[Senate Hearing 111-304]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 111-304
 
 PROVIDING CARE FOR RURAL VETERANS: COMMUNITY-BASED OUTPATIENT CLINICS 

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                            AUGUST 26, 2009

                               __________

       Printed for the use of the Committee on Veterans' Affairs


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate

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                     COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Patty Murray, Washington             Lindsey O. Graham, South Carolina
Bernard Sanders, (I) Vermont         Johnny Isakson, Georgia
Sherrod Brown, Ohio                  Roger F. Wicker, Mississippi
Jim Webb, Virginia                   Mike Johanns, Nebraska
Jon Tester, Montana
Mark Begich, Alaska
Roland W. Burris, Illinois
Arlen Specter, Pennsylvania
                    William E. Brew, Staff Director
                 Lupe Wissel, Republican Staff Director

















                            C O N T E N T S

                              ----------                              

                            August 26, 2009
                                SENATORS

                                                                   Page
Isakson, Hon. Johnny, U.S. Senator from Georgia..................     1

                               WITNESSES

Williams, Joseph, Deputy Under Secretary for Health, Operations 
  and Management, Veterans Health Administration, U.S. Department 
  of Veterans Affairs; accompanied by Lawrence Biro, Network 
  Director, Veterans Integrated Service Network 7; and Rebecca 
  Wiley, Director, Charlie Norwood VA Medical Center.............     3
    Prepared statement...........................................     6
Cook, Tom, Assistant Commissioner, Field Operations and Claims, 
  Georgia Department of Veterans Services........................    14
    Prepared statement...........................................    15
Nordeoff, Cort, Southeast Georgia District Commander, Disabled 
  American Veterans..............................................    18
    Prepared statement...........................................    19
Spears, Albert R., Quartermaster, Department of Georgia, Veterans 
  of Foreign Wars of the United States...........................    24
    Prepared statement...........................................    26

                                APPENDIX

Southwest Atlanta Medical Center; brochure.......................    35


 PROVIDING CARE FOR RURAL VETERANS: COMMUNITY-BASED OUTPATIENT CLINICS

                              ----------                              


                       WEDNESDAY, AUGUST 26, 2009

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                         Jesup, GA.
    The Committee met, pursuant to notice, at 2:35 p.m., in C. 
Paul Scott Polytechnical Center, Altamaha Technical College, 
Jesup, Georgia, Hon. Johnny Isakson, presiding.
    Present: Senator Isakson.

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

    Senator Isakson. Good afternoon and welcome. I am U.S. 
Senator Johnny Isakson and I am delighted to be here. I want to 
thank the Technical College and their President for all their 
cooperation and hospitality in allowing us to hold this hearing 
today.
    Before I get into my opening remarks, I want to say to all 
our veterans that are in the audience today, first of all, on 
behalf of all Georgians and all Americans, we thank you for 
your service. One of the reasons that I asked to be on the 
Veterans Committee when I was elected to the Senate was because 
I wanted to do everything I could to see to it that the 
promises made to our veterans were delivered, and everywhere we 
could improve veterans services, we would do that. Community-
Based Outpatient Clinics are certainly one of those areas where 
that is taking place, and that is the purpose of this hearing 
today. Most importantly, on behalf of all the people of our 
country and of this State, we want to thank you for your 
service and your sacrifice for the United States of America.
    On community-based outpatient clinics: 1922 is when the 
first service to our veterans who came home took place, and it 
was generally--it was always a patient-based hospital service. 
And then in 1994, in Amarillo, Texas, a change took place and 
VA converted to--they didn't convert from hospitals to 
community-based clinics, but began opening community-based 
clinics around the United States. Today, there are over 700 
community-based clinics in the United States of America serving 
our veterans.
    A while back, there was a proposal made by the 
administration and the Department of Veterans Affairs to open 
two new clinics in this part of Georgia--one in Hinesville and 
one in Glynn County--and that is substantially the purpose of 
this meeting today.
    Now, I am aware that both of those clinics have been 
somewhat delayed--Hinesville for very obvious reasons. The 
Veterans Administration decided after determining we needed an 
expanded clinic here, and what was originally thought to be a 
10,000 square-foot outpatient center is now planned to be, as I 
understand it--and I will be corrected by our witnesses, I am 
sure, if I am wrong on this--a 25,000 square-foot outpatient 
facility, including mental health services.
    As everyone knows, there is a tremendous challenge in the 
Gulf War, the wars in Afghanistan and Iraq, for those returning 
with PTSD or TBI. I have personally had the privilege of seeing 
the marvelous work that the Augusta Uptown VA and the 
Eisenhower Medical Center in Augusta have done to create a 
seamless transition for our veterans going from DOD into 
veterans health care, to see the many people who came out of 
the war with TBI or PTSD who have been remediated, have been 
treated, and are back in society--as we want everybody to 
possibly be. So, the expansion of that clinic precipitated 
somewhat of a delay.
    Glynn County: I am not sure I know exactly why, and I am 
sure part of the testimony will be to answer that, as well; but 
we have a substantial and significant number of veterans in 
this part of Georgia, in no small measure because of the 
facilities at Kings Bay in Camden County and Fort Stewart in 
Liberty County. We want to make sure that the services to our 
veterans are complete, and that in terms of health care, it is 
reachable or within the reach of every single veteran.
    The change in 1994 at Amarillo reflected the change in both 
injuries as well as the need for services, and it is now a lot 
easier in Georgia for a veteran to get service at a clinic 
rather than having to drive to either Dublin, Atlanta, or 
Augusta, which are the location of the three hospitals. I want 
to personally thank the Veterans Administration for the 
outreach they have provided and for the investment they have 
made in Georgia and the clinics we have been able to open since 
I was elected to the U.S. Senate, for which I take no credit 
except to be a part of. I thank the Veterans Administration for 
having done that and for what they have done in it.
    I want to introduce a couple of staff members who are with 
me today. Lupe, raise your hand. Lupe is the brains of the 
operation. I am just the front man. And Chris--Chris is the VA 
staff person in my office. They will be here to assist me 
today.
    We have passed out three-by-five cards. After the testimony 
and the questioning that I will give, if you will pass those 
forward or give them to one of my people. Nancy Bobbit is here 
in the back. She will collect them if you have a question, and 
I will ask those questions of our panelists if we have time. 
That will be in the off-the-record program after the testimony 
of this field hearing today from panel one and from panel two.
    With that said, let me invite our first panel to come 
forward. Joe Williams, the Deputy Under Secretary for Health, 
Operations, and Management.
    Lawrence Biro--did I pronounce it right? I do it wrong 
every time. I said it wrong when you were in Washington, I 
know, and I apologize. It is only four letters. I ought to be 
able to get that right. He is the Director of Veterans 
Integrated Service Network.
    Rebecca Wiley, Director of the Charlie Norwood VA medical 
center. I have already bragged in my opening remarks about the 
Charlie Norwood Center once, but I want to brag about them 
again. They were featured on ``NBC Nightly News'' about 2 
months ago because of the miraculous and marvelous work that 
they are doing. And as long as I am able to serve in the U.S. 
Senate, I am going to attempt to see to it that whenever we 
have a DOD facility and a veterans facility in the same city, 
that they can replicate what has been done in Augusta, Georgia. 
It is truly a great service to our veterans and I congratulate 
you on that.
    I don't know what order you were told, but my mother raised 
me that ladies were always first, so Rebecca? If you will, try 
to keep your remarks to around 5 minutes; but if you go over, 
that is fine. We will take your testimony first.
    Ms. Wiley. Thank you, sir. I am going to defer to Mr. 
Williams.
    Senator Isakson. OK. I am sorry, Mr. Williams, but she is a 
lot prettier than you are, so I wanted her to go first.
    Mr. Williams. Yes, sir, and I am glad you recognize that. 
[Laughter.]
    Senator Isakson. I am old, but I am not that old.
    Mr. Williams?

   STATEMENT OF JOSEPH WILLIAMS, DEPUTY UNDER SECRETARY FOR 
      HEALTH, OPERATIONS AND MANAGEMENT, VETERANS HEALTH 
     ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
   ACCOMPANIED BY LAWRENCE BIRO, NETWORK DIRECTOR, VETERANS 
   INTEGRATED SERVICE NETWORK 7, U.S. DEPARTMENT OF VETERANS 
   AFFAIRS; AND REBECCA WILEY, DIRECTOR, CHARLIE NORWOOD VA 
                         MEDICAL CENTER

    Mr. Williams. Mr. Chairman, thank you for the opportunity 
to appear before you today to discuss the Department of 
Veterans Affairs' health care and facility issues in Georgia.
    I am accompanied today by Mr. Lawrence Biro, the Network 
Director for the VA Southeast Network, VISN 7, and Ms. Rebecca 
Wiley, the Director of Charlie Norwood (Augusta) VA Medical 
Center.
    Today, my testimony will address the process by which VA 
determines where to build new Community-Based Outpatient 
Clinics, how such clinics are built, and the services that they 
provide. I will also discuss how VA provides care to veterans 
in Georgia. Thanks for providing this opportunity to us to 
address these important issues and for your continued support 
of our veterans.
    VA determines its health care and benefits infrastructure 
requirements through a strategic planning process that is 
closely linked to the Department's missions and goals. VA is 
further committed to further improving the access to health 
care for veterans, including veterans in rural areas, by 
comprehensively evaluating demographics in the market, 
determining clinical need for services in the area, and then 
aligning capital investment strategies to meet the health care 
needs of those veterans. VA carefully analyzes utilization 
trends. We look at our veteran population and the enrolled 
users to ensure that the appropriate mix of services is 
available to meet the needs of our local veterans.
    Over the last few decades, CBOCs have shown to be effective 
in improving access to care for our veterans and assist us in 
providing a high quality of care in a cost-effective manner. 
The Veterans Health Administration plans to continue meeting 
those comprehensive health care needs for veterans nationwide 
by establishing new CBOCs, new outreach clinics, mobile clinics 
utilizing state-of-the-art technology to bring care closer to 
our veterans' home, and using resources within the communities 
when clinically necessary. By the end of the fiscal year 2010, 
VA plans to operate 833 CBOCs, and that will be 78 more than we 
had active in 2008.
    CBOCs are developed through a methodology that partners 
Central Office with our VISNs. This allows the decisionmaking 
with regard to CBOCs and the needs and the priorities to be 
made in the context of future and local markets and those 
market circumstances. The methodology evaluates the convergence 
of geographic access as measured by drive-time guidelines for 
primary care services and projected demand for primary care and 
mental health services, as well. The methodology drives the 
initial step in VHA's national CBOC deployment plan.
    A comprehensive business plan is required to submit an 
application, and several alternatives are reviewed within this 
business plan and these alternatives include renovations of the 
existing facility. It may include construction of a new 
facility, procuring a lease for space, or contracting within 
for community resources. These are all things that we look at 
to address the health care gaps as we move the CBOC application 
forward.
    Once the analysis is completed and the access gaps are 
identified, VISNs will determine if a CBOC will best meet the 
needs of the veterans in that particular area. The VISN will 
then submit a Business Plan to VA Central Office for review by 
a panel of experts. The review considers much of the following 
criteria: the quality and need of the proposal; the location in 
the market not meeting VA access guidelines; they will look at 
the quantity of users and enrollees, and market penetration. 
There will be considerations for unique things, included in the 
proposal: how their proposal improves access for minority 
veterans; how it overcomes geographic barriers; or reaches out 
to the medically underserved areas. Cost effectiveness and the 
impact on waiting times is also looked at as part of that 
review criteria.
    VA uses both a VA personnel management model and a 
contracting model when we consider staffing our CBOCs. The VA 
personnel management model ensures direct accountability of 
staff to VA managers, direct coordination of care and services 
with other VA programs. It delivers more efficient records 
management in a VA-staffed CBOC. It ensures DOD and VA 
collaboration at a higher degree, and education and teaching 
opportunities that we can all leverage and benefit from.
    The contracting operations management model is used 
generally in areas where the veteran population is small, and 
we see some of those particularly in some of the smaller rural 
areas. The contract operation model must meet VA's quality and 
patient safety standards, and is cost effective because it 
allows VA to take advantage of existing community resources 
where the numbers are small.
    Georgia is supported by two VISNs, the VA Southeast 
Network, which is the VISN 7, and the VA Sunshine Health Care 
Network, which is Network 8. Although the latter extends into 
the Southeastern portion of the State, VISN 7 provides services 
to veterans in South Carolina, Georgia, and Alabama. There are 
an estimated 1.46 million veterans living within the boundaries 
of VISN 7 in fiscal year 2008, and 457,000 veterans are 
enrolled in that health care system.
    VISN 7 includes eight VA medical centers or health care 
systems based in Augusta, Georgia; Atlanta, Georgia; Dublin, 
Charleston, South Carolina; Columbia, South Carolina; 
Birmingham, Alabama; Tuscaloosa; and the Central Alabama 
Veterans Health Care System, which have locations in Montgomery 
and Tuskegee.
    In fiscal year 2008, the network provided services to about 
328,000 veterans out of the 457,000 enrolled. There were about 
3.56 million outpatient visits and a total of 30,335 hospital 
inpatient discharges. The cumulative full-time employee level 
for this network was 12,678, and the operating budget was over 
$2.1 billion.
    Six of our VA medical centers or health care systems have 
robust research programs and each has been fully accredited by 
the Association of Accreditation for Human Research Protection 
Programs. These facilities also have their own research 
compliance officer. Some highlights of the research being done 
in VISN 7 include Rehabilitation Research Center of Excellence 
in Atlanta and Geriatric Research Education and Clinical 
Centers in Atlanta and Birmingham.
    Specialty services are also available at a number of our 
facilities. For example, both Augusta and Birmingham offer 
blind rehabilitation services. Augusta is home to a spinal cord 
injury unit program. Central Alabama, Tuscaloosa, Atlanta, and 
Birmingham offer residential rehabilitation treatment programs. 
Augusta, Central Alabama, and Dublin provide domiciliary 
support, and all VA medical centers in VISN 7 have women's 
veterans programs.
    Access to care is a priority in VISN 7. Between fiscal year 
2009 and fiscal year 2010, we are opening four new CBOCs in 
Georgia alone to support that.
    Georgia is a home to three VA medical centers, Augusta, 
Atlanta, and Dublin. The Atlanta facility employs 2,500 full-
time employees and served more than 65,000 unique patients in 
fiscal year 2008. More than 3,500 of those who served in 
Operation Enduring Freedom and Operation Iraqi Freedom were 
served by this facility. Augusta employs more than 2,100 people 
and serves more than 38,000 uniques and provided care to 2,400 
OEF/OIF veterans in 2008. Dublin, which has been designated as 
a rural access facility, employs approximately 850 full-time 
employees and serves approximately 28,500 veterans. This 
includes over 1,600 OEF/OIF veterans or patients in 2008. The 
three facilities provide approximately 660,000, 360,000, 
190,000 outpatient visits, respectively.
    There are currently 15 active CBOCs and primary care 
clinics in Georgia and four more are scheduled to open by the 
end of 2010. The Committee has expressed interest in two 
specific CBOC projects, Brunswick and Hinesville. The Brunswick 
CBOC is currently in the lease advertisement process for clinic 
space. VA will evaluate the offers received, which will include 
site selection. Proposals were due by July 31, and VA is in the 
process now of reviewing those responses. VA currently expects 
to open the clinic sometime in February 2010.
    Regarding the Hinesville market area, VA has a space plan 
under review by VA Real Property Service that will likely 
require approval by the Secretary. VA currently estimates the 
Hinesville CBOC to be activated around October 2011.
    In summary, with the support of the Senate Committee on 
Veterans' Affairs and the Georgia Congressional delegation, VA 
is meeting the health care needs of veterans in the area.
    Again, Mr. Chairman, we want to thank you for the 
opportunity to testify today at the hearing. My colleagues and 
I are available to address any questions that you may have for 
us.
    [The prepared statement of Mr. Williams follows:]
  Prepared Statement of Joseph Williams, RN, BSN, MPM, Acting Deputy 
  Under Secretary for Health for Operations and Management, Veterans 
       Health Administration, U.S. Department of Veterans Affairs
    Mr. Chairman and Members of the Committee, thank you for the 
opportunity to appear before you today to discuss Department of 
Veterans Affairs (VA) health care and facility issues in Georgia. I am 
accompanied today by Mr. Lawrence Biro, Network Director, VA Southeast 
Network (Veterans Integrated Service Network [VISN] 7) and Ms. Rebecca 
Wiley, Director of the Charlie Norwood (Augusta) VA Medical Center 
(VAMC).
    Today, my testimony will address the process by which VA determines 
where to build new community-based outpatient clinics (CBOC), how such 
clinics are built, and the services they provide. It will also discuss 
how VA provides care to Veterans in Georgia. Thank you for providing 
this opportunity to address these important issues and for your 
continued support of America's Veterans.
          community-based outpatient clinic selection process
    VA determines its health care and benefits infrastructure 
requirements through a strategic planning process that is closely 
linked to the Department's mission and goals. VA is committed to 
further improving access to health care for Veterans, including 
Veterans in rural areas, by comprehensively evaluating demographics in 
a given market, determining the clinical need for services in the area, 
and then aligning capital investment strategies to meet the health care 
needs of Veterans in the area. VA carefully analyzes utilization 
trends, Veteran Population (VetPop) data, and enrolled users to ensure 
that the appropriate mix of services is available to meet the needs of 
local Veterans. Over the last decade, CBOCs have shown to be effective 
in improving access to care for Veterans and providing high-quality 
care in a cost-effective manner. The Veterans Health Administration 
(VHA) plans to continue meeting the comprehensive health care needs of 
Veterans nationwide, by establishing new CBOCs, outreach clinics, 
mobile clinics, utilizing state-of-the-art technology to bring care 
closer to the Veteran's home, and using community resources when 
clinically necessary. By the end of fiscal year (FY) 2010, VA plans to 
operate 833 CBOCs, 78 more than were active in FY 2008.
    CBOCs are developed through a methodology that partners VA's 
Central Office and VISN staff. This allows decisions regarding CBOC 
needs and priorities to be made in the context of current and future 
local market circumstances. The methodology evaluates the convergence 
of geographic access as measured by drive-time guidelines for primary 
care services and projected demand for primary care and mental 
services. The methodology drives the initial step in VHA's national 
CBOC deployment plan. Comprehensive business case applications are 
submitted that provide several alternatives (including renovation of an 
existing facility, construction of a new facility, procuring a lease, 
or contracting with community resources) to address any health care 
gaps.
    Once the analysis is completed and access gaps are identified, 
VISNs will determine if a CBOC will best meet the needs of Veterans in 
the area. The VISN will submit a Business Plan for the CBOC to VA's 
Central Office for review by a panel of experts. This review considers 
the following criteria:

     Quality and need of the proposal
     Location in a market not meeting VA Access Guidelines
     Quantity of users and enrollees
     Market penetration
     Unique considerations, including whether the proposal 
improves access for minority Veterans, overcomes geographic barriers, 
or reaches out to medically underserved areas
     Cost effectiveness and
     Impact on waiting times

    VA uses both the VA personnel management model and contracting 
operation management model to staff CBOCs. The VA personnel management 
model ensures direct accountability of staff to VA managers, direct 
coordination of care and services with other VA programs, delivers 
efficient records management compliance, DOD and VA collaboration, and 
education and teaching opportunities. The contract operations 
management model is used generally in areas where the Veteran 
population is small, particularly in rural areas. The contract 
operation model must meet VA's quality and patient safety standards and 
is cost effective because it allows VA to take advantage of existing 
community services.
                        visn support in georgia
    Georgia is supported by two VISNs: VA Southeast Network (VISN 7) 
and VA Sunshine Healthcare Network (VISN 8), although the latter 
extends only into the southeastern portion of the state. VISN 7 
provides services to Veterans in South Carolina, Georgia and Alabama. 
There were an estimated 1.46 million Veterans living within the 
boundaries of VISN 7 in FY 2008, and 457,349 Veterans were enrolled in 
VA for health care.
    VISN 7 includes eight VA medical centers or health care systems 
based in Augusta, GA; Atlanta, GA; Dublin, GA; Charleston, SC; 
Columbia, SC; Birmingham, AL; Tuscaloosa, AL; and the Central Alabama 
Veterans Health Care System (locations in Montgomery, AL and Tuskegee, 
AL). In FY 2008, the Network provided services to about 328,000 out of 
more than 457,000 enrolled Veterans. There were about 3.56 million 
outpatient visits and 30,335 hospital inpatient discharges. The 
cumulative full-time employee level was 12,678, and the operating 
budget was about $2.1 billion.
    Six of our VAMCs or health care systems have robust research 
programs, and each has been fully accredited by the Association for the 
Accreditation of Human Research Protection Programs (AAHRPP). These 
facilities also have their own research compliance officer. Some 
highlights of the research being done in VISN 7 include a VA 
Rehabilitation Research Center of Excellence in Atlanta and Geriatric 
Research Education and Clinical Centers in Atlanta and Birmingham. 
Specialty services are available at a number of our facilities. For 
example, both Augusta and Birmingham offer Blind Rehabilitation 
Services; Augusta is home to a Spinal Cord Injury (SCI) program; 
Central Alabama, Tuscaloosa, Atlanta and Birmingham offer Residential 
Rehabilitation Treatment Programs; Augusta, Central Alabama and Dublin 
provide domiciliary support; and all VA medical centers in VISN 7 have 
women Veterans' programs. Access to care is a priority in VISN 7, and 
between FY 2009 and FY 2010, we are opening four new CBOCs in Georgia 
alone.
                     georgia health care facilities
    Georgia is home to three VA medical centers: Augusta, Atlanta, and 
Dublin. The Atlanta facility employs approximately 2,500 full-time 
employees and served more than 65,000 unique patients in FY 2008, more 
than 3,500 of whom served in Operation Enduring Freedom or Operation 
Iraqi Freedom (OEF/OIF). Augusta employs more than 2,100 people, serves 
more than 38,000 unique patients, and provided care to 2,400 OEF/OIF 
Veterans in FY 2008. Dublin, which has been designated a rural access 
facility, employs approximately 850 full-time employees and served 
approximately 28,500 Veterans (including over 1,600 from OEF/OIF) in FY 
2008. The three facilities provided approximately 660,000, 360,000, and 
190,000 outpatient visits respectively.
    There are currently 15 active CBOCs and primary care clinics in 
Georgia, and four more are scheduled to open by the end of FY 2010. The 
Committee has expressed interest in two specific CBOC projects: 
Brunswick and Hinesville. The Brunswick CBOC is currently in the lease 
advertisement process for clinic space. VA will evaluate offers 
received which will include site selection. Proposals were due by July 
31, 2009, and VA is reviewing these responses. VA currently expects to 
open the clinic in February 2010.
    Regarding the Hinesville market area, VA has a space plan under 
review by VA Real Property Service that will likely require approval by 
the Secretary. VA currently estimates the Hinesville CBOC will be 
activated in October 2011.
                               conclusion
    In summary, with the support of the Senate Committee on Veterans' 
Affairs and the Georgia Congressional delegation, VA is meeting the 
health care needs of Veterans in the area. Again, Mr. Chairman, thank 
you for the opportunity to testify at this hearing. My colleagues and I 
are available to address any questions you may have for us.

    Senator Isakson. Well, thank you very much, Mr. Williams. I 
appreciate your testimony, and I want to make note, by the end 
of this year, we will have 78 more clinics--833--is that right?
    Mr. Williams. Yes, sir.
    Senator Isakson. That is an outstanding condition.
    With regard to Brunswick, my understanding is there was an 
RFP put out for that clinic. It came in. You all made a 
decision, then you decided to reopen it and you are just now in 
the process of making a final decision on a site, is that 
correct?
    Mr. Williams. Yes, sir. I will defer to Mr. Biro for 
comments.
    Mr. Biro. Yes, that is right. There was a technical flaw in 
the bidding process that we had to resolicit the bid. We got 
back several offers and we plan to move ahead on that right 
now.
    Senator Isakson. Will this be a leased facility?
    Mr. Biro. The building itself, yes, will be a leased 
facility.
    Senator Isakson. With regard to Hinesville, I think the 
testimony of Mr. Williams said probably the fall or October 
2011 would be the target date. Is that meetable? Is that target 
meetable?
    Mr. Biro. That is a very conservative date. The problem 
there is the belief that there isn't a suitable building in the 
Hinesville area, at least with our real estate people right 
now. We just rode over from Charleston and we kind of feel 
that, looking a little harder, we may find a building that 
would be appropriate for a veterans clinic. We are also 
thinking of starting maybe--doing some outreach there a little 
bit earlier, as early as we can. But right now, the 2011 date, 
based on the size of the lease, requires many more approvals.
    Senator Isakson. I would like to ask you to consider doing 
something in Hinesville, if you don't mind. As you probably are 
aware, the Secretary of the Army recently pulled back on a 
previous commitment to move a brigade combat team to Fort 
Stewart. The community has made a significant investment in 
additional facilities in anticipation of the brigade combat 
team coming. I don't know if any of those facilities would be 
appropriate for a veterans clinic, but I think there is an 
obligation on behalf of the country, because of pulling that 
commitment, to do everything they can to make that community 
whole.
    So, I would like to personally ask if you would make sure 
that you reach out to the banks and the development community 
who have put in over $400 million in investments in the 
Hinesville-Fort Stewart area in anticipation of that combat 
team coming, which is now not coming. If there was a building 
that was suitable and the VA could lease it for that purpose, 
it would be a win-win proposition for the VA and certainly help 
that community that is going to struggle because of the pull-
out of that commitment by Secretary Gates. So, if you would 
promise me you would make that consideration, I would very much 
appreciate it.
    Mr. Biro. Yes, I will. I will make contact immediately and 
do the market survey there.
    Senator Isakson. Mr. Williams, did I understand correctly 
that in Regions 7 and 8, there are 1.4 million veterans, or in 
just Region 7? Do you remember?
    Mr. Biro. Can I answer that? That is just VISN 7.
    Senator Isakson. Just VISN 7. And 457,000 are enrolled in 
care?
    Mr. Biro. That is enrolled, yes.
    Senator Isakson. And you treated--what was the number you 
actually treated?
    Mr. Biro. Roughly over 300,000. I think it is 324,000. But 
it is over 300,000.
    Senator Isakson. Mr. Biro, you are responsible for the 
Atlanta hospital, are you not?
    Mr. Biro. Yes.
    Senator Isakson. OK. This hearing is not about the Atlanta 
hospital, but I think I have an obligation to ask a question 
about it, too, particularly on behalf of our veterans. The 
hospital is going through a renovation and an expansion, which 
I was proud to help procure the money for. But the Clairmont 
Road facility and the need for construction has significantly 
restricted parking for veterans going for services. I want to 
thank the hospital publicly for the efforts they have made in 
terms of shuttles and other things, but are we making some 
improvement in accessibility, to your knowledge, for those 
veterans that go there for services?
    Mr. Biro. The remote parking--we are making progress with 
that. We ran into one little glitch about how we can transport 
people, but we are making progress. We do have on the plans, 
which would not be real immediate, a parking structure in the 
front of that building where the parking lot is, which would 
then alleviate the parking problems. So we are working on it in 
as many ways that we can.
    Besides being the Network Director, I am a veteran and I do 
get my services at Atlanta. I frequently joke that if I saw 
that parking problem, I would drive by. I have a spot, so I can 
park. But yes, that is an issue I am very sensitive of.
    Senator Isakson. I appreciate that. I don't want to 
interrupt my questions, but would the Mayor of Hinesville who 
just arrived stand up? Didn't I see him come in back there? I 
want the record to reflect that I have already asked for the VA 
to consider utilizing the existing facilities that Hinesville 
has prepared that were in anticipation of the brigade combat 
team for its lease operation be considered for its veterans 
clinic, Mr. Mayor. So, I wanted to let you know we have already 
looked out for you. Thank you, sir, and thank you for what you 
do, Mayor.
    Ms. Wiley, I always brag about what you all do there. It is 
nothing short of remarkable. How is the progress coming with 
the seamless transition, and how is the rate of cures in terms 
of TBI progressing?
    Ms. Wiley. Well, thank you, Senator, for your continued 
support of our program. We are very proud of it, too. At this 
time, we continue to have a very strong relationship with the 
DOD, and this year already we have treated approximately the 
same number of active duty soldiers through our rehab and TBI 
program that we treated for the total year last year. So we 
continue to see a very strong relationship.
    We have also initiated another program through our 
domiciliary--our TRRP program--and that was a pilot program 
this last year. We have had tremendous success with treatment 
of patients with specific TBI-related diagnoses who did not 
need hospital-level care, but needed domiciliary type of care. 
I believe that our results to date have been approximately a 35 
percent return to duty rate for those soldiers. So, it is our 
aim for the coming year to continue to explore ways to work 
with the DOD, not only at Fort Gordon, but expand that a bit in 
the Southeast to offer that service for other soldiers.
    Senator Isakson. If I am not mistaken, not only is the 
return rate now at 35 percent and improving, but a lot of those 
people are returning actually to the theater of operations in 
Afghanistan or Iraq. Is that not correct?
    Ms. Wiley. That is correct, sir. I am just not sure of the 
35 percent--how many of those return to the theater.
    Senator Isakson. Well, it is a great credit to Augusta. 
When I had the field hearing at Augusta, I guess it has been 2 
years ago now--it may have been last year--I met a Sergeant 
Harris as I was touring the facility, and if you remember, she 
turned the corner. She had been hit with an IED her second day 
in Iraq and had suffered from TBI. She came back, was assigned 
to veterans and dismissed from the military. You all turned her 
around at the clinic and she was reenlisting and was going back 
to Iraq, which is a great testimony to what you are doing there 
at the Augusta center.
    At the Augusta facility, there was an incident with regard 
to either endoscopy or colonoscopy in terms of equipment and 
sterilization. Has that been addressed?
    Ms. Wiley. Absolutely, sir. Our situation regarding 
reusable medical equipment had to do with endoscopies, which is 
the device that is used to go down the nose or the throat. 
Since that time, we have instituted a complete revision of all 
of our standard operating procedures, all of our processes for 
reusable medical equipment, and we have been surveyed 
externally and internally numerous times in the last 2 months 
and have had 100 percent results from those surveys.
    Senator Isakson. Mr. Williams, on that subject, has that 
incident resulted in a change within the system to ensure a 
redundancy in terms of sterilization?
    Mr. Williams. Yes, sir. The changes that Ms. Wiley spoke to 
are not only changes that are happening at the Augusta 
facility, but they are happening across the country. Our 
network directors and medical center directors all took 
aggressive actions to move forward to assess where they were 
with regards to standard operating procedures and outcomes. We 
deployed managers, leaders, teams across the country to assess 
all of our facilities.
    From that, and I am sure you are aware that a recent review 
by the IG teams that went out indicated that we had substantial 
compliance with the standards. Not only did we demonstrate that 
we had addressed those issues that had been identified, that we 
had actually moved beyond and were learning new things and 
taking opportunities to make even more efficiencies occur, such 
as limiting the number of places where we perform these 
procedures, standardizing our standard operating procedures at 
medical centers, readdressing our training and education.
    So, yes, sir, we have looked at this from a systems 
standpoint and we are demonstrating that type of improvement in 
compliance across the country.
    Senator Isakson. Thank you for that answer.
    In your testimony, when you talked about where you place--
the criteria you go by to place an outpatient clinic, you 
mentioned quality, access guidelines, market penetration, and 
the medically underserved.
    Mr. Williams. Yes, sir.
    Senator Isakson. And when I heard you talk about the 
medically underserved, I heard you mention that the 
preponderance of your contract providers were in medically 
underserved clinics. Is that correct? Did I hear you say that, 
or was I not----
    Mr. Williams. I don't recall.
    Senator Isakson. Well, let me ask the question another way 
and maybe Mr. Biro would want to answer it. Of our 800, or soon 
to be 833 outpatient clinics, how many of the providers are 
staff VA providers and how many of them are contract providers?
    Mr. Williams. I don't have that specific information, but 
we can provide that for you.
    Mr. Biro. We will have to take it for the record.
    Senator Isakson. Do you have just a ballpark guess?
    Mr. Biro. I think only about two out of the ones in 
Georgia----
    Senator Isakson. Are contract?
    Mr. Biro [continuing]. Are contract, yes.
    Senator Isakson. OK. Thank you very much.
    I am going to ask the question I have been handed, but I 
don't know if I understand the question or not. What is the 
potential for VA/DOD collaboration at the Hinesville clinic?
    Mr. Biro. It is great. We are already working with Fort 
Stewart. We have people there already as liaison. We are 
already doing the discharge or exit physicals there. We will 
certainly talk to the Commander of the hospital there on how we 
can cooperate.
    Senator Isakson. Well, let me ask you this question with 
regard to Uptown VA in Augusta and Eisenhower. The closest 
hospital, I guess, to Hinesville would be Dublin?
    Mr. Biro. That is right. The Hinesville facility is going 
to be run by the Charleston VA.
    Senator Isakson. By Charleston? Is it----
    Mr. Biro. Right, Charleston, South Carolina.
    Senator Isakson. I know proximity is essential to what you 
all have done in Augusta, Ms. Wiley, but is it possible to 
adopt some of the seamless transition procedures they have done 
in Augusta in this new Hinesville facility with Charleston?
    Mr. Biro. Yes. Yes. Like I said, we are doing the 
separation physicals now; at least we are coordinating them and 
we are in the process of doing even more. So, we will make sure 
that that continues to work.
    Senator Isakson. I think Secretary Shinseki has been very 
impressed with what has happened there and I think the results 
bear out that this is an important thing to cover.
    Two questions. Ms. Wiley, let me ask you this question. You 
have been at Augusta long enough to make a determination since 
the Warrior Transition Centers were upgraded, the beginning of 
the upgrade here was about, I guess, 18 months ago. Are the 
Warrior Transition Centers helping in terms of the condition of 
the veterans who come out of DOD and into VA health care? Is 
that a loaded question?
    Ms. Wiley. Yes, it is, sir.
    Senator Isakson. OK.
    Ms. Wiley. What I can tell you----
    Senator Isakson. Well, give me a loaded answer.
    Ms. Wiley. What I can tell you that I observe is maybe not 
an answer that could be applicable to everyplace else, because 
in Augusta, we have such a close relationship with the Warrior 
Transition Unit and the VA. We have a lot of interconnectedness 
that occurs that is unique to our situation, and because of 
that, the positive working relationship that we have--because 
of the active duty unit--also translates to a very positive 
working relationship as we are transitioning soldiers back into 
veteran status.
    Senator Isakson. Second question. With regard to the 
Transition Centers. I was struck, when I went through the 
center at Fort Stewart last year, by the number of women that 
were going through the Warrior Transition Center; and unlike 
TBI and PTSD, many of their problems were orthopedic, in 
particular because of the weight of the equipment that many of 
them were carrying on the battlefield. Was that a correct 
observation, number 1, on my part? And number 2, what are we 
doing to address that in terms of their care?
    Ms. Wiley. Well, again, I could tell you what we are doing 
in Augusta as soldiers become veterans. We have established a 
women's clinic that opened in April----
    Senator Isakson. Great.
    Ms. Wiley [continuing]. Specifically to address women's 
needs, and we have a gynecologist and a practitioner who is 
devoted to the women's clinic. We also have a relationship with 
Eisenhower regarding mammography services and work 
collaboratively with them on all of our women's needs.
    Senator Isakson. Was I correct in my observation about 
orthopedic problems, or is it more of other types?
    Ms. Wiley. I can't tell you that for sure, but I will find 
that out for you.
    Senator Isakson. I wish you would, because when I was with 
the people at Fort Stewart, that specifically was the question 
I asked. It appeared to me there were a disproportionate number 
of women in the center versus the ratio in the service and I 
asked the question, why? And the immediate answer was, because 
of the orthopedic difficulties from weights and things like 
that. So, check into that for me and let me know.
    With regard to the underserved and rural care, we now have 
11 community-based clinics now, right? No, that is wrong. We 
have 15 going on 19 in Georgia, is that correct?
    Mr. Biro. Yes.
    Senator Isakson. Can you tell me, Mr. Biro, about how that 
affects accessibility for the average veteran? I mean, we are 
in a technical college in Georgia and we like to say that we 
have a technical education center within 45 minutes of every 
student that wants technical education. Are we getting to a 
point that our veterans have reasonably quick access to 
outpatient clinics if they don't go to the hospital?
    Mr. Biro. We are getting there. We are working on this. We 
have this formula, as Mr. Williams had pointed out, that there 
be no more than a particular length of commuting time. It is 
about 30, 60, or 90 minutes, depending upon saturation. So, we 
have a map and we are turning that map green by--the map is 
gray, and as we put new clinics in, it turns green, showing 
that the clinics are close enough. Are we finished? No, but we 
are making progress. We are making a lot of progress.
    Senator Isakson. Thirty to 90 minutes is great progress 
compared to three hospitals and no clinics, which was the case 
just a few years ago. So, I commend you on what you are doing 
and continuing to do.
    I am going to summarize--unless somebody behind me reminds 
me of something I forgot to ask--by talking about a couple of 
things I had mentioned earlier. One, we thank you very much for 
the emphasis on Glynn County and Brunswick and the emphasis on 
Hinesville. I think both of the answers were that the opening 
of Brunswick in 2010 and the opening of Hinesville in late 2011 
are conservative estimates, which means it might happen sooner 
and we certainly hope that takes place.
    But also with regard to Hinesville, I want to repeat what I 
said earlier. I sincerely hope the administration will consider 
looking at those facilities that have been built in preparation 
for the brigade combat team which has now been withdrawn, to 
see if one of those facilities will match with the VA's use, 
which would be a win-win, I think, for the VA and the Army. It 
would certainly be a win for Liberty County and the city of 
Hinesville.
    Senator Isakson. OK. Mr. Williams, I have been asked to ask 
you a question which you know the answer to. The new Health 
Care Center Facility Program--do you know what that is?
    Mr. Williams. Pardon me, sir----
    Senator Isakson. The new Health Care Facility Program? HCC? 
I am not an acronym guy. I apologize.
    Mr. Williams. Yes, sir.
    Senator Isakson. Tell me how that is going to work.
    Mr. Williams. Well, the concept of a health care center is 
one of the components of our continuum of care that we provide 
to our veterans. If you look from our mobile clinics to an 
outreach clinic to a CBOC, we are able to increase the number 
of services we provide based upon the needs in those particular 
areas and based upon the resources that are available and are 
able to be provided.
    The HCC kind of fits in between a medical center with 
inpatient beds and an independent clinic. It is a large 
outpatient operation with--it typically would have some 
special--a lot of specialty care, ambulatory surgery, high-end 
diagnostic capabilities. It typically will not have an 
inpatient bed section, and you will see some of these can be as 
large as from 300,000 to 500,000 square feet, depending on 
need. But again, what distinguishes it from others is that it 
is typically much larger than a CBOC and sometimes larger than 
an independent clinic, but does not fit a full medical center 
profile. Typically, it doesn't have inpatient beds.
    Senator Isakson. Well, let me thank all three of you for 
your testimony and for your service to our veterans. I will 
excuse you, and I am going to call our second panel up. Thank 
you very much.
    Mr. Williams. Thank you, sir.
    Senator Isakson. Mr. Williams, will you be able to stay 
until the second panel is complete? Thank you very much.
    Our second panel is Mr. Tom Cook, the Assistant 
Commissioner of the Georgia Department of Veterans Services; Al 
Spears, the Quartermaster, Georgia Veterans of Foreign Wars; 
and Cort Nordeoff, the Southeast Georgia District Commander for 
Disabled American Veterans.
    I think each one of you are prepared to give testimony, is 
that correct?
    Mr. Spears. Yes, sir.
    Senator Isakson. Yes. Good. I want to say to Mr. Tom Cook, 
I want you to deliver my best wishes to Pete Wheeler.
    Mr. Cook. Certainly.
    Senator Isakson. Georgia is proud of all of its veterans, 
but it is particularly proud--we have had the best Commissioner 
of Veterans Affairs any State could possibly have. He is older 
than dirt and he has been around, and his entire life he has 
dedicated to the veterans of Georgia. I just want you to 
personally extend him my thanks. I worked with him for years 
when I was in the Georgia Legislature, as I have worked with 
you, and I think you all do a fantastic, tremendous job. And 
please tell him I said so.
    Mr. Cook. I certainly will. Yes, sir.
    Senator Isakson. If it is all right with you, we will go 
with Mr. Cook first for his testimony, then to Mr. Nordeoff, 
and then Mr. Spears. Is that all right? Mr. Cook?

STATEMENT OF TOM COOK, ASSISTANT COMMISSIONER, FIELD OPERATIONS 
      AND CLAIMS, GEORGIA DEPARTMENT OF VETERANS SERVICES

    Mr. Cook. Thank you, Mr. Chairman and distinguished guests. 
It is an honor for me to be here, and thank you for inviting 
our Department to testify this afternoon. Commissioner Wheeler 
sends his personal regrets for not being able to be here due to 
his wife's serious health problems. It is my privilege to 
testify on his behalf; and Senator Isakson, Commissioner 
Wheeler wants you to know that he values your friendship and 
that he appreciates the interest of your Committee regarding 
veterans having top-notch and accessible health care available 
throughout all of Georgia.
    As requested, we will limit our oral testimony to 5 
minutes. We submitted our complete written testimony to you. We 
believe that our testimony reflects the feelings of the 
majority of veterans who are being treated in the VA clinics.
    The feedback we received has been overwhelmingly positive 
and veterans are very pleased with the quality of care they are 
receiving. They speak highly of the screening done by the 
nurses. They state that the physicians are very dedicated to 
their jobs, very thorough in their examinations, that they 
listen carefully to what they say. Veterans seem very impressed 
with the increasing availability of clinics and they are 
delighted that they no longer have to make the long drive to 
Atlanta, Dublin, Augusta, or Northern Florida for their routine 
appointments. They state that their appointments are scheduled 
in a timely manner and that they are seen promptly once they 
arrive. On a very positive note, we received many favorable 
comments regarding mental health treatment.
    Co-location of State veterans service offices within the 
clinics facilitates one-stop shopping for our veterans health 
care and benefits concerns. We are presently co-located in the 
Athens, Savannah, St. Mary's, and Valdosta clinics and we would 
like for future plans to include space for our Department's 
representatives, as well, if possible. We currently have, as 
has been said, 15 clinics open in Georgia.
    Within the past year, new clinics have opened in St. 
Mary's, Perry, and Stockbridge, and within the next few months 
we would hope they would be open in Newnan, certainly, then 
Brunswick as soon as possible. We eagerly await also the 
opening of clinics within the next months or so in Hinesville, 
Statesboro, Blairsville, Carrollton, and Milledgeville. 
Additionally, we understand that VA is planning to open a 
clinic in Waycross. These clinics are centrally and 
strategically located throughout Georgia and it is absolutely 
critical that all of them open as planned for our veterans to 
have the accessible outpatient health care they deserve.
    We are disappointed that the contract for the Brunswick 
clinic had to be rebid due to complaints for contractors, and 
our understanding is that the estimates are that the clinic 
will open later this fall or down the road, as soon as we can. 
Although the delay is inconvenient for the veterans in the 
area, it does not seem to us to be excessive, at least not yet. 
We believe that VA is doing everything they can to open the 
clinic as soon as possible.
    Although the focus of this hearing is on clinics, we 
believe that it is imperative that we emphasize the need for 
another VA hospital on the Southwest side of Atlanta. The 
Atlanta VA Hospital has too many patients and too few parking 
spaces. As Commissioner Wheeler would so eloquently state, the 
situation is much like trying to put a size 12 foot inside a 
size 6 shoe. We believe the answer to this problem is the 
Southwest Atlanta Medical Center, which is available on the 
Southwest side of Atlanta right now, and we understand that a 
request is at the VA Central Office. We request the support of 
your Committee, sir, in getting this important request approved 
by the VA as soon as possible. We have provided pictures of 
that hospital so you can see how nice it is and how much 
parking is available there. I have some extra copies with me, 
as well.
    Thanks again for allowing us to testify. I will be happy to 
answer any questions you might have now or later, and may God 
bless the important service you provide and may God bless the 
United States of America. Thank you, sir.
    [The prepared statement of Mr. Cook follows:]
     Prepared Statement of Tom Cook, Assistant Commissioner, Field 
     Operations and Claims, Georgia Department of Veterans Service
    Mr. Chairman and Members of the Committee: Thank you for the 
opportunity to present the views of Commissioner Wheeler and Georgia 
Department of Veterans Service regarding veterans' perceptions of 
Community Based Outpatient Clinics in Georgia. Commissioner Wheeler 
sends his personal regrets in not being able to testify due to 
circumstances surrounding his wife's health. He wants you to know that 
he values the friendship and support of Senator Isakson; and he 
appreciates the interest and concern of the Senate Committee on 
Veterans' Affairs regarding veterans having top notch and accessible 
health care available in the rural areas of Georgia, as well as in the 
more densely populated metropolitan areas of the state.
                            quality of care
    Once we were notified of this hearing, we solicited comments from 
veterans and our department's field office representatives throughout 
Georgia to prepare for the hearing. Although time did not allow for 
investigation of complaints or confirmation of compliments, we believe 
that our testimony reflects the feelings of the majority of veterans 
who are being treated at our Community Based Outpatient Clinics 
(CBOC's).
    The overwhelming response has been that veterans are extremely 
pleased with the outstanding quality of care they receive in the 
CBOC's. The reputation of the CBOC's among our veterans is 
exceptionally good. Veterans generally report being treated with 
courtesy and respect by a great staff. They speak highly of the 
screening done by the nurses. They state that the physicians are very 
dedicated to their jobs, that they are very thorough in their 
examinations, and that they listen carefully to what they say.
    Veterans report that they believe the quality of care has improved 
at the Albany CBOC since the change from a private contract with Phoebe 
to a VA run clinic. We believe this is a significant lesson learned in 
providing top notch VA health care for CBOC's throughout the United 
States.
    In some instances, veterans believe that personnel behind the sign 
in window are overly strict in the enforcement of ``the line'' to stand 
behind when another veteran is already at the window. This is 
particularly true when veterans come to the clinic for the first time. 
They may not know about ``the line'' and inadvertently cross over it. 
In some cases, veterans describe being made to feel like a ``criminal'' 
and being somewhat rudely ``ordered'' to get behind the line. 
Similarly, they state that in some cases the security guards are called 
out to ensure that they get behind ``the line.'' Certainly, if a 
veteran is unruly, then calling security is appropriate. However, 
calling security seems premature for innocent violations of policy 
regarding ``the line'' when no disruptive behavior is involved.
    We know that the Privacy Act and HIPPA requirements impose a high 
level of sensitivity regarding access to veterans' personal 
information. We fully support protecting the privacy and identity of 
our veterans. Perhaps some personnel are just being overly zealous in 
the enforcement of those requirements.
    This is really the only area where we have received specific 
complaints regarding discourteous treatment. We do not intend to 
chastise the VA by raising this issue because we really believe that 
the overall courtesy and treatment of our veterans at the CBOC's is 
exceptionally good. We raise the issue simply because we suspect it is 
one that merits being given some attention across the VA health care 
system in clinics and in medical centers.
    We think this could be addressed by having more prominent signs 
posted at the clinics regarding the policy and by including written 
notice of the policy in correspondence that goes to the veterans. We 
also think that training could be given to ensure that veterans who 
``cross the line'' are treated in a courteous manner.
    An additional observation along the same line of thought is that 
some veterans are frustrated by the protective glass window at some of 
the clinics. They report feeling like they are ``in prison talking 
through a bullet proof glass.'' So, perhaps the tension between the 
need for adequate security and the need for a ``warm'' reception needs 
to be evaluated.
                        availability of services
    The feedback we have received from veterans indicates that they are 
very impressed with the steadily increasing availability and 
accessibility of outpatient treatment that is being offered through the 
CBOC's in Georgia. Many veterans are delighted that they no longer have 
to make the long drive to Atlanta, Dublin, Augusta, or Northern Florida 
for routine appointments in a VA Medical Center.
    In most cases, veterans seem pleased that their appointments are 
scheduled in a timely manner. Once they arrive for their appointments, 
they report being seen promptly. In fact, some veterans report that 
they believe the CBOC's are much better organized and run than the VA 
medical centers.
    However, due to the steadily increasing number of veterans in need 
of treatment throughout Georgia, some of the CBOC's (for example, 
Oakwood) have already reached capacity and are no longer accepting new 
patients. Other clinics (for example, Columbus) are reported to be too 
small for the number of veterans served. Some clinics (for example, 
Valdosta) are reported to be in need of another Medical Team because of 
the size of the provider's panels.
    These concerns highlight the need for VA to expand the size and 
staffing of existing clinics while opening additional clinics 
throughout Georgia. We are pleased with the progress that has been made 
thus far, but we are very cognizant of the fact that we cannot remain 
stagnant. We must continue to expand in order to provide the level of 
service to our veterans that they deserve.
    We have received some complaints regarding the availability of 
specific treatment for women veterans. Some in Smyrna state that they 
are being referred to non-VA providers. Some women veterans have 
complained that pap smears and mammograms are not routinely provided in 
clinics.
    We have received many favorable comments regarding mental health 
treatment. PTSD therapy has been overwhelming popular and has received 
many accolades. The only drawback is the length of time for the 
appointments due to the popularity.
    We received a number of complaints regarding being able to ``get 
through'' or ``leave messages'' on the telephone systems. Similarly, 
some say that their messages are not answered and that their calls are 
not returned. Also, we have been informed that the number for the Perry 
Clinic is not listed anywhere. Consequently, our local office receives 
about 10 calls per day from veterans wanting the number for the 
clinic.
    We are told that the Athens Clinic does not show up on GPS or 
MapQuest. Consequently, some veterans drive ``all over creation'' 
trying to find the clinic. Perhaps sending veterans a strip map would 
be helpful.
    Co-location of State Veterans Service Offices within the CBOC's 
enhances the level of services available for the veterans and 
facilitates one stop shopping for their health care and benefit 
concerns and entitlements. We are presently co-located in the Athens, 
Savannah, St. Mary's and Valdosta clinics. We would like for future 
plans to include space for our department's representatives as well. We 
believe this is particularly important for Brunswick, Statesboro, 
Blairsville, Carrollton and Waycross. We also would like for 
consideration of co-location to be given during planning for expansion 
of any of the other clinics, especially Newnan and 
Stockbridge.
                          placement of clinics
    We currently have 13 CBOC's and two additional Outpatient Clinics 
open in Georgia. We are aware of plans to open eight additional CBOC's 
within the next couple of years. Within the past year, new CBOC's have 
opened in St. Mary's, Perry and Stockbridge. VA will open the Newnan 
CBOC in September of this year.
    We eagerly await the opening of CBOC's in Brunswick, Hinesville and 
Statesboro. VA has assured us that these clinics will open within the 
next year. The addition of these clinics will greatly increase 
accessibility for veterans in Southeast Georgia. Similarly, VA has 
assured us that CBOC's will open in Blairsville, Carrollton and 
Milledgeville, which will greatly improve accessibility in other areas 
of Georgia. We also understand that the CBOC in Carrollton will be a 
Mega, or Super, Clinic with up to 45K square feet of space and a number 
of specialty clinics, and that it will open within the next year.
    Additionally, we understand that VA is planning to open a CBOC in 
Waycross. This location fills a great gap in distance for the veterans 
of Southeast Georgia. It is vital that a clinic open in Waycross as 
soon as possible.
    These clinics are centrally and strategically located throughout 
Georgia. It is critical that all of them open as planned for our 
veterans to have the accessible outpatient health care they deserve.
    We also emphasize that Georgia is the largest state east of the 
Mississippi River in land area. That fact, coupled with the steadily 
increasing veteran population in Georgia, highlights the need for 
additional clinics to be planned in the near future for other areas of 
the state. We suggest Canton, Dalton, Tifton, LaGrange, Griffin, and 
Hazlehurst for consideration.
                    rebidding of brunswick contract
    We are interested in getting a CBOC in Brunswick as soon as 
possible. In that regard, we are disappointed that the contract had to 
be rebid due to complaints from contractors. Our understanding is that 
the latest estimates project that the clinic will be open by late 
September or early October 2009. We have been told that the nursing 
staff has already been hired and that they are going through 
orientation training. We have been informed that the physicians are 
currently going through the credentialing process, and that the 
remainder of the administrative staff position will be posted soon.
    Although the delay is inconvenient for the veterans in the area, it 
does not seem to us to be excessive. We believe that VA is doing 
everything they can to open the clinic as soon as possible.
                  va hospital on west side of atlanta
    Although the focus of this hearing is on CBOC's, we believe that it 
is imperative that we emphasize the need for another VA Medical Center 
on the West or Southwest side of Atlanta. The Atlanta VA Medical Center 
located in Decatur is faced with a continually growing number of 
patients and with a steadily increasing parking problem.
    On a daily basis, veterans contend with long lines of vehicles 
extending to the highway waiting for their turn to park at the Atlanta 
VA Medical Center. Many veterans have to wait long periods of time 
before they are able to go to their appointment. Once they get inside 
the hospital, they are faced with additional delays due to the ever 
increasing number of patients being treated at the hospital.
    Even if we could solve the parking problem today, the patient care 
problem would still exist. In fact, the number of patients will 
continue to increase due to the referrals that are made from the 
increasing number of CBOC's in the Atlanta area, as well as due to the 
treatment of increasing numbers of OIF/OEF veterans. The parking 
problem outside the hospital and the patient care problem inside the 
hospital combined are like trying to put a size twelve foot inside a 
size six shoe.
    We need another VA hospital in Atlanta in order to provide timely 
and quality health care for the steadily increasing number of patients. 
We believe the answer to this problem is the Southwest Atlanta Medical 
Center, which is available on the southwest side of Atlanta right now. 
We are attaching information and photographs of this hospital for your 
perusal. This facility has more than adequate parking and is ready made 
for patient care. Once approved, VA will just need to negotiate the 
lease agreement and staff the hospital.
    We understand that a request for another hospital is at the VA 
Central Office for a decision by Secretary Shinseki. We request the 
active support of the Senate Committee on Veterans' Affairs in getting 
this important request for an additional hospital in Atlanta approved 
by the VA as soon as possible.

    Senator Isakson. Well, Tom, thank you very much. In your 
reference to Brunswick, I would say the numbers the VA 
committed, I think by mid-2010 in Brunswick, not the end of 
this year, but certainly within that reasonable period of time. 
I appreciate that very much.
    Also, for all of you, your previously submitted printed 
testimony will, by unanimous consent, be published in the 
record, so it will be accepted from all of you.
    Mr. Nordeoff?

    STATEMENT OF CORT NORDEOFF, SOUTHEAST GEORGIA DISTRICT 
             COMMANDER, DISABLED AMERICAN VETERANS

    Mr. Nordeoff. Senator Isakson, I am honored and privileged 
to appear before you today. As the Southeast District Commander 
of the Disabled American Veterans, I appear here today on 
behalf of the State Commander of Georgia, Freddie Swint, and 
the 54,526 fellow disabled veterans in the Southeast District 
of Georgia.
    Our National Office in Washington, DC, submitted a written 
statement for this hearing today. I ask that the statement be 
made a part of the record of this hearing.
    Senator Isakson. Without objection.
    Mr. Nordeoff. At this time, sir, I would like to thank you 
and the Department of Veterans Affairs for all the positive 
steps that each of you have taken to provide for increased 
medical health for the veterans of the State of Georgia.
    Due to the overwhelming numbers of Disabled American 
Veterans who reside in the districts, the need for a VA clinic 
is of utmost importance. For the State of Georgia, we have 133 
community-based clinics, with only two on the East Coast. One 
clinic is located in the Northeast of the district, while the 
other one is located in the Southeast of the district.
    While the Hinesville clinic would help serve the 15,425 
disabled veterans who reside in the five surrounding counties, 
which could lessen the number of veterans who are currently 
being seen at the Savannah, Georgia, clinic, and that is not 
counting the 25,672 disabled veterans that are located in 
Chatham County. This could cut down on travel times for the 
veterans from 1-2 hours to approximately 30-40 minutes anywhere 
within the district.
    Hinesville is the home of the Third Infantry Division, 
which is currently discharging soldiers on a daily basis, which 
adds to the percentage of 7,620 disabled veterans who reside in 
Liberty County and Hinesville. Also, with a clinic in 
Brunswick, we could help serve those 7,480 disabled veterans 
who reside in the three surrounding counties, which could 
lessen the number of veterans that are currently being seen in 
Kingsland, Georgia, clinic, which is not counting the 5,949 
disabled veterans who reside in Camden 
County.
    With the number of disabled veterans that are now in the 
district, the Disabled American Veterans just recently 
purchased a van for the Southeast District to provide 
transportation for disabled veterans so they will be able to 
make their appointments or any other medical treatment that the 
VA orders.
    Thank you, sir. This concludes my testimony. On behalf of 
the Disabled American Veterans, I would be pleased to answer 
any questions from you or from the other members.
    [The prepared statement of Mr. Nordeoff follows:]
    Prepared Statement of Cort Nordeoff, Southeast Georgia District 
                 Commander, Disabled American Veterans
    Senator Isakson and Members of the Committee: Thank you for 
inviting the Disabled American Veterans (DAV) to testify at this 
oversight hearing of the Committee to evaluate Georgia veterans' 
perceptions of Veterans' Affairs (VA) community-based outpatient 
clinics in terms of their quality of care, availability of services, 
and the placements of clinics in Georgia. Also the Committee 
specifically asked that I address the recent contract that was rebid 
for the community based outpatient clinic in Brunswick, GA. We value 
the opportunity to discuss our views. Rural health is an issue of 
significant importance to many DAV members in Georgia and veterans in 
general.
    Approximately 3.2 million, or 41 percent, of veterans enrolled for 
VA health care throughout the country are classified by VA as rural or 
highly rural. Also, 44 percent of current active duty military 
servicemembers, who will be tomorrow's veterans, list rural communities 
as their homes of record. In the State of Georgia, rural Georgians have 
a proud tradition of military service dating all the way back to the 
American Revolution. VA estimates that 773,000 veterans live in 
Georgia, of which almost 23,000 are proud members of the DAV. In 
Georgia, VA meets veterans' health care needs with major medical 
centers in Atlanta, Augusta and Dublin. VA operates fourteen community-
based outpatient clinics, in Albany; Athens; Columbus; Decatur; East 
Point; Lawrenceville; Macon; NE Georgia/Oakwood; Perry; Rome; Savannah; 
Smyrna; Stockbridge; and, Valdosta. VA plans to establish additional 
clinics based on unmet need. As a general rule, DAV is very pleased 
with the VA commitment to rural health care access in the State of 
Georgia. Nevertheless, research shows that when compared with their 
urban and suburban counterparts, veterans who live in rural settings in 
general have worse health-related quality-of-life scores; are poorer 
and have higher disease burdens; worse health outcomes; and are less 
likely to have alternative health coverage. Such findings anticipate 
greater health care demands and thus greater health care costs from 
rural veteran populations.
    Over the past several years, through authorizing legislation and 
additional appropriations, Congress has attempted to address unmet 
health care needs of veterans who make their homes in rural and remote 
areas. With nearly half of those currently serving in the military 
residing from rural, remote and frontier areas, access to VA health 
care and other veterans services for them is perhaps VA's biggest 
challenge. We recognize that rural health is a difficult national 
health care issue and is not isolated to VA's environment. We also 
appreciate that many service-connected disabled veterans living in 
rural areas face multiple challenges in accessing VA health care 
services, or even private services under VA contract or fee basis. 
Shortage of health care providers, long travel distances, weather 
conditions, geographical and financial barriers all negatively impact 
access to care and care coordination for many rural veterans, both the 
service-connected and nonservice-connected alike.
    Section 212 of Public Law 109-461 authorized VA to establish the 
Veterans Health Administration (VHA) Office of Rural Health (ORH). We 
deeply appreciate the due diligence of this Committee and Congress as a 
whole in exerting strong support for rural veterans by enacting this 
public law.
    As required by the Act, the function of the ORH is to coordinate 
policy efforts across VHA to promote improved health care for rural 
veterans; conduct, coordinate, promote and disseminate research related 
to issues affecting veterans living in rural areas; designate in each 
Veterans Integrated Service Network (VISN) rural consultants who are 
responsible for consulting on and coordinating the discharge of ORH 
programs and activities in their respective VISNs for veterans who 
reside in rural areas; and, to carry out other duties as directed by 
the Under Secretary for Health. In the Act, VA also was required to do 
an assessment of its fee-basis health care program for rural veterans 
to identify mechanisms for expanding the program and the feasibility 
and advisability of implementing such mechanisms. There were also a 
number of reports to Congress required including submission of a plan 
to improve access and quality of care for enrolled veterans in rural 
areas; measures for meeting the long term care and mental health needs 
of veterans residing in rural areas; and, a report on the status of 
identified and opened community-based outpatient clinics (CBOCs) and 
access points from the May 2004 decision document associated with the 
Capital Asset Realignment for Enhanced Services (CARES) plan. Finally, 
the Act required VA to conduct an extensive outreach program to 
identify and provide information about VA health care services to 
veterans of Operations Iraqi and Enduring Freedom (OIF/OEF) who live in 
rural communities for the purpose of enrolling these veterans into the 
VA health care system prior to the expiration of their statutory 
eligibility period (generally, five years following the date of 
military discharge or completion of deployments).
    In addition to establishing the ORH, in 2008, VA created a 13-
member VA Rural Health Advisory Committee to advise the Secretary on 
issues affecting rural veterans. This panel includes physicians from 
rural areas, disabled veterans, and experts from government, academia 
and the non-profit sectors. We applaud former VA Secretary Peake for 
having responded to our recommendation in the Fiscal Year (FY) 2009 
Independent Budget (IB) to use VA's authority to form such a committee. 
We hold high expectations that the Rural Veterans Advisory Committee 
will be a strong voice of support for many of the ideas we have 
expressed in previous testimony before Congress, and joined by our 
colleagues from AMVETS, Paralyzed Veterans of America, and the Veterans 
of Foreign Wars of the United States, in the IB.
    We are pleased and would like to congratulate VA on its progress to 
date in establishing the necessary framework to begin to improve 
services for rural veterans. It appears that ORH is reaching across the 
Department to coordinate and support programs aimed at increasing 
access for veterans in rural and highly rural communities. We note; 
however, that the ORH has an ambitious agenda but only a minimal staff 
and limited resources. The ORH is still a relatively new function 
within VA Central Office and it is only at the threshold of tangible 
effectiveness, with many challenges remaining. Given the lofty goals of 
Congress for rural health improvements, we are concerned about the 
organizational placement of ORH within the VHA Office of Policy and 
Planning rather than being closer to the operational arm of the VA 
system. Having to traverse the multiple layers of VHA's bureaucratic 
structure could frustrate, delay or even prevent initiatives 
established by this office. We believe rural veterans' interests would 
be better served if the ORH were elevated to a more appropriate 
management level in VA Central Office, with staff augmentation 
commensurate with its stated goals and plans.
    We understand that VA has developed a number of strategies to 
improve access to health care services for veterans living in rural and 
remote areas. To begin, VA appointed rural care designees in all its 
VISNs to serve as points of contact in liaison with ORH. While we 
appreciate that VHA designated the liaison positions within the VISNs, 
we expressed concern that they serve these purposes only on a part-time 
basis. We are pleased that VA is conducting a pilot program in eight 
VISNs to determine if the rural coordinator function should be a part-
time or a full-time position.
    VA reported that its approach to improving services in rural areas 
includes leveraging existing resources in communities nationwide to 
raise VA's presence through outreach clinics, fee-basis, contracting, 
and use of mobile clinics. Additionally, VA testified it is actively 
addressing the shortage of health care providers through recruitment 
and retention efforts; and harnessing tele-health and other 
technologies to reduce barriers to care. Also, in September 2008, VA 
announced plans to establish new rural outreach clinics in Houston 
County, Georgia, Juneau County, Alaska, and Wasco County, Oregon. VA 
plans to open six additional outreach clinics by August 2009 in: 
Winnemucca, NV; Yreka, CA; Utuado, PR; LaGrange, TX; Montezuma Creek, 
UT; and Manistique, MI.
    VA also reported that it has conducted other forms of outreach and 
developed relationships with the Department of Health and Human 
Services (HHS) (including the Office of Rural Health Policy and the 
Indian Health Service), and other agencies and academic institutions 
committed to serving rural areas to further assess and develop 
potential strategic partnerships. Likewise, VA testified it is working 
to address the needs of veterans from OIF/OEF by coordinating services 
with the HHS' Health Resources and Services Administration community 
health centers, and that these initiatives include a training 
partnership, technical assistance to community health centers and a 
seamless referral process from community health centers to VA sources 
of specialized care.
    In August 2008, VA announced the establishment of three ``Rural 
Health Resource Centers'' for the purpose of improving understanding of 
rural veterans' health issues; identifying their disparities in health 
care; formulating practices or programs to enhance the delivery of 
care; and, developing special practices and products for implementation 
VA system-wide. According to VA, the Rural Health Resource Centers will 
serve as satellite offices of ORH. The centers are sited in VA medical 
centers in White River Junction, Vermont; Iowa City, Iowa; and, Salt 
Lake City, Utah.
    Given that 44 percent of newly returning veterans from OEF/OIF live 
in rural areas, the IB veterans service organizations believe that 
these veterans, too, should have access to specialized services offered 
by VA's Readjustment Counseling Service, through its Vet Centers. In 
that regard, we are pleased to acknowledge that VA is rolling out a 
fleet of 50 mobile Vet Centers this year to provide access to returning 
veterans and outreach at demobilization sites on military bases, and at 
National Guard and Reserve units nationally.
    The issue of rural health is an extremely complex one and we agree 
with VA that there is not a ``one-size-fits-all'' solution to this 
problem. To make real improvements in access to the quality and 
coordination of care for rural veterans, we believe that Congress must 
provide continued oversight, and VA must be given sufficient resources 
to meet its many missions, including improvements in rural health care.
    In regard to funding for rural health, in 2008 VA allocated almost 
$22 million to VISNs to improve services for rural veterans. This 
funding is part of a two-year program and would focus on projects 
including new technology, recruitment and retention, and close 
cooperation with other organizations at the Federal, state and local 
levels. These funds were used to sustain current programs, establish 
pilot programs and establish new outpatient clinics. VA distributed 
resources according to the fraction of enrolled veterans living in 
rural areas within each VISN. It is DAV's understanding that VISNs with 
less than three percent of their patients in rural areas, received 
$250,000, those with between three and six percent received $1 million, 
and those with six percent or more received $1.5 million.
    The ORH has testified VA allocated another $24 million to sustain 
these programs and projects into 2009, including the Rural Health 
Resource Centers, mobile clinics, outreach clinics, VISN rural 
consultants, mental health and long-term care projects, and rural home-
based primary care, and has convened a workgroup of VISN and Central 
Office program offices to plan for the allocation of the remaining 
funds. In February 2009, ORH distributed guidance to VISNs and program 
offices concerning allocation of the remaining funds to enhance rural 
health care programs.
    Concurrently, Public Law 110-329, the Consolidated Security, 
Disaster Assistance, and Continuing Appropriations Act, 2009, approved 
on September 30, 2008, included $250 million for VA to establish and 
implement a new rural health outreach and delivery initiative. Congress 
intended these funds to build upon the work of the ORH by enabling VA 
to expand initiatives such as telemedicine and mobile clinics, and to 
open new clinics in underserved and rural areas. Notably, the bill also 
included $200 million for additional fee-basis services.
    Health workforce shortages and recruitment and retention of health 
care personnel, are also a key challenge to rural veterans' access to 
VA care and to the quality of that care. The Institute of Medicine of 
the National Academy of Sciences report ``Quality through 
Collaboration: The Future of Rural Health'' (2004) recommended that the 
Federal Government initiate a renewed, vigorous, and comprehensive 
effort to enhance the supply of health care professionals working in 
rural areas. To this end, VA's deep and long-term commitment to health 
professions education seems to be an appropriate foundation for 
improving these situations in rural VA facilities as well as in the 
private sector. VA's unique relationships with health professions 
schools should be put to work in aiding rural VA facilities with their 
human resources needs, and in particular for physicians, nurses, 
technicians, technologists and other direct providers of care. The VHA 
Office of Academic Affiliations, in conjunction with ORH, should 
develop a specific initiative aimed at taking advantage of VA's 
affiliations to meet clinical staffing needs in rural VA locations. 
While VA maintains it is moving in this general direction with its 
pilot program in a traveling nurse corps; VA's pilot program in 
establishing a ``nursing academy,'' initially in four sites and 
expanding eventually to twelve; its well-founded Education Debt 
Reduction Program and Employee Incentive Scholarship Program; and, its 
reformed physician pay system as authorized by Public Law 108-445, none 
of these programs was established as a rural health initiative, so it 
is difficult for DAV to envision how they would lend themselves to 
specifically solving VA's rural human resources problems. We do not see 
them as specific initiatives aimed at taking advantage of VA's 
affiliations to meet clinical staffing needs in rural VA locations.
    The DAV has a national resolution from its membership, Resolution 
No. 247, reaffirmed at our National Convention in Denver, CO, August 
22-25, 2009, fully supporting the rights of rural veterans to be served 
by VA, but insisting that Congress provide sufficient resources for VA 
to improve health care services for veterans living in rural and remote 
areas. We thank VA and this Committee for supporting specific-purpose 
funding for rural care without jeopardizing other VA health care 
programs, consistent with our adopted resolution. Furthermore, we 
appreciate the Committee's interest in conducting this oversight 
hearing to learn more from VA about the local situation here in 
Georgia. Such information serves everyone's interest in ascertaining 
how rural veterans receive care at VA's expense that otherwise might 
not have received care were it not for the new resources made available 
for rural veterans, as well as gathering data on how their health 
outcomes have been affected as a measure of the quality of care.
    VA's previous studies of rural needs, identified the need for 156 
priority CBOCs and a number of other new sites of care nationwide, 
recently including some here in Georgia. A March 30, 2007, report 
submitted to Congress indicates 12 CBOCs had been opened, 12 were 
targeted for opening in FY 2007, and five would open in FY 2008. In 
June 2008, VA announced plans to activate 44 additional CBOCs in 21 
states during FY 2009. As of the end of the second quarter of FY 2009, 
VA reported 768 clinics in operation, 392 of which are in urban 
settings, 337 in rural areas, and 38 in highly rural locations. VA 
directly staffs 540 clinics, and the remainder of these CBOCs are 
managed by contractors. Of the CBOCs VA operates, 353 are doing real-
time video conferencing (predominantly tele-mental health), while 130 
CBOCs are transmitting tele-retinal imaging for evaluation by 
specialists in VA medical centers. Services such as these greatly 
enhance patient care, extend specialties into rural and highly rural 
locations, and drastically cut down on long-distance travel by 
veterans. In addition, VA is expanding its capability to serve rural 
veterans by establishing rural outreach clinics. Currently, 12 VA 
outreach clinics are operational, and more are planned. These are major 
investments by VA, and we appreciate both VA and Congress for 
supporting this level of extension of VA services into more and more 
communities.
    While we applaud the VHA for improving veterans' access to quality 
care and its intention to spread primary and limited specialty care 
access for veterans to more areas, enabling additional veterans access 
to a convenient VA primary care resource, DAV urges that the business 
plan guiding these decisions generally first emphasize the option of 
VA-operated and staffed facilities. When geographic or financial 
conditions warrant (e.g., highly rural, scarceness, remoteness, etc.), 
we do not oppose the award of contracts for CBOC operations or leased 
facilities, but we do not support the general notion that VA should 
rely heavily or primarily on contract CBOC providers to provide care to 
rural veterans.
    We understand and appreciate those advocates on this Committee and 
in Congress in general who have been successful in enacting authority 
for VA to increase health care contracting in rural areas through a new 
multi-VISN pilot program enacted in Public Law 110-387. However, in 
light of the escalating costs of health care in the private sector, to 
its credit, VA has done a remarkable job of holding down costs by 
effectively managing in-house health programs and services for 
veterans. While some service-connected and nonservice-connected 
veterans might seek care in the private sector as a matter of personal 
convenience, doing so may well cause them to lose the safeguards built 
into the VA system by its patient safety program, prevention measures, 
evidence-based treatments, national formulary, electronic health 
record, and bar code medication administration (BCMA), among other 
protections. These unique VA features culminate in the highest quality 
care available, public or private. Loss of these safeguards, ones that 
are generally not available in private sector systems or among 
individual practitioners or group practices (especially in rural 
areas), would equate to diminished oversight and coordination of care, 
lack of continuity of care, and ultimately may result in lower quality 
of care for those who need quality the most.
    For these reasons, we urge Congress and VA's ORH to closely monitor 
and oversee the development of the new rural pilot demonstration 
project from Public Law 110-387, especially to protect against any 
erosion or diminution of VA's specialized medical programs, and to 
ensure participating rural and highly rural veterans receive health 
care quality that is comparable to that available within the VA's 
health care system. We are pleased that the ORH reported it is 
coordinating with the Office of Mental Health Services, to implement 
this pilot program. We ask VA, in implementing this demonstration 
project, to develop a series of tailored programs to provide VA-
coordinated rural care (or VA-coordinated care through local, state or 
other Federal agencies, as VA has previously claimed it would be doing) 
in the selected group of rural VISNs, and to provide reports to the 
Committees on Veterans' Affairs, of the results of those efforts, 
including relative costs, quality, satisfaction, degree of access 
improvements and other appropriate variables, compared to similar 
measurements of a like group of rural veterans who remain in VA health 
care. To the greatest extent practicable, VA should coordinate these 
demonstrations and pilots with interested health professions academic 
affiliates. We recommend the principles outlined in the Contract Care 
Coordination section of the FY 2010 IB be used to guide VA's approaches 
in this demonstration, and that it be closely monitored by VA's Rural 
Veterans Advisory Committee, with results reported regularly to 
Congress.
    We also recommend that VA be required to provide more thorough 
reporting to this Committee, to enable meaningful oversight of the use 
of the funds provided, and the implementation of the authorizing 
legislation that serves as a foundation for this work. We urge the 
Committee to consider legislation strengthening recurring reporting on 
VA rural health as a general matter. We are concerned that funds 
Congress provided to VA to address shortages of access in rural areas 
will simply be dropped into the VA ``Veterans Equitable Resource 
Allocation'' (VERA) system, absent means of measuring whether these new 
funds will be obligated in furtherance of Congress's intent--to enhance 
care for rural and highly rural veterans, with an emphasis on outreach 
to the newest generation of war veterans who served in the National 
Guard, and hail from rural areas, including our State. Reports to 
Congress should include standardized and meaningful measures of how VA 
rural health care capacity or ``virtual capacity'' has changed; VA 
should provide recorded workload changes on a quarterly or semi-annual 
basis, and disclose other trends on whether the rural health care 
initiatives and funds allocated for them are achieving their designed 
purposes.
    In closing, DAV believes that VA is working in good faith to 
address its shortcomings in rural areas, but VA clearly still faces 
major challenges and hurdles. In the long term, its methods and plans 
may offer rural and highly rural veterans better opportunities to 
obtain quality care to meet their specialized health care needs. 
However, we caution about the trend toward privatization, vouchering 
and contracting out VA health care for rural veterans on a broad scale. 
As VA's ORH develops its policies and initiatives, DAV cannot stress 
enough the importance of communication and collaboration between this 
office, other VA program offices, field facilities, and other Federal, 
state and local organizations, to reach out and provide VA benefits and 
services to veterans residing in rural and highly rural areas. As noted 
above, we are concerned that the current staffing level assigned to ORH 
will be insufficient to effectively carry out its mission. Moreover, 
DAV believes ORH's position in VHA's organizational structure may 
hamper its ability to properly implement, guide and oversee VA's rural 
health care initiative. Also, Congress should monitor VA's funding 
allocation to ensure that rural health needs do not interfere with 
other VA medical obligations. Finally, we are hopeful that with 
continued oversight from this Committee and, with these principles in 
mind; rural veterans will be better served by VA in the future.
    Senator Isakson, your invitation letter asked specific questions 
regarding the local situation in rural Georgia, and in particular about 
the status of the Brunswick community-based outpatient clinic, that I 
would be pleased to discuss in my oral 
remarks.

    This concludes my formal statement submitted on behalf of DAV. I 
would be happy to address questions from you or other Members of the 
Committee.

    Senator Isakson. Thank you very much, Mr. Nordeoff.
    Mr. Spears?

    STATEMENT OF ALBERT R. SPEARS, ADJUTANT/QUARTERMASTER, 
 DEPARTMENT OF GEORGIA, VETERANS OF FOREIGN WARS OF THE UNITED 
                             STATES

    Mr. Spears. Good afternoon, Senator and members of your 
staff. First, if I can, I haven't heard anyone say anything, 
but I would like to offer the condolences, prayers, and best 
wishes for the family of Senator Kennedy, the lion of the 
Senate. Senator Kennedy helped many on both sides of the aisle 
in his many years and he was himself a veteran.
    Thank you for inviting the Veterans of Foreign Wars of the 
United States to share its views with you on this important 
topic. As you know, I am Albert Spears, the State Adjutant/
Quartermaster of the Department of Georgia Veterans of Foreign 
Wars.
    The topic of the Community-Based Outpatient Clinics, CBOCs, 
as you recognized, is both important and timely, but the topic 
is not a stand-alone topic. There are significant issues that 
affect the CBOCs and quality of care that they provide, the 
range of services that they offer, and the placement of those 
clinics. The idea is to place and staff CBOCs with Department 
of Veterans Affairs employees in a reasonable proximity of the 
homes of the veterans to be served. The CBOCs and the system 
administering them must not only be located near the population 
to be served, but also must provide the range of services 
required not just today, but tomorrow and into the future.
    I would like to sit here and tell you that everything is 
great with the CBOCs. I want to tell you that the quality of 
care is world class, the range of services is direct and as it 
should be, and that a CBOC is currently located exactly across 
Georgia, where it should be, but I cannot.
    Currently in Georgia, our CBOCs are operated by VAMCs in 
South Carolina, Florida, Alabama, as well as Georgia, and we 
have people from Georgia going into Tennessee. We need some 
sort of better coordination and may even need some sort of CBOC 
command in Georgia. The point will not be lost on you that 
these represent not only several different hospitals and 
medical centers, but several different Veterans Integrated 
Service Networks, or VISNs. Consistency of service is not a 
strong point.
    The CBOCs must meet the needs not only of the many elderly 
veterans from World War II, Korea, and Vietnam, they must 
increasingly meet the needs of the younger veteran of the 
current conflicts of the First Gulf War, Operation Enduring 
Freedom, and Operation Iraqi Freedom. Each must deal with the 
medical issues of age-related diabetes, for example, and those 
of Traumatic Brain Injury and traumatic amputation on the 
battlefield.
    We must also not ignore the needs of our female veterans. 
While each of us realizes the current makeup of the all-
volunteer military, we must acknowledge and understand that 
women are veterans, too. It is not just a slogan or a campaign 
speech. Women have been a vital part of the Armed Forces since 
the days when Molly Pitcher kept the guns firing at the Battle 
of Monmouth to today's females being awarded the Silver Star 
for gallantry in 
action.
    And to our enduring discredit, they have not always been 
treated with honor, respect, and the dignity which they 
deserve. Yet we have women veterans having their civilian 
medical insurance being charged by the VA when they are being 
treated at the VA for service-connected disabilities. This 
continues still.
    Regardless of the value of the CBOCs throughout Georgia, a 
female veteran cannot obtain routine care that is required for 
her as expected by her age group, and female veterans represent 
about 25 percent of the veterans population needing care in 
Georgia. Our female veterans express that the medical health 
care providers within the VA system and contracted health care 
providers frequently do not take them seriously. The providers 
do not seem concerned about our female warriors' medical 
problems and their association of various conditions from the 
combat environment.
    The VA simply must also deal with the issue of child care. 
Pap smears, mammograms, pre- and post-menopausal care, and 
sexual trauma care are practically nonexistent in the system 
today, especially in the CBOC. This does not even consider the 
other needs and other gynecological needs such as fertility 
counseling that may be necessary. Since we have decided to make 
so many of these young women into almost professional athletes 
by the various services' physical and strength training, many 
of our female warriors have not had normal menstrual cycles in 
years.
    There are various programs established for and targeting 
female veterans, but most require travel to centers and 
programs that simply cannot be considered reasonable, 
especially for our younger female veterans that are frequently 
single parents.
    One point that I pray is not missed and does not fall on 
deaf ears is that a female veteran that files a claim for 
service connection as a victim of military sexual trauma while 
in the service, whether it was last week or 60 years ago, 
should be considered presumptive if she is suffering the mental 
effects of that trauma. She should not be further traumatized 
and revictimized by having to prove service connection when 
every cog in the system in which she was operating told her to 
take it and forget it happened when it happened.
    Remember that the movie ``The General's Daughter'' was, in 
essence, a true story of rape in the military and that was what 
we call the modern military. We must all remember the scandals 
over the years of the drill sergeants and their trainees, the 
scandals of the rapes, and the institutional cover-ups at 
various service academies. Presumption of service connection is 
a must-do. It cannot wait and it must be done now, by 
legislation, if necessary.
    Again, I realize that the CBOC cannot do everything, but we 
are not serving any of our Post Traumatic Stress victims 
properly at the CBOC, nor are we doing a very good job at the 
VAMCs. The staff of each is trying hard, and I want to stress 
this. The staff of each is trying hard to accommodate the need, 
but it simply is not being met. The suicide rate demonstrates 
that fact.
    Our female warriors should be placed in PTSD group 
counseling sessions with other female veterans. This can be as 
simple as mental health visiting and establishing a group 
within the women's clinic each month.
    For the topic at hand, the Brunswick CBOC, I found no one 
that discussed any dissatisfaction with that facility except 
the time that it is taking to get it online.
    With noted exceptions regarding female veterans, the CBOCs 
are providing outstanding services and an adequate range of 
services. Many clinics have waiting times for appointments and 
procedures that are excessive.
    We must also remember that with the reduction of medical 
staffs in rural America, much of the previous access to medical 
care that may have been available in an area has been 
diminished drastically. I have noticed as I have driven through 
the State of Georgia numerous offices of health care providers 
that have been closed, as well as clinics and hospitals. There 
may be an opportunity to lease or purchase some of these 
facilities for CBOCs in needed areas, as an example, in McRae 
in Telfair County. That hospital was closed within the last 
year. Such efforts may be beneficial to attract medical-related 
businesses to the area, such as pharmacies and drug stores.
    Prime irritants within the CBOCs, and the entire VA health 
care system are--and I am just about finished, if you would 
bear with me--telephone numbers. There never seems to be a 
direct telephone number to anybody. I can call your office 
direct, and even if you are not on the floor, I can talk to 
you. Unfortunately though, I can't call Larry Biro, by way of a 
direct line. I have got to go through three switchboards and 
two patient advocates in order to get there.
    Appointment wait times--some CBOCs have a very short 
waiting time, such as Stockbridge, and others have a 
significantly longer waiting time, such as Smyrna. Endless 
``round-robin'' telephone systems--no one minds a truly 
responsive telephone menu system, but too many of them are 
endless loops within the VA system.
    In closing, I must reiterate the treatment of our female 
veterans. Our women warriors served this Nation in the true 
spirit of Palace Athena and they need to receive the health 
care treatment to which they are entitled. Only one clinic at 
the VAMC Atlanta treats these great warriors. The purchase of 
the Southwest Atlanta Medical Center is available now. Purchase 
of that facility and conversion to a VA medical center could 
facilitate the expansion of health care services across the 
board so desperately needed now by freeing up space in Decatur 
or making it available at Southwest Atlanta Medical.
    Thank you for inviting me here today, and I welcome any 
questions.
    [The prepared statement of Mr. Spears follows:]
 Prepared Statement of Albert R. Spears, State Adjutant/Quartermaster, 
  Department of Georgia Veterans of Foreign Wars of the United States
    Good Afternoon, Senator Isakson and members of this Field Hearing 
of the Senate Veterans' Affairs Committee. Thank you for inviting the 
Veterans of Foreign Wars of the United States to share its views with 
you on this important topic. As you will recall, I am Albert Spears, 
the State Adjutant/Quartermaster of the Department of Georgia Veterans 
of Foreign Wars of the U.S.
    The topic of Community-Based Outpatient Clinics (CBOCs) as you 
recognize is both important and timely and I will address it directly--
its strengths and its shortcomings. But the topic is not a stand-alone 
topic. There are significant issues that affect the CBOCs and the 
quality of care that they provide, the range of services that they 
offer, and the placement of those clinics.
    The ideal is to place and staff with Department of Veterans Affairs 
employees, CBOCs in a reasonable proximity of the homes of the veterans 
to be served. The CBOCs and the system administering them not only must 
be located near the population to be served but also must provide the 
range of services required not just today, but tomorrow and in to the 
future.
    I would like to sit here and tell you that everything is great with 
the CBOCs. I want to tell you that the quality of care is world class, 
that the range of services is direct and as it should be, and that a 
CBOC is currently located exactly where it should be. Alas, I cannot.
    Currently in Georgia, our CBOCs are operated by VAMCs in South 
Carolina, Florida, Alabama, Tennessee, as well as Georgia. We need some 
sort of better coordination and may even need a ``CBOC Command'' in 
Georgia. The point will not be lost on you that these represent not 
only several different hospitals/medical centers but also several 
different Veterans Integrated Service Networks (VISN). Consistency of 
services is not a strong point.
    The CBOCs must meet the needs not only of the many elderly veterans 
of World War II, Korea, and Vietnam; they must also meet increasingly 
the needs of the younger veteran of the current conflicts of the first 
Gulf War, Operation Enduring Freedom, and Operation Iraqi Freedom. Each 
must deal with the medical issues of age related diabetes (as an 
example) and those of Traumatic Brain Injury and traumatic amputation 
from the battlefield. We also must not ignore the needs of our female 
veterans. While each of us realizes the current make-up of the All 
Volunteer Military, we must acknowledge and understand that women are 
veterans too!
    Women are veterans too is not just a slogan or campaign speech. 
Women have been a vital part of the Armed Forces since the days of 
Molly Pitcher keeping the field guns firing at the Battle of Monmouth 
to today's females being awarded the Silver Star for gallantry in 
action. And to our enduring discredit, they have not always been 
treated with honor, respect, and dignity that they deserve. Yet, we 
have women veterans having their civilian medical insurance being 
charged by the VA when treated at the VA for established service-
connected disabilities.
    Regardless of the value of the CBOCs throughout Georgia, a female 
veteran cannot obtain routine care that is required for her as expected 
by her age group and female veterans represent about 25 percent of the 
veteran population needing care in Georgia.
    Our female veterans express that the medical healthcare providers 
within the VA System and contracted health care providers do not take 
them seriously. The providers do not seem as concerned about our female 
warriors' medical problems and the association of various conditions 
with combat and the combat environment.
    The VA simply must deal with the issue of child-care. The 
Department of Defense is working toward providing child-care while 
warriors are receiving medical treatment; the VA has to consider this 
as well. We have so many patients that need treatment--not all of whom 
are female nor even young--that are single parents and have no place to 
leave a child when going to the VA for treatment. This certainly 
requires a review.
    Pap smears, mammograms, pre/post menopausal care, sexual trauma 
care are practically non-existent in the system today. This does not 
even begin to consider other needs and other gynecological needs such 
as fertility counseling that may be necessary after we have made so 
many young women almost professional athletes by the various services' 
physical and strength training that many of our female warriors have 
not had normal menstrual cycles in years. There are several programs 
established for and targeting our female veterans but most require 
travel to centers and programs that simply cannot be considered 
reasonable especially for our younger female veterans that are 
frequently single parents.
    One point that I pray is not missed and does not fall of deaf 
ears--a female veteran that files a claim for service connection as a 
victim of sexual trauma while in the service whether or not it was last 
week or 60 years ago should be considered ``presumptive'' when she is 
suffering the mental effects of that trauma. She should not be further 
traumatized and re-victimized by having to prove service connection 
that every cog in the system told her she should just ``. . . take it 
and forget it happened . . .'' when it happened. Remember that the 
movie ``The General's Daughter'' was in essence a true story of rape in 
the military and it was what we call the modern military. We all 
remember the scandals over the various years of the drill sergeants and 
their trainees and the scandals of the rapes and institutional cover-
ups at the various service academies. Presumption of service connection 
is a must do; it cannot wait and must be done now, by legislation if 
necessary.
    Again, I realize that the CBOC cannot do everything but we are not 
serving any of our real Post Traumatic Stress victims properly at the 
CBOC nor are we doing a very good job at the Veterans Administration 
Medical Centers (VAMC). The staff of each is trying hard to accommodate 
the need but it is not being met. The suicide rate simply demonstrates 
that fact. Our female warriors should be placed in PTSD group 
counseling sessions with other female veterans. This can be as simple 
as mental health visiting and establishing a ``group'' in the Women's 
Clinic once each month.
    For the topic at hand, the Brunswick CBOC--I found no one that 
discussed treatment specifically at that clinic either good or bad. As 
I alluded to earlier in my testimony, the VFW prefers that all clinics 
be staffed with professionals employed by the Department of Veterans 
Affairs. We realize that may not always be possible and some may have 
to be staffed by contract. The difficulty with contracting is that 
regardless of the requirements that are or should be built into the 
contract as performance standards, the perception is that contract 
personnel are less receptive to the needs of veterans especially 
elderly ones. It seems to get lost to the contractor that the old man 
who is moving so slowly on the walker, has hearing aids in both ears, 
wears coke bottle thick glasses, and talks too loud in the waiting room 
was the same young man who charged a machine gun nest 65 years ago on 
an island in the Pacific saving the lives of countless Marines.
    With the noted exceptions regarding female veterans, the CBOCs are 
providing outstanding services and an adequate range of services. At 
many clinics the appointment waiting times (and procedures) are 
excessive.
    We must also remember that with the reduction of medical staffs in 
rural America, much of the previous access to medical care that may 
have been available in an area has been diminished drastically. I have 
noticed as I have driven the State of Georgia, numerous offices of 
healthcare providers that have closed as well as clinics and county 
hospitals. There may be an opportunity to lease or purchase some of 
these facilities for CBOCs in needed areas. Such efforts might also be 
beneficial to attracting medical related businesses to the area as well 
such as pharmacies and drug stores.
    Prime irritants regarding the CBOCs but also apply to the entire VA 
Health Care System are:

          a. Telephone Numbers--there never seems to be a published 
        direct telephone number to a clinic or a number at which a 
        patient can talk to a human being. I can (and do) pick up the 
        telephone and call your office, the Chief of Staff of the 
        Army's Office, the Secretary of Veterans Affairs Office, but I 
        cannot call the Office of the Director of VAMC-Atlanta's Office 
        or even the direct line to the Stockbridge CBOC.
          b. Appointment Wait Times--While some CBOCs have a very short 
        wait time, others have significant wait times even when the 
        appointment is needed solely for a referral for a serious 
        condition.
          c. Endless ``round robin'' telephone systems--No one truly 
        minds telephone menu systems that sort and a route to ultimate 
        solutions. Too many of those in the VA Health Care System 
        result in having to leave a message to await a call back at 
        some date in the future. Too frequently that call never comes. 
        Appointments, prescription refills, specialty referral 
        requests, and even calls to the patient advocate are too 
        frequently on such systems.

    In closing, I must return to treatment of our female veterans. Our 
women warriors served this Nation in the true spirit of Pallas Athena 
and they needed to receive the healthcare treatment they are entitled. 
Only one clinic at the VAMC-Atlanta treats these great warriors. The 
purchase of the Southwest Atlanta Medical Center in Atlanta is 
available now. Purchase of that facility and conversion to a VA Medical 
Center could facilitate the expansion of healthcare services so 
desperately required now by freeing space at Decatur or making it 
available at Southwest Atlanta Medical.

    Thank you for inviting me here today.

    Senator Isakson. Well, thank you, Mr. Spears.
    First of all, Mr. Nordeoff, if I made my notes correctly on 
your testimony, there are 54,526 disabled veterans in 
Southeastern Georgia?
    Mr. Nordeoff. Yes, sir.
    Senator Isakson. And you made note of the extensive burden 
on the Savannah facility now. So, I want to ask you this 
question. With the opening of a Hinesville facility in 2011 and 
the Brunswick facility in 2010, will that--do you think that 
meets the needs of those 54,000 and reduce the extended waiting 
time periods?
    Mr. Nordeoff. Yes, sir, I believe it is going to help a 
lot. Because right now, that would end up giving Hinesville and 
the local area 15,000 people going there. Savannah would have 
25,000. So it would influx a whole bunch of----
    Senator Isakson. Savannah would have 25,000 after the 
opening of Hinesville?
    Mr. Nordeoff. Yes, sir.
    Senator Isakson. OK.
    Mr. Nordeoff. Yes, sir. They have got 25,672 as we speak.
    Senator Isakson. OK.
    Mr. Nordeoff. Plus there are 15,000 from the surrounding 
areas in Hinesville, Georgia.
    Senator Isakson. Some of those 25,000 that are using 
Savannah now would probably transition to Hinesville, would 
they not?
    Mr. Nordeoff. Yes, sir, I would imagine.
    Senator Isakson. So, it would relieve some of Savannah's 
pressure by opening Hinesville.
    Mr. Nordeoff. Yes, sir. Yes, sir.
    Senator Isakson. What about the positive effect of 
Brunswick? Have you quantified that?
    Mr. Nordeoff. Yes, sir. Yes, sir. Brunswick, just where 
Kingsland is, sir, Camden County, they are doing 5,949 veterans 
as we speak. Now, from the three surrounding counties, there 
are 7,408 disabled veterans. So, with a Brunswick clinic and 
the three surrounding areas, they would end up taking 7,480 off 
of Kingsland, where Kingsland is running 5,949, sir.
    Senator Isakson. So the timely opening of Brunswick and 
Hinesville will make a dramatic improvement in the 
accessibility for veterans in this region?
    Mr. Nordeoff. Yes, sir. The Brunswick clinic wouldn't have 
to be as big as the Hinesville clinic. The Hinesville clinic 
has got to be something to maintain, you know, for PTSD and 
everything like that.
    Senator Isakson. Well, let the record reflect that is 
precisely why we are having this hearing today, so that is 
exactly the intent we plan for.
    Mr. Spears, on your statement with regard to the 
presumption of service connection in terms of sexual harassment 
or abuse, you are referring that presumption to the VA's 
responsibility to treat, not to the conviction of a 
perpetrator, is that correct?
    Mr. Spears. Yes, sir. I am not speaking of any prosecution 
or anything. I am talking about if a psychiatrist has found 
that this person has, indeed, suffered that trauma and so 
forth, it should be considered service-connected, period. I am 
not talking about prosecution or anything of that nature.
    Senator Isakson. I just want to make sure the record was 
correct on that.
    Mr. Spears. Yes, sir. Absolutely.
    Senator Isakson. Also, I do appreciate your emphasis on 
women. As you know, in the earlier panel, I made reference to 
the trauma which a number of women are going through in our 
Warrior Transition Centers because of the uniqueness of some of 
the injuries that they are affected with, orthopedically and 
other ways, so I appreciate your raising that again.
    I will say, in my interaction with the VA hospitals and 
facilities, I think that is of note to them now. Not that they 
were not looking at it before, but I think the intensity of the 
number of unique health-related circumstances is causing a 
bigger focus on our women veterans. We appreciate their service 
and I appreciate your bringing that up.
    Mr. Spears. Yes, sir. Thank you. I also noted that after I 
filed my testimony with your office and with the Senate 
Veterans' Affairs Committee, that Secretary Shinseki has come 
forward and modified some of the requirements on PTSD.
    Senator Isakson. Thank you for that. I have one other 
question for you, if I can.
    Mr. Spears. Yes, sir.
    Senator Isakson. From your discussions with veterans, have 
you been able to see a difference in patient satisfaction 
between VA-staffed clinics and contract clinics?
    Mr. Spears. Yes, sir. Quite honestly, and there is a 
portion of it in my prepared remarks. The veteran himself--and 
whether it is just a perception, but as you know, when you are 
in there, perception is reality--that they are better treated 
by VA employees. Many times it is because the VA employees 
themselves are veterans, as Mr. Biro mentioned. He is a 
veteran. They feel that they are better treated. You don't 
really get across, necessarily, to a contractor that the old 
guy wearing two hearing aids and walking on a walker and 
talking too loud in the waiting room is a guy who 65 years ago 
charged a machine gun nest and saved countless Marines.
    Senator Isakson. My comment on that would be, I think that 
is an appropriate issue to raise; and I think as the VA 
contracts for services, that recognition should be there so 
that sensitivity becomes a part of the contract. I don't think 
the care of the physicians itself is substandard, but I think 
maybe the lack of sensitivity to the veteran may not be there 
simply because, unfortunately, it is like the U.S. Senate. 
There are only 27 of us, I think, that served, or 30, something 
like that, and there is a disconnect in some cases. I think 
possibly the VA could note in their contracts with the 
providers to recognize who these men and women are and where 
they have come from and what they have done to sacrifice for 
our country.
    Tom, did VA contact your office when it was apparent that 
there would be delays in opening the Brunswick clinic? And how 
would you rate the communication from the VA to your Department 
in Georgia?
    Mr. Cook. My hearing is--did you ask, did VA contact us----
    Senator Isakson. Were you in contact when the delays of 
Brunswick were encountered with the first re-do of the first 
contract to go to a second offering? Were you made aware that 
was happening so you could communicate it?
    Mr. Cook. We were not made--to my knowledge, we were not 
made aware, no, sir, not until the--when the issue was raised 
by your office in conjunction with this hearing. That could be 
as much part of us as them. But I do not believe that as far as 
a delay in the contract or the rebidding process, that we were 
made aware of it until the call came to prepare for this 
hearing. We started asking questions at that point, as far as 
what was going on with it and what the delay involved.
    Senator Isakson. Well, the reason I asked the question is, 
I understand the tremendous--I understand Mr. Spears' comments 
about how many computers you have to talk to on the telephone 
before you get to a person. I deal with that frustration 
myself. Communication is a very important thing, and a lot of 
frustration with services is more out of frustration with the 
lack of information and communication than it is the actual 
service. So I think there is a good lesson. You know that in 
representing those you represent--either VFW, American Legion, 
Disabled Veterans, whatever.
    I think it should be well noted, one of the best things the 
Georgia Department of Veterans Services has going for it is 
Pete Wheeler--a one-man communications center--who makes sure 
the veterans know that he knows what is on their minds. So your 
comments there are well noted.
    Mr. Cook. The other part that I believe you asked, in terms 
of our communication level with the VA, I think it is very 
good. When we ask, we will certainly get an answer; and there 
is no problem there. I think, likely with the contract rebid 
issue and perhaps some other things that we don't get in on, it 
is more so the flurry of activity of what we are in on. The 
issues that we are dealing with and working with and so many 
things are going on at the same time, which if it doesn't get 
raised to our attention by, say, a veteran in the field 
somewhere or one of our offices, then we don't inquire whether 
it should have been shared or whether there could be--I am sure 
it could be improved.
    Communication on all accounts and all levels likely can be 
improved. But the Commissioner has a way of finding out and 
knowing. Some times we just have so much going on particularly 
right now with the budget issues and trying to fight for 
survival for our programs--that what we do has likely got us 
tunnel-visioned on some things that we should have been in on.
    Senator Isakson. Mr. Biro, why don't you join us up at the 
table. I am going to ask a question that might involve your 
participating in the answer. In fact, I know it will, so that 
is why I want you to join us.
    Pete Wheeler, as represented by Tom Cook's testimony, 
mentioned the second Atlanta VA hospital. You did a great job 
of testifying as to the criteria that you go through in terms 
of determining outpatient clinics. Can you share with me and 
with the audience what criteria you go through in terms of the 
establishment of a new residential hospital facility?
    Mr. Biro. It is very similar to the one we talked about for 
Community-Based Outpatient Clinics. It is based on data. It is 
an actuarial model of utilization that the Department runs for 
us and projects the demands for many, many services--I am 
saying 40 or 50 services--over a period of time based on the 
veteran population, using a model that takes private 
utilization, takes VA utilization, Medicare, and does a very 
complex analysis of that.
    Senator Isakson. Do you know if any analysis is being done 
given the Atlanta region now?
    Mr. Biro. Yes, it has been. It is finished. What the data 
shows is a tremendous growth in outpatient needs of several 
hundred thousand square feet of additional clinical space for 
outpatient facilities; need for residential rehabilitation for 
mental health patients; and what you are asking about. The 
acute care shows about 10 to 12 more beds, which are----
    Senator Isakson. For acute care?
    Mr. Biro. For acute care.
    Senator Isakson. So you need more clinical--the study 
indicates more clinical services, but not that much in actual 
bed services or residential services?
    Mr. Biro. Inpatient acute care.
    Senator Isakson. And that service is based on what the 
Clairmont facility will be when the renovations are finished 
there?
    Mr. Biro. Yes, sir. That is correct.
    Senator Isakson. OK. Will the Department normally, based on 
the study they run, make the request, or do you wait for the 
State through their Representatives or Senators to make the 
request for that consideration?
    Mr. Biro. We work off that data. As Mr. Williams pointed 
out, we work off that data. It is constantly updated. The 
appropriation is based on that data. Everything is based on 
that database. So we follow the plan--Senators and 
Representatives can ask for an exception--but we follow the 
plan. The Department follows the plan.
    Senator Isakson. Well, my observation to the results that 
you mentioned is that one of the reasons the outpatient clinics 
are so successful--and I think you can tell by the nods of 
heads every time something like that has been said by our 
veterans--is that the nature of care is changing dramatically 
from in-bed care to outpatient care. I go to Walter Reed quite 
frequently to visit with our amputees and with our men and 
women who sacrificed, and it is remarkable--the technology that 
VA is applying and how those veterans are coming out of those 
facilities. Their needs are more for outpatient services once 
they come out than they are for inpatient residential service. 
So, I guess what you are saying is that 12 beds residential is 
not a huge number compared to the number we already have, but 
there is a shortfall of the clinical services that we need to 
look at.
    Mr. Biro. Yes, that is right.
    Senator Isakson. All right. If that is the case--I am not 
being presumptive here and I don't want to be presumptive here, 
but I think Mr. Spears made reference to the same type of 
thing--does that beg the question that the need is a clinic, an 
outpatient clinic specifically for those PTSD, TBI, and other 
related mental health services?
    Mr. Biro. Yeah. We will proceed to get enough space. As you 
have already brought up, we have an application in for a health 
care center, which Mr. Williams talked about. We will also 
proceed along a parallel line to lease several hundred thousand 
square feet of clinic space in the Atlanta area. So we are 
moving on the plan.
    Senator Isakson. So the health care center might be one of 
the solutions to that problem?
    Mr. Biro. Right.
    Senator Isakson. OK. Tom, have you got any comments on 
those questions? I wanted Pete to make sure you knew I asked 
all of them.
    Mr. Cook. I believe certainly the Commissioner supports as 
many clinics and rehab facilities as we can open and any 
expansion of health care in any realm. I think the point that 
needs to be emphasized along with the bed space is the 
specialty care appointments issue. With the growth of the 
clinics and expansion of the clinics, particularly in the 
Atlanta area, the referrals to the medical center for specialty 
care appointments is growing, or at least that is our 
position--correct me if I am wrong. And if that is the case, 
that it is not just simply a bed issue--even though Position B 
would have made the hospital on the Southwest side of Atlanta--
but the specialty care referrals, as well, is where we have a 
problem right now inside the Atlanta Medical Center--with the 
specialty care.
    Senator Isakson. Well, my observation at Clairmont, I was 
overwhelmingly impressed with the specialty services available 
at Clairmont--particularly blindness, specialty services like 
that. I would presume, Mr. Biro, that those types of services 
could be accommodated in a clinical setting; because if I 
remember correctly, when I visited the Blind and Low-Vision 
Center at Clairmont, it was an outpatient part of the hospital 
itself, if I am not mistaken.
    Mr. Biro. Right, and I may have not been real specific. 
What we are saying is we are planning for not only primary care 
but all specialties, or the core set of specialties. So, we 
will have space to cover that. That requires what is happening 
in almost every VA is that the primary care is moving out of 
the main building and more specialty care is going there. But 
we are also going down the route of having more specialty care 
in the Community-Based Outpatient Clinics or remotely. So, we 
are moving along that way. We would take care of all needs.
    Senator Isakson. Well, I want to thank you. I learned a 
lot, and I appreciate your candor. I appreciate, Tom, your 
raising that question, because we have received, what, 
hundreds, Chris, of calls regarding Clairmont--mostly over the 
parking right now and that inconvenience--but also about the 
growing demand and need, particularly because of the number of 
Gulf War and Iraqi Freedom and Enduring Freedom veterans who 
are coming back to the metropolitan Atlanta region.
    Mr. Spears, my staff reminded me you were making comments 
with regard to the women's issue. S. 252 is expected to clear 
when we return. This has the pilot program for therapy in a 
retreat setting. It has a status report on implementation of 
having a Women's Veterans Coordinator in every health facility, 
day care for women, and things like that. So, the Committee is 
moving forward on those provisions and I am sorry I didn't 
mention that early during your comments.
    Mr. Spears. Yes, Senator, and those coordinators are doing 
an outstanding job, by the way. Much of what I got was from 
some of those coordinators.
    Senator Isakson. Thank you for that.
    I will tell you what. Let me see, Mr. Williams, if you 
could pull a chair up, and let our VA lady from Augusta come up 
and take this chair at the end. I am going to gavel the 
official hearing closed so we can then respond to some 
questions that have been presented to me from the audience.
    I would also note--Lupe, I think this is correct--I will 
ask unanimous consent that the record remain open for 10 days 
for any additional testimony you would like to submit with 
regard to questions I asked or any things that came up during 
the course of the hearing.
    But now, for the purpose of Q&A, I will gavel this part of 
the hearing closed.
    [Whereupon, at 3:50 p.m., the Committee was adjourned.]























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