our veterans. Once again, thank you very much.
We will try to get through the second panel before they
actually call the votes, and I would ask the second panel to
come forward.
We have Dr. Jack Smith, Acting Deputy Assistant Secretary
for Clinical and Program Policy from the Department of Defense,
and Dr. Lucille Beck from the Veterans Administration, who is
accompanied by Dr. Margaret Hammond from the VA, Deborah Amdur
from the VA and Billie Randolph from the VA.
I want to thank our second panel for coming forward. We do
have your full written testimony, which will be submitted for
the record, so if you could summarize your written testimony so
we are able to ask questions before they call for votes, I
would appreciate it.
We will start with Dr. Smith.
STATEMENTS OF JACK SMITH, M.D., MMM, ACTING DEPUTY ASSISTANT
SECRETARY FOR CLINICAL AND PROGRAM POLICY, U.S. DEPARTMENT OF
DEFENSE; LUCILLE B. BECK, PH.D., CHIEF CONSULTANT,
REHABILITATION SERVICES, OFFICE OF PATIENT CARE SERVICES, AND
DIRECTOR, AUDIOLOGY AND SPEECH PATHOLOGY SERVICE, VETERANS
HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY MARGARET C. HAMMOND, M.D., CHIEF CONSULTANT,
SPINAL CORD INJURIES AND DISORDERS SERVICES, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND BILLIE
RANDOLPH, DEPUTY CHIEF, PROSTHETICS, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF JACK SMITH, M.D., MMM
Dr. Smith. Well thank you, Chairman Michaud, distinguished
Members of the Subcommittee, thank you for the opportunity to
appear here to talk to you about the Department of Defense's
medical care for those who have suffered physical injuries in
combat.
On October 16th, 2009, Secretary of Defense Gates stated
quote, ``Beyond waging the wars we are in, treatment of our
wounded, their continuing care, and eventual reintegration into
everyday life is my highest priority. I consider this a solemn
pact between those who have risked and suffered and the Nation
that owes them its eternal gratitude.''
We who work in Military Health System completely agree with
Secretary Gates and share his commitment to provide the best
possible treatment for our wounded warriors.
One of the Military Health System's foremost sustained
priorities is to improve the experience of care for those who
are receiving treatment in our military treatment facilities
every day, the wounded, ill, and injured from our current
conflicts who are moving through the joint patient evacuation
system from point of injury and theater of operations to the
point of definitive care in the United States where many are
recovering from at our flag ship military medical centers in
the National Capital area and other clinical centers around the
country.
DoD has also long been a leader in research on improved
treatments for traumatic injuries.
The U.S. Army Institute of Surgical Research located at the
Brooke Army Medical Center in Texas, is dedicated to
laboratory, clinical trauma, and combat care research. Its
mission is to identify opportunities for improvement and
discover new treatments for combat injuries for servicemembers
across the full spectrum of military operations.
Severely injured servicemembers often require prolonged
treatment, time to heal, and rehabilitative care before a
decision can be made on the medical ability to remain on active
duty.
The Military Health System (MHS) is meeting this challenge
by improving our coordination of health care for servicemembers
with our partners in the VA.
The MHS is committed to ensuring that servicemembers are
provided outstanding clinical care and streamlined
administrative processes to return them to duty status if
possible or to assist them with a transition to civilian life
in coordination with the VA in an effective and timely manner.
To ensure a seamless transition of health services from one
agency to another, the MHS and the VA are working together to
ensure that medical providers have a full understanding of the
care capabilities within both agencies and that clear
communication of the transition plan between providers and each
agency and with the patient and family occur.
We are also working to ensure both timely transfer of all
pertinent medical records before or at the time of transfer of
the patient, and appropriate communication after the transfer
between the medical providers and with the patient and family.
The Department of Defense continues to improve the
transition of health care between the agencies by working in
partnership with the VA to establish and support Federal
Recovery Coordination Program, the VA Liaisons for Health Care
Program, and the Recovery Coordination Program.
DoD has also established a number of specialty centers of
excellence in collaboration with VA centers. Centers dedicated
to wounded warrior care include the Walter Reed Army Medical
Amputee Care Center and Gate Laboratory, the National Naval
Medical Centers National Intrepid Center of Excellence for
Traumatic Brain Injury and Psychological Health, the Center for
the Intrepid in Brooke Army Medical Burn Center at Fort Sam
Houston, Naval Medical Center San Diego Comprehensive Combat
Casualty Care Center, the Defense Centers of Excellence for
Traumatic Brain Injury and Psychological Health, and the
Centers of Excellence for Vision, Hearing, and Traumatic
Extremity Injuries and Amputations.
We have made tremendous progress in combat, trauma, and
rehabilitative care of our injured combatants over the last 9
years. The medical personnel of our combined services are
working very hard to develop and implement the MHS programs
necessary to return our severely injured servicemembers to duty
or to a protective civilian life.
Thank you for your continued support of our servicemembers
and their families, and I would be pleased to respond to any
questions.
[The prepared statement of Dr. Smith appears on p. 55.]
Mr. Michaud. Thank you.
Dr. Beck.
STATEMENT OF LUCILLE B. BECK, PH.D.
Dr. Beck. Good Morning, Chairman Michaud and Members of the
Subcommittee. Thank you for the opportunity to discuss the
Department of Veterans Affairs' full complement of specialty,
rehabilitative services for severely injured veterans and
servicemembers.
I am accompanied today by Deborah Amdur, Chief Consultant
for Care Management and Social Work Services, Dr. Margaret
Hammond, Chief Consultant for Spinal Cord Injuries and
Disorders, and Dr. Billie Randolph, Deputy Chief Consultant for
Prosthetics and Sensory Aid Service.
My testimony will discuss how VA supports and facilitates
the transition and care management of Operation Enduring
Freedom and Operation Iraqi Freedom veterans. I will highlight
the specialty rehabilitation services provided by VA for
severely injured veterans and servicemembers since 2003 for
four program areas: Blind Rehabilitation, Spinal Cord Injury,
Polytrauma Traumatic Brain Injury, and Amputation, Prosthetics,
and Sensory Aids.
VA and DoD partnered to create the Federal Recovery
Coordination Program in order to facilitate access to VA for
severely injured veterans and servicemembers and to assure that
these veterans and servicemembers receive the benefits and care
they need to recover.
Currently, 556 clients are enrolled in the FRC program and
another 31 individuals are being evaluated, 497 have previously
received assistance.
The VA care management and social work service coordinates
care for 5,800 severely injured servicemembers and veterans.
Additionally, VA has placed liaisons at military treatment
facilities and developed an OEF/OIF team at each VA medical
center to help coordinate the care for returning servicemembers
and veterans.
The first specialty rehab program I want to discuss is VA's
blind rehabilitation service which assesses, recommends, and
trains visually-impaired veterans in the use of technology and
assisted devices such as computers, personal digital
assistance, and global positioning systems.
Blind rehabilitation services are delivered at every
medical center and select outpatient rehabilitation clinics and
in-patient centers. These services are structured and
geographically located for visually-impaired veterans and
servicemembers to access the care they need.
A total of 1,098 OEF/OIF veterans and servicemembers are
tracked to ensure ongoing coordination. Of this total 126
servicemembers have attended in-patient blind rehabilitation
centers due to severely disabling visual impairment.
Second, VA's spinal cord injury system of care is
internationally regarded for its comprehensive and coordinated
services for rehabilitation, surgical, medical, preventive,
ambulatory, long-term, and home-based care.
VA promotes activity based therapies at SCI centers, and
recently enhanced the rehabilitation and training environments
to offer the latest and most effective interventions for newly
injured servicemembers and veterans.
VA has treated 503 servicemembers in its SCI units.
Third, the VA's polytrauma system of care is an integrated
tiered system that provides specialized interdisciplinary and
comprehensive care, including treatment by teams of
rehabilitation specialists, specialty care management, patient
and family education and training, psychosocial support, and
advanced rehabilitation and prosthetic technologies.
New programs at each polytrauma rehabilitation center
include transitional rehabilitation programs, emerging
consciousness care, and assisted technology laboratories.
VA has treated 1,792 patients at the PRCs: 907
servicemembers, and 885 veterans with severe injuries.
Finally, VA's Amputation and Prosthetic's and Sensory Aid
Program provides veterans with the full spectrum of
commercially available rehabilitation and prosthetic equipment
to maximize their independence and health.
Prosthetics currently serves 657 OEF/OIF amputee veterans
and servicemembers. Specialized prosthetic devices are provided
to meet the unique needs of returning veterans, and this
program has pioneered the use of best practices for management
of prosthetic devices and care through its clinical management
program.
Thank you again to the opportunity to appear today and
discuss VA's work in providing our OEF/OIF veterans with timely
access to the specialty care services they need. We appreciate
Congress's support in provides the resources we need to serve
our veterans.
My colleagues and I look forward to answering your
questions.
Thank you.
[The prepared statement of Dr. Beck appears on p. 58.]
Mr. Michaud. Thank you very much, Dr. Beck.
Mr. Bilirakis.
Mr. Bilirakis. In the interest of time I will submit my
questions for the record.
Mr. Michaud. Mrs. Halvorson.
Mrs. Halvorson. Thank you, Mr. Chairman, I will submit most
of mine, but I do have a couple questions.
First of all, Dr. Smith, could you just give me a short
answer on what is the status on the eye trauma registry that
Tom brought up earlier?
Dr. Smith. Sure. We worked very closely with the VA in
establishing the clinical requirements for the registry. Those
requirements have been established at this point. They were in
the process of putting together a model to build for that.
Meanwhile, we are utilizing our clinical data repository
and case management systems to identify the patients who need
care so that we can communicate and refer those to the VA.
We are also working on an eye forum in our joint theater
trauma registry, which begin to give us more visibility on
patients who have sustained injuries in the theater.
So there are multiple avenues we are pursuing, including
the registry, which is going to take a little more time to
build because of its need to draw information from the various
clinical repositories that we talked about and our ongoing
effort to establish and improve our electronic health record.
Mrs. Halvorson. And speaking of that, real quick. You know,
you say that you are working on a seamless transition, but yet
I hear from all my veterans that the VA can't talk to the DoD.
When the young service man leaves the theater, they get medical
records that the VA can't talk to the DoD.
Why can't they--when the servicemember leaves the DoD that
they can just get a CD of all their records or you can put it
on a USB and hand it to them and say here you go, you have your
medical records all to yourself?
Dr. Smith. We have for patients who are being transferred
to the polytrauma centers full copies of records go, including
imageries and----
Mrs. Halvorson. Where do they go?
Dr. Smith. They go to the polytrauma center.
Mrs. Halvorson. Which everybody loses something somewhere,
because that is what they tell me when they come to me.
Dr. Smith. Yeah. Well everything is scanned at the time
they are transferred from DoD to the VA.
We also have the Bi-Directional Health Information Exchange
which makes visible to VA doctors anything that is in our
electronic health record, and certainly I am not going to tell
you----
Mrs. Halvorson. But doesn't that servicemember own his own
record? You can't just give it to him?
Dr. Smith. Well, if he is being medically evacuated out of
the theater----
Mrs. Halvorson. No, no, no. Just when he leaves theater
can't he say I want my medical records, put it on a USB, a
little thing and it is mine?
Dr. Smith. We don't currently have that process. We do give
an electronic copy of the health record to the VA at the time
that people separate from the military.
Mrs. Halvorson. But they can't read it. You don't have the
same system so it is not seamless.
Dr. Smith. We do have interoperability ability initiatives
under way and the Bi-Directional Health Information Exchange I
believe is working.
Mrs. Halvorson. But it is not simple. Our office works all
day long trying the figure out the medical record issues.
I am just saying, and I am not going to belabor the issue,
we have to figure out the VA member--this is an issue, this is
a bad issue, and VA--the men and women who served our country
who worked so hard, their medical records should be something
that they own and that we shouldn't have this kind of problem
every day. When they leave they should own their own records
that they--because there is a problem with trust. And you guys
give them to the VA or you do something with them, but they own
them and then there is problems, and the VA can't read them.
So this is something that we need a whole Subcommittee on
just that. So something better be done so the VA can read your
records. Because I was in Landstuhl and they showed us a system
that should be seamless. And again, I don't want to get on my
high horse, but I am supporting and protecting my veterans, and
they are not happy.
So Mr. Chairman, I yield back.
Mr. Michaud. Thank you. Mr. McNerney.
Mr. McNerney. Well, thank you, Mr. Chairman. Thank you for
your testimony, Dr. Beck and Dr. Smith.
Dr. Beck, how would you respond to the Legioneer's claims
or comments that the returning soldiers get the best
rehabilitative treatment for amputations, but the long-term
prognosis is not that good or not that clear? In other words,
they are going to get the best possible treatment from the DoD,
but the long-term treatment is not as clear.
Dr. Beck. Thank you, Congressman.
We are working very closely with the Department of Defense
with the three centers who are providing the primary amputation
rehabilitation. Brooke Army Medical Center at the Center for
the Intrepid, Navy at Balboa, and at Walter Reed. We are
sharing staff at those centers. We have VA staff at the Center
for the Intrepid. We now have VA staff who are at Walter Reed
and at the DC VA Medical Center. We are working at all levels
to integrate and communicate all of the services. We are
training together. The military and the VA are training our
staffs, our interdisciplinary team of physicians and physical
therapists and occupational therapists and our clinical
prosthetics.
Mr. McNerney. Okay. I mean there is no doubt in my mind
that the intention is good.
I guess what I am trying to get at is that they get out of
Walter Reed or Bethesda, they are in pretty good physical
shape, but they need long-term guidance----
Dr. Beck. Yes, sir.
Mr. McNerney [continuing]. In some way to make sure that
they don't fall off the cart, you know, and get into problems.
Dr. Beck. Yes, sir. And what the VA is doing and has
developed in the last 3 years is a refreshed amputation some of
care, and in my written testimony we provided the information.
We have stood up seven regional amputation centers in the
VA around the country that are specialized centers providing
the full compliment of medical and rehabilitative care for our
amputees. We also have amputee specialty care at 21 of our
network sites, the Veterans Integrated Service Network sites,
and we have amputation clinic teams around the country. And the
intention and the effort is to manage and care for all of VA's
amputees. We have approximately 43,000 amputees already in the
VA system being served and are now addressing the need--their
needs as well as the needs of our OEF/OIF traumatic amputees.
So we are providing the latest in prosthetist equipment,
artificial limbs, and services through our network of private
prosthetist providers as well.
Mr. McNerney. Okay, thank you.
I am going to yield back, Mr. Chairman.
Mr. Michaud. Thank you very much. I have just a couple
quick questions for Dr. Smith.
Yesterday we had a Roundtable discussion in which we
discussed hyperbaric therapies that I know the DoD has been
using. There is a DoD report on hyperbaric therapy that has
never been submitted.
Could you provide the Committee with a copy of that report?
That is my first question.
[The DoD subsequently provided the following information:]
To our knowledge, the DoD participants at the House Veterans'
Affairs Committee Roundtable held the day before this hearing
did not reference any Hyperbaric Oxygen (HBO) report. The only
HBO report referenced that day was of another panelist and the
Department does not have an association with or knowledge of
the other panelist's report.
However, there is a separate HBO report which may be of
interest to the Committee. As requested by the Joint
Explanatory Statement for H.R. 3326, the Department of Defense
Appropriations Bill, 2010, DoD is currently working on a final
report to Congress on HBO due in September 2010.
Mr. Michaud. And my second question is, Congress passed
legislation requiring the DoD to perform a baseline evaluation
when soldiers go to Iraq and Afghanistan and an evaluation when
they come back. It is my understanding that they have stopped
doing that evaluation and that is a big concern. Is it because
in the evaluation that has been done that traumatic brain
injury issues are coming up and you don't want to face what our
soldiers are going through?
I do not want another Agent Orange with our veterans in
Iraq and Afghanistan, so please provide that report on
hyperbaric therapy, or what has been done on the report if it
is not completed, and also address in writing why the DoD is
not evaluating the soldiers when they come back.
[The DoD subsequently provided the following information:]
The Department of Defense (DoD) does not perform routine,
population-based, post-deployment neurocognitive assessments on
its returning servicemembers. Neurocognitive assessments are
focused exclusively on assessing cognition. At present,
research does not support the use of computerized
neurocognitive assessments tools such as Automated
Neuropsychological Assessment Metrics (ANAM) for post-
deployment population-based concussion screening. There are
many reasons (e.g. sleep deprivation, depression, concussion,
etc.) there could be changes in cognitive scores between pre-
and post-deployment.
However, DoD completes an overall screening post-deployment
with the goal of identifying all servicemembers who may have
persistent symptoms from a concussive injury obtained during
deployment. DoD screens the post-deployment population for the
entire spectrum of symptoms associated with concussion rather
than only evaluating symptoms of cognition. Because a
concussion can produce a variety of symptoms (with or without
cognitive dysfunction) such as headache, dizziness, insomnia,
irritability, mood and anxiety disturbances, in addition to
isolated cognitive disturbances, the tool used for post-
deployment screening is an adaptation of the Brief TBI Screen
that was recommended by the Institute of Medicine for this
purpose in its December 2008 report. Those servicemembers who
screen positive for having possible symptoms associated with a
concussion receive further medical evaluation to include
assessments of cognition with ANAM or other formal
neuropsychological assessments.
This process works to provide the comparative information
necessary for post-injury care of mild traumatic brain injury
in the acute phases of injury and identify cases that may not
have been evaluated in theater or have persistent symptoms. The
Department continues to look for the best methods for
delivering quality, evidence-based care to our servicemembers.
Mr. Michaud. Also for the VA, Dr. Beck, please provide to
the Subcommittee information on VA's progress in implementing
the caregivers legislation that was recently passed, including
when we can expect it to be fully implemented.
There will be additional questions from the Subcommittee as
well.
Unfortunately, the vote is open. We have 7 minutes to get
over there to vote, so I will provide additional questions for
the record from the rest of the Committee.
I want to thank both Dr. Smith and Dr. Beck and those who
you who are accompanied by, for coming today, as well as the
first panel for your enlightened testimony.
As you can tell from the questions both for the first panel
and that I know we would have asked on this panel had we had
the time, this is a very important issue that we have to deal
with. And some of the other questions that will come forward,
particularly of VA, as we heard from the Iraq and Afghanistan
folks, is there is still a concern about the time frame, and
about some of the concerns with VA having to put veterans on
hold for 45 minutes, and a pubic relations problem within the
veterans' community. Hopefully we will be able to address some
of those questions and we will be asking additional questions
of this panel as well.
So once again, I want to thank you all for coming. I really
appreciate it.
If there are no other questions, we will adjourn the
hearing.
So thank you.
[Whereupon, at 11:41 a.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Opening Statement of Hon. Michael H. Michaud,
Chairman, Subcommittee on Health
The Subcommittee on Health will now come to order. I would like to
thank everyone for attending this hearing.
The purpose of today's hearing is to explore how we can best serve
our veterans who have sustained severe physical wounds from the wars in
Iraq and Afghanistan. Today, we will closely examine VA's specialized
services for the severely injured, which include blind rehabilitation,
spinal cord injury centers, polytrauma centers, and prosthetics and
sensory aids services.
With advances in protective body armor and combat medicine, our
servicemembers are surviving war wounds which otherwise would have
resulted in casualties. Many servicemembers who are severely injured in
Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) will
require sophisticated, comprehensive, and often lifelong care. We know
that blast injuries from improvised explosive devices are the most
common causes of injury and death among our OEF and OIF servicemembers.
Blast injuries often include combinations of TBI, blindness, spinal
cord injuries, severe burns, and damage to the limbs which results in
amputations.
Today, we will examine whether VA is meeting the needs of the
severely injured and whether veterans have access to the most current
therapies for treating their physical war injuries. We will identify
what VA is doing well and what areas are in need of improvement. We
will also explore how VA ensures that the quality of care is consistent
and standardized across the VA health care system so that veteran
receive the same high quality care regardless of which VA facility they
visit. Finally, we will review VA's current efforts to coordinate
specialized services for the severely injured with the DoD and how we
can achieve improved coordination between the two departments.
I look forward to hearing from our witnesses today.
Opening Statement of Hon. Henry E. Brown, Jr.,
Ranking Republican Member, Subcommittee on Health
Thank you, Mr. Chairman, and good morning.
Yesterday, we reached a milestone. It was eighty years ago--on July
21, 1930--that President Herbert Hoover first established what we now
know as the Department of Veterans Affairs (VA).
Since that day, VA has endeavored to fulfill their mission to
``care for those who have borne the battle''. For those who return from
battle carrying the very worst wounds of war, including spinal cord
injury (SCI), traumatic brain injury (TBI), amputation, and blindness
the VA has developed specialized services to meet their unique
rehabilitative needs. Providing these types of services to our very
highest priority veterans is the backbone of the Department.
Since 1996, Congress has mandated that the VA maintain capacity for
these specialized rehabilitative services. And, in 2004, Congress
enacted legislation to provide comprehensive services for severely
injured servicemembers suffering with complex injuries resulting from
blast injuries. This came to be called VA's Polytrauma System of Care.
More than 2.1 million servicemembers have been deployed since
October 2001. As of April 3, one thousand five hundred and fifty two
have suffered amputations in Iraq or Afghanistan. Countless others have
suffered TBI, SCI, eye trauma, hearing loss, or other severe combat
wounds. These young heroes are going to require a lifetime of
rehabilitation and highly skilled medical services and support. They
risked life and limb in our name and in return it is our responsibility
to provide them with the care they require and so dearly deserve.
As the battles in Iraq and Afghanistan persist, the specialized
care given in VA Medical, Polytrauma, Spinal Cord Injury, and Blind
Rehabilitation Centers continue to take on increased importance.
We must diligently prioritize investment in specialized services,
medical research, and recruitment to have all the tools necessary to
provide all veterans and especially our most severely wounded veterans
with an active and full life characterized by independence,
functionality, and achievement.
I'm grateful to all our panelists and audience members for being
here this morning and I yield back.
Prepared Statement of Thomas Zampieri, Ph.D., Director
of Government Relations, Blinded Veterans Association
INTRODUCTION
Chairman Michaud, Ranking Member Congressman Brown, and members of
the House Veterans Affairs Subcommittee on Health, on behalf of the
Blinded Veterans Association (BVA), thank you for this opportunity to
present our testimony today on ``Healing the Physical Injuries of
War.'' BVA is the only congressionally chartered Veterans Service
Organization (VSO) exclusively dedicated to serving the needs of our
Nation's blinded veterans and their families for over 65 years. Today,
as U.S. forces remain engaged in two wars and with the surge into
Afghanistan resulting in more wounded returning from the battlefields,
this hearing is important in reviewing the current systems specialized
services and what works and does not work well. While the media often
covers the signature injury of the wars, ``Traumatic Brain Injuries''
and the mental health problems like Post Traumatic Stress Disorders
(PTSD) it is important to note that most wounded return with several
injuries ``polytrauma'' and they should all be considered in planning
for VA specialized care and benefits they require.
SEAMLESS TRANSITION ISSUES
During the past couple years, BVA has worked extensively with the
members of the Committee and tried to get the House Armed Services
Committee (HASC) to hold DoD more accountable for the many
organizational problems associated with the Seamless Transition process
involving the battle eye-injured and those with visual complications
associated with Traumatic Brain Injury (TBI). Many severely eye-injured
OIF and OEF wounded servicemembers are not centrally tracked, making
the implementation of the Eye Trauma Registry vital. This tracking
failure negatively affects some in their access to the full continuum
of VA Eye Care Service, Blind Rehabilitation Service (BRS), and Low-
Vision outpatient programs that these committees helped establish. BVA
again stresses that, according to DoD data compiled between March 2003
and December 2009, DoD reported 10 percent of all combat-injured
casualties evacuated from OIF and OEF had associated mild, moderate, or
severe eye injuries, considering that 38,497 U.S. servicemembers have
been evacuated from being wounded or injured this is obviously a
significant number. Fortunately, due to advanced combat surgery teams,
and the rapid evacuation military aero-medical system, the severely eye
injured in these wars have had their vision sometimes fully or
partially restored, but approximately 124 blinded have required
treatment at one of the ten VA Blind Rehabilitation Centers (BRCs) and
there are large numbers with TBI low vision problems. There has been
insufficient governance or oversight of the Vision Center Excellence
(VCE) by the Joint Executive Council (JEC) and some failure of both
agencies to provide detailed budgets, necessary for VCE joint staffing,
implementing the Eye Trauma Registry has been delayed, and the planned
construction renovation for 3,870 square feet of office space for the
VCE at the National Naval Medical Center in Bethesda is not expected to
be completed until April FY 2011. BVA requests that no further delays
for the immediate operational implementation plans for the VCE in FY
2010 are acceptable and they should not be tolerated.
BVA points to the frustrating fact that despite the MILCON/VA
Appropriations including $6.8 million for FY 2009 for VA implementation
of its portion of the VCE initiative, it was April 2010 before VA had a
total of four staff appointed to the VCE. Members found that the
funding had been reprogrammed over five years instead of utilizing the
funds to urgently start the VCE operations. BVA requests that Congress
include $9,350,000 in the Defense Appropriations FY 2011 and require
that VHA and DoD Assistant Secretary Defense for Health Affairs (ASDHA)
report quarterly on VCE joint staffing plans, the status of the Eye
Trauma Registry, and expenditures of the MILCON/VA appropriations
provided to HVAC and HASC.
BVA believes that the VCE and its Eye Trauma Registry are where
improved coordination to ensure availability of eye care and vision
rehabilitation services, best outcome practices, and evidence-based
clinical research measures can be developed and refined for the TBI-
wounded who face vision dysfunction and those suffering penetrating eye
wounds. Research coordinated with the Defense Veterans Brain Injury
Centers (DVBIC) and the Defense Intrepid Center of Excellence (NICOE)
for TBI, along with VA Polytrauma sites, can be facilitated, data-
analyzed, and published to improve both acute injury care and long-term
vision rehabilitation. We predict that the number of TBI-injured will
continue to rise as a result of the troop surge into Afghanistan this
year.
VA's Full Continuum of Care
A very positive note is that VA continues to build on a now 62-year
history of successful blind rehabilitation programs, which include 10
residential Blind Rehabilitative Centers (BRC's) throughout the United
States and construction on two new BRC's is occurring now. At present,
the implementation of a sweeping $40 million, three-year Full Continuum
of Care plan has been completed that this committee supported. While
the plan was originally initiated to serve the projected aging
population of veterans with degenerative eye diseases requiring
specialized services, the new 55 intermediate and advanced low vision
blind rehabilitation outpatient programs also have specialized staffing
in place to provide the full range of basic, intermediate, and advanced
vision services essential to the new generation of eye injured veterans
from OIF and OEF. In addition, VA continues to emphasize medical vision
research and the latest advances in prosthetic adaptive equipment, with
access to new vision technology through a coordinated team approach
that is designed to benefit both low vision and blinded veterans of all
eras.
VA Blind Rehabilitative Centers
BRCs are especially important for the returning OIF and OEF service
personnel because they often suffer from multiple traumas that include
TBI, amputations, other neurosensory losses, and limb injuries. One VA
research study found PTSD in 44 percent of TBI patients, 22 percent
suffer depression, 40 percent had acute and chronic pain management
issues. Mild TBI was found in 44 percent of these 433 patients, with 56
percent diagnosed with moderate to severe TBI with 12 percent of those
had penetrating brain trauma. The Defense Veterans Brain Injury Center
(DVBIC) reports that an analysis of the first 433 TBI wounded found 19
percent had concomitant amputation of an extremity. The VA BRC can
deliver the entire array of highly specialized care needed for them to
optimize their rehabilitation outcomes and successfully reintegrate
within their families and communities. Mr. Chairman, we wish to
strongly emphasize that private agencies may lack all of the highly
specialized consultant services, and prosthetics expertise, that our
residential blind centers have now developed, and they all have
Commission on Accreditation of Rehabilitation Facilities (CARF)
approval. Only the inpatient VA Blind Centers have all the various
specialized consultant services needed such as prosthetics,
orthopedics, neurology, rehabilitative medicine, surgery, ophthalmology
and low vision optometry, and psychiatry to treat these polytrauma
servicemembers.
There is no environment of which we are aware that better
facilitates the initial emotional adjustment to the severe problems
associated with the traumatic loss of vision than full, comprehensive
VA blind rehabilitation. One BVA recommendation though is that VHA BRS
should have more central control over VA blind center staffing
resources and the funding levels because BRS will be better able to
track demand for workload across all centers, monitor waiting times,
and improve the overall allocation of critical resources in meeting new
staffing demands.
VISUAL IMPAIRMENT SERVICES TEAMS AND BLIND REHABILITATION OUTPATIENT
SPECIALISTS
The mission of each Visual Impairment Service Team (VIST) program
is to provide blinded veterans with the highest quality of adjustment
to vision loss services and blind rehabilitation training. To
accomplish this mission, VIST has established mechanisms to maximize
the identification of blinded veterans and to offer a review of
benefits and services for which they are eligible. The VIST concept was
created in order to coordinate the delivery of comprehensive medical
and rehabilitation services for blinded veterans. VIST Coordinators are
in a unique position to provide comprehensive case management and
Seamless Transition services to returning OIF/OEF service personnel for
the remainder of their lives. They can assist not only the newly
blinded veteran but can also provide his/her family with timely and
vital information that facilitates psychosocial adjustment.
The VIST system now employs 114 full-time Coordinators and 43 who
work part-time. The average caseload is 375 blinded veterans. VIST
Coordinators nationwide serve as the critical key case managers for
some 49,269 blinded veterans, a number that is projected to increase to
52,000 within a couple of years. The VIST teams are able to coordinate
local services when a veteran requires them and follow blinded veterans
who attend a BRC and later require any additional training due to
improvements in adaptive equipment or technology.
BLIND REHABILITATIVE OUTPATIENT SPECIALISTS (BROS)
VA BRS established several new Blind Rehabilitative Outpatient
Specialists positions during FY 2009 in facilities throughout the
system, bringing the total of BROS to 73 working full-time, triple the
number from 2004 largely due to the efforts of this committee and
Chairman Michaud. The creation of the positions placed VA in a better
position to deliver accessible, cost-effective, top-quality outpatient
blind rehabilitation services.
While the BROS is a highly qualified professional who, often is
dually certified; that is, he/she has a dual masters science degree
both in Orientation and Mobility (living skills and manual skills) and
Rehabilitation Teaching and is credentialed and privileged in VA
medical centers there is problem within DoD medical treatment
facilities (MTF). The defense health care system has never before
credentialed BROS professionals because for sixty years blinded
servicemembers were sent to VA BRC's. While DoD credentials other
occupations with similar master's degrees for example, occupational and
physical therapists, DoD has no policy for credentialing of VA BROS. We
credit VHA and VCE director, COL Gagliano, for trying over the past
year for DoD MTF's to credential these VA BROS into selected MTF's to
begin early blind rehabilitative training skills for the severely
wounded that may be pending being transferred to VA BRC.Walter Reed Med
Center and Navy Medical Center currently have been unable to credential
the local VA BROS so they can provide this training. Such training
prepares these individuals to provide the full range of mobility,
living, and adaptive manual skills that are essential early skills in
recovery and return to the veteran's home environment and BROs provide
reassurance to family members that the training will lead to
independence. Today in several DoD and VA medical centers there are
wide number of clinical providers, social workers, and other staff
working together within each department's facilities to improve
transition and clinical care. BVA would strongly recommend that the VA
Committee working with HASC provide ``NDAA report language'' that VA
credentialed and privileged BROS shall be granted MTF clinical
privileges as VA clinical consultants representing VA Blind
Rehabilitative Service and that DoD and VHA report back to the
committees on the implementation of this privileging process.
ADVANCED BLIND REHABILITATION PROGRAMS
Pre-admission home assessments, individualized evaluations, and
outpatient training, all of which are complemented by a post-completion
home follow-up, are part of the new three year expansion of VA's
Advanced Outpatient Blind programs. These programs have been referred
to historically as VISOR (Visual Impairment Services Outpatient
Rehabilitation Program). They consist of a nine-day rehabilitation
experience, offering Living Skills Training, Orientation and Mobility,
and Low-Vision Adaptive Devices Therapy with appropriate prosthetics
while staying in Hoptel bed at a medical center with nursing care as
necessary during the stay. A VIST Coordinator with low-vision
credentials manages the program with other key staff members consisting
of certified BROS, Orientation and Mobility Specialists, Rehabilitation
Teachers, Low-Vision Therapists, and Low-Vision Ophthalmologists. These
new programs considerably improve access, provide new rehabilitation
services of the highest quality, reduce waiting times, and decrease
veteran travel across networks.
INTERMEDIATE LOW-VISION OPTOMETRY PROGRAMS: VICTORS
Another important model of service delivery that does not fall
under VA BRS is the Visual Impairment Center to Optimize Remaining
Sight (VICTORS), an innovative program operated by VA Optometry
Service. It consists of special services to low-vision veterans who,
although not legally blind, suffer from severe visual impairments.
Veterans must usually have a visual acuity of 20/70 through 20/200 to
be considered for this service. The program, entirely outpatient,
typically lasts three days. Veterans undergo a comprehensive, low-
vision optometric evaluation and then appropriate low-vision
prosthetics devices are then prescribed. The Low-Vision Optometrists
employed in Intermediate programs are ideal for the highly specialized
skills necessary for the assessment, diagnosis, treatment, and
coordination of services for returnees from Iraq or Afghanistan with
TBI visual dysfunction and who also require low-vision services. These
new low-vision programs assist veterans with some residual vision from
conditions such as macular degeneration, diabetic retinopathy, glaucoma
and other degenerative eye diseases in maintaining independence and
functional status at home or work.
PRIVATE AGENCIES AND POLY TRAUMA REHABILITATION SERVICES
BVA objects to finding that private agencies for blind are asking
for members to earmark various `centers of excellence' and private
agencies trying to initiate new independent programs to ``manage these
new OIF and OEF combat wounded,'' adding to the confusion and
negatively impacting transition between DoD and VA. Recent combat
blinded servicemembers often suffer from multiple traumas that include
TBI, amputations, neuro-sensory losses, PTSD, pain management, and
depression. The New England Journal of Medicine's January 31, 2008
article on the experience of mild TBI wounded found even mild cases
were significantly more likely within three to four months after injury
to develop altered mental status, depression, headaches, emotional
distress in up to 30 percent of cases, again evidence that without
neurology, neuro-psychology or psychiatry staff, the specialized
treatment necessary for recovery will be missed. Only VA Blind
Rehabilitation Centers (BRC's) can deliver the entire full array of
these inpatient medical-surgical and psychiatric specialized care often
needed for veterans to fully optimize their rehabilitation outcomes and
successfully reintegrate into their families and communities. They need
the specialized VA mental health services with coordinated
multidisciplinary health care teams that the VA medical centers are
capable of providing.
We caution that residential private agencies for the blind do not
have the full specialized nursing, physical therapy, pain management,
speech pathology, pharmacy services, and lab or radiology support
services, along with subspecialty surgery specialists, to provide the
clinical care necessary for the wounded. The lack of electronic health
care records in the private agencies would make things worse when
veterans returned into DoD or VA medical services. BVA requests that
any private agencies should demonstrate peer reviewed quality outcome
measurements that are a standard part of VHA BRS and they also must be
accredited by either the National Accreditation Council for Agencies
Serving the Blind and Visually Handicapped (NAC) or the Commission on
Accreditation of Rehabilitation Facilities (CARF) and blind
rehabilitation instructors must be certified by the Academy for
Certification of Vision Rehabilitation and Education Professionals
(ACVREP). They should also have the specialized medical staffing
necessary for complex wounds.
BVA believes that the DoD-VA Seamless Transition process for eye
trauma cases must include the sharing of outcome studies, clinical
guidelines, and joint peer reviewed research projects on vision care
and vision loss prevention through the exchange of electronic medical
records and clinical specialized consultation. These components are not
present in private agencies for the blind.
RECOMMENDATIONS
Congress must ensure the full establishment and
budget of the Vision Center of Excellence VCE and Eye Trauma
Registry must become operational. Joint DoD/VA staffing
resources available now is critical for successful Seamless
Transition of eye injured. Request DoD appropriations include
$9,350,000 for FY 2011 for operations and staffing for the VCE.
Section 1624 of NDAA FY 2008 must be modified and specific
organizational governance alignment for the VCE Director and VA
Deputy Director shall report directly to the Assistant
Secretary of Defense for Health Affairs and to the Under
Secretary of Health (USH) in VHA.
BVA would strongly recommend that the VA Committee
with HASC provide ``NDAA report language'' that VA credentialed
and privileged Blind Rehabilitative Outpatient Specialists
(BROS) `shall be granted MTF clinical privileges as VA clinical
staff' for VA Blind Rehabilitative Service (BRS) and that DoD
and VHA shall report back to the committees on the
implementation of this privileging process for BROS.
The new, specialized VA programs for blinded and low-
vision veterans Continuum of Care must be utilized by DoD and
to ensure that continuing education of DoD staff about this
must occur along with the various VA Case Managers, the Federal
Recovery Coordinators (FRCs) and the Vision Center of
Excellence (VCE). Veterans and their families must know where
these resources are located so that they continue to receive
the high quality VA vision health care.
BVA supports the National Alliance for Eye Vision
Research's (NAEVR) position that extramural defense vision
research funding through the dedicated Peer Reviewed Medical
Research-Visionline item in the DoD's Congressionally Directed
Medical Research Program (PRMRP) is essential. BVA urges that
PRMR-Vision be funded at $10 million in FY2011 defense
appropriations and BVA also appreciates the dear colleague
letter of Congressman Walz dated July 15, 2010 requesting
members support this level of funding.
CONCLUSION:
Once again, Mr. Chairman, and Members of the subcommittee, BVA
appreciates this opportunity to present our testimony on Specialized VA
Health Care services confronting the newly injured returning from OIF
and OEF. I will answer any questions you have.
Prepared Statement of Carl Blake, National
Legislative Director, Paralyzed Veterans of America
Chairman Michaud and Members of the Subcommittee, on behalf of
Paralyzed Veterans of America (PVA), I would like to thank you for the
opportunity to present PVA's views on how the Department of Veterans
Affairs (VA) is caring for the severely injured Operation Enduring
Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans. The
challenges the VA has faced in delivering care to OEF/OIF veterans have
been unique as this generation of servicemembers has experienced new
and different actions in combat, such as the wide-spread use of
improvised explosive devices (IED). And yet, the delivery of
specialized health care is something that the VA has greatly improved
upon over the years and has established itself as a world leader.
The wars in Afghanistan and Iraq have now continued for an extended
period of time. The number of casualties and new veterans being created
has had a significant impact on the VA. PVA appreciates the
Subcommittee's continued efforts to sufficiently fund the care for this
growing number of veterans. VA has done a great many things to provide
for the care of our newest generation of veterans. The open enrollment
of OEF/OIF veterans into the VA health care system for up to five years
after these servicemembers leave the service, creation of multiple
polytrauma centers to address the complex and severe disabilities that
some servicemembers are experiencing as a result of their service, the
expansion of mental health programs as well as programs targeted at
women veterans, and other efforts to ensure the proper care of these
men and women demonstrates VA's willingness to go the extra distance to
provide timely and sufficient care.
It is important to emphasize that specialized services are part of
the core mission and responsibility of the VA. For a long time, this
has included spinal cord injury care, blind rehabilitation, treatment
for mental health conditions--including post-traumatic stress disorder
(PTSD)--and similar conditions. Today, traumatic brain injury (TBI) and
polytrauma injuries are new areas that the VA has had to focus its
attention on as part of their specialized care programs.
Specialized services were initially developed to care for the
unique health care needs of veterans. The VA's specialized services are
incomparable resources that often cannot be duplicated in the private
sector. With this in mind, we believe that the VA must be given the
opportunity to show what it is capable of doing in addressing TBI and
polytrauma conditions for this newest generation of veterans.
The provision of specialized services is vital to maintaining a
viable VA health care system. Specialized services are part of the
primary mission of the VA. The erosion of these services would lead to
the degradation of the larger VA health care mission. With growing
pressure to allow veterans to seek care outside of the VA, the VA faces
the possibility that the critical mass of patients needed to keep all
services viable could significantly decline. All of the primary care
support services are critical to the broader specialized care program
provided to veterans with spinal cord injury. If primary care services
decline, then specialized care is also diminished.
As such, we are pleased to see that the VA has applied the spinal
cord injury care model to treatment for polytrauma and TBI. PVA
believes that the hub-and-spoke model used in the VA's spinal cord
injury service serves as an excellent model for how this network of
polytrauma centers can be used. Second level treatment centers (spokes)
refer spinal cord injured veterans directly to one of the 23 spinal
cord injury centers (hubs) when a broader range of specialized care is
needed.
Treatment of polytrauma and TBI can function in the same fashion.
The new level two polytrauma centers (spokes) being established will
better assist VA to raise awareness of the complex medical issues that
severely injured servicemembers and veterans are facing. These
increased access points will also allow VA to develop a system-wide
screening tool for clinicians to use to assess TBI patients. When more
comprehensive treatment is needed, a veteran can be referred to the
level one polytrauma center that serves as the hub. Unfortunately, the
ability of VA to provide this critical care has been called into
question. PVA recognizes that the VA's ability to provide the highest
quality TBI care is still in its development stages; however, it
continues to meet these veterans' needs while continuing to expand its
capabilities.
While VA has gone to great lengths to provide appropriate care for
OEF/OIF veterans, there have been several recent media reports
indicating problems with proper identification and treatment of
servicemembers suffering from TBI. This has occurred despite increased
attention to the problem. Those with significant cases of TBI are being
identified and well cared for. It is those with less severe cases of
TBI that seem to be falling through the health care cracks. In most
cases, this is not VA's fault. Instead, the identification and
treatment by Department of Defense (DoD) personnel on the scene or at
the initial care sites are not making this identification. This is
leading to a lack of continued care when those veterans who may suffer
from mild to moderate, but undiagnosed, TBI injuries leave the service
and seek care at VA facilities. We expect VA will continue to work
closely with DoD to ensure TBI care is provided to all veterans who
have suffered this often debilitating injury.
But for PVA, there is an ongoing problem that has not received a
similar level of appropriate media coverage. Some active duty soldiers
with a new Spinal Cord Injury/Dysfunction (SCI/D) are being transferred
directly to civilian hospitals in the community and bypassing the VA
health care system. This is particularly true of newly injured
servicemembers who incur their spinal cord injury in places other than
the combat theaters of Iraq and Afghanistan. This violates a Memorandum
of Agreement between VA and DoD that was effective January 1, 2007
requiring that ``Care management services will be provided by the
Military Medical Support Office (MMSO), the appropriate Military
Treatment Facility (MTF) and the admitting VAMC as a joint
collaboration'' and that ``whenever possible the VA health care
facility closest to the active duty member's home of record . . .
should be contacted first.'' In addition, it requires that ``To ensure
optimal care, active duty patients are to go directly to a VA medical
facility without passing through a transit military hospital,'' clearly
indicating the critical nature of rapidly integrating these veterans
into an SCI health care system.
This is not happening. For example, servicemembers who have
experienced a spinal cord injury while serving in Afghanistan and Iraq
are being transferred to Sheppard Spinal Center, a private facility, in
Atlanta when VA facilities are available in Augusta. When we raised our
concerns with the VA regarding Augusta in a site visit report, the VA
responded by conducting an information meeting at Sheppard to present
information and increase referrals. However, reactionary measures such
as this should not be the standard for addressing these types of
concerns.
Of additional concern to PVA, it was reported that some of these
newly injured soldiers receiving treatment in private facilities are
being discharged to community nursing homes after a period of time in
these private rehabilitation facilities. In fact, some of these men and
women have received sub-optimal rehabilitation and some are being
discharged without proper equipment. PVA is greatly concerned with this
type of process and treatment. There is a serious need to reinforce
compliance by DoD regarding the Memorandum of Agreement toward the
treatment of soldiers with new SCI/D at VA SCI centers.
Ensuring that these men and women gain quick access to VA care in
spinal cord injury centers is critically important because it begins
what will become a lifelong treatment process. SCI/D care in the VA is
unique from private care for spinal cord injury rehabilitation because
of the care coordination that the veteran receives for the remainder of
his or her life. Care coordination begins as soon as a new injury
enters the VA SCI service. Failure to transfer new injuries into the VA
only serves to deny these men and women the world-class specialized
care the VA will provide. While we understand that local VA medical
centers and DoD facilities are taking actions to improve this process,
we ask that the Subcommittee work with your colleagues of the House
Committee on Armed Services to ensure our SCI/D veterans are getting
the complete, proper and appropriate care for their sacrifices.
VA has historically been the best provider of care for our injured
veterans. They are familiar with the wounds of war and the
physiological and psychological conditions that accompany them. It is
unacceptable that DoD might move its disabled warriors to sub-standard
care and we can only believe that this is because some individuals
within the DoD health care system do not understand the complexities of
SCI/D care and the multitude of conditions that require attention for
veterans with spinal cord injuries.
PVA also remains concerned that the VA must maintain its capacity
for the provision of SCI/D care as mandated by P.L. 104-262, the
``Veterans Health Care Eligibility Reform Act of 1996.'' This law
required the VA to maintain its capacity to provide for the special
treatment and rehabilitative needs of veterans with spinal cord injury,
blindness, amputations, and mental illness. The baseline of capacity
for spinal cord injury was established based on the number of staffed
beds and the number of full-time equivalent employees assigned to
provide care on the date of enactment of the law.
Ultimately, we cannot emphasize enough that any reduction in
staffed beds can have a direct negative impact on the newest generation
of veterans as well as veterans of previous generations. Unfortunately,
the single biggest accountability measure--an annual capacity reporting
requirement--expired in April 2004. This allows the VA to make changes
to its SCI/D capacity in a less than transparent manner. In accordance
with the recommendations of The Independent Budget for FY 2011, PVA
calls on this Subcommittee to approve legislation to reinstate this
vitally important reporting requirement.
Additionally, the SCI/D programs of the VA face a common challenge
with the larger health care system--a shortage of qualified nurse
staffing. As a result, VA is experiencing delays in admissions and bed
reductions at its SCI centers. In order to meet this challenge head on,
some SCI centers in the VA have offered recruitment and retention
bonuses to enhance their nurse staffs. Unfortunately, this is not a
uniform national policy and these actions are subject to the budget
decisions of local VA medical center and Veterans Integrated Service
Network (VISN) directors. In accordance with recommendations of The
Independent Budget, we believe it is time for the Veterans Health
Administration (VHA) to centralize policies and funding for systemwide
recruitment and retention of SCI nurse staffing. Additionally, we
believe Congress should establish a specialty pay provision for nurses
working in the SCI service, and should consider extending similar
provisions to the other VA specialized services.
PVA appreciates the emphasis this Subcommittee has placed on
reviewing the care being provided to the most severely disabled
servicemembers and veterans returning from OEF/OIF. It cannot be
overstated that the VA is the best option for these men and women when
it comes to provision of specialized services. And yet, we have only
touched on a small segment of this population--SCI/D veterans--in our
testimony today. There are many more severely injured servicemembers
and veterans who are dealing with TBI, vision impairment, amputations,
and serious mental illness. We would encourage the Subcommittee to
review The Independent Budget for FY 2011. This comprehensive policy
document includes significant discussion about the challenges of
providing care to this generation of war-wounded veterans, as well as
the individual issues with the different segments of specialized
services.
PVA would like to thank the Subcommittee once again for allowing us
to provide testimony on these important health care issues facing OEF/
OIF veterans, as well as other severely disabled veterans. We certainly
appreciate the continued attention this Subcommittee has placed on
these issues. I would be happy to answer any questions that you might
have. Thank you.
Prepared Statement of Joy J. Ilem, Deputy National
Legislative Director, Disabled American Veterans
Mr. Chairman, Ranking Member Brown, and Members of the
Subcommittee:
Thank you for inviting the Disabled American Veterans (DAV) to
testify at this hearing of the Subcommittee on Health, titled ``Healing
the Physical Injuries of War.'' We appreciate the Subcommittee's
leadership in enhancing the Department of Veterans Affairs (VA) health
care programs on which many service-connected disabled veterans must
rely, and to comment on how the VA is caring for the severely injured
servicemembers and veterans of Operations Enduring and Iraqi Freedom
(OEF/OIF) through its specialty programs. We also appreciate the
Subcommittee's interest in identifying any gaps in care or services
that may exist within these programs. We are specifically focusing our
testimony on VA's Polytrauma/Traumatic Brain Injury (TBI) System of
Care.
According to VA's June 2010 Queri Fact Sheet on Polytrauma and
Blast Related Injuries more than 37,000 OEF/OIF servicemembers have
been wounded in action, and of those, more than 20,000 were unable to
return to duty within 72 hours, presumably because of the severity of
their injuries. Blasts were listed in the Fact Sheet as the most common
cause of injury. In combat, sources of blast injury includes artillery,
rocket and mortar shells, mines, booby traps, aerial bombs, improvised
explosive devices (IEDs), and rocket-propelled grenades
According to VA, from March 2003 through March 2010 a total of
1,792 inpatients with severe injuries have been treated at Polytrauma
Rehabilitation Centers.\1\ Within this total group of patients, 774
were injured in OEF/OIF with the remaining injured in non-combat, non-
deployed incidents.\2\ Blast injuries are often polytraumatic, meaning
they affect multiple body systems or organs, resulting in physical,
cognitive, psychological, and psychosocial impairments and functional
disabilities.\3\ As a result of these blasts, servicemembers and
veterans who are classified as polytraumatic often experience a
combination of amputations, spinal card injury (SCI), visual and
auditory impairments, brain injury, post traumatic stress disorder
(PTSD) and other catastrophic medical conditions. Patients presenting
with these types of injuries require a high level of provider
coordination, interdisciplinary clinical support and a wide range of
specialized services.
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\1\ R. Jesse, M.D., Ph.D., Acting Principal Deputy Under Secretary
for Health, Veterans Health Administration, Department of Veterans
Affairs; Testimony before the United States Senate Committee on Armed
Services; June 22, 2010.
\2\ D.X. Cifu, M.D., Acting National Director VHA PM&R Services,
Chief of PM&R Richmond VAMC; VA Polytrauma System of Care; PowerPoint
Presentation, November 3, 2009.
\3\ VA QUERI Fact Sheet; Polytrauma & Blast-Related Injuries; June
2010.
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As reported by the Army Office of the Surgeon General, from
September 2001 to January 12, 2009, there were 1,184 amputations in
personnel deployed to OIF and OEF, nearly three-quarters of which were
major amputations. IEDs caused 55 percent of the 1,184 OEF/OIF
amputations.\4\ Through our research we have found it difficult to come
up with a firm number representing the total number of severely wounded
from OEF/OIF as it appears that VA and Department of Defense (DoD)
track veterans and servicemembers separately, with VA using only the
number of servicemembers or veterans who have been treated in one of
its Polytrauma Centers. We suggest that VA and DoD collaborate to
provide an accurate accounting of the number of severely wounded, how
they classify a person in this category, where they were treated, as
well as their active duty or veteran status at time of accounting.
---------------------------------------------------------------------------
\4\ Institute of Medicine; Preliminary Assessment of Readjustment
Needs of Veterans, Servicemembers, and Their Families; Ch. 5, March 31,
2010.
---------------------------------------------------------------------------
In 2005, due to the number of polytrauma casualties from the wars
in Afghanistan and Iraq, VA expanded the scope of services available at
its existing VA TBI Centers to establish a more integrated, tiered
system of specialized, interdisciplinary care for polytrauma injuries
and TBI. Currently, VA operates four regional Polytrauma/TBI
Rehabilitation Centers (PRCs) that provide specialized inpatient
rehabilitation treatment and expanded clinical expertise in polytrauma.
The PRCs are located at VA medical centers in Minneapolis, Palo Alto,
Richmond, and Tampa, and a fifth PRC is currently being established in
San Antonio. These PRCs are the hub of the Polytrauma/TBI System of
Care, which includes four Polytrauma Transitional Rehabilitation
Programs that are co-located within the PRCs; 22 specialized outpatient
and subacute residential rehabilitation programs referred to as
Polytrauma Network Sites (PNS) that are geographically distributed
within each of the VA's 21 integrated service networks (VISNs)
including one at the VA medical center in San Juan, Puerto Rico. VA has
also reportedly designated Polytrauma Support Clinic Teams at smaller,
more remote VA facilities; and has established a point of contact and
referral at all other VA facilities.\5,\ \6\
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\5\ Wade, Sarah, Statement before House Veterans' Affairs
Subcommittee on Oversight and Investigations, April 28, 2009.
\6\ Lynch, Cheryl, Statement before House Veterans' Affairs
Subcommittee on Oversight and Investigations, April 28, 2009.
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Today's injured military servicemembers are experiencing higher
survival rates than in previous wars, with the overall survival rate
among wounded troops being about 90 percent. This increase is
attributed to the widespread use of body armor, improved battlefield
triage procedures and expedited medical evacuation.\7\ For a majority
of our wounded servicemembers, the first level of complex intervention
on their journey to a VA PRC normally occurs at the Landstuhl Regional
Medical Center in Germany, operated by the U.S. Army. Up until 2009, VA
received little to no information about wounded servicemember
transport, the full extent of the acute care process that
servicemembers had undergone, or the stress that these patients had
experienced before arriving at a VA PRC. However, in October of 2009, a
team of two VA physicians and two nurses from VA's Polytrauma System of
Care spent four days at Landstuhl to gather information and put a
system in place to establish a regular exchange of information between
medical teams in the military and VA's PRCs. The PRCs are now able to
track patients from the beginning of their journeys and can identify
medical complications much earlier. This system of coordination has
established a continuum of care that is not proprietary to the DoD or
VA, and has aided them to develop one system that benefits our wounded
personnel and veterans.\8\ We are pleased with this relatively new
development and believe it addressed one key area where gaps in care
were evident for those who were treated before its implementation at VA
PRCs.
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\7\ Institute of Medicine; Preliminary Assessment of Readjustment
Needs of Veterans, Servicemembers, and Their Families; Ch. 5, March 31,
2010.
\8\ Vanguard; Better Care for Wounded Warriors; Winter 2009/2010.
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Recently DAV National Commander Roberto ``Bobby'' Barrera visited
VA's PRC in Tampa, Florida. In meeting with injured servicemembers,
veterans and their families, our Commander received very positive
feedback about the level and coordination of care provided to severely
injured patients, and remarked on the high regard these families held
for the dedicated medical staff caring for their loved ones.
In preparing for this hearing, I had the opportunity to talk with
the father of a severely disabled servicemember who was injured nearly
nine months ago in Afghanistan and is now an inpatient at the Tampa
PRC. I was very pleased to learn that his impression, from the date of
his son's injury to the present, the care provided--initially in
Afghanistan, then in Landstuhl and subsequently in VA's PRC in Tampa,
was seamless. This father commented on the high level of coordination
of care and expert staff, in both VA and DoD, that was necessary and
existed every step of the way as his son was transported to the United
States and from Tampa to Walter Reed Army Medical Center (WRAMC) for
surgeries and returned to the Tampa PRC.
DAV was very pleased to hear this stellar report about DoD/VA
collaboration and coordination of care and acknowledge the dedicated
staff who created this critical system--to optimize care coordination
and transition of complex patients across the DoD and VA health care
systems. This helps to ensure every severely injured servicemember and
disabled veteran has the best care available, and reduces the burden
that families must endure during these extreme circumstances post-
injury of a loved one. I was pleased to learn that this particular
veteran is now beginning to communicate and walk--although it was
apparent that his recovery will be slow and he likely will require
years of surgeries, comprehensive rehabilitation, family support--and a
lifetime of attendance by VA.
In a March 2010 report, the Institute of Medicine (IOM) suggested
that more research and program development are needed to substantiate
the potential usefulness and cost-effectiveness of protocols in use for
the long-term management of TBI and polytrauma, including:
Prospective clinical surveillance to allow early
detection and intervention for health complications;
Protocols for preventive interventions that target
high-incidence or high-risk complications;
Protocols for training in self-management aimed at
improving health and well-being;
Access to medical care to treat complications; and
Access to rehabilitation services to optimize
functional abilities.\9\
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\9\ Institute of Medicine; Preliminary Assessment of Readjustment
Needs of Veterans, Servicemembers, and Their Families; Ch. 5, March 31,
2010.
According to the IOM, the array of potential health outcomes
associated with TBI suggests that injured servicemembers and veterans
will present long-term medical and psychosocial needs from the
persistent physical disability as well as cognitive deficits and
psychosocial problems that may develop in later life. Access to
rehabilitation therapies are essential--including psychological,
social, and vocational services. Although VA has established a
comprehensive system of rehabilitation services for polytrauma and
severe TBI patients that addresses acute and chronic needs that arise
in the initial months and years after injury--protocols and programs to
manage the devastating lifetime effects that many of these veterans
must live with are not in place and have not been studied for either
military or civilian populations. We concur with IOM that as in other
chronic health conditions, long-term management of TBI may be effective
in reducing mortality, morbidity, and associated costs of VA's caring
for this extraordinary population.\10\
---------------------------------------------------------------------------
\10\ Ibid.
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VA testified that in 2007 it developed and implemented Transitional
Rehabilitation Programs at each PRC. These facilities consist of 10-bed
residential units with a home-like environment to facilitate community
reintegration. The average stay is approximately 3 months in one of
these rehabilitation units. Other specialized services developed by VA
include the establishment of an Emerging Consciousness care path at the
four PRCs for severe TBI patients that are slow to recover
consciousness as well as a program to evaluate ocular health and visual
function.\11\ According to VA it has also developed policies regarding
comprehensive long-term care for post-acute TBI rehabilitation that
includes residential, community and home-based components utilizing
interdisciplinary treatment teams.\12\ However, in some cases it may be
difficult to find appropriate residential placement options for OEF/OIF
veteran patients who are ready for discharge from acute rehabilitation
but unable to return home. For many of these severely disabled young
men and women medical foster care or nursing home placement is not an
appropriate option. However, we are not aware of any age-appropriate,
government sponsored facilities for this unique younger patient
population with polytraumatic injuries and brain injury. These types of
facilities for long-term placement only exist in the private sector,
but again, they may not be appropriate placement options for a variety
of reasons. In this connection, DAV National Commander Barrera heard
about an extraordinary proposal called ``Heroes Ranch'' while on his
visit to the Tampa PRC.
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\11\ R. Jesse, M.D., Ph.D., Acting Principal Deputy Under Secretary
for Health, Veterans Health Administration, Department of Veterans
Affairs; Testimony before the United States Senate Committee on Armed
Services; June 22, 2010.
\12\ L. Beck, PhD., Chief Consultant, Office of Rehabilitation
Services, Office of Patient Services, Veterans Health Administration,
Department of Veterans Affairs; Testimony before the United States
Senate Committee on Veterans' Affairs; May 5, 2010.
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We understand that 85 acres of land is available for the proposed
Tampa-area Heroes Ranch--and would serve as a post-acute long-term care
residential brain injury facility for active duty military
servicemembers and veterans. The location of the land for the proposed
Ranch is approximately 15 miles from the Tampa VA PRC. This cutting
edge residence would serve the most severely injured--including
individuals in a vegetative state, patients with neurobehavioral
problems, and those persons that require a structured day program for
ongoing recovery after completing acute inpatient rehabilitation.
According to the proposal a three-tiered program would include:
1. Post-acute long-term care for patients in a state of
emerging consciousness who have completed twelve weeks of acute
inpatient TBI rehabilitation and whose families are not ready,
or are unavailable, to care for them at home;
2. Sub-acute residential rehabilitation in a safe environment
to treat patients with residual neurobehavioral issues; and
3. Outpatient day rehabilitation in a structured environment
for brain injured, neurologically and cognitively impaired
veterans.
To meet the long term needs of this unique population and the goal
of an interdisciplinary approach, resources would be needed to staff
the facility with a Medical Director to guide a team consisting of
psychiatrists, neuropsychologists, psychologists, physical therapists,
speech/cognitive therapists, recreational therapists, occupational
therapists, vocational counselors, psychosocial counselors, nursing
staff, nurse practitioners, physician assistants, living skills
advisors, social workers, administrative personnel, and family
therapists as well as support personnel, equipment and supplies.
We understand this proposal is pending consideration within VA but
not yet formally approved or funded. We ask that the Subcommittee
inquire about this exceptional idea in order to clarify VA's intent.
Clearly, an offsite VA therapeutic residential facility of this type is
needed to ensure the ongoing recovery of this uniquely and
catastrophically disabled veteran population, and as an aid to their
families. VA's mission is to provide leadership excellence for
therapeutic, rehabilitative, vocational, and recreational services to
sick and disabled veterans, and as a nation, it is our duty to ensure
that a proper life-time age appropriate care center is established
within VA for these men and women who courageously served the nation
and nearly made the ultimate sacrifice. DAV has testified in the past
before this Committee to support VA's development and deployment of
therapeutic residential care facilities for our newest war generation.
On May 7, 2007, Adrian Atizado, DAV Assistant National Legislative
Director, gave the following testimony:
Mr. Chairman, when we think of long-term care, we assume that
these programs are reserved for the oldest veterans, near the
end of life. Today, however, we confront a new population of
veterans in need of specialized forms of long-term care--a
population that will need comfort and care for decades. These
are the veterans suffering from poly-traumatic injuries and
traumatic brain injuries as a consequence of combat in Iraq and
Afghanistan. In discussion with VA officials, including
facility executives and clinicians now caring for some of these
injured veterans, it has become apparent to DAV and others in
our community that VA still needs to adapt its existing long-
term care programs to better meet the individualized needs of a
truly special and unique population, VA's existing programs
will not be satisfactory or sufficient in the long run. In that
regard, VA needs to plan to establish age-appropriate
residential facilities, and additional programs to support
these facilities, to meet the needs of this new population.
While the numbers of veterans sustaining these catastrophic
injuries are small, their needs are extraordinary. While today
they are under the close supervision of the Department of
Defense and its health agencies, their family members, and VA,
as years go by VA will become a more crucial part of their care
and social support system, and in many cases may need to
provide for their permanent living arrangements in an age-
appropriate therapeutic environment.
We are very pleased to see that at least one PRC, such planning for
these unique therapeutic residential facilities is now underway. We
strongly endorse the development of the facility in Tampa as well as
the establishment of similar facilities in other areas of the country
with concentrated populations of severely injured veterans with
polytrauma and TBI.
Another issue DAV is concerned about relates to family caregiver
needs and VA's pending implementation of the family support provisions
of Public Law 111-163, the Caregivers and Veterans Omnibus Health
Services Act of 2010. We ask the Subcommittee to provide oversight at
regular intervals to ensure VA is making progress to fully implement
all of the provisions in this important Act, and especially to move
forward rapidly on provisions that are uncomplicated (more flexible and
expanded respite services, for example). Caregivers of the severely
wounded have waited years for this important and comprehensive package
of services mandated in this precedent-setting legislation.
Likewise, although much of the knowledge DoD and VA have gained on
TBI is likely to transfer to the care of polytrauma patients, the
information needs of caregivers of patients with catastrophic injuries
may be distinct from those with TBI because the context, number and
severity of the injuries and the amount and type of medical information
required to treat them are more vast and complex. Similarly,
administrative information is complex because patients are often
involved in two, or sometimes three, health care and benefit systems
simultaneously, including DoD and TRICARE, VA, and private, contract
hospitals or clinics in their home communities. Research is needed to
assess the specific information needs of caregivers who face these
complexities.\13\
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\13\ J. M. Griffin, PhD, G. Friedemann-Sanchez, PhD, et al; JRRD;
Families of Patients with Polytrauma: Understanding the Evidence and
Charting a New Research Agenda; Vol. 46, No. 6, pp 879-892, 2009.
---------------------------------------------------------------------------
Furthermore, researchers suggest that few studies have been
conducted to determine the information needs of families based on
severity of injury, to determine the best timing and approach to
communicate information based on the patient's level of cognitive
functioning, or the best training for providers on communicating with
families who are grieving or angry about their loved one's conditions
and often-changing prospects for survival and recovery--especially
early on in this process. Family caregivers respond and adjust
differently depending on family composition, kinship to patient and
other factors. No research exists today that addresses different
information needs of family members, according to caregiver gender, on
polytrauma or TBI cases.\14\ We believe such research should be done on
a priority basis.
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\14\ Ibid.
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As required by section 1702 of Public Law 110-181, the National
Defense Authorization Act of 2008, and according to VA in testimony
earlier this year, VA has developed and implemented a national template
to ensure that it provides every veteran receiving inpatient or
outpatient treatment for TBI who requires ongoing rehabilitation, an
individualized rehabilitation and community reintegration plan. VA
integrates this national template into its electronic health record,
and includes in the record results of the comprehensive assessment,
measurable goals that were developed as a result of the plan, and
recommendations for specific rehabilitative treatments. The patient and
family participate in developing the treatment plan and are provided a
copy of the plan. According to VA, since April 2009, in consonance with
this mandate, 8,373 of these individualized plans have been completed
and filed for veterans who receive ongoing rehabilitative care in
VA.\15\
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\15\ L. Beck, PhD., Chief Consultant, Office of Rehabilitation
Services, Office of Patient Services, Veterans Health Administration,
Department of Veterans Affairs; Testimony before the United States
Senate Committee on Veterans' Affairs; May 5, 2010.
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Intervention studies that test the effectiveness of communication
strategies for families and caregivers of those with a TBI are almost
entirely absent, and these same gaps, therefore, probably occur in
cases of caregivers of patients with polytrauma. Currently, no
evidence-based guidelines have been developed on best practices for
communication and education to support the adaptation and adjustment of
families of patients with polytrauma across the continuum of treatment,
rehabilitation, and lifelong services.\16\ DAV believes these studies
should be done and the results of them distributed across the
Polytrauma System of Care.
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\16\ J. M. Griffin, PhD, G. Friedemann-Sanchez, PhD, et al; JRRD;
Families of Patients with Polytrauma: Understanding the Evidence and
Charting a New Research Agenda; Vol. 46, No. 6, pp 879-892, 2009
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While DAV believes great strides have been made over the past two
years, VA recently acknowledged embracing opportunities for further
improvement in its Polytrauma System of Care, and states the
Department's ongoing goals as follows:
1. Ensuring that blast-exposed veterans receive screenings and
evaluation for high-frequency, invisible sonic wounds that may
produce mild TBI, PTSD, and other psychiatric problems, or pain
and sensory loss;
2. Promoting identification and evaluation of potentially the
best practices for polytrauma rehabilitation, including those
that optimize care coordination and transition across care
systems and settings such as DoD and VA;
3. Optimizing the ability of caregivers and family members to
provide supportive assistance to veterans with impairments
resultant from polytrauma and blast-related injuries;
4. Identifying and testing methods for improving process of
care and outcomes, even when the evidence base is not well
established; and
5. Identifying and testing methods for measuring readiness to
implement and sustain practice improvements in polytrauma
care.\17\
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\17\ VA QUERI Fact Sheet; Polytrauma & Blast-Related Injuries; June
2010.
Historically, VA has focused its health care system on individual
veterans, often to the exclusion of the needs of their family members,
even including family caregivers. Thus, family-centered care is
relatively new in VA. In that regard we were pleased to learn that the
Minneapolis PRC, located at the Minneapolis VA Medical Center, has
participated in a six-month pilot program designed to embrace the
principles of family-centered care, and to include families as partners
in care delivery of their wounded loved ones. As a part of this pilot
program, a ``Family Care Map'' was created. The Family Care Map is a
web-based resource that helps families navigate the many layers of
information, ranging from where to find temporary lodging to locating
sources of personal counseling. Soon this Web site is expected to be
migrated to the main VA Web site for the VA Polytrauma System of Care
so that all PRC-involved families may benefit from access to
consolidated information to help them cope with these extraordinary
circumstances.\18\
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\18\ C. Hall, RN, PhD, CCDOR, Minneapolis VAMC; Second Annual
Trauma Spectrums Disorders Conference; VA Polytrauma Rehabilitation
Centers' Family Care Collaborative; December 10, 2009.
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We appreciate VA's efforts to standardize family-centered care and
improve communications for this population and urge VA to move forward
quickly to make this important information available to these families.
Overall, based on our monitoring of their progress and as reviewed in
this testimony, we believe that in most cases DoD and VA PRCs are
collaborating well with respect to the most severely injured and are
providing comprehensive, coordinated care in PRCs for this relatively
small population. However, DAV remains concerned about the gaps that
exist in the Federal Recovery Coordination Program and social work case
management essential to coordinating complex components of care for
polytrauma patients and their families. These gaps were highlighted by
disabled veterans and their families in hearings held by the House
Veterans' Affairs Subcommittee on Oversight and Investigation in 2009
and 2010 and warrant continued oversight and evaluation.
In testimony VA, reported the development and implementation of its
``TBI Screening and Evaluation Program'' for all OEF/OIF veterans who
receive care within VA. According to VA, from April 2007 through March
2010:
408,474 OEF/OIF veterans were screened for possible
TBI;
56,161 who screened positive were evaluated and
received follow-up care and services appropriate to their
diagnosis and their symptoms;
30,368 were confirmed with a diagnosis of mild TBI;
and
Over 90 percent of all veterans who were screened
were determined not to have TBI, but all who screened positive
and completed a comprehensive evaluation were referred for
appropriate treatment.\19\
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\19\ R. Jesse, M.D., Ph.D., Acting Principal Deputy Under Secretary
for Health, Veterans Health Administration, Department of Veterans
Affairs; Testimony before the United States Senate Committee on Armed
Services; June 22, 2010.
In 2009, VA and DoD collaboratively developed a clinical practice
guideline for mild TBI and deployed this methodology to health care
providers in both systems, and provided other recommendations as well
in the areas of cognitive rehabilitation, driver training, and the
management of the comorbidities of mild TBI, posttraumatic stress
disorder (PTSD) and pain. Also, the 2009 VA-led collaboration with DoD
and the National Center for Health Statistics produced revisions to the
International Classification of Diseases, Clinical Modification (ICD-9-
CM) diagnostic codes for TBI, resulting in significant improvements in
the identification, classification, tracking, and reporting of TBI and
its associated symptoms.\20\ These are late-arriving, but welcome,
improvements during the sunsetting of our wars overseas. As more and
more veterans are being identified with mild to moderate TBI, some
several years after-the-fact, VA appears to be making progress, but we
are concerned it may still lack a robust universal system of treatment
and care for this population.
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\20\ Ibid.
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Although there are not definitive numbers on how many veterans may
need specialized services for mild to moderate TBI in the next five
years--the findings from initial studies, articles and reports on these
conditions, including PTSD and other post-deployment mental health
issues, and VA's current workload based on preliminary mental health
and TBI screening numbers for OEF/OIF veterans indicate that in the
near future, VA will likely be confronted with a significant population
seeking care. To this regard, DAV remains concerned that screening and
treatment of veterans with mild-to-moderate TBI in medical centers
outside the five designated VA PRCs may not be receiving a commensurate
level of additional VA resources they may need to fully assess and care
for these injured veterans. Based on our discussion with VA staff some
non-PRC sites may struggle to provide timely access to care,
comprehensive evaluations, treatment and support for this particular
patient population. We ask the Subcommittee through its oversight of
VA's specialized programs to make inquiry to ensure that sufficient
resources and staff to accomplish this mission has been provided to
non-PRC sites for treatment of mild-to-moderate TBI cases.
We also ask the Subcommittee to evaluate VA's current approaches
and plans to ensure the care for those with mild-to-moderate TBI
receive commensurate attention from VA, in contrast to the overwhelming
response to the severely injured being cared for in PRC sites. We
believe the situation and potential demand warrants an independent
evaluation of its outpatient TBI programs. VA TBI specialists with whom
we have consulted believe a new ``dual track'' specialized program is
necessary to meet the individualized needs of veterans with mild-to-
moderate TBI residuals accompanied by PTSD. It is likely more
resources, staffing, training, research and education will be necessary
to stand up effective programs to reliably deliver this type of
appropriate interdisciplinary care.
Mr. Chairman, in summary, DAV has concluded that DoD and VA have
done a commendable job in saving the lives of, and addressing the
catastrophic medical, surgical and rehabilitative needs of a new
generation of severely disabled American war veterans, but we note that
recent progress was years in the making. We hope VA will now turn its
attention to the unmet needs of thousands of veterans with less life
threatening but troubling injuries to the brain caused by war that are
still little understood but in need of appropriate attention. We also
urge VA to move forward swiftly in establishing needed therapeutic
residential rehabilitation facilities modeled on the Tampa proposal for
the sustained and unique care of the most severely injured OEF/OIF
veterans who will not easily or possibly ever be able to return to
their homes.
Mr. Chairman, this concludes my statement on behalf of DAV. I would
be pleased to address your questions, or those of other Subcommittee
members.
Prepared Statement of Tom Tarantino, Legislative
Associate, Iraq and Afghanistan Veterans of America
Mr. Chairman, Ranking Member, and members of the subcommittee, on
behalf of Iraq and Afghanistan Veterans of America's one hundred and
ninety thousand members and supporters, I would like to thank you for
allowing us testify before your subcommittee on ``Healing the of
Physical Injuries of War.''
``Veterans need to know that their country will continue to
take care of their service-related injuries. A servicemember's
body pays a heavy toll from the high physical demands of
deployments. It's more than just paying disability claims, it's
a back or knee that starts to cause problems for a middle-aged
man because he spent four years humping with a pack and
patrolling with 60 lbs of gear.''--IAVA Veteran
My name is Tom Tarantino and I am a Legislative Associate with
IAVA. I proudly served 10 years in the Army beginning my career as an
enlisted Reservist, and leaving service as an Active Duty Cavalry
Officer. During these ten years, my single most important duty was to
take care of other soldiers. In the military they teach us to have each
other's backs. And although my uniform is now a suit and tie, I am
proud to work with this Congress to continue to have the backs of
America's servicemembers and veterans.
Over the past few years this Committee has helped secure impressive
improvements to the VA health care system. For the first time in over
twenty years, the VA now has a timely and fully funded budget that will
end the practice of rationing health care services. The VA is
developing a virtual lifetime service record that will seamlessly
transition a veteran's health record from DoD to the VA, ensuring a
higher quality of care. Female veterans can now receive postnatal care
for their newborn babies, and family caregivers of severely wounded
veterans will have the training and assistance they need to support
their loved ones. Thank you for all the work this Committee has done
and will continue to do in the months and years to come.
Specifically, we look forward to the work this Committee will do to
continue to improve VA health care. The VA is the largest health care
provider in the nation, and overall, it provides much higher quality of
care than the nation's private sector hospitals. The pressing problem
with the VA health care system is not the quality of care, but a lack
of access to the system. In order to continue to improve on both the
quality of care and access to the system, IAVA fully supports all of
the recommendations contained in this year's Independent Budget that
address issues related to specialized services, access to care,
invisible wounds, prosthetics, long term-care, finance and
administration. IAVA would like to focus our testimony on just few of
those key issues as they relate to Iraq and Afghanistan veterans
seeking treatment for combat injuries, especially Traumatic Brain
Injury.
We asked our members what they thought of the treatment they were
receiving at the VA and we received a wide range of opinions, both
complimentary and critical. However, several common themes appeared: 1)
Long waits for quality appointments 2) Rude administrative staff 3)
Growing distrust of VA health care 4) Long drives to VA facilities. We
received only a few complaints about the actual quality of care at the
VA.
I. Rethink and adapt the VA's rehabilitation practices for wounds of
the wars in Iraq and Afghanistan
Traumatic Brain Injury (TBI) is the signature wound of the wars in
Iraq and Afghanistan. To properly treat these returning combat veterans
with mild to severe TBI, the VA must completely rethink and adapt their
medical rehabilitation practices just as the DoD has had to adapt to
fight an unconventional war against insurgents.
``I suffered a TBI in Iraq and now have PTSD. Due to my
symptoms, I lost my job, my family, my self-respect and for a
time, my freedom! I have had to swallow my pride and accept
Government assistance. I would rather work but the jobs I might
be able to hold for a short time pay so little I would not be
able to visit and take care of my sons. At times I feel like a
complete failure.''--IAVA Veteran
As our friends over at Wounded Warrior Project (WWP) have stated,
any successful rehabilitation of a veteran suffering from TBI ``must be
veteran-centered.'' This means ensuring that all TBI patients are given
a thoughtful individualized rehabilitation plan that is thorough and
honest about what the VA can and cannot provide. Any rehabilitation
plan must include the veteran's family as a core component to
rehabilitation.
``After my wife straightened out the VA doctors and fired a
few, I finally got a doctor that truly listens and does what
needs to be done to make sure I have what I need. She spends
time talking with me and my wife. Some of the doctors have a
problem talking with my wife, but I have a TBI and I don't
understand things well and she explains them to me and makes
sure I do as I am suppose to. She is my caregiver and my best
friend. She advocates for me and does whatever she has to, to
make the doctor understand me, and vice versa.''--IAVA Veteran
IAVA is concerned that the VA has limited or denied access to some
veterans seeking recovery services for Traumatic Brain Injury. Current
statute requires that the VA provide services to ``restore'' function
to wounded veterans.\1\ Full recovery should always be the desired
outcome for a rehabilitation plan. However, sustaining current
functions or preventing future harm should also warrant access to VA
services. I have no doubt that the members of this committee agree that
the VA's role isn't just to help those who might get better, but it
also to help those who might get worse. IAVA recommends adjusting these
statutes to embrace the realities of injuries like TBI. Veterans should
be able to focus more on recovery then fighting with the VA.
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\1\ ``such professional, counseling, and guidance services and
treatment programs as are necessary to restore, to the maximum extent
possible, the physical, mental, and psychological functioning of an ill
or disabled person.'' 38 U.S.C. 1701(8).
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``I have a possible traumatic brain injury or it could be PTSD but
whatever it is, there is no way I could sit there and try and read
through 10 pages of legal speak. Believe me I tried. Even if I read
through all of it, I have no idea what I am reading cause I can't focus
on anything.''--IAVA Veteran
II. I have to wait how long to see a VA doctor?
Among IAVA members seeking services at the VA, the single most
common complaint is how long it takes to schedule an appointment.
``I did visit the VA, but will not again. Sorry to say, but
the process to get an appointment is impossible. I had to get
an appointment to get an appointment. What I mean is this--It
took 3 weeks to get an appointment to see a nurse who assessed
my injury, then she made an appointment to for me to see a
doctor about my injury for 3 weeks later. By the time I was
able to see a doctor, it was over 6 weeks. I lost 2 days of
work. It seems like the process is set up to discourage patient
care.''--IAVA Veteran
When veterans began returning home from Iraq and Afghanistan, the
VA was caught unprepared, with a serious shortage of staff and an
exceedingly inadequate budget. Wait times varied regionally, but for
some patients, lasted six months or more. The problems weren't limited
to primary care along; the backlog was especially severe for veterans
seeking mental health treatment. In recent years, wait times for
primary and specialty care at the VA have improved, but approximately 8
percent of patients--or more than 450,000 veterans--are still waiting
more than 30 days for their desired appointments, according to the
VA.\2\ Moreover, the VA's Inspector General suggests that wait may be
even longer than the VA admits. And there are still some veterans who
have ``to wait on the phone for 2+ hours to speak with someone to set
an appointment with [a] primary care physician that ends up being 4-6
weeks away from the date of my call.'' Even when veterans are able to
schedule an appointment, many times they still have to sit around the
hospital for hours once they arrive because the VA ``booked 20 patients
during a 2 hour window.''
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\2\ VA Performance and Accountability Report, FY 2009, p. II- 145.
---------------------------------------------------------------------------
For veterans, long wait times mean that they may have to suffer for
months until their next appointment or opt for not receiving the care
they need at all.
``Ortho is a nightmare. I had to schedule a cortisone shot 2
\1/2\ months in advance, even though my shoulder was in pain
now.''--IAVA Veteran
Just as the VA is working to address the VA disability backlog, the
VA must continue attacking the issue of long appointment wait times. As
recommended in the Independent Budget, the solution involves improved
tracking, a completely revamped scheduling IT system and an increase in
the number of medical providers in critical areas. To this end, IAVA
supports the following recommendations from the Independent Budget:
The Veterans Health Administration should make
external comparisons to measure its performance in providing
timely access to care.
The VHA should fully implement complementary aspects
of the Institute for Health care Improvement's Advanced Clinic
Access principles and measures for primary and specialty care
to maximize productivity of clinical care resources by
identifying additional high-volume clinics that could benefit.
VA should consider implementing complementary
recommendations contained in the Booz Allen Hamilton report
Patient Scheduling and Waiting Times Measurement Improvement
Study.
The VHA should certify the validity and quality of
waiting time data from its 50 high-volume clinics to measure
the performance of networks and facilities.
The VHA should complete implementation of the eight
recommendations for corrective action identified in the July 8,
2005 report by the VA Office of Inspector General.
VA must ensure that schedulers receive adequate
annual training on scheduling policies and practices in
accordance with the OIG's recommendations.
III. How far is too far to drive?
Some veterans have to drive for an ``entire day to get to their
local VA facility'' and IAVA is concerned that the VA has yet to
develop a consistent and humane policy for answering an age old
question, ``How far is too far to make a veteran drive to the VA?''
About 3 million veterans, or 37.8 percent of veterans enrolled in the
VA system, reside in rural areas,\3\ and as of 2003, ``more than 25
percent of veterans enrolled in VA health care--over 1.7 million-- live
over 60 minutes driving time from a VA hospital.'' \4\
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\3\ U.S. Department of Veterans Affairs, ``About Rural Veterans:
Common Challenges Faced by Rural Veterans,'' January 6, 2010: http://
www.ruralhealth.va.gov/RURALHEALTH/About_Rural_Veterans.asp.
\4\ GAO-03-756T, ``Department of Veterans Affairs: Key Management
Challenges in Health and Disability Programs,'' May 8, 2003, p. 6:
http://www.gao.gov/new. items/d03756t.pdf.
``I have an obvious service related injury that I receive a
prescription for (Celebrex for a knee that was injured by IED)
. . . rather than give me a referral to a local orthopedist in
town, they wanted me to drive 5.5 hours to Tucson, which I
could not do because of a busy work schedule. The whole process
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is very slow and cumbersome.''--IAVA Veteran
IAVA acknowledges that the VA can't always be a short drive from
every veteran. However, we believe that the VA should issue clear
guidelines for when a veteran lives too far from a local VA facility.
These veterans should be given the choice to continue using the VA or
access more convenient local medical care.
``My main concern with the VA health care system is distance.
We only have an outpatient clinic here and if I need anything
more than a flu shot, I have to drive 125 miles to the nearest
VA hospital.''--IAVA Veteran
IAVA also believes that the VA should assist veterans who need to
drive to their appointment or need a ride. IAVA recommends that that
the VA should (1) Promote, oversee, and evaluate a pilot program that
provides a network of drivers for veterans struggling to find
transportation to the nearest VA hospital and (2) Provide a lodging
stipend and mileage reimbursement for veterans forced to travel long
distances for VA medical care, comparable to the stipend paid to VA
employees when they travel.
``For anything dental or surgical I have to travel 2 hours and
often times for appointments that don't last 30 minutes.
Additionally, because I don't qualify for travel pay, I often
have to ask social workers for gas cards. The SWs appear to be
annoyed by me whenever I ask for their assistance in obtaining
gas cards.''--IAVA Veteran
IV. ``I hear the VA is a nightmare.''
Some of our members openly fear the VA. Recent media reports about
HIV and Hepatitis exposure have only served to fuel that fire. A
veteran returning home from Afghanistan who reads about his or her
battle buddies being exposed to infectious diseases while being treated
at the local VA will likely think twice before seeking the care s/he
needs.
``As a Navy Hospital Corpsman who has worked in a VA hospital
I am nervous about care provided by the VA.''--IAVA Veteran
Whether or not these fears are warranted is a topic for another
hearing, but the end result is still the same, VA health care has a
public relations problem. Until the VA adequately addresses this issue
many combat veterans will be weary to seek treatment. IAVA believes
that the VA must address this issue head on by owning the mistake,
doing everything in their power to take care of those affected and then
redoubling efforts to make sure proper medical procedures are followed
at other facilities.
What we don't want to see are stories like the saga of Judy
Yarzebinski. After being treated at a local VA she was notified that
she had been exposed to dirty equipment. Sadly she tested positive for
hepatitis C and due to other medical issues cannot be treated for it.
Judy will now have to live with fevers, headaches, fatigue, loss of
appetite, nausea, vomiting, and diarrhea for the rest of her life. To
make matters worse the VA now denies having caused the exposure in the
first place. Public battles such as this are exactly what make weary
veterans reluctant to seek out VA care.
IAVA believes that in order for the VA to conduct effective
outreach, it must centralize its efforts between VHA, VBA, and NCA and
aggressively re-brand itself 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, and
re-brand itself to the American people.
The Department of Veterans Affairs must develop a relationship with
servicemembers while they are still in the service. Like many
successful college alumni associations that greet students at
orientation and put on student programs throughout their time in
college, the VA must shed its passive persona and start recruiting
veterans and their families more aggressively into VA programs. Once a
veteran leaves the military, the VA should create a regular means of
communicating with veterans about events, benefits, programs and
opportunities. IAVA is encouraged by the development of the Veterans
Relationship Manager. Leveraging modern technology to develop a single
means of communication between all sectors of the VA and a veteran is a
step in the right direction. If a veteran received half as many letters
and emails from the VA, as college grads do from their alumni
association, we would be getting somewhere.
To assist in building this relationship IAVA recommends
automatically enrolling all troops leaving active-duty service, whether
from the active or reserve component, in VA health care.
``Getting a VA card AND being vested (and what vested means)
is a great way to prepare, even for those who work and have
their own insurance, in case of lay off or other emergency.''--
IAVA Veteran
In addition to providing a more seamless transition for separating
combat veterans, automatic enrollment will cement the relationship
between the VA and veterans.
Overall the VA continues to provide good care to our nation's
veterans. However, we must continue to strive for better. In the
military, they teach us to never stop improving our fighting position
and be forever vigilant. It is this proactive ethos that continues to
lead to victory on the battlefield. If we are to honor the service and
sacrifice of America's warriors, we must instill this spirit in all of
the services that we develop to care for them. No one program or piece
of technology will solve these problems, but together we can ensure
that the citizens of this country have a system of care that honors the
freedoms that we enjoy and care for those who have sacrificed blood and
limb on our behalf.
Prepared Statement of Denise A. Williams, Assistant
Director for Health Policy, 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 the Department of Veterans Affairs (VA) efforts in caring for
the severely injured servicemembers from Operation Enduring Freedom
(OEF) and Operation Iraqi Freedom (OIF).
The current Global War on Terror (GWOT) has introduced more
sophisticated forms of weaponry than in previous conflicts. As a
result, our servicemembers are sustaining severe and unique wounds. The
Department of Defense (DoD), reports that as of April 3, 2010, a total
of 8,810 servicemembers have been wounded in action during OIF and
2,038 have been wounded in action during OEF. Servicemembers are
surviving their wounds in considerably higher numbers because of
advancements in body armor, helmets, and improved battlefield medical
care. Currently the survival rate for wounded servicemembers is about
90 percent due to these improvements in equipment and the timely and
effective application of emergency medical treatment. The improvised
explosive device (IED) is the weapon of choice for our enemy, and is
insidious in its utilization and often even more devastating in its
long-term effects than gunshots due to the multiple and terrible wounds
and burns it produces. These devices have resulted in amputations,
Traumatic Brain Injuries (TBI), spinal cord injuries, and blindness.
Amputation: Prosthetics and Sensory Aids
The United States military operations in Iraq and Afghanistan have
produced a significant number of service men and women with
amputations. According to the DoD as of April 3, 2010, there has been a
total of 1552 servicemembers that suffered amputations. This unique
population of younger servicemembers requires extraordinary medical
care and rehabilitation. Walter Reed Army Medical Center (WRAMC), among
many DoD facilities dedicated to assisting wounded warriors, has highly
advanced programs to care for warriors with amputations. In addition,
there is an array of specialty physicians, rehabilitation,
psychological support groups, recreation sports group, and vocational
counselors. Once these servicemembers transition from the military to
the civilian world, their care is essentially in the hands of the
Veterans Health Administration (VHA). In response to the large number
of veterans with prosthetics and rehabilitative needs, VA established
Polytrauma Rehabilitation Centers (PRC). The VA Polytrauma
Rehabilitation Centers provide treatment through multi-disciplinary
medical teams including Cardiologists, Internal Medicine, Physical
Therapist, social work and Transition Patient Case managers and much
more specialty medical service areas, to help treat the multiple
injuries. Currently, VA maintains four VA Polytrauma Rehabilitation
Centers in Richmond, VA; Minneapolis, MN; Palo Alto, CA and Tampa, FL.
However, the American Legion is concerned about VA's ability to
consistently meet the long term needs of these young veterans. As
stated by the Military Medicine Journal, rehabilitation is a crucial
step in optimizing long-term function and quality of life after
amputation. Although returning veterans with combat-related amputations
may be getting the best in rehabilitative care and technology
available, their expected long term health outcomes are considerably
less clear. It is imperative that both DoD and VA clinicians seriously
consider the issues associated with combat-related amputees and try to
alleviate any foreseeable problems that these OIF/OEF amputees may face
in the future. The Military Medicine Journal further cautioned that
research findings indicate that traumatic lower-limb amputees,
particularly bilateral transfemoral amputees, are vulnerable to a
number of health risks including Cardio Vascular Disease (CVD) and
Ischemic Heart Disease (IHD). Considering these facts, The American
Legion recommends that VA conducts further research on this matter to
stay ahead of the curve and counter any long-term issues these veterans
may encounter as they get older.
The VA has made great strides in addressing the increased influx of
young veterans with amputations. However, it has been reported that VA
does not have the state-of-the art prostheses available in comparison
to the Department of Defense. That is why it is of utmost importance
that VA receives the adequate funding to ensure that all VA medical
centers are fully equipped to address these veterans' prosthetic needs.
This is especially vital for the veterans that reside in rural and
highly rural areas. It would be a grave disservice to these veterans if
they have to bear the burden of travelling hundreds of miles in order
to receive health care in addition to enduring their debilitating
condition. The American Legion applauds VA on the establishment of the
Prosthetics Women's Workgroup to enhance the care of female veterans in
regard to their prosthetics requirements. Despite this implementation,
there are still cases where the fitting of the prostheses for women
veterans has presented problems due to their smaller physique. The
American Legion urges VA to increase their focus on amputation and
prosthetics research programs in order to enhance and create innovative
means to address this population of veterans' health care needs.
Polytrauma Centers
The VA has designated five VA Medical Centers as Polytrauma
Rehabilitation Centers (PRC). These centers provide specialized care
for returning servicemembers and veterans who suffer from multiple and
severe injuries. They also provide specialized rehabilitation to help
injured servicemembers or veterans optimize their level of independence
and functionality. In addition to the four centers mentioned above,
there is a fifth center currently under construction in San Antonio,
TX. In addition to the five designated sites, VA has established 18
Polytrauma Network Sites (PNS); one in each Veterans Integrated Service
Network (VISNs); and approximately 81 Polytrauma Support Clinic Teams
to augment the care of those with severe/multiple injuries.
The Veterans Health Administration defines polytrauma as two or
more injuries sustained in the same incident that affect multiple body
parts or organ systems and result in physical, cognitive,
psychological, or psychosocial impairments and functional disabilities.
During our ``System Worth Saving'' site visits to the Polytrauma
centers some facilities reported that there were staffing shortages in
certain specialty areas such as: physical medicine and rehabilitation,
speech and language pathology, physical therapy, and certified
rehabilitation nursing. This was attributed to the competitive salaries
being offered for these positions in the private sector. Considering
the complex nature of these severely wounded veterans The American
Legion finds this unacceptable. The Department of Veterans Affairs
needs to step up their recruiting efforts in these areas so that in the
future these veterans are not faced with the dilemma of going outside
of the VA for care.
Blind Rehabilitation
There are currently 49,460 blind veterans enrolled in the VA health
care system and that number is expected to increase because of the
number of eye injuries in Iraq and Afghanistan. The Department of
Defense reports that in the current conflict, eye injuries account for
13 percent of all injuries. The American Academy of Ophthalmology
reports that eye injuries are a very common form of morbidity in a
combat environment. Although effective counter measures have been
developed to protect some parts of the human body against the effects
of IEDs, such as body armor to protect the chest and abdomen, and
helmets which protect the brain, there are no proven counter measures
effective for protection of the eyes which will not impair visual
requirements. Consequently, many warriors who survive blasts now face a
future with terrible burns, amputations, and blindness.
The Department of Defense does not provide rehabilitation for
blindness. Unlike other injuries where after rehabilitation warriors
may be retained and continue service, blinded warriors are medically
discharged and are relegated to utilizing the VA for their
rehabilitative needs. Currently VA employs about 155 Visual Impairment
Service Team (VIST) Coordinators and 73 Blind Rehabilitation Outpatient
Specialists (BROS). Given the prediction that the number of blinded
veterans is expected to increase over the next several years, The
American Legion urges VA to recruit more specialists to fill this gap.
In addition, VA has a long history of providing inpatient and
outpatient care for blind veterans. However, this has been for the
older veteran population with visual impairment or blindness due to
their age. Mr. Chairman, The American Legion would like to encourage VA
to continue to modernize their overall rehabilitation programs and
approach in order to help these newly blinded and younger veterans meet
and overcome the challenges of visual impairment.
Section 1623 of the National Defense Authorization Act of 2008
requires DoD to establish a Center of Excellence (COE) in the
prevention, diagnosis, treatment, and rehabilitation of eye injuries
and for DoD to collaborate with VA on all matters pertaining to the
center. In addition, Section 1623 directs DoD and VA to implement a
joint program on traumatic brain injury post traumatic visual syndrome,
including vision screening, diagnosis, rehabilitative management, and
vision research. Unfortunately, the center has yet to be fully
established because of constant funding delays and bureaucratic
hurdles. The American Legion calls for immediate action from the
Secretary of Defense and the Secretary of VA to rectify this important
issue.
Spinal Cord Injury Centers
As with most serious injuries, spinal cord injury is a life-
altering and chronic condition that can affect an individual's
independence, sense of self worth, and create additional health
problems. The Veterans Health Administration reported that since Fiscal
Year 2003, they have treated a total of 503 active duty servicemembers
at their Spinal Cord Injury (SCI) Centers and of that number 162
sustained their injury in combat. The Veterans Health Administration is
the largest health care system to care for spinal cord injuries. VA has
a total of 24 SCI centers throughout the country and they serve about
14,000 veterans annually. The Journal of Women's Health reports that
spinal cord injury patients are at a greater risk of having chronic
conditions, especially as they get older. It is important that VA
receives sufficient funding to ensure adequate staffing at these
facilities to provide the necessary long-term care to these veterans.
Mr. Chairman and Members of the Subcommittee, the American Legion
sincerely appreciates the opportunity to submit testimony and looks
forward to working with you and your colleagues on these important
issues.
That concludes my written statement and I would welcome any
questions you may have.
Prepared Statement of Jack Smith, M.D., MMM, Acting Deputy
Assistant Secretary for Clinical and Program Policy,
U.S. Department of Defense
Introduction
Chairman Michaud, Congressman Brown, distinguished Members of the
Subcommittee, thank you for the opportunity to appear here to talk to
you about the Department of Defense's (DoD) medical care for physical
injuries in combat. On behalf of DoD, I want to take this opportunity
to thank you for your continued support and demonstrated commitment to
our servicemembers, veterans, and their families. Today, I will
describe some of the aspects of DoD medical care for severely injured
servicemembers who have returned from Operation Iraqi Freedom (OIF) and
Operation Enduring Freedom (OEF).
On October 16, 2009, Secretary of Defense Gates stated ``Beyond
waging the wars we are in, treatment of our wounded, their continuing
care, and eventual reintegration into everyday life is my highest
priority. I consider this a solemn pact between those who have risked
and suffered and the nation that owes them its eternal gratitude.'' We
who work in military medicine completely agree with Secretary Gates.
Prevalence of Injuries in OIF and OEF
Over the last nine years, a new era of combat has emerged in which
our servicemembers are constantly challenged by the demands of a high
operational tempo. More than 2.1 million servicemembers have deployed
to OEF and OIF from October 2001 to May 30, 2010. Of those, 31,882 were
wounded in action in OIF, and 6,773 were wounded in action in OEF. A
total of 61,874 servicemembers have been transported out of Iraq and
Afghanistan to receive medical care. Of those who were transported, 18
percent were for battle injuries, 21 percent were for non-battle
injuries (such as motor vehicle injuries), and 61 percent were for
diseases.
DoD Care for Polytrauma
Severely injured servicemembers often require prolonged and
intensive medical treatment and rehabilitative care. DoD has addressed
this challenge by establishing specialty centers of excellence. DoD
also has strengthened its partnership with the Department of Veterans
Affairs, including with the four Polytrauma Rehabilitation Centers.
Servicemembers who sustain severe injuries require complex, well-
integrated care from a variety of medical specialties, which DoD
provides at centers that specialize in providing care for combat
trauma.
Key components of DoD health care for severely injured
servicemembers include three DoD amputee care centers, the Brooke Army
Medical Center Burn Center, and the Defense and Veterans Brain Injury
Center. DoD has established three major centers that specialize in the
treatment and rehabilitation of combat injuries. The Military Advanced
Training Center at Walter Reed Army Medical Center opened in 2007 to
provide optimal amputation care and prosthetics. The Center for the
Intrepid at Brooke Army Medical Center opened in January 2007 in San
Antonio to provide state-of-the-art rehabilitation for servicemembers
with amputations or severe burns. The Comprehensive Combat and Complex
Casualty Care Center at the Naval Medical Center San Diego has a
similar mission; and its mission and infrastructure were expanded in
2007. Each of these three trauma care centers provides orthopedic
surgery, reconstructive plastic surgery, amputee care and prosthetics,
and care for traumatic brain injuries (TBI) and post-traumatic stress
disorder.
DoD has long been a leader in research on improved treatments for
traumatic injuries. The U.S. Army Institute of Surgical Research
(USAISR) is located at the Brooke Army Medical Center in Texas. USAISR
is dedicated to both laboratory and clinical trauma research. Its
mission is to discover new treatments for combat casualty care for
injured servicemembers across the full spectrum of military operations.
In addition, USAISR is involved in providing state-of-the-art trauma,
burn, and critical care to servicemembers around the world and to
civilians in the local community. Brooke Army Medical Center has a
world class burn care center, and it is considered one of the world's
leaders in burn care research.
The Defense and Veterans Brain Injury Center (DVBIC) was
established in 1992 to provide state-of-the-art care for servicemembers
who were diagnosed with traumatic brain injuries (TBIs). TBI is often
part of the spectrum of polytrauma, which includes spinal cord
injuries, amputations, and visual and hearing impairment. DVBIC serves
servicemembers and veterans with TBI and their families, through state-
of-the-art medical care, and through innovative clinical research and
educational programs. DVBIC has established several specialized
centers, including centers at the Walter Reed Army Medical Center,
Naval Medical Center San Diego, and San Antonio Military Medical
Center. For polytrauma patients who have sustained a TBI, DVBIC is part
of the comprehensive medical team, coordinating and contributing to
multidisciplinary treatment. Through a network of TBI Regional Care
Coordinators, DVBIC also assists in coordinating servicemember
transitions as they move among different systems of care, including
between military medical treatment facilities, Department of Veterans
Affairs (VA) Polytrauma Centers, and local community care.
DoD has established three Centers of Excellence focused on hearing
impairment, vision impairment, and extremity injuries and amputations.
These centers collaborate to the maximum extent practicable with VA,
institutions of higher education, and other appropriate public and
private entities (U.S. and international) to carry out their
responsibilities. In addition, they are working together to create
registries that will enable them to document injuries and follow
treatments of servicemembers suffering eye, ear, or extremity injuries.
These centers augment the work of the Defense Centers of Excellence for
Psychological Health and Traumatic Brain Injury (DCoE), which was
established in 2007. The DCoE offers a central coordinating point for
activities related to traumatic brain injuries and psychological
health. DCoE focuses on the full continuum of medical care and
prevention to enhance coordination among the Services, Federal
agencies, and civilian medical organizations.
DoD Extremity and Amputation Center of Excellence
The DoD Extremity and Amputation Center of Excellence (EACE) was
approved for establishment in May 2010 pending final agreements with
VA, but it has been working since early 2009 to serve as the lead
organization for identifying policy issues, providing direction and
oversight of a multidisciplinary network for care, and research on
traumatic amputations and extremity injuries. The EACE will promote
excellence in the research, diagnosis, treatment, and rehabilitation of
traumatic injuries; and its vision is to assist servicemembers as they
return to the highest possible levels of physical and psychological
functioning. The EACE will oversee medical care from the time of injury
through definitive care and rehabilitation to reduce disability and
optimize the quality of life of servicemembers and veterans. EACE
services will include rehabilitation, in collaboration with the VA.
EACE will include several affiliated regional centers, including the
three DoD amputee centers, and the VA Polytrauma Rehabilitation
Centers.
DoD Vision Center of Excellence
The DoD Vision Center of Excellence (VCE) was formally established
in May 2010 with the Navy as the Lead Component, but it has been
working since 2008 to provide leadership in the prevention, diagnosis,
treatment, and rehabilitation of eye injuries.
VA has provided the deputy director for this center. The VCE will
provide clinical support for the full scope of military eye care,
treatment, and research; and it will provide clinical education
programs on eye injuries in servicemembers for both the DoD and VA.
Servicemembers can experience vision problems through a variety of
mechanisms: trauma from explosions and projectiles, vision
abnormalities secondary to TBI, and eye injuries from chemical hazards,
biological hazards, or extreme environmental conditions. The VCE is
working with VA to coordinate transition of medical care. For example,
a collaborative process has been developed at Walter Reed Army Medical
Center for servicemembers to receive blind rehabilitation care from VA
while they are still receiving DoD care. The VCE is involved in several
innovative research projects, including evaluating treatments for blast
and burn injuries to eye structures and treatments for TBI-associated
visual problems. The VCE is planning to establish four Regional
Clinical Centers for Ocular Disease and Trauma at military medical
centers that have ophthalmology residency training programs. The VCE
recently added two VA staff members with expertise in Blind
Rehabilitation and Low Vision Research; they will work closely with the
VA Blind Rehabilitation Centers and Polytrauma Centers in tracking and
caring for patients with eye and vision injuries across the DoD and VA
continuum of care. In addition, there are several research centers in
DoD and VA that are collaborating with the VCE.
DoD Hearing Center of Excellence
The Hearing Center of Excellence (HCE) also was established in May
2010, but has been working since early 2009 to promote excellence in
the prevention, diagnosis, treatment, and rehabilitation of hearing
loss and injuries of the vestibular system in servicemembers and
veterans. The Air Force is the Lead Component for this center. The
scope of the HCE includes hearing loss, tinnitus, and problems with
balance and equilibrium, which could be due to injuries from blasts,
blunt trauma, barotrauma, and high noise levels. Hearing loss is very
frequent in veterans, and hearing loss and tinnitus are the top two
diseases in terms of VA disability compensation. In addition, vertigo
and dizziness are common symptoms in patients with TBI. There is close
collaboration with affiliated Regional Centers for Otologic Disease and
Trauma at several military and VA hospitals, including Walter Reed Army
Medical Center, Naval Medical Center San Diego, and Madigan Army
Medical Center in Tacoma, WA. In addition, there are several research
centers in DoD and VA that are collaborating with the HCE.
DoD Program on Spinal Cord Injuries
DoD is conducting a robust research program on spinal cord injuries
that includes laboratory research on repair and regeneration of damaged
spinal cords and clinical research to improve rehabilitation therapies.
The program focuses on innovative projects that have the potential to
make a significant impact on improving the function, wellness, and
overall quality of life for servicemembers. The scientific areas
include neuroprotection and repair, and rehabilitation and
complications of chronic spinal cord injuries.
DoD Support Programs for Severely Injured Servicemembers and Their
Families
DoD has developed many support resources to assist injured
servicemembers, veterans, and their families. One important resource is
the Recovery Coordination Program, which was established in 2008, to
ensure that wounded, ill, or injured servicemembers receive the non-
medical support they need to successfully navigate the road to
recovery. A servicemember who has a serious injury would be eligible
for a Recovery Care Coordinator (RCC), if the servicemember would not
return to duty within a specified time determined by the Military
Wounded Warrior Program or if the servicemember might be medically
separated. The RCC works for one of the programs in any of the four
Services, including the Army Reserve, as well as the Special Operations
Command Care Coalition. The RCC develops a recovery plan, evaluates its
effectiveness, and adjusts it as transitions occur. The RCC makes sure
the plan meets the servicemember's and the family's goals, and works
with the individual's Commander to coordinate the services included in
the plan. Currently, there are 130 RCCs in 55 locations nationwide.
DoD provides outreach to servicemembers and families to promote
awareness of the available resources. We conduct outreach to encourage
servicemembers and families to seek help from these programs, when
needed, and to ensure the most complete recovery possible. One of the
most important support resources is Military One Source, which provides
assistance to servicemembers and their families to evaluate their
needs, and coordinate referrals to other programs to provide the
appropriate services. Military One Source is a central coordination
point to ensure accessibility to the many available resources for
servicemembers and their families.
Four service-specific programs provide assistance: the Army Wounded
Warrior Program, Marine Wounded Warrior Regiment, Air Force Wounded
Warrior, and Navy Safe Harbor. The wounded warrior programs assist and
advocate for severely wounded, ill, and injured servicemembers,
veterans, and their families, wherever they are located. The four
Service-specific programs provide counseling, employment assistance,
family support, and other services needed to transition to home and the
community. These services are provided as long as severely injured
servicemembers and their families require support.
Transition from DoD Care to VA Care for Severely Injured Servicemembers
DoD and VA are working together to improve their coordination of
medical care for servicemembers and veterans, including those who were
severely injured in OIF and OEF. The key objectives of our coordinated
transition efforts include: ensuring continuity of medical care from
DoD to VA health care providers; and providing clear and comprehensive
information about available support programs to servicemembers and
their families.
DoD takes advantage of the four VA Polytrauma Rehabilitation
Centers (Tampa, Minneapolis, Richmond, and Palo Alto) to meet the needs
of active-duty servicemembers who have experienced multiple, severe
injuries, including TBI. DoD has a longstanding relationship with VA to
ensure continuity of care, and DoD refers injured servicemembers to VA
for long-term rehabilitation. From March 2003 to June 2010, more than
500 active-duty servicemembers who were injured in theater were treated
in the four VA Polytrauma Rehabilitation Centers. In addition, 21 VA
Polytrauma Network Sites nationwide provide continuing long-term care
to these injured veterans
In August 2003, DoD incorporated a VA Liaison Program at Walter
Reed Army Medical Center to provide case management for combat
veterans. When severely injured servicemembers need long-term medical
care, VA liaison personnel work with them to coordinate VA services.
This joint program has expanded to 12 more military hospitals. At these
13 hospitals, 27 VA nurses and social workers provide the linkage to
follow-up care at VA facilities near the servicemembers' homes. As of
June 2010, this program had made more than 10,000 patient referrals to
VA to ensure continuity of care.
Conclusion
DoD is providing comprehensive, state-of-the-art care for severely
injured servicemembers in collaboration with our partners at VA. We are
committed to continued and more expansive collaboration and
coordination with VA because we believe it is essential to our ability
to provide servicemembers, veterans, and their families with
consistently superior medical care and support services as well as
continuity of care in the most comprehensive way.
Thank you for the opportunity to address this vital issue. I will
be pleased to respond to any questions you may have and to participate
in an ongoing dialogue to better serve our current and former
servicemembers.
Prepared Statement of Lucille B. Beck, Ph.D. Chief Consultant,
Rehabilitation Services, Office of Patient Care Services, and Director,
Audiology and Speech Pathology Service, Veterans Health Administration,
U.S. Department of Veterans Affairs
Good Morning, Chairman Michaud, Ranking Member Brown, and Members
of the Subcommittee. Thank you for the opportunity to appear to discuss
the Department of Veterans Affairs' (VA) work in caring for severely
injured Operation Enduring Freedom (OEF) and Operation Iraqi Freedom
(OIF) Veterans and Servicemembers through our full complement of
specialty, rehabilitative services. VA's mission includes ensuring we
have appropriately staffed facilities that provide timely, accessible,
coordinated, high quality specialty care for our severely injured
Veterans. We appreciate Congress' support in providing VA the resources
necessary to meet the needs of our Veterans.
VA is committed to helping Servicemembers transition from active
duty to Veteran status as smoothly as possible. The Veterans Health
Administration (VHA) is well-known for its integrated system of health
care and its expertise in treating spinal cord injuries and disorders
(SCI/D), traumatic brain injury (TBI), and blindness and visual
impairment. Our provision of quality rehabilitation care is supported
through a system-wide, long-term collaboration with the Commission on
Accreditation of Rehabilitation Facilities (CARF) to achieve and
maintain national accreditation for all appropriate VHA rehabilitation
programs. VA continues to increase collaborations with private sector
facilities to successfully meet the individualized needs of Veterans
and complement VA care and services. This ensures that quality
rehabilitation programs are offered in a timely manner that meet the
unique needs of severely injured Veterans and provide a catalyst for
improving their quality of life.
Our severely injured Veterans returning from OEF/OIF rightfully
expect us to provide the latest in treatment, technology, and
rehabilitation services. VA has established policies and supports its
facilities to ensure that specialty services are structured
appropriately, fully staffed, and effectively coordinated. We
understand and appreciate the specialized skills required to deliver
the care our Veterans need and deserve, and to that end VA has created
numerous education and training opportunities for our clinical
providers.
Facility capacity and bed occupancy rates are routinely monitored
at the local level and are reported to the national program offices at
least monthly to ensure our OEF/OIF Veterans have open access to our
care and services. Any surge in demand for services are addressed with
corrective actions such as temporarily increased staffing, use of
additional existing authorized beds at the Polytrauma Rehabilitation
Centers (PRCs), careful planning of elective admissions, and transfers
within the Polytrauma System of Care (PSC) of non-traumatically
disabled Veterans to ensure that the first priority for admissions
remains allocated to Servicemembers and Veterans with severe injuries.
Flexibility is available to provide additional resources at specific
locations, if necessary.
My testimony will begin by explaining how VA supports and
facilitates the transition and care management of severely injured OEF/
OIF Veterans into specialty rehabilitation programs, then provide a
detailed review of four major rehabilitation areas: VA's Blind
Rehabilitation Service, its Spinal Cord Injury/Disorders program (SCI/
D), the Polytrauma and TBI System of Care, and the Amputation System of
Care and Prosthetics and Sensory Aids Service.
Transition and Care Management of OEF/OIF Veterans
VA recognizes that severely injured Servicemembers face a
significant transition when returning home and becoming Veterans. In
addition to treating Veterans with blindness, SCI&D, polytrauma/TBI,
and amputations, VA and Department of Defense (DoD) have worked
together through a Memorandum of Agreement for almost 30 years to
deliver rehabilitation services to active duty Veterans and
Servicemembers with such injuries.
As soon as the pre-requisites for medical stability are met, the
DoD physician and the VA admitting physician at one of VA's specialty
centers begin discussion on the patient's medical status and arrange
for appropriate transportation and admission to the VA facility closest
to the Veteran's or Servicemember's home. Each patient receives a
customized rehabilitation plan designed to achieve patient-centered
goals and maximal functional independence. Rehabilitation serves to
improve any bodily functions affected by the injury, teach compensatory
functions using remaining intact body systems, anticipate and prevent
medical complications, alter the environment as needed, and educate the
person to promote autonomy and to achieve their full potential and
quality of life.
In order to make VA easier to access for those most in need, we
have responded by partnering with DoD to create the Federal Recovery
Coordination Program, and creating a Care Management and Social Work
Service responsible for developing policies and deploying staff to VA
and DoD facilities.
VA's Care Management and Social Work Service
In October 2007, VA established the Care Management and Social Work
Service to address the needs of wounded and ill Veterans and
Servicemembers. VA's Military Liaisons for Health care are social
workers or nurses who serve as essential resources for transitioning
injured and ill OEF/OIF Veterans and Servicemembers. VA now has 33 VA
Military Liaisons for Health care stationed at 18 military medical
treatment facilities (MTFs) to transition ill and injured
Servicemembers from DoD to a VA more appropriate for the specialized
services their medical condition requires, or closer to home.
VA Military Liaisons are co-located with DoD Case Managers at MTFs
and provide onsite consultation and collaboration regarding VA
resources and treatment options. They educate Servicemembers and their
families about VA's system of care, coordinate the Servicemember's
initial registration with VA, and secure outpatient appointments or
inpatient transfer to a VA health care facility as appropriate. VA
Military Liaisons make early connections with Servicemembers and
families to begin building a positive relationship with VA. Our
Liaisons coordinated 5,000 referrals for health care and over 20,000
professional consultations in fiscal year (FY) 2010 through June.
Each VA medical center has an OEF/OIF Care Management team in place
to coordinate patient care activities and ensure that Servicemembers
and Veterans are receiving patient-centered, integrated care and
benefits. Members of the OEF/OIF Care Management team include: a
Program Manager, Clinical Case Managers, Veterans Benefits
Administration (VBA) Service Representatives, and a Transition Patient
Advocate. The Program Manager, a nurse or social worker, has overall
administrative and clinical responsibility for the team and ensures
that all OEF/OIF Veterans are screened for case management. Severely
injured OEF/OIF Veterans are provided a case manager, and any other
OEF/OIF Veteran may be assigned a case manager based upon initial
assessment or upon request. Clinical 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.
VBA team members assist Veterans by educating them about VA
benefits and assisting with the benefit application process. The
Transition Patient Advocate helps the Veteran and family navigate VA's
system by acting as a communicator, facilitator and problem-solver.
Since many 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 now serves as a central communication
point for the patient and his or her family. 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. The OEF/OIF Care Management program now serves over 44,000
Servicemembers and Veterans, including 5,800 who are severely injured.
OEF/OIF Care Management team members actively support outreach
events in the community, such as annual `Welcome Home' events. OEF/OIF
team members also participate in the demobilization process, the Yellow
Ribbon Reintegration Program, Post-Deployment Health Reassessment
events, and Individual Ready Reserve musters. OEF/OIF staff regularly
make presentations to community partners, Veterans Service
Organizations, colleges, employment agencies and others to collaborate
in providing services and connecting with returning Servicemembers and
Veterans. VHA and VBA officials coordinate on the full range of
services and benefits to Veterans and their families to support their
transition back to civilian life.
Federal Recovery Coordination Program
The needs of severely injured Servicemembers and Veterans are also
met through the services provided by the Federal Recovery Coordination
(FRC) Program. FRCs serve to ensure that severely injured Veterans and
Servicemembers receive access to the benefits and care they need to
recover. Since its creation in 2008, the FRC Program has helped
Servicemembers and Veterans access Federal, state and local programs,
benefits and services, while supporting the families of these heroes
through their recovery, rehabilitation, and reintegration into the
community. Currently, 556 clients are enrolled and another 31
individuals are being evaluated for enrollment; an additional 497 have
received assistance through FRC.
Blind Rehabilitation
The VA Blind Rehabilitation Service (BRS) provides world-class
comprehensive evaluation, planning, and rehabilitation treatment for
OEF/OIF Veterans and Servicemembers with any level of visual
impairment. BRS assesses, recommends and trains Veterans in the use of
technology and assistive devices with enlarged print, Braille or speech
output such as computers, personal digital assistants and global
positioning systems. BRS, together with VA eye care practitioners,
incorporates the latest in optical enhancing devices into
rehabilitation care. This technology serves to enhance independence,
social functioning, employment, and education.
Blind Rehabilitation Services are delivered at every VA medical
center, with 157 Visual Impairment Service Team Coordinators who
provide care management, and 77 Blind Rehabilitation Outpatient
Specialists who provide in-home and in-community service. Additionally,
VA has 55 outpatient blind and vision rehabilitation clinics, and 10
inpatient Blind Rehabilitation Centers; three additional inpatient
centers will open in FY 2011 in Cleveland, OH, Biloxi, MS, and Long
Beach, CA. VA blind rehabilitation services are structured and
geographically located for visually impaired Veterans and
Servicemembers to access the care they need.
The BRS database tracks OEF/OIF Veterans with visual impairment to
ensure ongoing coordination of care for these patients. As of June
2010, Blind Rehabilitation Service is tracking 1,098 OEF/OIF Veterans
and Servicemembers who have received blind and vision rehabilitation
care, or who have been referred for screening to rule out possible
visual consequences associated with TBI. Of this total, 126 active duty
Servicemembers have attended inpatient blind rehabilitation centers due
to severely disabling visual impairment. VA has also held several
national training conferences on the visual consequences of TBI to
educate our providers, and has added specific medical codes to document
the visual consequences of TBI in VA's clinical patient record system.
We have placed Blind Rehabilitation Outpatient Specialists at Walter
Reed Army and National Naval Medical Centers, as well as at locations
in VA's Polytrauma System of Care. Results indicate that patients
completing VA's inpatient blind rehabilitation programs have better
functional outcomes than patients from blind rehabilitation programs in
the private sector.
Spinal Cord Injury
VA's Spinal Cord Injury Program is the largest single network of
care and rehabilitation in the Nation for the treatment of persons with
spinal cord injury (SCI). VA facilities nationwide in 2009 provided a
full range of services to 27,067 Veterans with SCI/D; 13,398 of these
Veterans received specialized care within the 24 Spinal Cord Injury
Centers or SCI Support Clinics. For Veterans with SCI, VA provides
health care and rehabilitation services, maintains medical equipment
and supplies, and offers education and preventive health services.
Since 2003, 503 Servicemembers have been treated in VA SCI units, and
of those Servicemembers, 162 incurred a spinal cord injury in an OEF/
OIF theater of operations.
VA's SCI system of care is internationally regarded for its
comprehensive and coordinated services for rehabilitation, surgical,
medical, preventive, ambulatory, long term, and home-based care.
Interdisciplinary teams of professionals with highly specialized
knowledge and experience deliver rehabilitation care, SCI specialty
care, and broadly based medical services. VA is a world leader in best
practices providing outstanding clinical care, customized wheelchairs,
adaptive equipment, technological interventions, therapies, teaching,
and training so Veterans with SCI can be as healthy and independent as
possible in their homes and communities.
VA promotes activity-based therapies at its SCI Centers to improve
mobility, recovery of walking and hand function. Recently, VA enhanced
the rehabilitation and training environments to offer the latest and
most effective interventions to fully utilize sensory patterned
feedback, re-training of central pattern generators, use of body weight
support, and electrical stimulation for newly injured Servicemembers
and Veterans in all VA Spinal Cord Injury Centers. These services
include: early standing and weight-bearing; body weight support and
treadmill training; over ground training for walking; and electrical
stimulation for weak and paralyzed muscles in the lower limbs for
ambulation and upper limbs for hand function. There is currently a
growing and integrated system of telehealth services for Veterans with
SCI, and recent funding has provided telehealth systems in every SCI
Center and to more than 90 percent of the SCI support and primary care
teams.
VA's SCI System of Care prevents and treats co-morbid problems
related to the original spinal cord injury. For example, pressure
ulcers (bed sores) are a common and costly complication resulting in
high rates of illness and death. Data from FY 2008-2010 demonstrate
that our new prevention efforts are successful and have reduced the
rate of developing a new hospital-acquired pressure ulcer to an
extremely low level. The data reflects that 95 percent of patients with
SCI were screened for pressure ulcer risk within twenty four hours of
admission, 96 percent of at-risk patients had a documented plan of skin
care within 48 hours of admission, and only 1.3 percent of patients
with SCI who were hospitalized in FY 2009 developed pressure ulcers.
Polytrauma/Traumatic Brain Injury
VA also offers rehabilitation services for returning OEF/OIF
Veterans and Servicemembers with polytrauma and traumatic brain
injuries. ``Polytrauma'' is a new word in the medical lexicon that was
termed by VA to describe the injuries to multiple body parts and organs
occurring as a result of exposure to explosive devices or blasts to
those serving in OEF/OIF. Polytrauma is defined as two or more injuries
to physical regions or organ systems, one of which may be life
threatening, resulting in physical, cognitive, psychological, or
psychosocial impairments and functional disability. Traumatic brain
injury (TBI) frequently occurs in polytrauma in combination with other
disabling conditions such as amputation, auditory and visual
impairments, spinal cord injury, post-traumatic stress disorder (PTSD),
and other medical problems. Due to the severity and complexity of their
injuries, Servicemembers and Veterans with polytrauma require an
extraordinary level of coordination and integration of clinical and
other support services.
VA has developed and implemented numerous programs that ensure the
provision of world-class rehabilitation services for Veterans and
active duty Servicemembers with TBI. Since 1992, VA has had four lead
TBI Centers designated as part of the Defense and Veterans Brain Injury
Center (DVBIC) collaboration to provide comprehensive rehabilitation
for Veterans and active duty Servicemembers. In 1997, VA designated a
TBI Network of Care to support care coordination and access to services
across VA's system.
Beginning in 2005, VA expanded the scope of services at existing VA
TBI Centers to implement an integrated nationwide Polytrauma System of
Care (PSC) that provides world-class rehabilitation services, and
ensures that Veterans and Servicemembers with TBI and polytrauma
transition seamlessly from DoD and VA and back into their home
communities. Today, the VA Polytrauma System of Care is an integrated,
tiered system that provides specialized, interdisciplinary care for
polytrauma injuries and TBI across four levels of facilities,
including: 4 Polytrauma Rehabilitation Centers, 22 Polytrauma Network
Sites, 82 Polytrauma Support Clinic Teams, and 48 Polytrauma Points of
Contact. The System offers comprehensive clinical rehabilitative
services including: treatment by interdisciplinary teams of
rehabilitation specialists; specialty care management; patient and
family education and training; psychosocial support; and advanced
rehabilitation and prosthetic technologies.
Polytrauma Rehabilitation Centers (PRCs) serve as regional referral
centers for the most intensive specialized care and comprehensive
rehabilitation care for Veterans and Servicemembers with complex and
severe polytrauma. PRCs maintain a full staff of dedicated
rehabilitation professionals and consultants from other specialties to
support these patients. Each PRC is accredited for Brain Injury
Rehabilitation by the Commission on Accreditation of Rehabilitation
Facilities (CARF), and each serves as a resource to develop educational
programs and best practice models for other facilities across the
system. The four regional Centers are located in Richmond, VA; Tampa,
FL; Minneapolis, MN; and Palo Alto, CA. A fifth Center is currently
under construction in San Antonio, TX, and is expected to open in 2011.
The next three levels of the Polytrauma System of Care provide
specialized rehabilitation services and coordinate care at locations
closer to the Veterans' home communities. Polytrauma Network Sites
(PNS) provide inpatient and outpatient rehabilitation care and
coordinate TBI and polytrauma services throughout the Veterans
Integrated Service Network (VISN). The inpatient rehabilitation units
at the PNS maintain CARF accreditation for Comprehensive Inpatient
Medical Rehabilitation. Polytrauma Support Clinic Teams conduct
comprehensive evaluations of patients with positive TBI screens and
develop and implement rehabilitation and community reintegration plans
for Veterans and Servicemembers in their catchment areas. Polytrauma
Points of Contact ensure that Veterans and Servicemembers needing
specialized rehabilitation services are referred to the appropriate
level of care within or outside of VA, if necessary. VA appreciates
Congress' work in passing the Caregivers and Veterans Omnibus Health
Services Act of 2010 (Public Law 111-163), which will allow VA to
provide specialized residential care for TBI patients and
rehabilitation services for Veterans with TBI at non-Department
facilities.
VA continually enhances the scope of specialized rehabilitation
services available through the Polytrauma System of Care. New programs
and initiatives include:
In 2007, VA developed and implemented Transitional
Rehabilitation Programs at each PRC. These 10-bed residential
units provide rehabilitation in a home-like environment to
facilitate community reintegration for Veterans and their
families. Through December 2009, 188 Veterans and
Servicemembers have participated in this program spending, on
average, about 3 months in transitional rehabilitation. Almost
90 percent of these individuals return to active duty or
transition to independent living.
Beginning in 2007, VA implemented a specialized
Emerging Consciousness care path at the four PRCs to serve
those Veterans with severe TBI who are slow to recover
consciousness. To meet the challenges of caring for these
individuals, VA collaboratively developed this care path with
subject matter experts from Defense and Veterans Brain Injury
Center (DVBIC) and the private sector. From January 2007
through December 2009, 87 Veterans and Servicemembers have been
admitted into VA's Emerging Consciousness program.
Approximately 70 percent of these patients emerge to
consciousness before leaving inpatient rehabilitation.
In April 2009, VA began an advanced technology
initiative to establish Assistive Technology laboratories at
the four PRCs to provide the most advanced technologies related
to cognitive-communication, sensory and motor impairments. This
initiative allowed VA to enter into a contractual agreement
with the University of Pittsburgh to develop state-of-the-art
Assistive Technology (AT) labs. The goal of this initiative is
to develop extensive banks of AT devices for equipment trials,
a method for evaluating new AT technology, standardized
evaluation procedures, and an outcomes data collection tool. AT
can contribute to enhancing an individual's ability to function
in their environment and achieve the highest level of
independence possible for persons with disabilities.
Since March 2003, an average of 130 Servicemembers with severe
polytraumatic injuries have been referred annually for acute medical,
surgical, and rehabilitative care at the four PRCs, ranging from 99 (FY
2003) to 330 (FY 2008), for a total of 907 Servicemembers. Of the total
907 Servicemembers served, 754 were injured in OEF/OIF areas of
operations. Thus far in FY 2010, a total of 110 Servicemembers have
been treated at the PRCs. Additionally, a total of 885 Veterans with
severe injuries have been admitted to the PRCs since 2003. In FY 2009,
49,207 patients were seen across VA for inpatient or outpatient
services related to TBI; 46,990 patients were treated in outpatient
clinics for a total of 83,794 visits. This represents a 30 percent
increase over FY 2008.
VA has developed and implemented the TBI Screening and Evaluation
Program for all OEF/OIF Veterans who receive care within VA. From April
2007 through April 2010, VA has screened 418,109 OEF/OIF Veterans for
possible TBI; of these, 57,569 Veterans who screened positive have been
evaluated and have received follow-up care and services appropriate for
their diagnosis and their symptoms. A total of 31,480 Veterans have
been confirmed with a diagnosis of having incurred a mild TBI. Over 90
percent of all Veterans who are screened are determined not to have
TBI, but the 10 percent who screen positive and complete the
comprehensive evaluation are referred for appropriate treatment.
Completion of the TBI screening and evaluation for each OEF/OIF Veteran
allows VA to continually assess resources and access to care.
VA has sufficient resources to meet the needs of Veterans with TBI,
and TBI is a Select Program in VA budget submissions. In FY 2010,
$231.9 million has been programmed for TBI care for all Veterans and
$58.2 million is programmed for OEF/OIF Veterans.
Amputation/Prosthetics and Sensory Aid Programs
A closely related Program is the Amputation System of Care and VA's
Prosthetics and Sensory Aid Services. These two efforts complement each
other in providing quality, accessible care to Veterans across the
country.
Amputation System of Care
VA has an extensive program for amputation rehabilitation. In 2007,
VA's Offices of Rehabilitation and the Prosthetics and Sensory Aids
Service collaborated to develop an Amputation System of Care (ASC)
designed to standardize care delivery, reduce variance, and increase
access to state-of-the-science rehabilitation techniques and prosthetic
technology. VA began deploying this System in 2009, enhancing
structures within VA to create tiered levels of expertise and
accessibility across four distinct components of care. Today there are
7 Regional Amputation Centers, 15 Polytrauma/Amputation Network Sites,
101 Amputation Clinic Teams, and 31 Amputation Points of Contact across
the ASC. Collectively, this system delivers specialized expertise in
amputation rehabilitation incorporating the latest practice in medical
rehabilitation management, rehabilitation therapies, and technological
advances in prosthetic components.
Regional Amputation Centers provide the highest level of
specialized expertise in clinical care, technology, and rehabilitation
for Veterans with the most severe extremity injuries and amputations.
These Centers have clinical expertise in state-of-the-science medical
and rehabilitation techniques and prosthetic components and design.
These Centers provide comprehensive, holistic rehabilitation care
through an interdisciplinary team that includes physiatrists, physical
therapists, occupational therapists, prosthetists, social workers, case
managers, nurses, psychologists and recreation therapists. These
Centers also serve as a resource for other facilities in the System
through the development of tele-rehabilitation for consultation, models
of care, best practices, educational programs, and the evaluation of
new technology.
Polytrauma/Amputation Network Sites also provide inpatient and
outpatient amputation rehabilitation as well as prosthetic labs closer
to the Veteran's home. These Sites provide care to Veterans with
multiple impairments, including amputation, and addressing the long-
term care needs and coordinating access to specialized services either
directly or via consultation. These Sites also provide
interdisciplinary care, with the clinical teams at these facilities
well-trained in evaluation techniques, rehabilitation methods, and
prescription of prostheses. In addition to providing the full range of
clinical and ancillary services, the Sites serve as a resource and
consultant for complex management issues to other facilities within
their network.
Amputation Clinic Teams are designated at facilities with limited
resources that may not provide a full scope of services, but still
offer an interdisciplinary amputation care team. Facilities at this
level may or may not have an in-house Prosthetic/Orthotic Laboratory or
an inpatient rehabilitation bed program. Any sites without such
services are augmented as necessary either through a contract, referral
to a Polytrauma/Amputation Network Site, or through fee-based referral
to an accredited facility in the private sector community. Finally,
Amputation Points of Contact are located at smaller VA facilities and
ensure that Veterans and Servicemembers needing specialized
rehabilitation and prosthetic services are referred to appropriate
level of care or to other non-VA services.
VA provides care to more than 43,000 amputees, many of whom are
older Veterans who require amputations as a result of medical problems
such as dysvascular disease or diabetes. A growing number of OEF/OIF
Veterans with traumatic amputations also come to VA for services. As of
June 1, 2010 there were 1,011 OEF/OIF Veterans or Servicemembers with
major amputations, of which 657 (or 65 percent) have sought care in VA.
Much of this care has been in the area of prosthetics where new
prosthetic limbs and limb repair is provided. All Veterans with
amputation seen within VA, including OEF/OIF Veterans who account for
1.67 percent of these patients, require specialty care for the rest of
their lifetime. VA's Amputation System of Care will ensure that VA is
able to meet their needs.
The VA Amputation System of Care works collaboratively with the
Department of Defense's Amputation Centers at Walter Reed Army Medical
Center, the Center for the Intrepid in San Antonio at Brooke Army
Medical Center, and the Amputation Center at the Balboa Navy Medical
Center to coordinate transition services, train interdisciplinary
amputee teams, and develop best practices.
VA and the Amputee Coalition of America (ACA) have partnered to
establish a Peer Visitation Program within VA. The ACA has trained 20
VA instructors across the Nation who can now train Veterans to be peer
visitors. VA currently has over 30 Veterans certified as peer visitors,
and expects to double this number in 2011. This program has been
extremely successful at Walter Reed Army Medical Center and was
identified by Servicemembers as the most important factor supporting
their rehabilitation, second only to physical therapy with amputations.
VA and ACA are currently exploring establishing a peer visitation
program for caregivers of amputees.
VA and DoD partnered to develop the Amputation Rehabilitation
Clinical Practice Guideline, which represents the first attempt to
provide an evidence-based structure for rehabilitation in lower limb
amputation. This will further assist in identifying priorities for new
research efforts and allocation of resources to incorporate new
technology as rehabilitation practices emerge. VA and DoD also
partnered to develop the Amputation Patient Education Handbook ``The
Next Step.'' This publication has received extensive positive feedback
from Veterans, Servicemembers, and clinicians in its pre-release, and
will be available for distribution across VA and DoD by the end of July
2010.
Lastly, VA is developing a Telehealth Amputation Program to improve
access to specialty amputation care closer to the Veteran's home.
Telehealth will be used to connect all four levels of the ASC, and
amputation specialty care to community based outpatient clinics.
Prosthetics and Sensory Aids
VA's Prosthetic and Sensory Aids Service (PSAS) provides Veterans
with the prescribed equipment they require to maximize their
independence and health. PSAS exceeds other health care organizations
in providing the variety and array of equipment and services. PSAS
provides everything from state-of-the-science bionic limbs, to custom
wheeled mobility and seating solutions, to home and vehicle
adaptations. PSAS has a national evaluation process for reviewing and
approving the purchase of new or experimental technology and services
that are medically prescribed by the Veterans VA health care provider.
This process allows for the provision of devices that are not typically
provided by DoD, Medicare, or any private health care provider.
Female Veterans particularly find the personal attention required
for their specific needs through PSAS. Prosthetic devices such as
breast prostheses or breast pumps, or a prosthetic style designed for
women instead of men, are provided by PSAS to meet the unique needs of
this Veteran population. In FY 2009, PSAS provided items and services
to 116,000 female Veterans at a cost of over $61 million. Over 40,000
female Veterans received eyeglasses through VA with timely, accurate
service, and an eyeglass style with which they are comfortable. Our
interdisciplinary Prosthetic Women's Workgroup provides guidance
regarding new items that are available to this special population, and
is assisting with developing a brochure that targets female Veterans to
inform them about PSAS services. PSAS provides the personal service to
ensure that every female Veteran receives the equipment and services--
in the preferred style unique to women--to maximize her independence
and quality of life.
Although not exclusive to the OEF/OIF Veteran, this population has
helped bring to the forefront a wide range of technologies to keep this
population active and engaged in their community. VA provides computers
for blind as well as physically disabled Veterans to assist them in
managing their lives and retaining their independence. VA also provides
global positioning systems (GPS), smartphones, and the most advanced
wheeled-mobility and seating solutions available. VA was the first in
the U.S. to provide a microprocessor knee over ten years ago, and we
have remained at the cutting edge of technology in the realm of
prosthetic limbs. We are currently optimizing the DEKA arm in hopes of
getting it to the market place soon so that all Americans with upper
extremity amputations might benefit. VA is also receiving several of
the new X-2 knees developed through a public-private endeavor to build
a knee that can navigate stairs, water, and even enable the user to
walk backwards.
PSAS is a pioneer in the area of standardizing care through its
Prosthetic Clinical Management Program. PSAS developed national
contracts that not only saved VA $400 million over the past few years,
but also elevated the level of care for all Veterans by awarding
national contracts to companies that provide only the highest quality
products. Interdisciplinary teams of clinical, patient safety and
engineering experts rigorously review each offer to ensure only the
best products are procured for our Veterans. This Program has also led
the development of more than 35 clinical practice recommendations that
provide guidance to clinicians for prescribing prosthetic devices. The
result has been the successful elevation of the quality of devices and
evaluations for Veterans.
Care to Women Veterans
The conflicts in Iraq and Afghanistan have introduced a new
generation of Veterans into VA with specialized needs. One segment of
this new generation is Women Veterans. Of the 1.1 million OEF/OIF
Veterans, 128,397 are women Veterans; approximately 50 percent of these
women Veterans utilized VA health care between FY 2002 and the first
quarter of FY 2010. Our women Veterans have unique health care needs
compared with the larger male Veteran population. On average, women
Veterans are younger than male Veterans with over two-thirds of OEF/OIF
women Veterans being in reproductive age groups. VA again thanks
Congress for its work on Public Law 111-163, which has given VA the
authority to provide newborn care for women Veterans. VA has enhanced
its current system to transition from a disease model to a wellness
model of care that assures equal access for all Veterans, and continues
to deliver world-class health care for our Veterans who have served.
Conclusion
Thank you again for this opportunity to speak about VA's role in
providing timely, coordinated care to our severely injured OEF/OIF
servicemembers and veterans. I am prepared to answer any questions the
subcommittee might have.
MATERIAL SUBMITTED FOR THE RECORD
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
July 27, 2010
Thomas Zampieri, Ph.D.
Director of Government Relations
Blinded Veterans Association
477 H Street, NW
Washington, DC 20001
Dear Dr. Zampieri:
Thank you for your testimony at the U.S. House of Representatives
Committee on Veterans' Affairs Subcommittee on Health oversight hearing
on ``Healing the Physical Injuries of War'', which took place on July
22, 2010.
Please provide answers to the following questions by Tuesday,
September 7, 2010, to Jeff Burdette, Legislative Assistant to the
Subcommittee on Health.
1. Do you believe that VA is meeting the needs of our
servicemembers and veterans who are severely injured from the
war in Iraq and Afghanistan? What is VA doing well and what
areas are in need of improvement.
2. Is VA properly staffed to care for severely injured
veterans and do our veterans have access to the most current
therapies?
3. How would you rate the coordination between DoD and VA in
providing medical care for severely injured OEF/OIF veterans?
What are your recommendations for enhancing coordination
efforts between VA and DoD?
4. Of the total number of veterans who are blind or have low
vision, do you have a sense of how many of these veterans are
accessing care at VA?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by September 7, 2010.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Blinded Veterans Association
Washington, DC.
August 13, 2010
The Honorable Michael Michaud
Chairman, House VA Subcommittee Health
United States Congress
335 Cannon House Office Building
Washington, DC 20515
Dear Chairman Michaud,
The Blinded Veterans Association (BVA), is the only congressionally
chartered veterans service organization exclusively dedicated to
serving the needs of our nation's blinded veterans and their families
and we appreciated the invitation to provide testimony before committee
on July 21, and chance to respond to the questions. BVA is concerned
that the Vision Center of Excellence established in the NDAA FY 2008
section 1623 has not had the full staffing, funding, and operational
support necessary to meet the needs of ensuring that the combat eye
injured have seamless transition of eye care, from DoD and VA medical
treatment centers. These eye wounded require the coordination of vision
services during these transitions. Visually impaired must be provided
contacts with VA Visual Impairment Service Team (VIST) Coordinators and
the Blind Rehabilitative Outpatient Specialists (BROS) they need. The
claim that the Office of the Assistant Secretary Defense for Health
Affairs (ASDHA) does not have enough operational funds to establish the
VCE since January 2008 is completely absurd. The small amount spent of
less than $ 2.5 million is reflective of bureaucratic indifference and
lack of governance for the eye wounded and BVA requests the VA
Committee request a GAO investigation into the implementation of the
VCE.
Regarding the questions you have submitted this is our responses:
1. BVA has seen tremendous effort and resources devoted to
improving the outpatient services for blinded and low vision
veterans in the establishment of 55 new specialized programs
and addition of 276 staff since January 2007 with the Continuum
of Care that VHA approved. As VA expanded the staffing, and
improved access to specialized rehabilitation services for
vision loss from injuries the problem has been communications
between DoD medical treatment facilities eye care
professionals, case managers, and transition coordinators to VA
staff for those with either combat eye injuries or Traumatic
Brain Injury with vision functional impairments know where
these services are located.
2. BVA would request that the issue of Blind Rehabilitative
Outpatient Specialists (BROS) who are employed by the VA and
assigned to MTF's but are not being credentialed and privileged
within DoD MTF's is significant problem. While new combat
wounded are awaiting transfer into a VA Blind Center the
wounded and families benefit from the training the VA BROS can
provide. However, because DoD has never employed BROS as allied
health occupation they have no mechanism to credential them to
provide rehabilitation to servicemembers within MTF's. For two
years no progress has been made on this problem despite
meetings and outreach from VA. We recommend that the HVAC work
with the HASC on language in NDAA that would resolve this
problem with out further delays.
3. The Vision Center of Excellence is required to have joint
Eye Trauma Registry to track eye injured or TBI visually
impaired servicemembers with vital eye care consultant reports,
surgery records, diagnostic testing results, and share this
with VA eye care providers. The work on this registry started
in FY 2007 and CONOPS were approved in August 2009. Defense
Veterans Eye Injury and Vision Registry (DVEIVR) was tested
from March 15-24, 2010 and successfully but still is not being
funded with the $ 6 million to implement the sharing of data
elements between DoD and VA clinicians.
4. The VA witness during the hearing stated VA Blind
Rehabilitative Services (BRS) has provided inpatient blind
rehabilitative training to 126 OIF and OEF veterans. VA BRS is
also following an additional 1,089 with low vision impairments,
from TBI injuries mostly and we believe that there are others
that have entered the system without being identified as having
visual injuries that must all be screened. TBI's rarely result
in legal blindness, but reports find rising numbers with vision
problems diagnosed with variety visual impairments. The VA
Polytrauma Centers report that 80 percent of all TBI patients
have complained of visual symptoms from there blast exposure.
VA research has further revealed that approximately 65 percent
of those with diagnosis of visual dysfunction have at least
one, and often three of the following associated visual
disorders including diplopia, convergence disorder,
photophobia, ocular-motor dysfunction, visual field loss, color
blindness, and an inability to interpret print. One research
study that examined 25 TBI veterans found none of the following
visual complications during the normal medical evacuation
process were diagnosed early; corneal damage 20 percent,
cataracts 28 percent, angle recession glaucoma 32 percent,
retinal injury 22 percent, these all would place these
individuals at high risk of progressive visual impairments if
not diagnosed and treated early. With 1,200 diagnosed with
optic nerve damage this is a significant population of wounded
requiring specialized VA services and they must be entered into
the (DVEIVR) so both DoD and VA can ensure high quality care
and avoid unnecessary complications and coordinate new research
protocols for vision impairments.
BVA also included in our testimony concern that some private
agencies are trying to get earmarks to provide specialized services for
blinded veterans without having the same staffing and accreditation
standards that VA provides within its specialized rehabilitation
centers. We strongly object and would request that language be
supported in the MILCON VA appropriations report clarifying that any
private agency should demonstrate peer reviewed quality outcome
measurements that are standard part of VHA BRS, and should it ever be
necessary to refer a visually impaired or blinded veteran to a non VA
BRC, they should be accredited by National Accreditation Council for
Agencies Serving the Blind and Visually Handicapped (NAC) and/or the
Commission For Accreditation of Rehabilitation Facilities (CARF), and
that the employed Blind Instructors or Specialists be Certified by the
Academy for Certification of Vision Rehabilitation and Education
Professionals (ACVREP). Private agencies without nursing, medical, and
psychology staffing on site should not be allowed to provide services
to acute polytrauma new injured servicemembers.
BVA appreciates your strong leadership on this important veteran's
health care issue for those suffering eye injuries from the current
wars and TBI visual complications, and we request that both DoD and
senior VA JEC management report back to your subcommittee and move the
Vision Center of Excellence quickly into full operations.
Sincerely,
Thomas Zampieri Ph.D.
Director Government Relations
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
July 27, 2010
Mr. Carl Blake
National Legislative Director
Paralyzed Veterans of America
801 18th Street NW
Washington, DC 20006
Dear Mr. Blake:
Thank you for your testimony at the U.S. House of Representatives
Committee on Veterans' Affairs Subcommittee on Health oversight hearing
on ``Healing the Physical Injuries of War'', which took place on July
22, 2010.
Please provide answers to the following questions by Tuesday,
September 7, 2010, to Jeff Burdette, Legislative Assistant to the
Subcommittee on Health.
1. Do you believe that VA is meeting the needs of our
servicemembers and veterans who are severely injured from the
war in Iraq and Afghanistan? What is VA doing well and what
areas are in need of improvement.
2. Is VA properly staffed to care for severely injured
veterans and do our veterans have access to the most current
therapies?
3. How would you rate the coordination between DoD and VA in
providing medical care for severely injured OEF/OIF veterans?
What are your recommendations for enhancing coordination
efforts between VA and DoD?
4. You noted that the growing pressure of allowing veterans to
seek care outside of VA threatens the VA health care system
because VA would lose the critical mass of patients that are
needed to maintain specialized services at VA. What do you
propose for our severely injured veterans in rural communities
who do not live near VA facilities?
5. You discussed the coordination issues presented by DoD's
transfer of SCI patients to a civil hospital, rather than to
the VA. Do you have further information on the prevalence of
this practice or the rationale for it?
6. Your testimony addressed the important of VA maintaining
the SCI capacity mandated by P.L. 104-262. Given that the
capacity levels set by this legislation were established prior
to the current conflicts, do you believe the mandated capacity
remains sufficient?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by September 7, 2010.
Sincerely,
Michael H. Michaud
Chairman
__________
Paralyzed Veterans of America
Washington, DC.
August 31, 2010
Honorable Michael Michaud
Chairman
House Committee on Veterans' Affairs
Subcommittee on Health
338 Cannon House Office Building
Washington, DC 20515
Dear Chairman Michaud:
On behalf of Paralyzed Veterans of America (PVA), I would like to
thank you for the opportunity to present our views on ``Healing the
Physical Injuries of War.'' We also appreciate the opportunity to
address what the Department of Veterans Affairs (VA) is doing in caring
for severely injured veterans, in particular, veterans of Operation
Enduring Freedom and Operation Iraqi Freedom (OEF/OIF).
As we testified, specialized services are part of the core mission
and responsibility of the VA, including spinal cord injury care,
blinded rehabilitation, and mental health treatment, including
traumatic brain injury. The VA's specialized health care programs are
unmatched by private health care facilities. We appreciate the
Subcommittee's interest in ensuring that these veterans receive the
absolute best care available.
Attached are responses to each of the questions presented in your
July 27, 2010 follow-up questions. Thank you.
Sincerely,
Carl Blake
National Legislative Director
__________
Question 1: Do you believe that VA is meeting the needs of our
servicemembers and veterans who are severely injured from the war in
Iraq and Afghanistan? What is VA doing well and what areas are in need
of improvement?
Answer: VA continues to provide exceptional care for severely
injured veterans of the wars in Iraq and Afghanistan. The law that
allows for a veteran to receive care for up to five years following his
or her return from a combat theater has been a tremendous benefit to
these veterans. It has ensured that if they suffer from any health
problems, including mental health issues such as PTSD, they have a
place with knowledgeable professionals to seek treatment.
However, we believe that there is still an ongoing need to ensure
proper delivery of care to veterans living in rural communities.
Deployment of National Guard and Reserve servicemembers, a large
percentage who generally come from more rural communities, has created
a growing demand for health services from those same rural areas.
However, we believe that VA has the infrastructure in place to provide
the vast majority of care needed for these men and women through its
extensive network of Community-Based Outpatient Clinics (CBOCs) and its
hospital system. Additionally, the hub-and-spoke delivery system used
for spinal cord injury care has allowed the VA to address the demands
of the most severely disabled veterans it cares for. This same model
can be applied to other specialized health care concerns.
Question 2: Is VA properly staffed to care for severely injured
veterans and do our veterans have access to the most current therapies?
Answer: Based on a recent staffing survey (July 2010) of the Spinal
Cord Injury (SCI) service, the VA is clearly understaffed in some
critical areas. As expressed in our testimony, the most notable
shortage is in the number of nurse staff. As of the July survey, the VA
SCI service faced a total nurse deficit of approximately 134 nurses.
This is particularly troublesome because these are the individuals who
provide the majority of bedside care to SCI veterans. Additionally,
while the survey is specific to SCI staffing, it may be applicable to
other specialized care services.
PVA believes it is critical that a uniform national policy be
established for nurse staffing and VHA should centralize policies for
funding a systemwide recruitment and retention plan for SCI nurses.
Additionally, as we recommended in our testimony, we believe it is time
for the VA to consider a nurse specialty pay for those nurse staff
working in SCI centers.
In the meantime, the VA SCI service also faces shortages in doctor,
social worker, psychologist, and therapist staffing. While our veterans
do have access to the most current treatments and therapies, these
staff shortages can have a severe impact on their ability to receive
this critical care in a timely manner.
It is important, however, to point out that not all VA SCI centers
are understaffed. In fact, several currently meet the fully staffed bed
requirements that have been established. Likewise, the staffed levels
of facilities are constantly changing due to the changing acuity levels
of the patients that come and go from the various facilities. However,
the fact remains that across the system the VA SCI service still faces
shortages in all of its critical health professional areas.
Question 3: How would you rate the coordination between DoD and VA
in providing medical care for severely injured OEF/OIF veterans? What
are your recommendations for enhancing coordination efforts between VA
and DoD?
Answer: The coordination between the Department of Defense (DoD)
and the VA to provide care for severely injured veterans is generally
good, particularly for veterans of Operation Enduring Freedom and
Operation Iraqi Freedom (OEF/OIF). The transfer of patients from the
primary DoD health care centers, such as Walter Reed Army Medical
Center, Bethesda Naval Hospital, Brooke Army Hospital, and Balboa Naval
Hospital, generally works well, particularly when trying to move spinal
cord injured servicemembers from those facilities to VA SCI centers.
However, as mentioned in our testimony, we have seen some
complications in this transfer when it comes to servicemembers who were
not injured in the combat theater, but instead at their home
installations. In order to improve and enhance this coordination, we
believe that continued education, particularly in DoD facilities, is
critical to ensuring that the DoD facilities are aware of their
responsibilities in expeditiously transferring severely injured
servicemembers, particularly those with SCI and other polytrauma, to
the appropriate VA medical center. Additionally, we think continued
congressional oversight is necessary to ensure that DoD and VA are both
fulfilling their responsibilities to care for these men and women.
Question 4: You noted that the growing pressure of allowing
veterans to seek care outside of VA threatens the VA health care system
because VA would lose the critical mass of patients that are needed to
maintain specialized services at VA. What do you propose for our
severely injured veterans in rural communities who do not live near VA
facilities?
Answer: PVA's points regarding the growing pressure of outside care
dealt with the challenges of maintaining capacity in the VA system.
This can only be done if sufficient patients are treated at a facility,
otherwise the costs per patient can rise significantly. PVA believes
VA's hub-and-spoke model of Medical Centers supporting Community-Based
Outpatient Clinics (CBOC) is an excellent method to maintain a critical
mass of patients in an area while providing for veterans living at ever
greater distances from VA hospitals.
This is perhaps most important in rural communities. We recognize
the fact that veterans in rural communities have greater challenges
getting care from VA facilities. But this is not only a problem for
veterans. Rural communities are bereft of specialty care facilities,
not only for veterans, but for all members of the community. While
general care may be available, the specialized care needed by those
with any type of catastrophic injury may be hundreds of miles away. PVA
has worked to educate our members that due to the limited availability
of some forms of specialized care, there will sometimes be the need to
travel some distance to receive this care at a VA facility. Moreover,
our members have come to realize that in order to receive the absolute
best specialized care, they sometimes must travel significant distances
to a VA facility because comparable care is simply not available in
their local communities.
The success of CBOCs only confirms the need for greater expansion
of these valuable resources further into the rural community. This will
create a wider net of care facilities, providing ever increasing
services to rural veterans. PVA strongly supports this method of
providing for our severely injured veterans in rural communities.
Question 5: You discussed the coordination issues presented by
DoD's transfer of SCI patients to a civilian hospital, rather than to
the VA. Do you have further information on the prevalence of this
practice or the rationale for it?
Answer: We cannot provide specific data on the prevalence of this
occurrence. However, as we mentioned in our testimony, this
coordination and transfer issue tends to be more prevalent when it
involves a servicemember who was injured somewhere other than in the
combat theaters of Iraq and Afghanistan, such as at their home
installations. We find this particularly troublesome as it suggests a
lesser priority is placed on getting these men and women to the
appropriate care in the VA as opposed to those injured in Iraq and
Afghanistan. We also believe it reflects the fact that the Memorandum
of Agreement that the VA has with DoD to transfer spinal cord injured
servicemembers is not well-publicized beyond the major intake centers
such as Walter Reed and Bethesda, and that some of the local DoD health
care facilities are unaware of this responsibility.
Question 6: Your testimony addressed the important of VA
maintaining the SCI capacity mandated by P.L. 104-262. Given that the
capacity levels set by this legislation were established prior to the
current conflicts, do you believe the mandated capacity remains
sufficient?
Answer: With the length of the wars in Afghanistan and Iraq and the
anticipation that the current conflicts may continue well into the
future, PVA believes in is necessary for VA to reevaluate its mandated
capacity levels to reflect changes since 9/11. It is PVA's experience
that VA is generally meeting the needs of veterans with Spinal Cord
Injury (SCI). However, capacity is a function of available beds and
staff. Staffing challenges, particularly nursing shortages, continue to
plague VA.
In addition, the demographics of the veteran population have
changed with the increased numbers of National Guard and Reserves
serving, a military population generally older than regular Active Duty
forces. With approximately 160 new combat injured SCI veterans and
hundreds more non-combat related injuries since the beginning of the
war, and the possibility of increasing numbers as the weapons used
increase in destructive power and availability, there is a real
possibility of even higher rates of catastrophic disabilities.
Considering these conditions and the fact that the nature of health
care delivery has changed since enactment of P.L. 104-262, it would
make sense for VA to look forward and anticipate these effects on
future capacity.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
July 27, 2010
Ms. Joy J. Ilem
Deputy National Legislative Director
Disabled American Veterans
807 Maine Avenue, SW
Washington, DC 20024
Dear Ms. Ilem:
Thank you for your testimony at the U.S. House of Representatives
Committee on Veterans' Affairs Subcommittee on Health oversight hearing
on ``Healing the Physical Injuries of War'', which took place on July
22, 2010.
Please provide answers to the following questions by Tuesday,
September 7, 2010, to Jeff Burdette, Legislative Assistant to the
Subcommittee on Health.
1. Do you believe that VA is meeting the needs of our
servicemembers and veterans who are severely injured from the
war in Iraq and Afghanistan? What is VA doing well and what
areas are in need of improvement.
2. Is VA properly staffed to care for severely injured
veterans and do our veterans have access to the most current
therapies?
3. How would you rate the coordination between DoD and VA in
providing medical care for severely injured OEF/OIF veterans?
What are your recommendations for enhancing coordination
efforts between VA and DoD?
4. You raised concerns about the gaps that exist in the
Federal Recovery Coordination Program. What are these gaps, why
do you think they exist, and what can we do to eliminate them?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by September 7, 2010.
Sincerely,
Michael H. Michaud
Chairman
__________
POST-HEARING QUESTIONS FOR JOY J. ILEM, DEPUTY
NATIONAL LEGISLATIVE DIRECTOR OF THE DISABLED AMERICAN
VETERANS, FROM THE COMMITTEE ON VETERANS' AFFAIRS,
SUBCOMMITTEE ON HEALTH, HEARING, HEALING THE PHYSICAL
INJURIES OF WAR, JULY 22, 2010
Question 1: Do you believe that VA is meeting the needs of our
servicemembers and veterans who are severely injured from the war in
Iraq and Afghanistan? What is VA doing well and what areas are in need
of improvement?
Answer: It appears to DAV that the Department of Veterans Affairs
(VA) four regional Polytrauma/TBI Rehabilitation Centers (PRCs),
designed to provide specialized inpatient rehabilitation treatment and
expanded clinical expertise in polytrauma, are meeting the needs of
severely injured servicemembers from Iraq and Afghanistan. These PRCs
are the ``hub'' of the VA's Polytrauma/TBI System of Care, which
includes four Polytrauma Transitional Rehabilitation Programs that are
co-located within the PRCs--established to help patients transition
from the acute post-injury phase into a rehabilitation mode aimed at
restoring as much independence and functional capacity as possible so
they can return home. The reports DAV has received from veterans and
their families during these initial stages of care and recovery have
for the most part been positive, including high regard for VA staff and
satisfaction with their coordination of care.
As the Subcommittee is aware, the VA has also established a
specialized outpatient and sub-acute residential rehabilitation
program, referred to as a Polytrauma Network Site (PNS) within each of
the VA's 21 integrated service networks (VISNs), plus one at the VA
Medical Center in San Juan, Puerto Rico. VA has also reportedly
designated Polytrauma Support Clinic Teams at smaller, more remote VA
facilities; and has established a point of contact for polytrauma
referrals at all other VA facilities.\1,\ \2\
---------------------------------------------------------------------------
\1\ VA QUERI Fact Sheet; Polytrauma & Blast-Related Injuries; June
2010.
\2\ L. Beck, PhD., Chief Consultant, Office of Rehabilitation
Services, Office of Patient Services, Veterans Health Administration,
Department of Veterans Affairs; Testimony before the United States
Senate Committee on Veterans' Affairs; May 5, 2010.
---------------------------------------------------------------------------
DAV has expressed concern about these secondary sites of specialty
care, noting that we are less confident that VA has attuned their
available services to achieve consistency of polytrauma care throughout
the system nationwide. Although we believe at the national program
level appropriate directives and policies have established that
consistency, it is not clear if these mandates are actually being
carried out in all sites of care. We have received continued reports
from veterans seeking VA care for what they believe is a mild TBI--but
not being satisfied with the limited cognitive testing and seemingly
fragmented services offered by VA at those sites. Two veterans who
contacted DAV recently expressed concern that VA staff did not offer a
well-rounded comprehensive program to initially educate patients about
TBI and cohesively treat symptoms such as memory deficit, anger control
issues, and depression or provide family education, marital or mental
health counseling. In one case the veteran requested and was authorized
care in the private sector at VA expense and was very impressed with
the holistic ``TBI program'' and services that were available at a
local facility specializing in head injuries. He further commented that
he received care at VA for his other service-related conditions, was
satisfied with that care and could not understand why VA (in his
opinion) was unable to properly screen, diagnose and treat him for his
mild TBI condition, a condition that had greatly impacted his job,
family and his own self-esteem.
Additionally, these veterans appeared to be labeled as ``difficult
patients'' and reported having had trouble getting the services they
needed from VA. Having worked with TBI patients in the private sector
before I joined DAV, I can attest that issues related to mood,
behavioral problems and difficulty managing anger are common symptoms
and behaviors associated with TBI patients. We believe appropriate VA
medical personnel should be trained and equipped to handle these
challenges to ensure patients are treated properly for the symptoms
that are associated with head injuries--regardless if they are mild,
moderate or severe. In such cases we have contacted VA staff at VA's
Central Office or the local facility involved and asked that the
various specialty coordinators reach out to these veterans and help
resolve their issues.
DAV believes these types of reports warrant investigation and
oversight of VA's secondary system of TBI care, and recommends an
independent review by GAO or another qualified entity to determine the
effectiveness of these services and patient satisfaction levels.
Question 2: Is VA properly staffed to care for severely injured
veterans and do our veterans have access to the most current therapies?
Answer: As noted above, DAV remains concerned about veterans'
access to current therapies at all secondary VA TBI/Polytrauma Network
Sites of care. Likewise, we are concerned about sufficient staffing
levels and availability of specialists and other resources at all VA
Polytrauma primary and secondary sites. We recommend the Subcommittee
survey the four regional sites to address this issue, as well as a
sample from the secondary sites. Because of the medical complexity and
severity of these patients' injuries these positions are often
associated with a high level of stress, staff burn-out and elevated
turnover rates.
Access to current therapies remains important to TBI patients.
Several veterans have expressed their desire to be able to access more
holistic, comprehensive programs to treat TBI symptoms to include
education for themselves and family members about brain injuries,
access to mental health and marital counseling, and to be seen by
specialists who work as a team to address all of these patients' issues
and most of all compassionate medical personal that understand the
associated behaviors and challenges TBI patients face. In addition, as
we noted in our testimony during the hearing, we strongly believe that
a gap exists between VA's acute polytrauma and TBI programs and a
severely injured veteran's optimal long-term rehabilitation and
stabilization. Today, VA is able to offer limited options, primarily
nursing home placements. The ``Heroes Ranch'' concept being developed
at the Tampa VA PRC is one that we embrace and that we believe offers a
good model of age-appropriate therapeutic residential care that could
begin to fill that gap.
As noted in our testimony, VA has developed and implemented a
national template to ensure that it provides every veteran receiving
inpatient or outpatient treatment for TBI who requires ongoing
rehabilitation, an individualized rehabilitation and community
reintegration plan. VA integrates this national template into its
electronic health record, and includes in the record results of the
comprehensive assessment, measurable goals that were developed as a
result of the plan, and recommendations for specific rehabilitative
treatments. The patient and family participate in developing the
treatment plan and are provided a copy of the plan. These are all
positive steps; however, we encourage VA to periodically survey
patients and family members in these programs about their experiences
in care and treatment programs and settings to gauge if there are any
improvements that can be made and to ensure consistency and
effectiveness of treatments.
Finally, as noted in our statement, while DAV believes great
strides have been made over the past two years, VA recently
acknowledged embracing opportunities for further improvement in its
Polytrauma System of Care, and states the Department's ongoing goals as
follows:
1. Ensuring that blast-exposed veterans receive screenings and
evaluation for high-frequency, invisible sonic wounds that may
produce mild TBI, PTSD, and other psychiatric problems, or pain
and sensory loss;
2. Promoting identification and evaluation of potentially the
best practices for polytrauma rehabilitation, including those
that optimize care coordination and transition across care
systems and settings such as DoD and VA;
3. Optimizing the ability of caregivers and family members to
provide supportive assistance to veterans with impairments
resultant from polytrauma and blast-related injuries;
4. Identifying and testing methods for improving process of
care and outcomes, even when the evidence base is not well
established; and
5. Identifying and testing methods for measuring readiness to
implement and sustain practice improvements in polytrauma
care.\3\
\3\ VA QUERI Fact Sheet; Polytrauma & Blast-Related Injuries; June
2010.
DAV fully supports VA's goals, and we ask the Subcommittee, through
oversight, to monitor VA's progress in achieving them for this
---------------------------------------------------------------------------
deserving population with the most severe physical wounds of war.
Question 3: How would you rate the coordination between DoD and VA
in providing medical care for severely injured OEF/OIF veterans? What
are your recommendations for enhancing coordination efforts between VA
and DoD?
Answer: As noted in our testimony DAV gives VA high marks for
coordination of care between the two Departments at VA's four regional
PRCs and associated military treatment facilities. VA has made new
inroads to improve communication between the agencies' medical systems
to ensure polytrauma patient care is truly seamless from the time of
injury throughout all stages of transition and care. From what we have
read, seen and heard--there have been significant improvements over the
years in this regard; however, we encourage VA and DoD to continue to
collaborate and improve on this very complex network of highly
specialized care. We do understand that compatibility of IT systems and
access to electronic health records between the Departments is a
continuing challenge and needs significant additional improvement. In
that connection, we were pleased that VA announced on August 23, 2010,
the establishment of a very progressive pilot program of interactive
electronic health record portability among VA, DoD and private
facilities in the Richmond-Tidewater area of Virginia (but also
involving the San Diego, California area facilities as well). We hope
the Subcommittee will closely monitor this effort because we believe,
if it is successful, it may serve as a model of responsive IT
interactivity, not only for polytrauma patients, but for all forms of
VA health care for sick and disabled veterans.
Question 4: You raised concerns about the gaps that exist in the
Federal Recovery Coordination Program. What are these gaps, why do you
think they exist, and what can we do to eliminate them?
Answer: As noted in our testimony, DAV remains concerned about the
gaps that exist in the Federal Recovery Coordination Program and social
work case management essential to coordinating complex components of
care for polytrauma patients and their families. These gaps were
highlighted by disabled veterans and their caregivers in hearings held
by the House Veterans' Affairs Subcommittee on Oversight and
Investigation in April 2009 and January 2010 and warrant continued
oversight and evaluation by the full Committee and its Subcommittees.
Prior to the establishment of the Federal Recovery Coordination
(FRC) Program, veterans and their families reported a complex and
frustrating bureaucracy requiring them to try to navigate the DoD and
VA systems ``on their own.'' One witness described it as, ``. . . a
journey of blind exploration.'' There were complaints of a lack of
continuity, coordination of care and communication between DoD and VA
during a servicemember's transition from active duty, the return home,
veteran status and VA health and benefits systems. Likewise, families
complained they felt they were carrying the burden of a servicemember's
recovery and reintegration back into civilian life and had little
guidance or support from VA or DoD. One witness at the hearing noted
that lost paperwork, confusing processes and lack of information were
common occurrences. This witness also reported that he had had a total
of 13 social work representatives within VA and DoD--but none of them
communicated regularly with each other to make sure everything was
covered in his case.\4\
---------------------------------------------------------------------------
\4\ Brogan, Mark A. (Capt., USA, Ret.), Statement before House
Veterans' Affairs Subcommittee on Oversight and Investigations, April
28, 2009.
---------------------------------------------------------------------------
Another witness, the spouse of a severely disabled veteran,
reported a similar experience prior to the establishment of the FRC
program but noted that, once the program was up and running, things
began to go more smoothly until a new FRC was assigned to their case--
after only four months--requiring them to start all over again. High
personnel turnover rates appeared to be a trend early on in the program
for other families as well--and hope for a single point of contact that
was fully knowledgeable about her husband's injuries and case as well
as a complete understanding of all their benefits and a comprehensive
``life plan'' were dashed.\5\
---------------------------------------------------------------------------
\5\ Wade, Sarah, Statement before House Veterans' Affairs
Subcommittee on Oversight and Investigations, April 28, 2009.
---------------------------------------------------------------------------
One witness said it best when referring to the life-altering nature
and responsibility of caring for a brain injured veteran--``The
responsibility is daunting, the stress is never ending, and we need a
lifeline.'' Although the hearing witnesses all agreed that the FRC
program was needed and had the potential to be beneficial, there still
seems to be a number of issues that need to be addressed including
better communicating, educating, promoting visibility of the program
and streamlining the referral process. It appears some family members
are not aware they have an option to request an FRC and are sometimes
confused about the roles of the multitude of advocates, program
managers, and DoD and VA social workers and case managers to their
wounded loved ones. The FRC's level of knowledge about catastrophic
injuries and their impact on patients and families--as well as being
knowledgeable about DoD and VA health and benefits systems and
community services are of vital importance to family members and
caregivers alike. They also want to be able to rely on the FRC to help
address the need of lifelong care and caregiving for their injured
loved ones should these veterans outlive their parents, spouses or
other caregivers, or in cases where their caregivers become unable to
continuously care for these veterans.\6\
---------------------------------------------------------------------------
\6\ Lynch, Cheryl, Statement before House Veterans' Affairs
Subcommittee on Oversight and Investigations, April 28, 2009.
---------------------------------------------------------------------------
The Executive Director of the FRC Program, Dr. Karen Guice,
acknowledged there are ongoing challenges for the program and that
there have been many lessons learned and adjustments in the program to
improve its overall effectiveness. For these reasons, we again urge
continued Congressional oversight of this extremely important program
and recommend the FRC program be continually monitored and that
families and veterans be surveyed periodically to make needed
adjustments and improvements to the program.\7\
---------------------------------------------------------------------------
\7\ Guice, Karen, M.D., MPP, Executive Director, Federal Recovery
Coordination Program, Department of Veterans Affairs, Statement before
House Veterans' Affairs Subcommittee on Oversight and Investigations,
April 28, 2009
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
July 27, 2010
Mr. Tom Tarantino
Legislative Associate
Iraq and Afghanistan Veterans of America
308 Massachusetts Avenue, NE
Washington, DC 20002
Dear Mr. Tarantino:
Thank you for your testimony at the U.S. House of Representatives
Committee on Veterans' Affairs Subcommittee on Health oversight hearing
on ``Healing the Physical Injuries of War,'' which took place on July
22, 2010.
Please provide answers to the following questions by Tuesday,
September 7, 2010, to Jeff Burdette, Legislative Assistant to the
Subcommittee on Health.
1. Do you believe that VA is meeting the needs of our
servicemembers and veterans who are severely injured from the
war in Iraq and Afghanistan? What is VA doing well and what
areas are in need of improvement.
2. Is VA properly staffed to care for severely injured
veterans and do our veterans have access to the most current
therapies?
3. How would you rate the coordination between DoD and VA in
providing medical care for severely injured OEF/OIF veterans?
What are your recommendations for enhancing coordination
efforts between VA and DoD?
4. You noted that you ``received only a few complaints about
the actual quality of care at VA.'' This may be the case for
the veterans enrolled in VHA, but do you believe that there is
a perception problem out there for our OEF and OIF veterans who
view VA health care as substandard care, and therefore not even
enroll in VHA?
5. You raised some concerns about VA limiting or denying
access to some veterans who seek recovery services for TBI. Can
you expand on this point and give us some examples of the types
of care that VA is limiting or denying?
6. In your testimony you discussed the often lengthy drive
times faced by veterans seeking VA care. Have you found this
issue to be of particular relevance to veterans seeking
specialty care, and especially for those with particularly
severe injuries?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by September 7, 2010.
Sincerely,
Michael H. Michaud
Chairman
__________
House Veterans' Affairs Subcommittee on Health, ``Healing
the Physical Injuries of War.'' Questions for the Record for
Tom Tarantino, Iraq and Afghanistan Veterans of America (IAVA)
Question 1: Do you believe that VA is meeting the needs of our
servicemembers and veterans who are severely injured from the war in
Iraq and Afghanistan? What is VA doing well and what areas are in need
of improvement?
Response: The VA is meeting many of the needs of servicemembers and
veterans who are severely injured, however there is much left to be
desired. VA has some of the brightest Doctors and best protocols for
handling combat injuries, but access to that level of care can be
limited at best.
Question 2: Is VA properly staffed to care for severely injured
veterans and do our veterans have access to the most current therapies?
Response: The VA is still understaffed across the board, hence the
long wait times for appointments. We've heard numerous complaints from
veterans who have not been able to see a physical therapist for months
at a time, nor come in for routine check-ups on past VA care.
Question 3: How would you rate the coordination between DoD and VA
in providing medical care for severely injured OEF/OEF veterans? What
are your recommendations for enhancing coordination efforts between VA
and DoD?
Response: We would rate the coordination as significantly improved,
but nowhere near seamless. Seamless transition will be when a veteran
walks into the VA and doesn't have to prove that they served in the
military and their military medical records are available immediately
to both the health care and benefits staff.
Question 4: You noted that you ``received only a few complaints
about the actual quality of car at VA.'' This may be the case for
veterans enrolled in VHA, but do you believe that there is a perception
program out there for our OEF and OIF veterans who view the VA health
care as substandard care and therefore not even enroll in VHA?
Response: As we stated in our testimony the VA has a huge
perception issue among returning veterans. Many veterans think of the
VA as a health care of last resort and avoid the VA altogether. One
particular quote Questions for the Record, HVAC Health Tom Tarantino,
IAVA ``Healing the Physical Injuries of War'' 2 of 2 from our members
sticks out in my mind, ``You get what you pay for.'' The implication is
that the service at VA is substandard because it is supposedly free.
The truth of the matter is that many veterans pay a hefty price to earn
access to VA health care. We believe that VA must do a better job
showing veterans why VA health care is safe, accessible and high
quality.
Question 5: You raised concerns about VA limiting or denying access
to some veterans who seek recovery services for TBI. Can you expand on
this point and give us some examples of the types of care that VA is
limiting or denying?
Response: As we put together our testimony for this hearing we
consulted with several other veterans groups on what they felt needed
to be discussed. This particular issue regarding TBI was brought up by
the Wounded Warrior Project in a Senate Hearing on May 5th, 2010. They
listed a number of examples including a veteran suffering from TBI in
Tampa where the VA ``refused [the wife's] requests for further therapy
to prevent reversal in the gains he had made.'' The end result was the
veteran seeking help through Medicare and being discharged from the VA.
The veteran then ``moved into his own apartment, but--without structure
and supervision, and with a condition marked by impulsivity and lack of
insight--he spun out of control, and has struggled since then with
PTSD, depression, and substance--use complicating his TBI problems.''
Only after being admitted at Navy Bethesda Hospital and receiving a
thorough and helpful care plan was this veteran put back on the right
track and the Tampa VAMC finally acquiesced. .
Question 6: In your testimony you discussed the often--lengthy
drive times faced by veterans seeking VA care. Have you found this
issue to be of particular relevance to veterans seeking specialty care,
and especially for those with particularly severe injuries?
Response: Long wait times and longer drives to get to VA care has
been continually relayed to us by our members. The issue of lengthy
drives seemed to apply to both general and specialty care.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
July 27, 2010
Ms. Denise A. Williams
Assistant Director for Health Policy
Veterans Affairs and Rehabilitation Commission
The American Legion
1608 K Street, NW
Washington, DC 20006
Dear Ms. Williams:
Thank you for your testimony at the U.S. House of Representatives
Committee on Veterans' Affairs Subcommittee on Health oversight hearing
on ``Healing the Physical Injuries of War'', which took place on July
22, 2010.
Please provide answers to the following questions by Tuesday,
September 7, 2010, to Jeff Burdette, Legislative Assistant to the
Subcommittee on Health.
1. Do you believe that VA is meeting the needs of our
servicemembers and veterans who are severely injured from the
war in Iraq and Afghanistan? What is VA doing well and what
areas are in need of improvement.
2. Is VA properly staffed to care for severely injured
veterans and do our veterans have access to the most current
therapies?
3. How would you rate the coordination between DoD and VA in
providing medical care for severely injured OEF/OIF veterans?
What are your recommendations for enhancing coordination
efforts between VA and DoD?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by September 7, 2010.
Sincerely,
Michael H. Michaud
Chairman
__________
American Legion
Washington, DC.
September 8, 2010
Honorable Michael H. Michaud, Chairman
Subcommittee on Health
Committee on Veterans' Affairs
335 Cannon House Office Building
Washington, D.C. 20515
Dear Chairman Michaud,
The American Legion appreciates the opportunity to submit responses
in reference to your July 27 letter from the ``Healing the Physical
Injuries of War.'' testimony held on July 22, 2010.
1. Do you believe that VA is meeting the needs of our
servicemembers and veterans who are severely injured from the
war in Iraq and Afghanistan?
The American Legion has noted improvements in recent years by both
the Department of Defense (DoD) and Department of Veterans Affairs (VA)
in the treatment of severely injured and transitioning servicemembers
but gaps still exist.
Some of the positive steps DoD and VA undertook included
implementation of the Federal Recovery Coordinators, VA Polytrauma
Rehabilitation System of Care, VA Operation Enduring Freedom (OEF) and
Operation Iraqi Freedom (OIF) case management teams and establishing
directives for Traumatic Brain Injury (TBI) screening, clinical
reminders and a new symptom and diagnostic code for TBI. The American
Legion believes most of the visible wounds of Iraq and Afghanistan are
adequately being addressed by VA's interdisciplinary medical team at
the VA Polytrauma Rehabilitation Centers. However, some of the concerns
we have include: shortages of specialty medical providers and the
influx of the two million returning troops overburdening the
capabilities of access and quality of care.
In addition, The American Legion continues to be concerned about
prevention, screening, diagnosis and treatment and combat-related
research for the invisible wounds of war such as TBI and Post Traumatic
Stress. The American Legion believes TBI and PTS are interrelated and
DoD and VA are treating the symptoms of these injuries and not the
diagnosis. During an Improved Explosive Device (IED) explosion, a
servicemember can experience a penetrating woundor have an undetected
mild, moderate or severe case of TBI. From this experience, it is very
likely that the veteran may develop PTS leading to substance abuse,
depression and regrettably, suicide.
2. Is VA properly staffed to care for the severely injured
veterans and do our veterans have access to the most current
therapies?
The American Legion believes VA health care is the ``best care
anywhere,'' and is the model for the national health care. The VA
Health care system is a system designed to meet unique and complex
needs of our nation's veterans. In order to ensure quality of care for
veterans, The American Legion developed a System Worth Saving program
in 2003 to report on best practices and challenges in the delivery of
VA Health Care as well as to obtain feedback from veterans on their
level of care. In the 2010 System Worth Saving site visits, it was
noted that there is a shortage of specialty providers across the
country in areas such as Psychiatrists, Gastrointestinal (GI),
Cardiology physicians, Radiation and Hematology Oncologists and
Anesthesiologists, Audio and Speech Pathology, Dietetics, Social Work,
Rehabilitation Medicine, Physical Therapists, Nurses, Pharmacists and
many other critical areas.
As a result of shortages in these critical staffing areas and rural
location challenges, VA's Fee-Basis or Purchased Care costs have
doubled in the last four years. In FY 2005, approximately 496,885
veterans were fee-based into the community for their health care needs
at an expense of $1.6 Billion and in FY 2009, 920,404 veterans were
fee-based into the community at a cost of $3.8 Billion. In most of the
facilities visited, their Fee-Basis budget was between 15-25 percent of
their hospital operating budget which significantly impacts the medical
center's ability to prioritize other medical center needs and projects.
The American Legion recommends Congress designate specific funding
to address recruitment and retention and rural health incentives. In
addition, The American Legion was pleased that the House Veterans
Affairs Committee recently held a hearing on Innovative Treatments for
TBI and PTS to discuss new technologies, research and treatment for
these injuries. The American Legion has continued to recommend that
Congress exercise oversight and appropriate the necessary funding for
DoD and VA to fully explore and fund research and studies to prevent,
diagnose and treat these complex injuries.
3. How would you rate the coordination between DoD and VA in
providing medical care for severely injured OEF/OIF Veterans?
What are your recommendations for enhancing coordination
efforts between VA and DoD?
The American Legion would rate the coordination between DoD and VA
as improved but gaps still remain. As highlighted in our testimony, DoD
reported that as of April 3, 2010, there were a total of 8,810
servicemembers wounded in action during Operation Iraqi Freedom (OIF)
and 2,038 have been wounded in action during Operation Enduring Freedom
(OEF). Of the two million servicemembers currently deployed, The
American Legion is concerned that VA does not have a capacity and
number of specialty providers necessary to accommodate for an increase
in demand of these returning soldiers. Due to medical advances on the
battlefield in the current conflicts in Iraq and Afghanistan, our
nation's heroes are surviving life threatening injuries at a higher
rate but will require significant lifelong care in the VA.
VA's Seamless Transition process targets the severely injured
servicemembers and the Military Treatment Facilities (MTFs) have VA
Nurse Liaisons and VA Social Workers on site to ensure a warm handoff
into one of the four lead Polytrauma Rehabilitation Centers. In
addition, VA established Polytrauma Network sites at each of their 22
Veteran Integrated Service Networks (VISNs), 82 Polytrauma Support
Clinic Teams and 48 Polytrauma Points of Contact to provide case
management close to the transitioning servicemember's home.
While the case management process has improved, a major impediment
still needing to be resolved is the bilateral record exchange between
DoD and VA. Both agencies will never truly have seamless transition if
their medical records are not interoperable. The American Legion has
fully supported the Lifetime Electronic Medical Record Initiative which
will create a bilateral record exchange from DoD into VA. Since 2007,
The American Legion has continued to advocate for this improvement
because every day without a bilateral record, a potential veteran can
fall through the cracks and need access their needed medical care.
The American Legion was pleased to see passage of the Caregiver and
Veterans Omnibus Health Services Act which will train and pay a stipend
to a family member caregiver in the homes of our severely wounded
soldiers. The American Legion's only concern with the Caregiver law is
that only OEF/OIF caregivers will receive a stipend when many other
veterans from previous conflicts do not receive this benefit and are
taken care of by a family member in their homes for many injuries or
illnesses.
The American Legion recommends that Congress exercise its oversight
to ensure VA provides an annual Mental Health Strategic Report, to make
transparent, the agency's efforts in appropriations and where these
funds are spent, as well as services provided through research,
screening and treatment for all Mental Health illnesses.
Once again, The American Legion appreciates the opportunity to
provide recommendations to improve DoD and VA's efforts to ensure both
agencies are prepared to meet the long-term and complex health care
needs of our nation's veterans.
Thank you for your continued commitment to America's veterans and
their families.
Sincerely,
Tim Tetz
Director, National Legislative Commission
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
July 27, 2010
Honorable Robert M. Gates
Secretary
U.S Department of Defense
1400 Defense Pentagon
Washington, DC 20301
Dear Secretary Gates:
Thank you for the testimony of Dr. Jack Smith, Acting Deputy
Assistant Secretary for Clinical and Program Policy at the U.S. House
of Representatives Committee on Veterans' Affairs Subcommittee on
Health oversight hearing on ``Healing the Physical Wounds of War'',
which took place on July 22, 2010.
Please provide answers to the following questions by Tuesday,
September 7, 2010, to Jeff Burdette, Legislative Assistant to the
Subcommittee on Health.
1. How does DoD define severely injured servicemembers? How
does DoD track the number of and the types of severe injuries?
Do you share this data with VA, and is it made available to the
public?
2. Does DoD offer the same types of specialized services as
VA? Are there certain specialized services that DoD offers, but
which VA does not?
3. Where is DoD headed in terms of further enhancing
coordination efforts with VA in caring for the severely
injured?
4. Why is it that VA's Blind Rehabilitation Outpatient
Specialists do not have clinical privileges at military
treatment facilities?
5. In PVA's testimony, they expressed concern that some mild
TBI cases are falling through the cracks because of DoD's
failure to diagnose and treat mild TBI? What can DoD do to
improve on this front?
6. During their testimony, PVA raised concerns about some
active duty soldiers with spinal cord injury and dysfunction
bypassing the VA health care system and being transferred
directly to civilian hospitals in the community. Why is this
happening? What is DoD's rationale for bypassing the VA health
care system?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by September 7, 2010.
Sincerely,
Michael H. Michaud
Chairman
__________
Hearing Date: July 22, 2010
Committee: HVA
Member: Congressman Michaud
Witness: Dr. Smith
Question 1: How does DoD define severely injured servicemembers?
How does DoD track the number of and the types of severe injuries? Do
you share this data with VA, and is it made available to the public?
Answer: The Department uses the following definitions:
Seriously Ill or Injured--The casualty status of a
person who has an injury; a physiological or psychological
disease or condition; or a mental disorder that requires
medical attention and medical authority declares that the
condition is life-threatening or life-altering, and/or that
death is possible, but not likely within 72 hours. This may
include post-traumatic stress disorder and associated
conditions. NOTE: A casualty status is assigned at a specific
point in time and can be changed.
Very Seriously Ill or Injured--The casualty status of
a person whose illness or injury is such that a medical
authority declares it more likely than not that death will
occur within 72 hours.
The Department of Defense tracks the number of medically evacuated
patients and the reason for evacuation using TRANSCOM data; collects
and evaluates trauma care using the Joint Trauma Registry; collects and
evaluates disease and injury trends using the Theater Medical Data
System records; and collects and reports theater morbidity and
mortality counts and reasons using personnel data sent to the Defense
Manpower Data Center (DMDC), Data, Analysis and Programs Division.
Direct individual medical information is available to the
Department of Veterans Affairs (VA) via data sharing (i.e., Bilateral
Health Information Exchange and Federal Health Information Exchange).
Inpatient medical records for severely injured members being
transferred to VA poly-trauma centers are also scanned and forwarded to
the VA. Medical information on individuals is not publicly available.
However, military casualty information is publicly available on the
DMDC Analysis and Programs Division Web site at http://
siadapp.dmdc.osd.mil/personnel/MMIDHOME.HTM.
Question 2: Does DoD offer the same types of specialized services
as VA? Are there certain specialized services that DoD offers, but
which VA does not?
Answer: DoD does offer specialized services, as does VA. The two
Departments have many MOAs regarding the sharing of specialty care.
These agreements center on the core competencies of each Department in
meeting the special needs of their beneficiaries. For example, there is
a long standing Memorandum of Agreement (MOA) between the Department of
Veterans Affairs (VA) and the Department of Defense (DoD) associated
with specialized care for Active Duty Servicemembers (ADSMs) sustaining
spinal cord injuries, traumatic brain injuries, blindness, or a
combination of injuries (polytrauma). The Veterans Health
Administration is known for its integrated system of health care for
these conditions and the VA/DoD Health Executive Council identified the
need for procedures governing the treatment of ADSM inpatients,
outpatients, and other related comprehensive services at VA facilities.
Question 3: Where is DoD headed in terms of further enhancing
coordination efforts with VA in caring for the severely injured?
Answer: Currently, we are sustaining the momentum of DoD and VA
collaboration by improving upon the existing programs as lessons are
learned as well as striving to identify new opportunities for
collaborative and cooperative activities with the VA. At all levels
within DoD, program managers and directors are working closely with
their VA counterparts to improve access, quality, and efficiency as the
keys to maintaining and improving upon the firm foundation for
coordinated health care services and benefits. These efforts have been
and will continue to be future high priorities for the DoD.
Question 4: Why is it that VA's Blind Rehabilitation Outpatient
Specialists do not have clinical privileges at military treatment
facilities?
Answer: The Veterans Health Administration (VHA) is the only
medical organization that credentials blind rehabilitation specialists
(BRS) and blind rehabilitation outpatient specialists (BROS) as an
occupational series, which is a subgroup of an occupational group or a
job family that includes all classes of positions at various skill
levels in a type of work. The VHA developed an occupational series to
organize, identify, and credential these professionals after World War
II, when the first VHA inpatient blind rehabilitation center opened.
When Medicare was deployed in the 1950's, a decision was made not to
include rehabilitation for visual impairment because age-related visual
impairment was not the health issue at that time that it is today.
Therefore, other third party medical insurers do not currently
recognize these professionals.
There has not been a similar credentialing system in place in the
Department of Defense (DoD). The DoD has not provided blind
rehabilitation training to Servicemembers since transferring that care
from DoD to the Department of Veterans Affairs (VA) following World War
II. In 1947, President Truman transferred blind rehabilitation training
programs at Valley Forge General Hospital (Valley Forge, PA), Dibble
General Hospital (Menlo Park, CA), and Old Farms Convalescent Hospital
(Avon, CT) to the VA via Presidential Order.
Although they are not credentialed rehabilitation providers in the
DoD at this time, BRS and BROS as additional occupational series' may
be considered by DoD in the future. We are conducting an analysis of
the requirements and courses of action for credentialing rehabilitation
providers in the DoD. Currently, VA BROSs can and do support DoD
credentialed providers such as optometrists, occupational therapists,
and physical therapists in establishment of rehabilitation care plans
for Servicemembers. DoD military treatment facilities refer to VA
health care facilities and blind rehabilitation providers as needed to
provide equal access to care.
Question 5: In PVA's testimony, they expressed concern that some
mild TBI cases are falling through the cracks because of DoD's failure
to diagnose and treat mild TBI? What can DoD do to improve on this
front?
Answer: The Deputy Secretary of Defense recently signed a policy
whereby mandatory medical evaluations occur in the presence of clearly
defined inciting events. In addition to these mandatory medical
evaluations for early detection and treatment of concussion, there are
also line commander reporting requirements to ensure those who are
exposed to possible concussive events undergo an evaluation.
All Servicemembers take the Post-Deployment Health Assessment and
the Post-Deployment Health Reassessment at the end of their deployment
cycle. Embedded within these assessments are TBI related screening
questions to further identify those who may have sustained a TBI with
current symptoms who may require further evaluation.
The Department of Defense (DoD) is committed to providing optimal
health care to all Servicemembers. This includes all who sustain any
severity of traumatic brain injury (TBI). While more severe levels of
TBI are obvious and easier to diagnose than mild TBI, the DoD will
continue to take steps to ensure that Servicemembers with a potential
concussive injury are fully evaluated and promptly treated.
*Note: The question refers to the testimony of Mr. Carl Blake,
National Legislative Director, Paralyzed Veterans of America (PVA).
Question 6: During their testimony, PVA raised concerns about some
active duty soldiers with spinal cord injury and dysfunction bypassing
the VA health care system and being transferred directly to civilian
hospitals in the community. Why is this happening? What is DoD's
rationale for bypassing the VA health care system?
Answer: Patient preference as to the location of their long term
treatment is the individual's prerogative. The responsible military
treatment facility (MTF) obtains the preference of the active duty
Servicemember (or their guardian, conservator, or designee) for those
individuals being considered for treatment under the spinal cord
injury, traumatic brain injury, blindness, or polytrauma injury
Memorandum of Agreement. The MTF will identify to the Servicemember or
their designee the appropriate participating VA facility and make all
transfer arrangements. Should the Servicemember or their designee
request transfer to a TRICARE network provider or other civilian
facility, the MTF will honor that request.
*Note: The question refers to the testimony of Mr. Carl Blake,
National Legislative Director, Paralyzed Veterans of America (PVA).
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
July 27, 2010
Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue NW
Washington, DC 20240
Dear Secretary Shinseki:
Thank you for the testimony of Dr. Lucille B. Beck, Chief
Consultant, Rehabilitation Services, Office of Patient Care Services in
the Veterans Health Administration at the U.S. House of Representatives
Committee on Veterans' Affairs Subcommittee on Health oversight hearing
on ``Healing the Physical Injuries of War'', which took place on July
22, 2010.
Please provide answers to the following questions by Tuesday,
September 7, 2010, to Jeff Burdette, Legislative Assistant to the
Subcommittee on Health.
1. Does VA track veterans by the number and types of severe
injuries?
2. While OEF/OIF veterans may currently comprise a small
proportion of the total number of veterans who use specialized
services at VA, this is likely to change as our veterans return
from Iraq and Afghanistan in increasing numbers. Given this,
does VA have a good sense of the future demand for specialized
services among our OEF/OIF veterans population? What is VA
doing to prepare for the pending increase in demand for
specialized services?
3. Dr. Beck's testimony emphasized VA's efforts in the area of
prosthetics for women veterans. Are there gender differences
where the needs of women veterans differ from their male
counterparts for other specialized services such as blind
rehabilitation, spinal cord injury centers, and polytrauma? If
such difference exist, what is VA doing in these other areas to
provide gender-specific care that meets the unique needs of
women veterans?
4. Does VA offer the same types of specialized services as
that of DoD? Are there certain specialized services that VA
offers but which DoD does not offer?
5. How does VA know that they are providing the right kinds of
specialized services? Also, how does VA know that they are
serving severely injured OEF/OIF veterans on a timely basis at
their current capacity? Can VA quickly ramp-up or ramp-down
services to accommodate changes in the severely wounded veteran
population?
6. How does VA ensure high quality of care for severely
injured OEF/OIF veterans? In other words, how does VA know that
care is consistent, standardized, and measurable across the VA
health care system?
7. In their testimony, DAV brought to the Subcommittee's
attention the proposed Tampa area Heroes Ranch, which would
serve as a post-acute long-term care residential brain injury
facility for active duty military servicemembers and veterans.
Where is the VA in reviewing this proposal? When can we expect
a formal decision from VA?
8. Where is VA in implementing the caregiver family support
provisions of public law 111-163? When will caregivers have
access to the supportive services provided in the recently
enacted caregiver legislation?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by September 7, 2010.
Sincerely,
Michael H. Michaud
Chairman
__________
Committee on Veterans' Affairs, U.S. House of Representatives,
Post-Hearing Questions for Lucille Beck, Ph.D., Chief Consultant
for Rehabilitation Services, U.S. Department of Veterans Affairs
from the Honorable Michael H. Michaud, ``Healing the Physical
Wounds of War,'' Oversight Hearing Subcommittee on Health, July 22,
2010
Question 1: Does VA track Veterans by the number and types of
severe injuries?
Response: Yes. Veterans are identified and tracked through a
database appropriate for their injuries and the type of rehabilitation
centers where they receive specialized services; e.g., Polytrauma
Rehabilitation Centers (PRC), Blind Rehabilitation Centers, Spinal Cord
Injury Centers. Additionally, VA established the Care Management
Tracking and Reporting Application (CMTRA) to track Operation Enduring
Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans and to ensure
appropriate care management of severely injured Veterans. Six
categories of severe injuries are tracked, including: amputations,
blindness/severe visual impairment, major burns, severe mental health,
spinal cord injury (SCI), and severe traumatic brain injury (TBI).
Question 2: While OEF/OIF Veterans may currently comprise a small
proportion of the total number of Veterans who use specialized services
at VA, this is likely to change as our Veterans return from Iraq and
Afghanistan in increasing numbers. Given this, does VA have a good
sense of future demand for specialized services among our OEF/OIF
veterans population? What is VA doing to prepare for the pending
increase in demand for specialized services?
Response: VA projects demand for VA health care services by OEF/OIF
Veterans for the next 20 years using a force-deployment scenario
developed by the Congressional Budget Office. This allows VA to project
enrollment and demand for VA health care services for OEF/OIF Veterans
who will separate from the military in the future. The OEF/OIF health
care utilization projections, including VA specialized services,
reflect their unique morbidity and reliance on VA health care. Further,
because this is a very dynamic population, VA studies evolving trends
each year and makes adjustments to the projections as necessary.
There are many actions undertaken by VA to provide and plan for
specialized rehabilitation services in the future, including:
Chartered the Polytrauma Rehabilitation and Extended
Care Task Force to address the long-term rehabilitative care
needs of seriously injured OEF/OIF Veterans, and develop
approaches to meet such needs through enhancements to current
VA programs and services.
Developed and implemented the VHA Strategic Plan for
TBI, and established TBI as a select program in VA budget
submissions.
Developed and implemented the Polytrauma/TBI System
of Care that provides specialized rehabilitation services
within every Veteran Integrated Service Network, nationwide.
This system of care consists of four levels of facilities,
including 4 Polytrauma Rehabilitation Centers, 22 Polytrauma
Network Sites, and 82 Polytrauma Support Clinic Teams with
interdisciplinary teams of rehabilitation specialists,
specialty care management, psychosocial support, and advanced
rehabilitation and prosthetic technologies.
Developed and implemented the Blind Rehabilitation
Continuum of Care establishing 55 new low vision and blind
rehabilitation clinics that provide the full spectrum of vision
services through this one-of-a-kind National model of care for
outpatient blind rehabilitation services.
Developed and established the VA Amputation System of
Care; a four component system of care that mirrors the model
utilized by the Polytrauma System of Care, to provide services
and expertise for Veterans with amputations.
Developed and implemented the TBI Screening and
Evaluation Program for all OEF/OIF Veterans receiving care
within VA. Veterans who screen positive are referred for
comprehensive evaluation and receive follow-up care and
services as appropriate for their diagnosis and symptoms.
Increase initiatives to use telehealth technology to
enhance access to specialty care, coordination of care and case
management, and therapeutic interventions.
Sustain the continued development of VA's future
workforce. Recruiting actions and innovative educational and
academic training programs are being established to attract the
best and brightest specialty providers, and to prepare these
professionals to meet the specialty needs of Veterans.
Maintaining the appropriate number of specialty rehabilitation
providers is necessary to support timely evaluation and
services for the wide range of symptoms commonly seen following
TBI and polytraumatic injuries.
Question 3: Dr. Beck's testimony emphasized VA's efforts in the
area of prosthetics for Women Veterans. Are there gender differences
where the needs of Women Veterans differ from their male counterparts
for other specialized services such as blind rehabilitation, spinal
cord injury centers, and polytrauma? If such differences exist, what is
VA doing in these other areas to provide gender-specific care that
meets the unique needs of women Veterans?
Response: VA Rehabilitation Services and Women's Health Care
Services within each medical facility partner to accommodate the
individual needs of women Veterans participating in rehabilitation with
a range of disabilities including amputation, polytrauma, and spinal
cord injury. Accommodation is made in fitting of prosthetic components,
spinal orthoses, and adaptive equipment needed for the treatment and
care of women Veterans. Certified mastectomy fitters and female
Orthotists/Prosthetists are available for the specialized fitting of
prostheses and orthoses. Spinal Cord Injury (SCI) primary care
providers arrange for timely women's health care and gender specific
screenings during the Veteran's annual evaluation, or earlier when a
need arises. These services are provided by trained SCI staff in
coordination with Women's Health clinical staff.
VA Prosthetic and Sensory Aids Service also formed a Prosthetics
Women's Workgroup to address the unique needs of female Veterans. This
Workgroup, comprised entirely of Women Veterans, developed a list of
gender-specific items that are routinely available for the health and
well-being of Women Veterans. Any specialized, medically indicated item
can also be procured.
While the number of severely injured women who require specialized
rehabilitation services is relatively small, women Veterans are an
increasingly important population that VA serves; nine percent of the
1.1 million OEF/OIF Veterans who are eligible for VA care are women. To
address the unique needs of this growing Veteran community, VA has
implemented tools to evaluate and expand care for all Women Veterans at
every site. There are now full-time Women Veteran Program Managers at
our 144 medical health systems, and VHA is implementing comprehensive
primary care for women at all facilities, with a completion date of
2013. In order to accomplish this, VA has provided mini-residency
training to over 500 providers in women's health.
Special accommodations are further made for women inpatients to
ensure privacy and safety, including: private hospital rooms, grouping
female patients together in adjacent rooms with private shower
facilities, and providing support for visiting families with small
children. VA Women's Health Program continues to address the unique,
gender-specific needs of all Women Veterans.
Question 4: Does VA offer the same set of specialized services as
that of DoD? Are there certain services that VA offers but which DoD
does not offer?
Response: VA offers the same set of rehabilitation services as DoD,
and further provides more advanced, specialized services that are not
available within DoD. DoD health care focuses primarily on short-term
rehabilitation for Servicemembers with less severe injuries, and return
to full military duty. VA provides the most comprehensive
Rehabilitation Services for patients with more complex severe injuries
and long-term consequences. Because of VA's capabilities in this area,
a Memorandum of Agreement has existed between DoD and VA since 1981 for
VA to provide specialized rehabilitation services for active duty
Servicemembers with Spinal Cord Injury, TBI/Polytrauma, and Blindness.
VA also provides the full range of rehabilitation services for patients
requiring general rehabilitation.
Question 5: How does VA know that they are providing the right
kinds of specialized services? Also, how does VA know that they are
serving severely injured OEF/OIF Veterans on a timely basis at their
current capacity? Can VA quickly ramp-up or ramp-down services to
accommodate changes in the severely wounded Veteran population?
Response: VA utilizes state-of-the-science care that is evidence-
based, and translates this into best practices that are defined in
clinical practice guidelines and deployed to VA health care providers
for use. Performance measures are established that monitor program and
treatment outcomes. As examples:
For 876 former patients with severe injuries treated
at Polytrauma Rehabilitation Centers (PRCs):
781 (89 percent) are living in a private
residence;
642 (73 percent) live alone or independently;
413 (47 percent) report they are retired
(age, disability, other reasons);
206 (24 percent) are employed;
90 (10 percent) are in school part-time or
full-time;
59 (7 percent) are looking for a job or
performing volunteer work.
VA implemented a specialized Emerging Consciousness
care path at the PRCs to serve those Veterans with severe TBI
who are slow to recover consciousness. Approximately 70 percent
of the 87 Veterans and Servicemembers admitted in VA Emerging
Consciousness care emerge to consciousness before leaving
inpatient rehabilitation.
For patients treated in Spinal Cord Injury Centers,
new prevention efforts have successfully reduced the rate of
developing a hospital-acquired pressure ulcer (which is a
serious health risk for SCI patients). Only 1.3 percent of
patients with SCI who were hospitalized in FY 2009 developed
new pressure ulcers.
With regard to monitoring VA capacity, at no time during the wars
in Iraq or Afghanistan has VA been unable to accommodate receipt of
severely injured Servicemembers upon request from DoD because of
capacity. Specialty units (Polytrauma Rehabilitation Centers, Blind
Rehabilitation Centers, Spinal Cord Injury Centers) regularly monitor
and report capacity, remaining ready and responsive in their capacity
to serve patients who are severely injured, and accommodate surges in
patient volume.
VA also partners with DoD to monitor and transition patients from
DoD to VA health care. VA Military Liaisons are co-located with DoD
Case Managers at military treatment facilities to provide onsite
consultation and collaboration regarding VA resources and treatment
options. They educate Servicemembers and their families about VA's
system of care, and facilitate inpatient transfer to a VA health care
facility as appropriate.
Question 6: How does VA ensure high quality of care for severely
injured OEF/OIF Veterans? In other words, how does VA know that care is
consistent, standardized, and measurable across the VA health care
system?
Response: VA employs a systems approach to ensure that that VA
specialty rehabilitation care programs adhere to the highest
professional standards of service and effectiveness. This includes:
Accreditation. VA specialty rehabilitation care
programs are accredited by the Joint Commission, and by the
Commission on Accreditation of Rehabilitation Facilities
(CARF). CARF is the internationally recognized standard of
excellence for rehabilitation programs. CARF accreditation is
mandatory for all VA inpatient rehabilitation programs and for
all levels of rehabilitation programming at the specialty
centers.
Outcomes Measurement. VA collects and analyzes
rehabilitation outcomes using the Functional Independence
Measure (FIM), the most widely accepted functional assessment
measure in use in the rehabilitation community. FIM data is
collected and analyzed by the Uniform Data System for Medical
Rehabilitation, which allows VA to benchmark outcomes against
those of other non-VA entities. The Functional Status and
Outcomes Database (FSOD) is used to track patient outcomes
across the full continuum of rehabilitative care from onset of
disease or injury to completion of the patient's rehabilitation
goals without respect to the venue in which services are
provided. VA also recently established a collaborative
relationship with the National Institute for Disability and
Rehabilitation Research to participate in the TBI outcome data
management project with 16 TBI Model Systems centers from the
private sector.
Translational Research. The VA Quality Enhancement
Research Initiative (QUERI) utilizes clinical practice needs to
inform VA's research agenda, that in turn translates research
results to identify interventions that improve the quality of
patient care. Spinal cord injury (SCI), polytrauma and blast-
related injuries are conditions that are part of the QUERI
effort, promoting the successful rehabilitation, psychological
adjustment and community re-integration of individuals who have
sustained these injuries.
In order to standardize consistent delivery of quality services
across VA health care system, VA Central Office provides guidance to
the field regarding the structure of the specialty care services and
systems, resource requirements, and the processes and procedures
involved in the delivery and coordination of services. Directives,
handbooks, and guidance have been issued that set policies and describe
procedures for the Polytrauma System of Care, Spinal Cord Injury and
Disorders, Blind Rehabilitation Services, other specialty
rehabilitation services and care management.
VA has created and provided numerous educational and training
opportunities for clinical providers, and other VA staff to become
familiar with the diagnosis and treatment of TBI, the continuum of
rehabilitation services available through the Polytrauma System of
Care, and managing other impairments associated with TBI (pain and
mental health issues). Over 25 national conferences and satellite
broadcasts, each with 50 to 1,200 participants, have been offered
though VA Employee Education System in the last three years. Speakers
have included internationally recognized experts in TBI. Prior to the
implementation of the mandatory TBI screening in 2007, over 60,000 VA
providers completed a mandatory four hour TBI education course.
Educational and training initiatives are also established and
ongoing for VA specialty providers who work with Spinal Cord Injury and
Disorders, Blind Rehabilitation Services, and Amputation System of Care
(e.g., physiatrists, neurologists, orthopedists, rehabilitation nurses,
rehabilitation therapists, mental health providers, social workers,
care managers, etc).
Question 7: In their testimony, DAV brought to the Subcommittee's
attention the proposed Tampa area Heroes Ranch, which would serve as a
post-acute long-term care residential brain injury facility for active
duty military Servicemembers and Veterans. Where is the VA in reviewing
this proposal? When can we expect a formal decision from VA?
Response: VISN 8 has submitted a proposal to pilot a post-acute,
long term, comprehensive care facility for active duty Servicemembers
and Veterans with TBI and/or polytrauma. This pilot project would be an
outpatient treatment facility that would serve the most severe
injuries, including those warriors in a vegetative and semi-conscious
state, those patients with neurobehavioral problems, and those persons
that require a structured day program for ongoing recovery after
completing acute inpatient rehabilitation. The proposal is currently
under review by the Deputy Under Secretary for Health for Operations
and Management (DUSHOM). VA is anticipating a formal decision regarding
Heroes Ranch in the first quarter of FY 2011.
Question 8: Where is VA in implementing the caregiver family
support provisions of Public Law 111-163? When will caregivers have
access to the supportive services provided in the recently enacted
caregiver legislation?
Response: The Office of Care Management and Social Work in the
Office of Patient Care Services, in collaboration with the Chief
Business Office, has primary responsibility for implementing the
caregiver programs required by title I of Public Law 111-163. VA has
developed a Steering Committee to direct the implementation process. VA
is working with the Gallup Organization to hold focus groups with
Veterans who may be eligible for the program and their family
caregivers; Veterans Service Organizations; and National Organizations
that specialize in providing assistance to individuals with
disabilities or family caregivers; the law requires that VA consult
with these groups, and DoD, in developing the family caregiver program
implementation plan. VA believes stakeholder feedback is critical as it
moves forward with plans for implementation. DoD is providing direct
input on the Steering Committee. VA is developing the plan for
implementation and will begin offering the services and benefits as
soon as possible.
In addition, VA has established four national Workgroups, comprised
of more than 50 subject matter experts from around the country, to work
on specific components of the law, including: eligibility, caregiver
benefits, clinical requirements, and information technology. These
Workgroups held face-to-face meetings in Washington the week of July 19
to develop recommendations for implementing key components of the law.
As of the beginning of August, the Workgroups are reporting their
recommendations to the Steering Committee.
This is a very complex program and will require time and
regulations to implement it fully. The timeline for regulations is
difficult to define specifically, but portions of the program, such as
training and other supportive services, are already available for
Veterans and their caregivers. VA routinely offers in-person
educational support for caregivers of Veterans undergoing discharge
from an inpatient stay at a VA facility and teaches techniques,
strategies, and skills for caring for a disabled Veteran. Counseling
for family members under 38 United States Code (U.S.C.) 1782 may also
be available, and VA's respite care program has benefited Veterans for
a number of years. Each VA medical center has designated a Caregiver
Support Point of Contact to coordinate caregiver activities and serve
as a resource expert for Veterans, their families and VA providers to
assist them in locating and accessing non-VA resources.
VA clinical experts are working on developing core competencies for
primary caregivers and developing a comprehensive training and support
program for caregivers. Training and support services will also be
integrated into a comprehensive caregiver Web site. VA will ensure
public awareness of the new benefits and services, as well as the
related application process through public service announcements and
other forms of outreach.
VA plans to submit its implementation plan to Congress within the
required 180 days.