[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

                              ----------                              


                        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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \14\ Ibid.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \18\ C. Hall, RN, PhD, CCDOR, Minneapolis VAMC; Second Annual 
Trauma Spectrums Disorders Conference; VA Polytrauma Rehabilitation 
Centers' Family Care Collaborative; December 10, 2009.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \20\ Ibid.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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).
---------------------------------------------------------------------------
    ``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.''
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \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 
---------------------------------------------------------------------------
        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.

                                 
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