[Senate Hearing 111-278]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 111-278

                     HAWAII FIELD HEARINGS DURING 
                           THE 111TH CONGRESS

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                       FIRST AND SECOND SESSIONS

                               __________

                  AUGUST 25, 2009 AND JANUARY 7, 2010

                               __________

       Printed for the use of the Committee on Veterans' Affairs


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                                 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                  Scott P. Brown, Massachusetts\1\
Mark Begich, Alaska
Roland W. Burris, Illinois
Arlen Specter, Pennsylvania
                    William E. Brew, Staff Director
                 Lupe Wissel, Republican Staff Director



----------
\1\ Hon. Scott P. Brown was recognized as a minority Member on March 
24, 2010.









                            C O N T E N T S

                              ----------                              

                            August 25, 2009
         Field Hearing on VA Outreach to Returning Guard Units
                                SENATORS

                                                                   Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........     1

                               WITNESSES

Tamayo, 1LT Tulsi Gabbard, Hawaii Army National Guard............     3
    Prepared statement...........................................     5
Tuimalealiifano, SFC Sualauvi, III, Hawaii.......................     7
Park, ``Clay'' William Clayton Sam, Veterans Program Director, 
  Papa Ola Lokahi................................................     8
    Prepared statement...........................................    10
Tuimalealiifano, Shannon, veteran and wife of SFC Sualauvi 
  Tuimalealiifano................................................    17
Betts, Tracey, Honolulu Regional Office Director, Veterans 
  Benefits Administration, U.S. Department of Veterans Affairs...    20
    Prepared statement...........................................    22
Cullen, Sheila, Director, Veterans Integrated Service Network 
  (VISN) 21, U.S. Department of Veterans Affairs; accompanied by 
  James Hastings, M.D., Director, VA Pacific Islands Health Care 
  System; and Adam W. Darkins, M.D., Chief Consultant for Care 
  Coordination, Veterans Health Administration...................    25
    Prepared statement...........................................    27
Ishikawa, BG Gary M., Deputy Adjutant General, State of Hawaii...    33
    Prepared statement...........................................    35
Jefferson, Raymond, Assistant Secretary, Veterans' Employment and 
  Training, U.S. Department of Labor.............................    36
    Prepared statement...........................................    37

                                APPENDIX

Moses, Mark S., Director, Office of Veterans Services, State of 
  Hawaii; letter.................................................    53

                              ----------                              

                            January 7, 2010
                  State of VA Services on Maui, Hawaii
                                SENATORS

Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........    55

                               WITNESSES

Calleon, Karl, Vietnam Veteran and Commander, 
  DAV, Chapter 2, Maiu, HI.......................................    56
Evangelista, Rogelio G., Advisory Board Member, VA Pacific 
  Islands Health Care System.....................................    58
    Prepared statement...........................................    59
Helm, CDR Larry, Molokai Veterans Caring for Veterans............    61
Kamai, Clarence, Jr., Molokai Representative, Veterans Caring for 
  Veterans.......................................................    63
Kanahele, Danny, VA Advisory Council Member......................    64
Laub, Paul, President, Maui County Veterans Council..............    65
    Prepared statement...........................................    66
Poaipuni, Terry, Wife of a Vietnam Veteran.......................    67
    Prepared statement...........................................    68
Skaggerberg, Mitch, President, Vietnam Veterans of Maui County...    69
    Prepared statement...........................................    70
Sodetani, Lloyd K., Maui Representative, Hawaii Office of 
  Veterans Services..............................................    71
    Prepared statement...........................................    72
        Attached Survey..........................................    73
        Addendums................................................    78
Betts, Tracey, Director, Honolulu VA Regional Office, U.S. 
  Department of Veterans Affairs.................................    94
    Prepared statement...........................................    96
    Response to request arising during the hearing by Hon. Daniel 
      K. Akaka.................................................128, 130
Cullen, Sheila, Director, VA Sierra Pacific Network (VISN 21), 
  Veterans Health Administration, U.S. Department of Veterans 
  Affairs........................................................    97
    Prepared statement...........................................    98
Halliday, Linda, Deputy Assistant Inspector General for Audits 
  and Evaluations, Office of Inspector General, U.S. Department 
  of Veterans Affairs............................................   105
    Prepared statement...........................................   106
    Attachment...................................................   109

 
                    FIELD HEARING ON VA OUTREACH TO 
                         RETURNING GUARD UNITS

                              ----------                              


                        TUESDAY, AUGUST 25, 2009

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                       Honolulu, HI
    The Committee met, pursuant to notice, at 10:30 a.m., at 
the Oahu Vet Center, 1298 Kukila Street, Honolulu, Hawaii, Hon. 
Daniel K. Akaka, Chairman of the Committee, presiding.
    Present: Senator Akaka.

     OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 
                    U.S. SENATOR FROM HAWAII

    Chairman Akaka. Aloha.
    Audience. Aloha.
    Chairman Akaka. A big welcome to all of you. Thank you very 
much for your patience. Welcome to today's hearing of the 
Senate Committee on Veterans' Affairs.
    This is the first of two field hearings that I am chairing 
here in the State this week. Today's hearing will focus on the 
benefits and services provided to returning Guard units and 
related transition issues. We held several hearings on this and 
related topics in the State before, and most recently held a 
hearing on the same topic last year in Washington, DC. Much has 
improved in recent years, for which I am grateful. However, it 
is important for the Committee to understand the remaining 
challenges.
    I applaud the efforts of VA employees in Hawaii. These men 
and women work hard to help the veterans who seek assistance. 
There are many things that VA does well in Hawaii. However, 
there is always room for improvement.
    Indeed, our unique geography, our diversity, and our way of 
life require that VA develop a unique strategy to care for our 
islands' veterans, including Hawaii veterans of the National 
Guard and Reserves. I want to hear what tools VA needs to make 
a difference in the lives of these men and women of the Hawaii 
National Guard and Reserves.
    Back in Washington, we have worked hard to ensure that VA 
has the resources to provide the best possible care. In my 
first 2 years as Chairman--2007 and 2008--Congress provided 
record-breaking funding increases to VA. This year we are 
working to get VA the funding it needs for next year. We are 
also hard at work fixing the broken way that VA's health care 
system is funded.
    I introduced legislation to fund VA health care 1 year 
ahead of the current budget process, which will allow VA health 
care dollars to go further for veterans and taxpayers. I am 
pleased to tell you that this bill, the Veterans Health Care 
Budget Reform and Transparency Act, passed the Senate just 
before the August break.
    We have also been focusing on finding ways to improve how 
VA and the Department of Defense work together to improve the 
transition process for servicemembers and veterans. We are 
working hard on seamless transition between active service and 
life as a civilian, which is part of our goal. Given the 
existing relationship between VA and Tripler Army Hospital, 
Hawaii should be on the forefront of national efforts to have 
the two Departments work more closely together. We will explore 
that issue today.
    Here in Hawaii, more than 5,000 members of the Guard and 
Reserve have been deployed. The Hawaii National Guard has 
recently returned from its second deployment and over 85 
percent of those mobilized were already combat veterans. It is 
important that these soldiers, and indeed all of those who have 
been sent into harm's way, know that VA will be there for them 
when they return home.
    After years of war, we appreciate that there are distinct 
challenges facing the reintegration of these citizen 
servicemembers. Unlike their active-duty counterparts, Guard 
veterans must transition from their civilian life and 
employment to active military service and back again. Despite 
VA's best efforts to conduct outreach to this population, it 
seems clear that some are still unaware of all that VA has to 
offer and how to access those services and benefits; and this 
is something that we also need to work on, to provide the 
information that they need. More work needs to be done.
    I hope that both of our panels will shed some light on why 
we continue to hear from veterans that they just did not know 
about their eligibility for VA benefits and services. We need 
to know how VA and the Congress can help bridge this 
information gap. This is particularly important for those who 
suffer from the invisible wounds of war and need more help 
readjusting to their civilian lives.
    I appreciate the Department of Labor and Hawaii National 
Guard's participation in today's hearing, as they both have 
important roles in the transition process.
    Finally, I note that there are many veterans here today who 
would like to testify. While we cannot accommodate everyone's 
request to speak, we do want to hear your views. The Committee 
is accepting written testimony, which will be reviewed and made 
part of the record of today's hearing. If you have brought 
written testimony with you, please give it to the Committee 
staff who are located here in the room. And if you do not have 
written testimony but would like to submit something, Committee 
staff will assist you. In addition, the Committee staff is 
joined by VA staff, who can respond to the questions, concerns, 
and comments that you raise.
    At this point, let me ask my staff members to please raise 
your hand. If you want to talk to one of them, please do so.
    Let me ask the VA staff who are here to raise your hands. 
These are the folks that you can talk to if you have any 
questions and want to make any statements.
    I hope today's witnesses will provide us with a real sense 
of what the next steps are so that no member of the Guard, or 
indeed any servicemember is unaware of their eligibility and 
the benefits available to them.
    Thank you very much again, and now, I would like to 
introduce our first panel. We have First Lieutenant Tulsi 
Gabbard Tamayo, Hawaii Army National Guard; Sergeant First 
Class Sualauvi Tuimalealiifano III from the U.S. Army; and also 
Clay Park, who is Veterans Program Director from Papa Ola 
Lokahi.
    We are waiting for the Sergeant to return, but in the 
meantime, I am going to ask Lieutenant Tamayo to please proceed 
with her statement. Welcome.

STATEMENT OF FIRST LIEUTENANT TULSI GABBARD TAMAYO, HAWAII ARMY 
                         NATIONAL GUARD

    Lieutenant Tamayo. Thank you, Senator. Good morning, 
Chairman Akaka and everyone gathered here. Thank you for the 
opportunity to speak here today regarding the VA's outreach and 
services to Guard and Reserve servicemembers.
    By way of introduction, I am a First Lieutenant, a Military 
Police Officer in the Hawaii Army National Guard. I enlisted in 
2003, earned my commission in 2007, and have just returned from 
my second deployment overseas. My statement today reflects only 
my personal opinions and experiences as an individual.
    As you are well aware, since September 11, 2001, the VA has 
begun to see a new kind of clientele. Veterans are younger--a 
new generation who grew up in a different culture and face new 
challenges. The Reserve component of the military has taken a 
role front and center like never before. The VA is now faced 
with hundreds of thousands of customers who are young combat 
veterans, but who also still actively serve in the National 
Guard or Reserves.
    My underlying message to you today, the bottom line shared 
up front, is that the DOD and the VA need to work together to 
think outside the box and find comprehensive strategies to 
reach, educate, and serve Guard and Reserve veterans.
    The VA's presence in our redeployment process, from point 
of reentry back to the U.S. to being released from active duty, 
has improved since 2006 when I returned from my first 
deployment. About a week and a half ago, as we went through 
demobilization at Fort Hood, TX, we received about a 2-hour 
briefing from the local VA rep on the various benefits 
available to us as veterans. He ensured that all 400 of us in 
the briefing tent filled out enrollment papers to join the VA 
or be registered in the VA and assisted and encouraged soldiers 
to fill out disability claims, applications, as well as talked 
about the VA Home Loan Guarantee. It was a lot of information 
packed into a short period of time, but it was informative and 
I walked away learning a few new things about the VA. However, 
this should not be the end of the story.
    I understand that the VA and DOD are two very separate 
agencies. However, for Guard and Reserve soldiers, the idea of 
a clean and complete transition between the DOD and VA is not a 
reality. The Reserve component has hundreds of thousands of 
servicemembers who are dual members of both agencies, eligible 
for benefits from both. It is highly likely, as you mentioned, 
that a servicemember will transition between Reserve and active 
status multiple times throughout his or her career.
    A short personal example, which I know is not an isolated 
incident, is I was attempting to take advantage of my G.I. Bill 
benefits while deployed and took a few classes. It took 7 
months, and I am still waiting for the VA to get confirmation 
from DOD that I am actually eligible for this G.I. Bill 
benefit. I called once a month, and every time I called was 
told that it takes a long time for the VA to get information 
from the DOD and to call back next month. I was also told that 
as a member of the National Guard, it takes even longer.
    As members of the Reserve component, there are specific 
limits to what benefits we are eligible for as well as special 
benefits that we are entitled to. However, in my experience the 
outreach and the education of Reservists and National Guard 
members has not been focused and comprehensive. Upon our 
redeployment, we don't have the luxury of time, unlike the 
active component. Like I said, in Texas, we were there for 5 
days and we received one briefing from the VA.
    Therefore, connecting with this group of veterans and 
ensuring education and access to all that the VA has to offer 
requires a different strategy.
    One thing I noticed is that under the VA Web site, there is 
not easily found a section that caters specifically to National 
Guard or Reservists. I have a lot of questions. Throughout my 
deployment I have talked to soldiers who I worked with and 
members of my command and there is neither knowledge nor 
understanding about what benefits are available to us. I know 
of a lot of things from my work with you, but this is not known 
by the mass Guard population. I think if there was an easy way 
on the Web site to find focused information about medical 
benefits and education benefits that target, specifically, the 
Reserve component, that would be helpful.
    Regarding VA outreach at the local level in each State, I 
think it is really about developing relationships between the 
local VA and the local Reserve units and commands. Because 
access to Guard and Reserve soldiers is sparse and spread out, 
the local VA developing a partnership with the local Guard and 
Reserve leadership so that they can coordinate and integrate 
the Guard schedule with VA outreach, would also provide a lot 
more access and direct access for the soldiers from to VA. To 
me, this partnership should not be short-term, but rather a 
continuous conversation. By doing this, the VA would provide 
faces and names to these soldiers and their families before, 
during, and after deployments--to include the break between 
deployments--which would greatly improve availability and 
access. It would take away the common view that the VA is a big 
bureaucratic organization that is not user friendly.
    The best counselors are veterans themselves. I have talked 
to soldiers during my deployment who would like to help other 
soldiers upon returning from deployments and feel that they 
have the gift and the need to help other soldiers, but they 
don't have the training, the official training or the degree or 
the background to do so. If there is a way that the VA could 
channel those veterans interested into a training program where 
they could have the official training and certification, 
possibly along with a commitment from the veteran to work for 
the VA, both sides would be served well.
    I also think there should be mandatory counseling, both 
one-on-one and in groups, for returning Guard and Reserve 
veterans. As many of us know, soldiers may be too proud to seek 
assistance or seek help or know where to go to get it. These 
one-on-one counseling sessions would provide that opportunity 
for a soldier to speak freely.
    Also, these counselors should be trained to ask the right 
questions, be personable, develop a relationship, and know what 
the unique challenges that Reserve veterans face with 
reintegrating back into their civilian life. This would also 
provide the soldier the opportunity to enroll in the VA system, 
provide focused information, as well as a face, a name, and a 
phone number that the soldier can utilize to follow up for any 
additional care.
    There are other concerns and issues that exist, as well as 
those that we have not discovered yet. By working together and 
being creative in finding solutions, progress can be made.
    Thank you for the opportunity to share my experiences and 
thoughts.
    [The prepared statement of Lieutenant Tamayo follows:]
     Prepared Statement of First Lieutenant Tulsi Gabbard Tamayo, 
                       Hawaii Army National Guard
    Chairman Akaka, and Members of the Committee, thank for the 
opportunity to speak here today regarding the VA's outreach and 
services to Guard and Reserve Servicemembers.
    I am a First Lieutenant, Military Police officer, in the Hawaii 
Army National Guard. I enlisted in 2003, earned my commission in 2007, 
and have just returned from my second deployment overseas. My statement 
today reflects only my personal opinions and experiences as an 
individual.
    As you are well aware, since 9/11, the VA has begun to see a new 
kind of clientele. Veterans are younger, a new generation who grew up 
in a different culture, and face new challenges. Also, the reserve 
component of the military has taken a role front and center like never 
before. The VA is now faced with hundreds of thousands of customers who 
are young combat veterans, but who also still actively serve in the 
National Guard or Reserves.
    Between the period of September 2001 and November 2007, over 
450,000 Reserve and National Guard Soldiers were deployed to either 
Iraq or Afghanistan. Thousands more have deployed since that time, many 
on their second and third tours.
    My underlying message to you, the bottom line up front, is that the 
DOD and the VA need to work together to think outside the box, and find 
comprehensive strategies to reach, educate, and serve Guard and Reserve 
veterans.
    The VA's presence in our redeployment process (from point of re-
entry back to the US, to being released from active duty) has improved 
since 2006, when I returned from my last deployment. About a week and a 
half ago, as we went through demobilization at Ft. Hood, TX, we 
received a roughly 2-hour briefing from the local Texas VA rep, on all 
the various benefits available to us as veterans. He ensured that all 
400 of us in the briefing tent filled out the enrollment papers, 
assisted those who wished to fill out disability claims applications, 
and passed out the application for VA Home Loan guaranty. It was 
informative, and I walked away learning a few new things. However, this 
should not be the end of the story.
1. DOD and VA cross-talk & coordination
    I understand that the VA and DOD are two very separate agencies; 
however, for Guard and Reserve Soldiers, the idea of a clean and 
complete transition between the DOD and VA is no longer a reality. The 
Reserve component has hundreds of thousands of servicemembers who are 
dual members of both agencies, eligible for benefits from both. It is 
highly likely that a servicemember will transition between reserve and 
active status multiple times in his/her career.
    A short personal example, I have been waiting 7 months for the VA 
to get confirmation from the DOD that I am indeed eligible for the GI 
Bill (even though I was deployed and sent the VA a copy of my 
mobilization orders). I have called at least once a month for the last 
7 months, provided all the documentation that was requested, but am 
still being told that nothing can be done. I was told by the VA Case 
Manager that it takes a lot longer to get information from the DOD when 
dealing with a Guard servicemember. Perhaps with a better system of 
coordination between the DOD and the VA, Guard and Reserve Soldiers who 
go back and forth between active/reserve status, would not get caught 
in this gray area of ``in-between.''
2. Outreach to reserve component members
    As members of the Reserve component, there are some specific limits 
to what benefits we are eligible for, as well as specific benefits we 
are entitled to. However, the outreach and education of Reservists does 
not seem to be focused and comprehensive.
    Upon redeployment, the Guard/Reserve do not have the luxury of 
time, unlike the Active Component. Guard and Reservists have to take 
time off from civilian work to seek help. Therefore, connecting with 
this group of veterans, and ensuring education and access to all that 
VA has to offer requires a different strategy.

          a. I could not easily find under any tab on the va.gov web 
        site, a section that catered solely to Reserve component 
        members. There are many questions our benefits, especially in 
        the areas of health care, home loans, and education that could 
        be answered in a specific section, rather than trying to sift 
        through all the information and figure out what applies to us 
        and what doesn't.
          b. VA offices in each state could develop a partnership with 
        the local Guard/Reserve leadership to coordinate and integrate 
        VA outreach with the annual training/work schedule, and to find 
        innovative ways to meet the needs of Guard and Reserve 
        veterans.
          This partnership should not be short-term, but rather a 
        continuous conversation. VA's providing a face and continuous 
        outreach to Soldiers and their families before, during, and 
        after deployments, to include the break between deployments, 
        would greatly improve availability and access. It would take 
        away the common view that the VA is a big bureaucratic 
        organization that is not user-friendly.

    3. The best counselors are veterans themselves. Those who have been 
through what we have been through can provide the best understanding 
and support. However, many veterans do not have a 4-year degree or are 
not certified counselors. VA could channel those who are interested 
into a program that would give them the additional training needed, 
along a commitment from them to work for the VA, so that these veterans 
can become counselors.
    4. There should be mandatory counseling--both one-on-one and in 
groups--for returning Guard/Reserve Veterans. If this is a DOD/VA 
mandate, local commands will find time for this to ensure it is 
executed properly. Soldiers may be too proud to seek assistance on 
their own. These one-on-one counselors should be trained to ask the 
right questions, encourage the Soldier to enroll in the VA system, 
provide focused information to the Soldier based on whatever benefits 
he/she find applicable, and then provide a name and phone number who 
the Soldier can follow-up with for any additional care that is 
required.
    After my last deployment, we were required to come in 6 months 
after returning home for the Post-Deployment Health Re-Assessment. The 
VA was present and provided counseling to those who needed, and also 
had a table set up to enroll any one had not yet enrolled in the VA. I 
don't know if this has changed since then, but the VA should be front 
and center at these briefings, since at this time Soldiers have had a 
chance to get through the excitement of being at home, have settled in, 
and had more time to think about what kinds of benefits the VA has to 
offer them.
    5. A central 800 number for Guard/Reserves, which will 
automatically route the call directly to a local VA office, similar to 
how the phone company or Pizza Hut have their systems, will put a 
Soldier directly in touch with their local VA rep who is familiar with 
the Guard/Reserve.

    There are other concerns and issues that exist, as well as those we 
have not discovered yet. By working together and being creative in 
solutions, progress can be made. Thank you for the opportunity to share 
my experiences and thoughts.

    Chairman Akaka. Mahalo and thank you very much, Lieutenant 
Tamayo. We certainly are grateful to hear you share your 
personal challenges. This will certainly help us to restructure 
our system so that we can provide services that are needed to 
our veterans.
    I would like to call now on Sergeant Sualauvi 
Tuimalealiifano. Thank you so much for being here. At this 
time, we would like to receive your statement.

STATEMENT OF SERGEANT FIRST CLASS SUALAUVI TUIMALEALIIFANO III, 
                             HAWAII

    Sergeant Tuimalealiifano. Good morning, Senator Akaka.
    Chairman Akaka. Good morning.
    Sergeant Tuimalealiifano. I want to thank you for the 
privilege, honor, and opportunity to testify before you today. 
I am Sergeant First Class Sualauvi Malua Tuimalealiifano III of 
the 96th Civil Affairs Battalion, Airborne, Fort Bragg, North 
Carolina. I am processing through the Bravo Company Warrior 
Transition Unit of Tripler Army Medical Center.
    My 13-year career brought me to Fort Bragg, North Carolina, 
with two tours in Iraq, Operation Iraqi Freedom, and a third in 
Afghanistan, Operation Enduring Freedom, as part of the proud 
and legendary All-American 82nd Airborne Division and the USA 
Special Operations Command, Civil Affairs with Third and 
Seventh Special Forces Group, Airborne. The results of a 
mission in mid-July 2007 in South Afghanistan brought me here 
today and to my home of Hawaii.
    After 11 months as an inpatient through four different 
hospitals in three different States, I have come to know of 
many challenges related to injuries and recovery. Because of 
what happened on the day I was injured, I am here before you 
today. Just as a rock tossed into the water will have a ripple 
effect that continues on, the day that I was injured has caused 
ripple effects that still continue. I believe this is also true 
for others who are wounded in the service of their country. 
Today, I hope to represent not just myself, but other injured 
servicemembers, whether their injuries are physical, like mine, 
or within.
    My testimony will focus on what I can offer this Committee, 
honest answers based on the experiences I have had in the 
service of my country. I will not focus on studies, promises, 
or the ideas of others. My strength is that I can speak 
firsthand of what a wounded soldier has experienced and what I 
have seen others go through.
    Senator Akaka, I have with me additional points and issues 
that I wanted to bring before you and the Committee.
    A lack of confidence in therapists and limited time with 
therapy--not according to a group overall, but individual to 
that soldier's will and his or her injury.
    Acupuncture, but not massages. We'll allow skin-piercing 
needles with jolts of electricity but not manual body/muscle 
stimulation to body and nerves as well, according to a soldier 
or patient.
    I have a story of a National Guard Texas soldier who was 
left with no unit support while in the care of James Haley 
Veterans Affairs Hospital in Tampa, Florida. I was unaware of 
any soldier not having any connection or ties with their unit 
or the unit that they were mobilized with. With this individual 
soldier, he was 23 years old, just got married before he 
deployed, and is now a double amputee--both legs above the 
knee. We met at the Fisher House.
    After we spoke and got together, the wives and myself found 
out that he has had no connection with any of his unit members. 
I was very upset, very upset. I found out the unit's 
information and discussed it with the person on the other side. 
But his wife and family were unaware of the way the military 
works. His wife was very bitter, and I understood why. She 
didn't see any help. According to them, they didn't see any 
help in any way--maybe sending a soldier of the unit there 
periodically, maybe once a month to check up on them--but there 
were no ties of any kind. I was told they probably demobilized, 
and I don't know what else became of that, but from what I 
could have done, I did. I just hope from being there that no 
other soldier, injured or not, returning home would have to go 
through that.
    I also have on my list here Special Operations. We have an 
organization that we call the Care Coalition, and throughout 
the time in the hospital the Care Coalition is very 
informative, very supportive to, it is sad, but it is to the 
Special Operations soldiers and families.
    There are things and events that are accessible, funded and 
looked after by this Care Coalition. I spoke with them in 2007, 
shortly after the War Transition Units were starting to stand 
up--and they are working their way in sharing the ideas and 
ways of standing up an organization or program to support all 
soldiers, regardless of National Guard, Reserves, or active 
duty. I think that there are citizen soldiers that were sent 
overseas to do what we can do to keep home safe, and when we 
return, I think we should all have a similar status of whatever 
care and help that we can get.
    The other notation I have here is regarding Fisher House. 
It provides a great service but could be more family friendly. 
It is a nice museum. Everything is beautiful--top-notch funds, 
I guess--but they are not friendly toward or prepared for 
children. I think the main purpose for that house is to house 
the wives and the husbands who come there with their children 
to support their loved ones. The Fisher House I have been 
through hasn't been family-friendly. They have a very nice 
parlor, but no child-friendly room to play in, unlike the 
Ronald McDonald House geared toward the family and the 
children.
    And the last one, sir, is the G.I. Bill. I believe it is 
earned and should be used as desired. The question is, for 
seminary or church classes--we are not allowed to use it toward 
theology without getting the State involved. The point I am 
trying to make is, I tried to take classes through my church 
school, but I am not allowed to use the G.I. Bill for any 
Christian courses and I just want to know why, or if we are 
looking into it.
    That is all, and I would like to thank you for your time, 
for hearing me out, and for letting me come by and testify. 
Thank you, sir.
    Chairman Akaka. Thank you very much, Sergeant 
Tuimalealiifano, for our testimony.
    Now, we will hear from Clay Park, who is the Veterans 
Program Director, Papa Ola Lokahi. Clay, will you please 
proceed with your testimony.

  STATEMENT OF CLAY PARK, VETERANS PROGRAM DIRECTOR, PAPA OLA 
                             LOKAHI

    Mr. Park. Good morning, Mr. Chairman and Members of the 
U.S. Senate Committee on Veterans' Affairs. Thank you for the 
opportunity to address the Committee. My name is William 
Clayton Sam Park. I am of Native Hawaiian ancestry, a disabled 
veteran who served as a combat medic during the Vietnam War, 
and a retired Master Sergeant with 3 years active duty with the 
U.S. Army and 21 years of service with the Hawaii Army National 
Guard. I am presently the Veterans Program Director with Papa 
Ola Lokahi. My comments today are based on my experiences in 
that role, and in particular with regard to situations faced by 
our returning OEF/OIF National Guard and Reserve troops as they 
transition from the military to veteran status and back to 
their lives in the community.
    Though the impact of this current war will be my focus, my 
work on a recent day in which veterans I served included an 88-
year-old World War II veteran from Guam and a 19-year-old Oahu 
Iraqi war veteran reminds me to emphasize the message of 
General Shinseki during his confirmation hearing for the 
position of Secretary of the Department of Veterans Affairs. We 
must care for all of our veterans. We cannot allow those who 
have served their country at any time, in any role, to be 
neglected.
    Having worked with the community agencies for the past 
several years in outreach efforts to our veterans, it is 
evident to me that the challenges faced by our newest warriors 
and their families remain great. As I have done in testimony 
before this Committee in prior years, I would like to use the 
stories of those who come to me to provide you with the human 
side of the statistics reported to you by officials of the 
military or the VA.
    Let me start with the experience of a full-time National 
Guard soldier activated in Iraq and wounded during that 
deployment. This individual was medically boarded with a 
disability rating and then discharged from the National Guard. 
Since his full-time position with the Guard was his employment 
and being a member of the Guard is required for that 
employment, this veteran is now without a job, without adequate 
income to maintain his former standard of living, and without 
health benefits for his family.
    Next, consider the young man activated with his Reserve 
unit for a second tour in Iraq and sent to the mainland for 
training, despite the unit knowing he had a medical condition 
likely to limit his performance. He was returned to Hawaii 
because he was not able to complete assigned functions. His 
unit was deployed to Iraq without him. He is now in limbo. He 
hears from the VA that they cannot help him because he is still 
an active duty soldier. The military tells him he is not truly 
on active duty, since his unit is overseas and he is here. 
Consequently, he has no income and no access to health care.
    A young Reservist's wife from a State on the mainland 
contacted me after reading an airplane article about the 
community outreach work in Hawaii. Her husband, a medic, was 
being deployed for the fourth time and she was fearful for his 
physical and emotional well-being but did not know where to 
turn for help. She believed if she spoke with anyone in his 
command about her fears or if word got to command from any 
other source she might share her fears with, this would reflect 
badly on her husband's career.
    I hear from other wives of physical and verbal abuse by the 
returning husbands. They are fearful for their children, 
contemplating divorce, and yet knowing the person they loved 
before he was deployed is still there somewhere, desperate to 
find him again but not knowing how to do that or where to go 
for help.
    In another situation, during a briefing with a Reserve unit 
about our community outreach efforts, I could see two young 
women soldiers in the audience, one with the 1,000-yard stare. 
After the briefing, she asked to speak with me off-line about 
her experience while deployed in Iraq. This young woman 
reminded me of one of my own daughters, and while she cried 
while telling me of being raped in Iraq by a fellow soldier, I 
knew I was limited in what I could do. She was fearful that she 
would be booted out of her unit and possibly even lose her 
full-time Federal job if she told anyone what happened. She 
felt she could certainly not trust that the other soldiers in 
her unit would be supportive and anticipated revenge instead of 
support.
    One can only wonder how many other women face this 
situation alone. I am so thankful that she had the courage to 
trust me and that I have a network of people and organizations 
in this community available as resources in such situations. In 
other situations where the individual is eligible for VA care, 
I do everything possible to bridge the trust and get the person 
to see one of our caring VA providers.
    Since I last testified to this Committee in 2007, I have 
seen changes in the VA, such as more emphasis on outreach, more 
visible service for women veterans. But as General Shinseki 
stated, we must care for all of our veterans. There are still 
those who do not reach the safety net of the VA through 
established channels or who are frustrated in attempts to seek 
help by bureaucratic obstacles. Transitioning home still is not 
easy. Senator Akaka's comments in 2007 still hold true. More 
can be done to assist veterans and their families in the 
reintegration of the wounded or injured veterans into their 
community.
    Mahalo nui loa for allowing me the time to share my mana'o 
with you today. Mr. Chairman, I will be pleased to answer 
questions you or your Members of your Committee have for me at 
this time.
    [The prepared statement of Mr. Park follows:]
      Prepared Statement of Clay Park, Veterans Program Director, 
                            Papa Ola Lokahi
    Mr. Chairman and Members of the U.S. Senate Committee on Veterans 
Affairs: My name is William Clayton Sam Park. I am of Native Hawaiian 
ancestry, a disabled veteran, who served as a combat medic during the 
Vietnam War, and a retired Master Sergeant with 3 years active duty 
with the U.S. Army and 21 years of service with the Hawai'i Army 
National Guard. I am presently the Veterans Program Director with Papa 
Ola Lokahi. Thank you for the opportunity to address the Senate 
Veterans' Affairs Committee.
    My comments today are based on my experiences in that role, and in 
particular with regard to situations faced by our returning OEF/OIF 
National Guard and Reserve troops as they transition from military to 
veterans status, and back to their lives in the community. Though the 
impact of this current war will be my focus, my work on a recent day in 
which the veterans I served included an 88 year old WWII veteran from 
Guam and a 19 year old Oahu Iraq War veteran reminds me to emphasize 
the message of General Shinseki during his confirmation hearing for the 
position as Secretary of the Department of Veterans Affairs (VA)--we 
must care for all of our veterans. We cannot allow those who have 
served their country at any time, in any role, to be neglected.
    Having worked with community agencies for the past several years in 
outreach efforts to our veterans, it is evident to me that the 
challenges faced by our newest warriors and their families remain 
great. As I have done in testimony before this Committee in prior 
years, I would like to use the ``stories'' of those who come to me to 
provide you with the human side of the statistics reported to you by 
officials of the military or the VA. Let me start with the experience 
of a full time, National Guard soldier, activated for duty in Iraq and 
wounded during that deployment. This individual was medically boarded 
with a disability rating and then discharged from the National Guard. 
Since his full time position with the Guard was his employment, and 
being a member of the Guard is required for that employment, this 
veteran is now without a job, without adequate income to maintain his 
former standard of living, and without health benefits for his family.
    Next, consider the young man activated with his Reserve Unit for 
his second tour in Iraq, and sent to the Mainland for training despite 
the Unit knowing he had a medical condition likely to limit his 
performance. He was returned to Hawaii because he was not able to 
complete assigned functions; his Unit was deployed to Iraq without him. 
He is now in limbo--he hears from the VA that they cannot help him 
because he is still an active duty soldier. The military tells him he 
is not truly on active duty since his unit is overseas and he is here. 
Consequently, he has no income and no access to health care.
    A young Reservist wife from a State on the Mainland contacted me 
after reading an airplane magazine article about the community outreach 
work in Hawaii. Her husband, a medic, was being deployed for the fourth 
time and she was fearful for his physical and emotional well-being, but 
did not know where to turn for help. She believed if she spoke with 
anyone in his Command about her fears, or if word got to Command from 
any other source she might share her fears with, this would reflect 
badly on her husband's career. I hear from other wives of physical or 
verbal abuse by their returning husbands. They are fearful for their 
children, contemplating divorce, yet knowing that the person they loved 
before he was deployed is still there somewhere--desperate to find him 
again, but not knowing how to do that or where to go for help.
    In another situation, during a briefing with a Reserve Unit about 
our community outreach efforts, I could see two young women soldiers in 
the audience--one with that ``thousand yard stare.'' After the briefing 
she asked to speak with me ``off-line'' about her experience while 
deployed in Iraq. This young woman reminded me of one of my own 
daughters, and while she cried while telling me of being raped in Iraq 
by a fellow soldier, I knew I was limited in what I could do. She was 
fearful that she would be booted out of her unit and possibly even lose 
her full time Federal job if she told anyone what happened. She felt 
she certainly could not trust that the other soldiers in her unit would 
be supportive, and anticipated revenge instead of support. One can only 
wonder how many other women face this situation alone. I am so thankful 
that she had the courage to trust me, and that I have a network of 
people and organizations in this community available as resources in 
such situations. In other situations, when the individual is eligible 
for VA care, I do everything possible to bridge the trust and get the 
person to see one of our caring VA providers.
    Since I last testified to this Committee in 2007, I have seen 
changes in the VA, such as more emphasis on outreach and more visible 
services for our women veterans. But, as General Shinseki stated--we 
must care for all of our veterans. There are still those who do not 
reach the safety net of the VA through the established channels, or who 
are frustrated in attempts to seek help by bureaucratic obstacles. 
Transitioning home is still not easy. Senator Akaka's comments in 2007 
still hold true, ``. . . more can be done to assist veterans and their 
families in the . . . reintegration of the wounded or injured veterans 
into their community.''

    Mahalo nui loa for allowing me the time to share my mana'o with you 
today. Mr. Chairman, I would be pleased to answer any questions that 
you or the Members of the Committee have for me at this time. Aloha.

    Chairman Akaka. Thank you very much, Mr. Park, for your 
testimony, and I thank all of you for your testimonies.
    I have a question here for each of you, so I will call on 
you starting with Lieutenant Tamayo. This question is to all of 
you, because you each bring your unique perspectives to today's 
discussion. It is clear that if we cannot reach veterans, their 
needs will go unmet. Over the years that I have been working 
with VA, one of the structuring goals is we want to change the 
structure from World War II to Iraq and Afghanistan, meaning to 
update what we are doing and to try to restructure VA so that 
we can deliver the necessary services to those veterans today.
    So the question is, what can VA do to improve the 
effectiveness of its outreach efforts--our outreach efforts? 
Nothing is off the table. We are looking for creative solutions 
and you folks have been there.
    That said, let me call on Lieutenant Tamayo for your 
response.
    Lieutenant Tamayo. I think the most important piece to 
answer that question is about building relationships and making 
veterans and servicemembers feel comfortable and feel that we 
have access to the local VA. I think it is easy--you know, the 
common perception is that the VA is just a big, huge government 
organization that is out there somewhere. Maybe we have access, 
maybe we don't. We have to wait in long lines, wait forever to 
get benefits.
    But by the local VA office or representatives developing 
relationships with these Guard and Reserve commands and units 
and having that access and availability there where you have a 
name, you have a face, and you know that if you have any 
questions, you can talk to them, and making that level of 
comfort be present at all levels so that the leaders in the 
Guard, from the platoon leaders to the company commanders, the 
battalion commanders, they feel comfortable. So, they know when 
they have a soldier who they are concerned about or a soldier 
who is seeking help, that relationship is there where it is not 
just calling an 800 number and not knowing who you are going to 
get at the other end of the line.
    It is developing that relationship and comfort not only 
with the units, but I think that is where it starts, because 
from there, you have the families. And I know something that is 
changing now that is different from our last deployment is the 
Family Readiness Groups are trying to remain active and not 
shutting down now that we are home. They are trying to stay 
active for each other and continue the support between the 
family members, but also the support that they experienced 
while we were gone. So that is another way for the VA to also 
develop relationships with the spouses and with the families 
and see what kind of care they are looking for and concerns 
they may have about their returning servicemember.
    Another thing is, you know, a lot of times those of us in 
the military, we say, OK, you have to go to this briefing or 
that briefing. You have to go to a suicide prevention briefing 
or an anger management briefing, you know, getting ready to 
come home. Too often, these become kind of check-the-block. 
Here is a 30-slide PowerPoint presentation. OK, you saw it. 
Sign your name. You are good to go. There is a difference 
between that and actually talking to someone or hearing from 
someone who is able to reach us.
    We had a briefing from a Major from Wyoming in Kuwait right 
before we came back, and he just--he is a social worker in his 
civilian job. He is a National Guard soldier. And he said, you 
know, this is called an anger management briefing, but I am 
here to talk to you about basically how to deal with yourself, 
how to deal with the experiences you have had and how to deal 
with your family. He talked a lot about himself, and it was a 
personal conversation. There were about 150 of us in the room, 
but I know each of us felt touched by his message and what he 
had to tell us because it was practical. It was real. We 
weren't just going through the motions.
    So, I think the more we can try to push that, and again, 
it's about developing relationships and having local support 
and local access.
    Chairman Akaka. Thank you very much.
    Let me now call on Sergeant Tuimalealiifano.
    Sergeant Tuimalealiifano. Thank you, Senator Akaka. I 
think, amongst many things and many ways, I think the best 
thing we could do is maybe, with the soldiers that have 
returned that are willing to help and assist those who are 
still there and still sitting in the same positions--
depressions that they were in--if we can take those veterans, 
train them--whether it be by certifying them or not--but to 
train them maybe with people skills or talking from their own 
personal experience, we take those veterans, train them up if 
that is what they desire to do.
    Like myself, that is what I would love to do, is to get 
back into the field that I just left, which is the field of 
depression. There is a large field that comes with depression 
and a lot of things that different soldiers and injuries, 
whether they come back fully physically able, they might not be 
within themselves.
    I think if we take those soldiers that have recovered to a 
certain extent, that have the desire to go back into those 
areas, that way, I think, when they are talking to those 
soldiers and helping them out, they convey that they have been 
there. They have done that. They have shared that. They know 
how it feels. They know how it was. I think if we take those 
veterans and train them and put them back in that field, if 
that would be desired, they could better help those that are 
coming in.
    The VA, I think, like the Lieutenant said, is a lot about 
the relationship. There are soldiers like Mr. Clay here shared 
that had the courage to come up and speak about rape. And there 
are many others that probably turned away because the 
information is not out there, not sharing the opening up to 
everyone to see that the VA is available, that there are 
organizations and programs available.
    But I think relationships, as the Lieutenant mentioned, 
with soldiers that are coming and going, I think the VA can do 
that, and then just putting themselves out there and to reach 
them, whether they want to be heard or not, I think.
    That is all I have, sir.
    Chairman Akaka. Thank you very much, Sergeant.
    Mr. Park?
    Mr. Park. Thank you, Mr. Chairman. That is a tough 
question, you know.
    Chairman Akaka. Yes. Your response to the question?
    Mr. Park. One of the things when I look at this is the 
predeployment briefing. I have never heard of the VA doing a 
predeployment briefing. I have done a predeployment briefing 
with the Hawaii Army National Guard, the 29th Brigade; and what 
I tell these people is that when you become Title X, when you 
are activated, keep all your documents because documentation is 
the key. You know, if you are in country and you are standing 
next to a sign that says, ``Welcome to Iraq,'' take a picture, 
because if the VA comes back and says, we have no evidence that 
you were in country, guess what, here it is.
    Look for LODs. Make sure you get your LODs if you got hurt 
while you were in the military. And again, I go back to 
documentation is the key. So these young men and women need to 
understand that they need all these documents. They need their 
orders. They need to know that the people they go with in 
country can write a buddy letter for them when they come back. 
So they need to understand that they can work with these people 
to help them with their application process, as well.
    An open door policy. The VA has an open door policy that if 
a veteran is having difficulty with talking to someone, maybe 
he can go up the chain and talk to somebody else.
    You know, we do education and training. That is the key, 
education and training, as well.
    The biggest thing is connecting with the community, 
connecting with community organizations. Hawaii is very unique. 
The people in Hawaii, we are so diverse--different ethnic 
backgrounds, the different ways we think. When you go to a 
community--I am going to pick a place like Hana. If you go to 
Hana to talk to the people in Hana, the first thing you need to 
do is you need to seek out the elders out there. Go talk to the 
Kupuna, because they are the ones that can give you guidance on 
where all these people are, where they are in the bush. They 
are the ones that can help you. So make that connection with 
the community. Thank you.
    Chairman Akaka. Mahalo. Thank you very much. As I said, we 
want to be creative in thinking of other ways that are not 
being used now to try to deal with the needs that our veterans 
have.
    Tulsi, as a veteran of several deployments, can you talk 
about improvements, improvements that have been made since your 
last assignment overseas? What challenges remain?
    Lieutenant Tamayo. Like I mentioned before, my return from 
my last deployment in 2006, the outreach and the process just 
in that short demobilization period--from where we are returned 
to the U.S. and released from active duty--the VA had a bigger 
presence this time and it was more focused solely on benefits.
    I don't know if this is how it is everywhere, but the VA 
rep who spoke to us was very encouraging and, I want to say, 
forceful in a good way in getting all soldiers to enroll in the 
VA and all soldiers to make sure they got a paper talking about 
the VA Home Guarantee. People were timid in the beginning. Like 
I said, there were over 400, 500 of us in the tent, but he made 
sure and he said, hey, you need to get one of these forms, or 
you need to fill this out. First, people weren't raising their 
hands, and he got basically almost everyone in the whole tent 
to raise their hands saying that they were interested and made 
himself available afterwards.
    So that, to me, was a big improvement from the last time we 
returned, where I was not left with an impression of the VA. 
The bottom line is, I didn't come back feeling that I had some 
big connection with the VA or something that I could take away.
    Six months after we returned home, we went through a post-
deployment health reassessment, and at that time, the VA was 
also available to us and provided one-on-one counseling to 
those who requested it. It was not a front and center piece in 
that PDHRA process. We will see in 6 months and see how things 
have changed this time around.
    Personally, I know that there has been a lot of development 
from the VA about benefits for Guard and Reserve soldiers and 
there is a lot more available to us now than there was 
previously. But again, it comes down to having that focused 
outreach to Guard and Reserves saying, this is what is 
available to you, this is what you are eligible for, rather 
than kind of getting a big, fat book of, hey, this is what the 
VA has to offer to everyone and trying to sift through it to 
find what actually applies to me or my family?
    Chairman Akaka. Thank you very much.
    Sergeant, will you describe your experiences with the 
Warrior Transition Battalion?
    Sergeant Tuimalealiifano. With the Warrior Transition 
Battalion, or War Transition Unit, my experience is not much. I 
have been through Fort Bragg's WTU. They were just standing it 
up. It was fairly new. My interactions with WT there were not 
much. I was still an active duty soldier, so I was still 
returning back to the unit, to and from, because I was from 
Fort Bragg.
    I came here to Hawaii and have been with Tripler's WTU. 
While the intentions are good, they still need more work. And 
there is a lot of--because the Guard, I believe they work with 
the active duty and I think with the Reserves, they don't 
really hold the same authority over each other. I am still 
trying to figure out where in there I might be able to fit in 
if I was to go to COAD.
    But as far as the WTU, Senator Akaka, the way they are 
moving, I think the way they are moving is progressing. They 
are getting better in what they are supposed to be doing and in 
what they are doing. Like anything else, a new program that you 
stand up, you run into obstacles and you learn to adapt to 
overcome or change routes or routines.
    My experience with the one here--I have been with the WTU 
here since January. They have been very supportive out there to 
really get you involved in activities and events, going out for 
a walk type deals or going to the beach and stuff like that. I 
would rather be doing therapy myself, but they have a lot of 
good intentions, a lot of good events for soldiers in regards 
to their active duty, National Guard and Reserves. They provide 
a lot of events. They provide courses and classes for those who 
need help with depression, if they feel suicidal.
    I think they are going in the right way, the right route 
and direction with what they are trying to provide soldiers. 
But with the wars now, you have got a lot of us young guys, 
young gals, a lot of new and different ways of looking at 
things. Some guys, we got our chest out too high or too far and 
chin up so high that we forget that on the inside it is always 
turning and it needs to be checked up or checked out every once 
in a while.
    But I think that the WTU is doing a great job, still 
progressing, still young, still new.
    Chairman Akaka. Thank you very much, Sergeant.
    Mr. Park, in your testimony, you state that trust must be 
established in order for servicemembers and veterans to be 
successfully served. My question to you is, how should VA go 
about building this trust?
    Mr. Park. One of the things that we established is what we 
call our Uncles Program, and I am happy to say that I have a 
few of my uncles in here right now. It is disabled veterans 
that help the veterans navigate the system in getting the 
application, going through the application process.
    And what happens with this is that when the veteran calls 
and needs somebody to talk to, these are the uncles that talk 
to these veterans. You know, in Hawaii, that is who you turn 
to. You turn to your uncle, and then your uncle helps you with 
whatever problems, whatever you have. Because the VA is a 
government organization and because the soldiers are asking if 
the command doesn't take care of them, the NCOs don't take care 
of them, they are looking at a government organization. They 
come right out and they go right back to another government 
organization. So the trust that you need to establish with the 
soldier is to be straight up front and tell them, this is how 
it is. This is what you have got.
    I will give you an example. My PHD tells me 10, 10, 30 adds 
up to 50, and my PHD is my public high school diploma. 
[Laughter.]
    Well, when a veteran comes up with 10, 10, 30 on his 
disability and they give him 40, he is going to start thinking, 
you know, my PHD tells me 10, 10, 30 is 50, it is not 40. You 
need to explain to these guys, we have a formula here. That is 
why you got 40, you didn't get 50. So the VA needs to be up 
front in telling these young soldiers, these veterans, that 
this is what we have and they need to educate these people on 
how to get the information across to them, because local guys, 
if you tell them no, that is it. They are out the door. They 
give up. You can't let them give up. We can't. I have got no 
time to sit back and let these guys give up, and I don't. And 
my uncles, they don't let them give up, either. I have a young 
uncle right there in that uniform. He just started, came back 
from Iraq.
    I think what the VA needs to do is they need to make that 
connection. They need to get that trust from the veterans. They 
need to go to the National Guard units and the Reserve units 
and talk to the commander, talk to the First Sergeant, talk to 
the NCOs. That is where it all begins. Thank you.
    Chairman Akaka. Thank you very much, Clay. When you say 
uncles, I am sure you also mean aunties.
    Mr. Park. That, too. [Laughter.]
    There is a Dr. Kathleen M. McNamara who holds a women's 
group in Maui. I think she is the only one that I know who does 
a women's group in Maui, and she does it in the evenings. I 
think there is a women's group here on Oahu. I am not sure 
there is, but I think there is one at the VA here on Oahu. But 
with my counterpart, Babette Galaang, standing there, we are 
trying to establish an aunties group, as well.
    Chairman Akaka. Thank you. This is really about the 
relationship between two people, and in this particular case, 
veterans with VA, right?
    Mr. Park. Yes, sir.
    Chairman Akaka. Well, thank you very much.
    This question is for all members of the panel. In your 
experiences, how are families affected by the reintegration 
process? I know this is a very sensitive question. However, 
this Committee would appreciate your candor so we can gain 
insight into the nature of this happy and sometimes difficult 
process.
    Let me first call on Sergeant Tuimalealiifano.
    Mrs. Tuimalealiifano. Excuse me, Senator, for barging in 
here.
    Chairman Akaka. Will you please identify yourself?

   STATEMENT OF SHANNON TUIMALEALIIFANO, VETERAN AND WIFE OF 
                    SERGEANT TUIMALEALIIFANO

    Mrs. Tuimalealiifano. My name is Shannon Tuimalealiifano, 
and I am Sergeant Tui's wife. Very briefly, before I speak on 
your question, let me say who I am. My mother was an active 
duty Army soldier in the Vietnam era. My father, as well, was a 
Vietnam veteran of 24 years. He retired. He spent the majority 
of his time at Fort Bragg, the mighty mighty Fort Bragg, NC. 
So, I am very familiar with the military historically and 
having also joined the military, I am a 10-year veteran myself.
    After 9/11, I was activated. My husband and I got married. 
I left active duty service after 6 years and was reactivated 
twice after 
9/11. So, I am familiar with the Reserve component and its 
difficulties, and the active-duty component and its novelties, 
and families of all types and sorts, growing up from a Vietnam 
veteran family, having been a member, and having not only dealt 
with deployment issues, but traumatic deployment issues. So, I 
just want to say that to let people know that when I speak, I 
am speaking from a broad array of experiences. I am so 
thankful, Senator, that you are asking for creative ideas on 
how to make a difference. I would like to say that the biggest 
reason that my husband and I came home after he was injured, 
was that the military gave us permission, because we knew 
without a shadow of a doubt that even though initially his neck 
was broken and he could not function from the neck down, we 
knew that God is good all the time and that the best healing 
comes at home. So we requested for a transfer. We were granted 
that transfer.
    The reason we came was because, as Mr. Park has said, 
Hawaii is different from the entire rest of the United States. 
Where the majority of the United States has had a breakdown in 
family components, there is still ohana here. You will still 
find uncles and aunties and grandmas and grandpas in the 
family, helping. In the mainland especially and in the 
military, you are disseminated throughout the United States. 
You are very far from any kind of support. And if your command 
is not strong and the wives of that command are not strong 
enough to understand that their role is to mentor the young 
wives coming in, then there is a lack of family connection at 
all.
    And the Lieutenant is very right. The main thing that we 
can do to help veterans, families, and all of the issues 
sprouting from the war and being military, period, is 
relationship.
    We have three children. The youngest was born when he 
deployed. He was injured 2 weeks before coming home, so the 
baby was one. The number 1 thing, sir, that I can say that 
would assist families, when people come home, they need to 
reconnect. When they come home different from the way they 
left--injured in any capacity--it is traumatizing. It is 
wonderful to focus on the outreach of the veterans to take care 
of them, but if the families are not cared for, then you are 
not caring for the veteran, because the brunt of the burden of 
the care will fall on that family. Because after business hours 
when everybody shuts down, the therapist, the counselors, and 
the family will take over--weekends, holidays, et cetera.
    So, the thing that I would say, sir, would be that programs 
such as child care so that the couple can seek counseling, or 
even can simply get together and reconnect in an informal 
atmosphere, of going on a date and simply talking. We need 
programs with child care, programs in the VA that reach out to 
the community for the family. There were so many things that my 
husband could not speak to me on, but he could speak to fellow 
veterans, and I understood that. I gave them their time to 
connect and console each other so that healing could come. Even 
just talking is wonderful.
    I received so many helpful people who would give me Web 
sites and numbers to call, applications to fill out. With three 
small children, one an infant, and my husband unable to 
function, if you give me a Web site, you might as well not give 
me information. I don't have the time.
    The VA would do well to have an organization, and I model 
this after the Care Coalition because they were our salvation 
when he was hurt. We were so overwhelmed with the future and 
the prospects of our entire lives. They banded around us. They 
poured love on us. They poured out information in pamphlets, 
but they also contacted organizations for us. They saw the 
need. They went to the community for us because I didn't have 
time to leave the hospital to go ask these people for help.
    And they came back with gift cards and gas cards for me 
driving back and forth to hospitals. I think many people are 
aware of Hero Miles, where they give free tickets for the 
families to help--gas cards and food, grocery cards--because we 
were living out of the Fisher House. We needed groceries. We 
needed all these things that normally we would have at home. 
But it was an expense out of our pocket with a sudden loss of 
income because, of course, I could not continue working.
    So if the VA could form a group where their purpose is to 
reach out to the community for these families, connect them to 
these groups, connect them to the families of their local 
environment, get things like gas cards or grocery cards or free 
child care tickets or things that just would take the pressure 
off of the couple trying to juggle their lives in the middle of 
the chaos while they are still trying to plan their future. 
These are the kind of programs and groups needed.
    And as I said, the Care Coalition, I do believe, is working 
with active duty components to attempt to form some groups, and 
they are doing the same thing. They are trying to draft some of 
these young soldiers who do not feel that they can continue in 
the military so that they don't have the bleak outlook of, I 
don't have a future. They ask them, would you like to reach out 
to other soldiers? Join our organization, be on staff, come 
talk to other soldiers in the hospital so that they don't give 
up on life because they don't see what can happen after, if 
they lose limbs, if they lose families from the stress.
    And the children, most importantly--we were blessed because 
my family lived nearby, and being Vietnam veterans they 
understood. When he got hurt, my parents took the children. I 
went to the hospital. My children didn't have to experience the 
trauma of watching me break down and cry. They were allowed to 
remain children because there was an environment to care for 
them. But without relationship, without a trusting back-up 
plan, I would have had to take them and they would have had to 
see every sordid detail of him coming off the plane, being 
connected to wires, tubes, and a neck brace. That was not 
something I wished for my children. But had those programs not 
been in place, I wouldn't have had a choice.
    So again, I say, it can be traumatic if there is not 
someone there to take the pressure off of the soldier and the 
spouse so that families can heal slowly instead of trying to 
put a pressure dressing immediately and keep it there while you 
are trying to figure out everything. So, thank you for letting 
me speak.
    Chairman Akaka. Mahalo. Thank you so much for that. 
[Applause.]
    Lieutenant, do you have a response to that?
    Lieutenant Tamayo. Just very briefly to touch on something 
you mentioned earlier and that you mentioned regarding soldiers 
not coming home the same way that they left. This comes in many 
shapes and forms. There is the physical aspect of it, and I 
know you have worked and you have talked a lot about the 
invisible wounds. My mom had actually asked me about PTSD the 
other day and asked me, how do they figure out who has PTSD and 
who doesn't, and that is the thing.
    Coming back from these experiences, there is no cut-and-dry 
formula, you had this many bullets shot at you or you went 
through this many explosions, therefore, you qualify or 
whatever. I can only speak from a Guard-Reservist perspective, 
but the baseline of leaving home, putting life on pause, and 
being away from your family is a stress in and of itself on a 
good day, but when you put together all the things that happen 
to a majority of us--not only the stresses of the mission but 
also being aware of and knowing things that are going on at 
home, things that are not going on at home that should be, and 
knowing that you can't do anything about it and you are 
powerless and have no control, you can't go home and save the 
day, you can't take care of things--there is a lot of stress in 
that and different people deal with it in different ways.
    The important thing is that when we come home, the support 
that was there for the families while we were gone continues 
for the families and us as we come home. I know for our unit--
and this is, I think, a testament to the Guard leadership 
here--there was quite a bit of family support. Families had a 
lot of gatherings, they had a lot of meetings, they had a lot 
of information and things that were available. I think it is 
definitely important that support continues now that we are 
home while we are trying to put all the pieces back together.
    Chairman Akaka. Thank you very much.
    Let me call on Clay Park for his response.
    Mr. Park. Well, Senator, after four children, 13 
grandchildren, and four great-grandchildren, I have come a long 
way.
    When I came back from Vietnam, I was angry. When I was told 
that I had PTSD, I said, no, I don't. And they said, well, then 
why do you sleep with a loaded pistol under your pillow? How do 
you know that?
    One day, my son got angry at me and he was going to throw 
something at me; and I still remember this in my mind right 
now. I was going to kill him, because I remembered that I had 
seen this young kid throw a grenade in the helicopter; and at 
that time I thought my son was a young VC. If my wife didn't 
yell at me, I would have run him over.
    I see a lot of spouses that go through their husbands self-
medicating. They are drinking, they are doing drugs, and the 
wives are getting hit at night. They don't know what to do. The 
families are getting pretty much beat up, and the reason for 
that is because they aren't getting help from nobody. They are 
doing it on their own. I know the VA is now trying to help the 
families, but that is my personal experience with PTSD. Maybe I 
have got a Traumatic Brain Injury, too, I don't know, but I 
have come a long way. So, after 35 years married to my wife, I 
have got a long way to go yet. Thank you, Senator.
    Chairman Akaka. Thank you for sharing your personal 
experience, Mr. Park.
    I want you to know that we have passed legislation on home 
care out of Committee. Hopefully we can pass it finally through 
the full Senate in September when we go back into Session.
    This comes down to helping the family help the soldier--
which includes training the family member and providing 
stipends that will help the family.
    This has been a great panel. Thank you so much for sharing 
your personal experiences. And without question, your responses 
will help us be more creative in trying to find services that 
can help you and your families. Mahalo nui loa. [Applause.]
    I want to welcome our second panel. Our first witness is 
Tracey Betts. She is the Honolulu Regional Office Director.
    Also, Sheila Cullen, who is Director of the Veterans 
Integrated Service Network 21 at the Veterans Health 
Administration. She is accompanied by Dr. James Hastings, 
Director of the VA Pacific Islands Health Care System, and Dr. 
Adam Darkins, who is the Chief Consultant for Care Coordination 
in the Office of Patient Services.
    And we have Brigadier General Gary Ishikawa, Deputy 
Adjutant General for the State of Hawaii.
    Our final witness is the Honorable Ray Jefferson. I want to 
welcome Ray home. He has just been confirmed as Assistant 
Secretary of Veterans' Employment and Training at the 
Department of Labor.
    I want to thank all of you on the second panel for being 
here this morning. Your full testimony will be, of course, 
printed in the record.
    Ms. Betts, will you please begin with your statement.

 STATEMENT OF TRACEY BETTS, HONOLULU REGIONAL OFFICE DIRECTOR, 
 VETERANS BENEFITS ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
                            AFFAIRS

    Ms. Betts. Chairman Akaka, it is my pleasure to be here 
today to discuss our efforts to meet the needs of veterans 
residing in the Pacific Region. The Honolulu Regional Office is 
responsible for delivering non-medical VA benefits and services 
to veterans and their families through the administration of 
comprehensive and diverse benefit programs. Today, I will 
specifically discuss important outreach and services provided 
to members of the National Guard and Reserves here in Hawaii.
    The Honolulu Regional Office serves the veteran population 
in Hawaii and the Pacific region, including Guam, American 
Samoa, and the Commonwealth of the Northern Mariana Islands. 
The Honolulu RO is also responsible for outreach to the 
veterans residing in the insular islands of the Republic of 
Palau, Federated States of Micronesia, and the Republic of the 
Marshall Islands.
    The Honolulu RO administers the following benefits and 
services: disability compensation, vocational rehabilitation 
and employment assistance, the Home Loan Guarantee Program, 
specially adaptive housing grants, and Native American direct 
home loan programs, outreach for all veterans, and survivor 
benefits.
    Over 118,000 veterans live in the jurisdiction served by 
the dedicated employees of the Honolulu RO. Of these veterans, 
approximately 19,200 currently receive disability compensation 
benefits.
    The Honolulu RO has two dedicated Military Service 
Coordinators who perform many of the outreach functions 
provided to returning servicemembers. The MSCs conduct regular 
briefings covering the full range of VA benefits as part of the 
Military Transition Assistance Program, referred to as TAP, at 
various military installations. Servicemembers are informed of 
the array of VA benefits and services available, instructed how 
to properly complete VA application forms, and advised of the 
evidence needed to support their claims. Since the beginning of 
the fiscal year, the Honolulu RO has conducted 171 TAP 
briefings to approximately 5,100 servicemembers in Hawaii. 
Claims submitted by seriously injured veterans of the Operation 
Enduring Freedom or Operation Iraqi Freedom receive priority 
processing through case management.
    The Honolulu RO has a Veterans Service Representative that 
travels throughout Hawaii to provide monthly benefit counseling 
to veterans residing in Kona, Hilo, Maui, Kauai, with bimonthly 
services to veterans on Molokai and semi-annual services to 
veterans on Lanai. Veterans Service Representatives travel to 
provide benefit briefings, answer questions, and accept the 
benefit claims. Outreach to the insular islands is scheduled to 
occur on a quarterly basis.
    In fiscal year 2009, the Honolulu Loan Guarantee Division 
closed 47 Native American direct loans totaling $8.3 million. 
The success of this program is attributed to the Loan Guarantee 
staff's promotion of the NADL program through weekly outreach 
with the Department of Hawaiian Homelands.
    We have expanded our outreach programs for National Guard 
and Reserve components, our participation in the OEF/OIF 
community events, and other information dissemination 
activities to ensure that benefit briefings are conducted when 
local National Guard and Reserve units return from deployment.
    In September 2009, the MSCs and our other Honolulu RO 
employees will be participating in the Hawaii Beyond the Yellow 
Ribbon Exposition at the convention center, where it is 
expected that over 3,000 soldiers and their families will 
attend.
    The Honolulu RO is also working with the Department of 
Defense to expand its role in their military pre-separation 
process. Specifically, we are working to place our MSCs on the 
grounds of the military treatment facility to expedite the 
delivery of consistent service to the wounded, ill, and injured 
servicemembers and veterans. Relocation of the MSCs will enable 
servicemembers and members of the National Guard and Reserve to 
file pre-separation claims, receive benefit briefings, and 
participate in personal interviews.
    Our vocational rehabilitation and education counselors have 
a presence in the Wounded Warrior battalions located at the 
Schofield Barracks and the Kaneohe Marine Corps Base. In fiscal 
year 2009 our counselors completed 20 briefings and provided 
education and vocational counseling to approximately 1,200 
servicemembers.
    Claims with a known discharge date between 60 and 180 days 
can also be processed as benefits delivery at discharge. The 
Honolulu RO is a BDD intake site and is responsible for taking 
and developing claims received from the eight military 
installations within its jurisdiction, to include Camp Smith, 
Fort Shafter, Hickham Air Force Base, Marine Corps Base, Pearl 
Harbor, San Island Coast Guard, Schofield Barracks, and Tripler 
Army Medical Center. Upon receipt of an application, the 
Honolulu RO coordinates with the Honolulu VA medical center to 
provide the separating servicemember with a VA examination.
    When the claim is fully developed, the claim is sent to the 
Rating Activity Site, located in Salt Lake City, UT. The 
Honolulu RO refers an average of 14 BDD claims per week to the 
RAS, which prepares rating decisions for all VA BDD intake 
claims for veterans separating in Honolulu. On an average, 
claims are completed by the RAS in less than 90 days.
    Claims received from servicemembers with a known discharge 
date of less than 60 days are categorized as quick-start 
claims. At the time of filing a quick-start claim, the 
servicemember is advised of the full array of VA benefits, to 
include disability compensation, health care, insurance, 
vocational rehabilitation, loan guarantees, specially adaptive 
housing, and education benefits. The Honolulu RO receives an 
average of ten quick-start claims per week. Upon receipt, 
medical examinations are ordered and the claim is sent to San 
Diego for expedited processing. The San Diego Regional Office 
has 100 employees dedicated specifically to processing quick-
start claims.
    The Honolulu Regional Office works diligently to provide 
services to the veteran population residing here in the Pacific 
region.
    Mr. Chairman, this concludes my testimony.
    [The prepared statement of Ms. Betts follows:]
Prepared Statement of Tracey Betts, Director, Honolulu Regional Office, 
 Veterans Benefits Administration, U.S. Department of Veterans Affairs
    Chairman Akaka, it is my pleasure to be here today to discuss our 
efforts to meet the needs of Veterans residing in the Pacific Region.
    The Honolulu Regional Office (RO) is responsible for delivering 
non-medical VA benefits and services to Veterans and their families 
through the administration of comprehensive and diverse benefit 
programs. Our goal is to deliver these benefits and services in a 
timely, accurate, and compassionate manner.
    Today I will specifically discuss important outreach and services 
provided to members of the National Guard and Reserves in Hawaii.
                        honolulu regional office
    The Honolulu RO serves the Veteran population in Hawaii and the 
Pacific Region, including Guam, American Samoa, and the Commonwealth of 
the Northern Mariana Islands (CNMI). The Honolulu RO is also 
responsible for outreach to Veterans residing in the Insular Islands of 
the Republic of Palau, Federated States of Micronesia, and Republic of 
the Marshall Islands.
    The Honolulu RO administers the following benefits and services:

     Disability Compensation
     Vocational Rehabilitation and Employment Assistance
     Home Loan Guaranty, Specially Adapted Housing Grants, and 
Native American Direct Home Loans
     Outreach for all Veteran and survivor benefits

    Over 118,000 Veterans live in the jurisdiction served by the 
dedicated employees of the Honolulu RO. Of these Veterans, 
approximately 19,200 receive disability compensation benefits.
                                outreach
    The Honolulu RO actively participates in various outreach 
activities. The Honolulu RO has two dedicated Military Service 
Coordinators (MSCs) who perform many of the outreach functions provided 
to returning servicemembers. The MSCs conduct regular briefings 
covering the full range of VA benefits as part of the military 
Transition Assistance Program (TAP) at various military installations 
in Hawaii. TAP briefings aim to prepare retiring and separating 
military personnel for return to civilian life. At these briefings, 
servicemembers are informed of the array of VA benefits and services 
available, instructed how to properly complete VA application forms, 
and advised of the evidence needed to support their claims. Following 
the general instruction segment, personal interviews are conducted with 
those servicemembers who request assistance in preparing and submitting 
their applications for compensation and/or vocational rehabilitation 
and employment benefits. Since the beginning of the fiscal year, the 
Honolulu RO has conducted 171 TAP briefings to approximately 5,177 
servicemembers in Hawaii.
    Claims submitted by seriously injured Veterans of Operation 
Enduring Freedom or Operation Iraqi Freedom (OEF/OIF) receive priority 
processing through case management. The Honolulu RO OEF/OIF coordinator 
works with military medical facilities and VA medical centers to ensure 
these servicemembers and their families receive expedited delivery of 
all benefits.
    In addition, the Honolulu RO has a Veterans Service Representative 
(VSR) travel throughout Hawaii to provide benefit counseling to 
Veterans. The VSR travels and provides monthly benefit services to 
Veterans residing on Kona and Hilo, Hawaii; and on Maui and Kauai. 
Quarterly service is also provided to the Veterans residing on Molokai, 
and semi-annual service is provided to Veterans residing on Lanai.
    The Honolulu RO is committed to providing benefit information and 
access to VA programs to Veterans and their dependents living on Guam 
and in the Insular Islands, to include the Federated States of 
Micronesia, the Republic of the Marshall Islands, and the Republic of 
Palau through their increased outreach presence. Veterans Service 
Representatives travel to these remote locations to provide benefits 
briefings, answer questions, and accept benefit claims. Outreach to the 
Insular Islands is scheduled to occur on a quarterly basis. The 
Honolulu RO also distributes informational materials, such as VA 
pamphlets and DVDs, to Veterans residing on the Insular Islands. A 
dedicated telephone line was established for Insular Island Veterans to 
contact the Honolulu RO to inquire about their individual claims and to 
request general VA benefit information.
    Homeless claims are case managed and processed expeditiously. The 
Honolulu RO has a Homeless Coordinator who actively works with the 
Veterans Health Administration Homeless Coordinators to provide 
services to homeless Veterans such as living placement, clothing, and 
food. The Homeless Coordinator participates in various outreach 
activities to include Homeless Stand Down events in Hilo on April 17, 
2009, and Kauai July 4, 2009.
    The Native American Direct Loan (NADL) Program, established in 1992 
and made permanent by Public Law 109-233, provides financing for homes 
for Native American Veterans and Veterans with Native American spouses. 
In fiscal year 2009, the Honolulu Loan Guaranty (LGY) Division closed 
47 Native American Direct Loans totaling $8,375,639. The success of 
this program is attributed to the Honolulu Loan Guaranty staff that 
regularly promotes the NADL Program through weekly outreach with the 
Department of Hawaiian Homelands. Quarterly outreach for the NADL 
Program is provided to Veterans in American Samoa, Guam, and CNMI. 
Continual training with lenders and realtors in the community is 
conducted.
    The RO staff and I regularly participate in various ceremonies and 
conventions, such as the Joint POW/MIA Accounting Command Repatriation 
Ceremony held at Hickam Air Force Base; the annual Vietnam Veterans 
Memorial Day Ceremony at the National Memorial Cemetery of the Pacific, 
also known as the Punchbowl; the annual State Governor's Memorial Day 
Ceremony at the Hawaii State Veterans Cemetery; and most recently, the 
Disabled American Veterans State Conference held in June on the island 
of Kauai. Additionally, employees participate in the graduation 
ceremonies of Post Traumatic Stress Disorder Residential Rehabilitation 
participants held quarterly at Tripler Army Medical Center.
    outreach services for members of the reserve and national guard
    We have expanded our outreach programs for National Guard and 
Reserve components and our participation in OEF/OIF community events 
and other information dissemination activities. The MSC ensures that 
benefit briefings are conducted when local National Guard and Reserve 
units return from deployment. During these briefings, the MSC provides 
a comprehensive briefing on VA benefits and assists with appropriate 
applications. All attendees receive a copy of VA pamphlet, A Summary of 
VA Benefits, as well as the VA Health Care and Benefit Information for 
Veterans wallet card. In addition, the MSC works in concert with the 
National Guard Yellow Ribbon Program to provide information and 
services to members of the National Guard. In September 2009, the MSCs 
and other Honolulu RO employees will be participating in ``Hawaii 
Beyond the Yellow Ribbon'' exposition. Over 3,000 soldiers and their 
families are expected to attend.
    The Honolulu RO is also working with the Department of Defense to 
expand its role in their military pre-separation process. Specifically, 
we are working to place our MSCs on the grounds of the military 
treatment facility to expedite the delivery of consistent service to 
the wounded, ill, and injured servicemembers and Veterans. Relocation 
of the MSCs will enable servicemembers and members of the National 
Guard and Reserve to file pre-separation claims, receive benefit 
briefings, and participate in personal interviews.
    Our Vocational Rehabilitation and Employment (VR&E) employees work 
closely with military facilities in Hawaii to ensure that outreach is 
extended to as many returning servicemembers as possible. The VR&E 
counselors have a presence in the Wounded Warrior Battalions located at 
Schofield Barracks and Kaneohe Marine Corp Base. They provide monthly 
briefings to these soldiers in addition to providing them education and 
employment counseling. In fiscal year 2009, VR&E completed 20 briefings 
and provided education and vocational counseling to approximately 1,200 
servicemembers.
    The VR&E Employment Coordinator from the Honolulu RO works with the 
Tripler Army Medical Center's Deployment Health Center to assist 
returning Reservists and National Guard members. In addition to 
providing information about VA services, the Employment Coordinator 
refers recuperating soldiers to the local Disabled Veterans Outreach 
Program for employment briefings offered by the Department of Labor. 
The Honolulu RO also has a VR&E counselor located at the Maui Community 
Based Outpatient Clinic full time providing VR&E services to Maui 
Veterans. He currently works with approximately 100 Veterans on Maui 
and has met with 1,200 Veterans this fiscal year.
    With the ongoing activation of Reserve and National Guard members 
in support of the military operations in Iraq and Afghanistan, 
servicemembers are becoming eligible for VA home loan benefits in 
greater numbers. Reserve and National Guard members are eligible for 
the Loan Guaranty and Native American Direct Loan Programs after 90 
days or more of active wartime service. In general, Veterans may 
qualify for VA-guaranteed and direct loans in amounts equal to the 
Freddie Mac conforming loan limit. As a result of the Veterans' 
Benefits Improvement Act of 2008, the amount in Oahu, a high-cost area, 
can be as high as $783,750, with no down-payment.
    The Honolulu Loan Guaranty Office administers VA Home Loan 
Workshops at Hickam Air Force Base to active duty servicemembers to 
include National Guard and Reservists. In fiscal year 2009, the Loan 
Guaranty staff completed five workshops, participated in various 
outreach activities such as the Mortgage Class/Financial Fair held at 
Fort Shafter, and participated in the Personal Financial Expo held at 
the Blaisdell Center earlier this month.
         benefits delivery at discharge and quick start claims
    Any servicemember may file a pre-discharge claim for disability 
compensation if that individual is within 180 days of release from 
active service. This includes members of both active duty and full-time 
reserve components and those undergoing medical evaluation board/
physical evaluation board proceedings.
    Those claims with a known discharge date between 60-180 days can be 
processed as a Benefits Delivery at Discharge (BDD) claim. The Honolulu 
RO is a Benefits Delivery at Discharge (BDD) intake site and is 
responsible for taking and developing claims received from the eight 
military installations within its jurisdiction (Camp Smith, Fort 
Shafter, Hickam Air Force Base, Marine Corp Base Hawaii, Pearl Harbor, 
San Island Coast Guard, Schofield Barracks, and Tripler Army Medical 
Center). Upon receipt of an application, the Honolulu RO coordinates 
with the Honolulu VA Medical Center to provide the separating 
servicemember with a VA examination. When the claim is fully developed 
to include completion of the VA examination, the claim is sent to the 
rating activity site (RAS) located at the Salt Lake City RO. The 
Honolulu RO refers an average of 14 BDD claims per week to the RAS, 
which prepares rating decisions for all VA BDD claims for Veterans 
separating in Honolulu. On average, claims are completed by the RAS in 
less than 90 days.
    Claims received from servicemembers with a known discharge date of 
less than 60 days are categorized as Quick Start pre-discharge 
disability claims. At the time of filing a Quick Start claim, the 
servicemember is advised of the full array of VA benefits to include 
disability compensation, health care, insurance, vocational 
rehabilitation, loan guaranty, specially adapted housing, and education 
benefits. The Honolulu RO receives an average of 10 Quick Start claims 
per week. Upon receipt, claims are immediately placed under control, 
have medical examinations ordered, and are then sent to the San Diego 
RO for expedited processing. The San Diego RO has 100 employees 
dedicated to the processing of Quick Start claims.
                               conclusion
    The Honolulu Regional Office works diligently to provide services 
to the Veteran population residing in the Pacific Region and ensure 
members of the National Guard and Reserve are knowledgeable of the 
array of benefits and services available to them through VA.

    Mr. Chairman, this concludes my testimony. I greatly appreciate 
being here today and look forward to answering your questions.

    Chairman Akaka. Thank you very much, Ms. Betts.
    Now, Sheila Cullen, will you please proceed with your 
statement.

   STATEMENT OF SHEILA CULLEN, DIRECTOR, VETERANS INTEGRATED 
 SERVICE NETWORK 21 (VISN 21); ACCOMPANIED BY JAMES HASTINGS, 
M.D., DIRECTOR, VA PACIFIC ISLANDS HEALTH CARE SYSTEM; AND ADAM 
   W. DARKINS, M.D., CHIEF CONSULTANT FOR CARE COORDINATION, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
                            AFFAIRS

    Ms. Cullen. Mr. Chairman, mahalo for the opportunity to 
appear before you today to discuss the Department of Veterans 
Affairs health care in Hawaii and the Pacific region. It is a 
privilege to be here on Oahu to speak and to answer questions 
about VA health care issues that are important to veterans 
residing in Hawaii.
    First, Mr. Chairman, I would like to thank you for your 
leadership and advocacy on behalf of veterans. Your vision and 
support have led to an unprecedented level of health care 
services for veterans, construction of state-of-the-art 
facilities here in Honolulu, and remarkable improvements in 
access to health care services for veterans residing on the 
Hawaiian neighbor islands, American Samoa and Guam.
    My written testimony, which I ask be submitted for the 
record, describes the VA Sierra Pacific Health Care Network. It 
provides an overview of the VA Pacific Islands Health Care 
System and the VA facilities here on Oahu. It discusses 
national and local telehealth programs, and it highlights 
outreach and seamless transition activities between the VA 
Pacific Islands Health Care System and the State of Hawaii 
National Guard.
    In the few minutes I have now, I would like to tell you 
about some recent expansions of care and services on the 
islands and to describe our outreach efforts to members of the 
Reserves and National Guard.
    VA Pacific Islands Health Care System currently provides 
care in ten locations, with two more soon to be added. The two 
planned facilities include a new interim community-based 
outpatient clinic to serve Leeward Oahu veterans with an 
expected opening in fiscal year 2010, and a new outreach clinic 
in Saipan set to open this fall.
    An inpatient Post Traumatic Stress Disorder residential 
rehabilitation unit is in its interim location on the Tripler 
campus, pending construction and activation of a new VA-funded 
facility during fiscal year 2011.
    VA Pacific Islands Health Care System also received 
approval for a VA-funded project, just under $7 million, to 
build a joint VA/DOD ambulatory surgery facility on the grounds 
of Tripler. The project is nearing design completion and is 
scheduled for construction and activation in fiscal year 2011.
    VA Pacific Islands Health Care System is also constructing 
a new replacement community-based outpatient clinic in Guam 
that will offer expanded capacity. It will be located along the 
perimeter of the Guam Naval Hospital, and is expected to open 
in March 2010.
    VA Pacific Islands Health Care System has served the needs 
of almost 3,400 total Operation Enduring Freedom/Operation 
Iraqi Freedom--or as we more often refer to them, OEF/OIF 
veterans--through July 2009, including 1,089 Hawaii National 
Guard members. Our experience to-date has shown that about one 
in four OEF/OIF veterans avail themselves of VA enrollment and 
health care.
    VA Pacific Islands Health Care System has a dynamic OEF/OIF 
program led by a program manager who, along with three staff, 
which includes two care managers and one Transition Patient 
Advocate, partner effectively with the Hawaii National Guard, 
the Army Reserve, and active duty military to serve the 
veterans' health care needs related to these organizations.
    These program staff members coordinate care and services 
for OEF/OIF veterans and their families throughout the VA 
Pacific Islands Health Care System by ensuring that 
comprehensive, preventive, mental and physical health 
examinations are performed. They also provide outreach services 
to veterans who are not currently VA users and assist in the 
case management of severely injured veterans who require 
complex care.
    VA Pacific Islands Health Care System OEF/OIF staff members 
meet and communicate frequently with Hawaii National Guard 
leadership and exchange data and information about troop 
status, including force deployment and return. VA is presently 
anticipating the health care needs from an estimated 1,158 
returning members of the Guard this month. The program is also 
decentralizing its staff and locating them on a full- and part-
time basis, as appropriate, to work on military bases on Oahu, 
including Fort Shafter, Kaneohe Marine Air Station, Schofield 
Barracks, and with the Hawaii National Guard at Kalaeloa. We 
expect that integrating VA staff with these military units will 
increase the visibility and level of service VA provides to 
individuals within these units and supports continued seamless 
transition activities between the organizations.
    In addition, VA program staff members regularly attend and 
participate in Guard post-deployment health assessment 
screenings and Yellow Ribbon events organized for 
servicemembers and their families.
    In summary, because of the support of this Committee and 
the Hawaiian Congressional delegation, VA is providing an 
unprecedented level of health care services to veterans 
residing in Hawaii and the Pacific region. VA Pacific Islands 
Health Care System still faces several challenges, including 
timely access to health care services, an aging veteran 
population, and the special needs of our newest veterans. VA 
Pacific Islands Health Care System will meet these challenges 
by working with DOD and community partners, activating an 
ambulatory surgical center, utilizing telehealth technologies, 
and opening new clinics, as necessary. I am proud of what VA 
has accomplished in Hawaii and the Pacific Islands region and 
look forward to future endeavors on behalf of veterans.
    Again, Mr. Chairman, mahalo for the opportunity to testify 
at this hearing, and my colleagues and I would be delighted to 
address any questions you may have for us.
    [The prepared statement of Ms. Cullen follows:]
 Prepared Statement of Ms. Sheila Cullen, Director, VA Sierra Pacific 
 Network (VISN 21), Veterans Health Administration, U.S. Department of 
                            Veterans Affairs
    Mr. Chairman and Members of the Committee, mahalo for the 
opportunity to appear before you today to discuss VA health care in 
Hawaii and the Pacific region. It is a privilege to be on Oahu to speak 
and answer questions about VA health care issues that are important to 
Veterans residing in Hawaii. I am accompanied today by Dr. James 
Hastings, Director of the VA Pacific Islands Health Care System 
(VAPIHCS), and Dr. Adam Darkins, Chief Consultant, Care Coordination, 
Office of Patient Care Services, Veterans Health Administration.
    First, Mr. Chairman, I would like to thank you for your leadership 
and advocacy on behalf of our Nation's Veterans. During your tenure as 
Ranking Member and Chairman of this Committee, you have consistently 
demonstrated your commitment to Veterans by introducing legislation 
designed to meet the needs of Veterans. As I will highlight later, your 
vision and support have led to an unprecedented level of health care 
services for Veterans, construction of state-of-the-art facilities here 
in Honolulu, and remarkable improvements in access to health care 
services for Veterans residing on the Hawaiian neighbor islands, 
American Samoa and Guam. In addition, we appreciate your interest in 
and support of the Department of Veterans Affairs (VA).
    Today, I will briefly review the operations of the VA Sierra 
Pacific Network that includes Hawaii and the Pacific region; provide an 
overview of VAPIHCS and the VA facilities here on Oahu; provide 
national and local information regarding telehealth programs; and 
highlight outreach and seamless transition activities between VAPIHCS 
and the State of Hawaii National Guard.
                  va sierra pacific network (visn 21)
    The VA Sierra Pacific Network (Veterans Integrated Service Network 
[VISN] 21) is one of 21 integrated health care networks in the Veterans 
Health Administration (VHA). The VA Sierra Pacific Network provides 
services to Veterans residing in Hawaii and the Pacific region 
(including the Philippines, Guam, American Samoa and Commonwealth of 
the Northern Marianas Islands), northern Nevada, and central/northern 
California. There were an estimated 1.1 million Veterans living within 
the boundaries of the VA Sierra Pacific Network in Fiscal Year (FY) 
2008.
    The VA Sierra Pacific Network includes six major health care 
systems based in Honolulu, HI; Palo Alto, CA; San Francisco, CA; 
Sacramento, CA; Fresno, CA; and Reno, NV, as well as an Independent 
Outpatient Clinic in Manila, PI. In FY 2008, the Network provided 
services to 213,000 out of 350,000 enrolled Veterans. There were about 
3.2 million clinic visits and 25,800 inpatient discharges. The 
cumulative full-time employment equivalents (FTEE) level was 9,607, and 
the operating budget was about $2.1 billion.
    The VA Sierra Pacific Network is committed to ensuring the care 
Veterans receive is of the highest quality. All six health care systems 
within the Network have major academic affiliations. The Network hosts 
a significant number of Centers of Excellence in VHA and supports a 
large and broad research portfolio. It also has expansive and 
collaborative relationships with the Department of Defense (DOD). The 
VA Sierra Pacific Network has not only exceeded patient satisfaction 
goals (inpatient and outpatient), but its employee satisfaction scores 
are among the top five Networks for overall job satisfaction in VHA. As 
reflected in the most recent employee satisfaction survey, the Network 
had the highest scores in VHA in several categories including 
leadership, supervisory support, customer service, conflict resolution, 
praise, and rewards.
    Given the large and diverse geographic nature (i.e. rural or 
frontier lands and remote islands) of VISN 21, access to care is a 
priority. In FY 2010, the Network will activate nine new sites of care 
in the Pacific (Hawaii and the Northern Mariana Islands), California, 
and Nevada. Finally, VISN 21 is proud to operate one of four Polytrauma 
Rehabilitation Centers in VHA dedicated to addressing the clinical 
needs of the most severely injured Veterans.
            va pacific islands health care system (vapihcs)
    As noted above, VAPIHCS is one of six major health care systems in 
VISN 21. Dr. James Hastings is the director and a practicing 
cardiologist at VAPIHCS. VAPIHCS is unique in several important 
aspects: its vast catchment area covers 2.6 million square-miles 
(including Hawaii, Guam, American Samoa and Commonwealth of the 
Northern Marianas); its remote island locations create access 
challenges; and it enjoys the cultural richness of the Pacific Islands 
with an ethnically diverse patient and staff population. In FY 2008, 
there were an estimated 118,000 Veterans living in Hawaii, and at least 
10,000 additional Veterans located beyond Hawaii in the VAPIHCS 
catchment area.
    VAPIHCS currently provides care in ten locations, with two more 
soon to be added. Our current facilities include an Ambulatory Care 
Center (ACC) and a Community Living Center (CLC) on the campus of the 
Tripler Army Medical Center (TAMC) in Honolulu; community-based 
outpatient clinics (CBOC) in Lihue (Kauai), Kahului (Maui), Kailua-Kona 
(Hawaii), Hilo (Hawaii), Hagatna (Guam) and Pago Pago (American Samoa); 
and outreach clinics on Molokai and Lanai. The two planned facilities 
include a new interim CBOC to serve Leeward Oahu Veterans (approved in 
FY 2008 with an expected opening in early FY 2010) and a new outreach 
clinic in Saipan set to open this fall. The inpatient Post Traumatic 
Stress Disorder (PTSD) residential rehabilitation unit is in its 
interim location on the campus of TAMC, pending construction and 
activation of a new VA-funded facility ($9.56 million), also at TAMC, 
during FY 2011. VAPIHCS also received approval for a VA-funded project 
($6.95 million) to build a Joint VA/DOD Ambulatory Surgery facility on 
the grounds of TAMC. The project is nearing design completion and is 
scheduled for construction and activation in FY 2011.
    VAPIHCS is also constructing a new replacement CBOC in Guam that 
will offer expanded capacity. It will be located along the perimeter of 
the Guam Naval Hospital, and we expect it to open in March 2010. VHA 
operates a total of six Vet Centers in Honolulu, Lihue, Wailuku, 
Kailua-Kona, Hilo and Guam. These facilities provide counseling, 
psychosocial support, and outreach. A Vet Center staff member was also 
added in American Samoa during FY 2008.
    In FY 2008, VAPIHCS provided services to nearly 24,000 Veterans, an 
increase of over seven percent from FY 2007. Of these Veterans, 19,000 
reside in Hawaii. There were 162,000 clinic stops in Hawaii during FY 
2008. The cumulative FTEE in FY 2008 for the health care system was 540 
employees. The operating budget for VAPIHCS (i.e., General Purpose 
allocation from appropriated funds) increased from $128.0 million in FY 
2007 to $142 million in FY 2008, an increase of 11 
percent.
    VAPIHCS provides or contracts for a comprehensive array of health 
care services. VAPIHCS directly provides primary care, including 
preventive services and health screenings, and mental health services 
at all locations. VAPIHCS does not operate its own acute medical-
surgical hospital and as a result faces some challenges in providing 
specialty services. VAPIHCS has hired specialists in orthopedics, 
ophthalmology, nephrology, infectious disease and inpatient medicine 
(``hospitalist''), and is providing selected specialty care in Honolulu 
and to a lesser extent at CBOCs. VAPIHCS also added a neurologist in FY 
2008 to improve the treatment of Traumatic Brain Injury (TBI). VAPIHCS 
is actively recruiting additional specialists and expects to have a 
newly hired cardiologist and endocrinologist this fall. Veterans with 
spinal cord injuries receive care from VAPIHCS dedicated staff, which 
provides a multidisciplinary approach to care. The team, located on 
Oahu, is planning to travel and care for patients on the neighbor 
islands during FY 2010. Veterans 
requiring other specialty care continue to be referred to DOD and 
community 
facilities.
    Inpatient long-term and acute rehabilitation care is available at 
the Community Living Center (CLC). Inpatient mental health services are 
provided by VA staff on a 20 bed ward within TAMC and at the 16 bed 
Post Traumatic Stress Disorder (PTSD) Residential Rehabilitation 
Program (PRRP). VAPIHCS contracts for care with DOD (at TAMC and Guam 
Naval Hospital) and community facilities for inpatient medical-surgical 
care.
                 national and local telehealth programs
National Telehealth Programs
    Telehealth involves the use of information and telecommunication 
technologies as a tool in providing health care services when the 
patient and practitioner are separated by geographical distance. The 
benefits of telehealth to health care systems include: improving access 
to care, making specialist services available in rural and remote 
locations, and supporting patients to live independently in their own 
homes and local communities. Because of the support of telehealth by VA 
and Congressional leadership, more Veterans are able to realize these 
benefits.
    Over the past 6 years telehealth in VA has transitioned from use in 
a range of discrete local projects and programs toward a unified, 
enterprise level approach that provides routine telehealth services 
that are mission critical to the delivery of care to Veterans. In 2009 
over 230,000 Veteran patients received care via VA's telehealth 
programs. Telehealth takes many forms. VA's enterprise telehealth 
programs deliver care to Veteran patients in their homes via home 
telehealth; telehealth care is also provided in VA medical centers 
(VAMCs), CBOCs and Vet Centers via clinical videoconferencing. In 
addition, VA routinely exchanges clinical images via store-and-forwards 
telehealth.
    I would like to briefly highlight some of the direct benefits these 
services are providing to Veterans. Almost 40,000 Veterans are 
receiving home-telehealth-based care that supports care delivery to 
them in their own homes. These care coordination/home telehealth (CCHT) 
services have reduced hospital admissions by 25 percent, hospital stays 
by 25 percent, and have high levels of patient satisfaction (86 percent 
mean score). In 2008 almost 50,000 Veterans received care via clinical 
videoconferencing (CCGT), the majority receiving mental health care 
services that reduced hospital admissions by 20 percent. In 2008 over 
100,000 Veterans were screened to prevent avoidable blindness by VA's 
teleretinal imaging programs (CCSF).
    The successful implementation of robust and sustainable telehealth 
services that VA entrusts to provide care to Veteran patients must 
satisfy stringent clinical, technological and business requirements 
that ensure they are appropriate, effective and cost-effective. These 
requirements include acceptance by patients and practitioners as well 
as staff training and quality management systems. Mr. Chairman, you and 
the Committee understand how the geography of Hawaii and the Pacific 
region poses particular challenges in implementing telehealth that are 
not encountered on the U.S. mainland. Services to Guam and American 
Samoa not only need to bridge a physical distance of 3,820 and 2,300 
miles respectively, they also need to bridge between patients and 
clinical communities that are distant and distinct from one another. 
Bridging these distances and linking these communities to enable them 
to integrate requires telecommunications bandwidth. VA is currently 
seeking to embrace Hawaii and the Pacific region within its clinical 
enterprise video conferencing network (CEVN) and in doing simplify the 
linkage to specialist services from medical center assets on the U.S. 
mainland.
    VA recognizes the pioneering role that Hawaii and the Pacific 
region have played in the development of telehealth solutions that 
range from teleretinal imaging to home telehealth. These innovations 
have included partnerships with DOD and the University of Hawaii within 
the collaborative framework of the Pacific Telehealth and Technology 
Hui (partnership, or ``Hui.''). VA appreciates the support of Congress 
in the establishment of VA's Office of Rural Health with sufficient 
resources that enable us to focus on extending current enterprise 
telehealth solutions as well as developing new telehealth solutions to 
serve Veterans, not only those in Hawaii and the Pacific region 
Islands, but also Veterans elsewhere in the Nation for whom 
geographical distance from VA's physical health care assets presents a 
challenge to receiving care. In considering future innovation for local 
and enterprise portfolios of telehealth services, VA is looking toward 
new iterations of a familiar technology--the telephone. Currently the 
telephone has meant that eight patients a month from Hawaii and the 
Pacific region have been able to access VA's suicide hotline and 
receive support from Canandaigua, New York. The transition of health 
applications onto mobile technologies such as cell phones promises to 
further revolutionize how telehealth can serve Veterans in areas such 
as Hawaii and the Pacific region.
    Mr. Chairman, I used the word Hui earlier. As you know, Hui 
describes a partnership, a union or a gathering. All health care is 
ultimately local, and my discussion so far has focused on the clinical, 
technological and business issues of implementing telehealth across the 
VA health care system. My attention will now turn to local telehealth 
initiatives that support Hawaiian Veterans and those living on other 
Pacific Islands.
Local Telehealth Programs
    In partnership with DOD, specifically TAMC, VAPIHCS began to 
develop this capability in 2001 with the support of Senator Daniel K. 
Inouye. The Pacific Telehealth and Technology Hui formed in 1999 allows 
joint development of telemedicine technologies for both organizations 
in the Pacific. This partnership (known as ``the Hui'') fielded many 
demonstration projects that have enabled both Departments to develop 
ongoing telehealth activity for our beneficiaries.
    For VAPIHCS, this partnership allowed us to begin developing 
telemedicine capabilities in collaboration with the local information 
technology (IT) department that developed the telecommunications 
network infrastructure and supported the deployment of video 
teleconferencing to VA CBOCs on the islands of Hawaii, Maui, Kauai, 
Guam, and American Samoa. Connectivity to Molokai and Lanai is also 
available, and we are presently studying connectivity for our newly 
approved Outreach Clinic in Saipan. Additionally, this initial 
investment allowed the development of procedures, practices, and 
protocols to support video teleconference clinical visits for primary 
care, mental health, and subspecialty care. Funds were provided for 
purchasing telemedicine ``carts,'' that allow the use of peripheral 
medical equipment (stethoscopes, otoscopes, cameras and other 
attachments), as well as teleretinal imaging equipment to permit 
screening for diabetic eye disease. Automated Drug Dispensing System 
(ADDS) machines were installed in CBOCs in 2003 allowing pharmacists in 
Honolulu to dispense medications and, through the use of video 
conferencing, to provide medication counseling to Veterans at the time 
of their clinic visits. The VAPIHCS also began tele-home care projects 
in 2003 by deploying home telemedicine units. This partnership and 
initial funding has helped us establish a foundation of experience upon 
which we continue to build to enhance the medical care provided in our 
facilities throughout the Pacific Region. Additionally, this early 
experience has allowed our facilities to compete for research dollars 
to further develop telemedicine and tele-mental health activities.
    The Hui also provided support for TAMC projects, including support 
for store and forward telemedicine for adult and pediatric care to the 
Western Pacific, cardiac sonography from TAMC to Guam and Japan, 
intensive care unit telemetry and consultation from TAMC to Guam Naval 
Hospital and Korea, speech therapy and other projects.
    Beyond the Hui, VAPIHCS and TAMC are working together to develop 
joint telemedicine capabilities in American Samoa to support co-
location of TAMC personnel at a VA CBOC. This arrangement would extend 
clinical expertise from TAMC to American Samoa to serve Veterans and 
active duty servicemembers, as well as members of the National Guard 
and Reserve who have experienced a Traumatic Brain Injury (TBI).
    Recently, VA expanded mental health programs, including significant 
growth in tele-mental health activities. VA recruited a clinical 
psychologist to fill a new position for a dedicated tele-mental health 
coordinator based in Maui. This new position expanded tele-psychology 
services equitably throughout the CBOC. Additionally, VA has begun 
conducting tele-mental health Compensation and Pension (C&P) 
examinations to expedite the assessment of Veterans for appropriate 
benefits.
    During fiscal year (FY) 2009, telehealth has been extremely helpful 
in delivering mental health services and dispensing medications to 
Veterans. A snapshot of relevant data, current through July 2009, 
includes:

     Over 2,000 telehealth patient encounters in VAPIHCS, 1,300 
of which were for mental health and 52 of which were for mental health 
C&P evaluations for patients in Guam or the Commonwealth of the 
Northern Mariana Islands; and
     Over 9,000 prescriptions filled at CBOCs on Kauai, Maui, 
Hilo, Kona, American Samoa and Guam using ADDS machines.

    VAPIHCS has other Telehealth services that are available to 
Veterans, including:

     Care Coordinated General Telehealth clinics (CCGT), which 
offer
           Individual and group psychology and psychiatry 
        support;
           PTSD group research clinic;
           Individual and family nutrition information;
           Mental health C&P examinations;
           Geriatric psychiatry;
           General surgery and neurosurgery through the San 
        Francisco VAMC;
           Treatment for spinal cord injury through the Palo 
        Alto VAMC;
           Wound care;
           Nephrology care; and
           Participation in VA's `MOVE!' (weight loss) program;

     Care Coordinated Store Forward clinics (CCSF):
           Teledermatology through the San Francisco VAMC; and
           Teleretinal Imaging;
           Care Coordination Home Telehealth, utilizing home 
        telehealth devices to support the care of Veteran patients in 
        their own homes on Oahu, Maui and Hilo.

    Our expanding and diverse experience with telehealth has provided 
many ``lessons learned'' to further shape the development of our 
VAPIHCS Telehealth Program. For example, numbers (i.e. encounters) 
alone do not tell the complete story of how technologies may be used to 
improve the health care of Veterans. In addition to increasing access 
to specialty services for Veterans, VAPIHCS has found telehealth 
technologies also allow CBOC providers to learn from telemedicine 
experiences (with distant providers), which can improve the skills of 
local physicians. VAPIHCS continually evaluates the use of telehealth 
services that are provided to Veterans within our service area and 
changes the program as necessary to meet the needs of the Veterans we 
serve. There is a new opportunity to expand the use of telehealth as we 
develop new outreach clinics to meet the needs of Veterans in highly 
rural areas.
    This increased ``hands-on'' care allows us to pursue new telehealth 
opportunities in even more remote locations to benefit Veterans. We are 
providing more care in the home, using VA's Care Coordination Home 
Telehealth (CCHT) protocols. This will provide us with patient data and 
information from the home that can be used to maximize our ability to 
manage medically complex patients in conjunction with our chronic 
disease team to improve the quality of life for Veterans.
    There are some local challenges with telehealth. We are adding 
additional staff, including telehealth nurses, to our sites so our 
clinics can both provide direct patient care and staff telehealth 
clinics as well. We anticipate that by this fall, we will have 
sufficient support for telehealth activities at each CBOC in the area.
    This table provides data about telehealth usage in the following 
facilities:

                    Number of Unique Patients by Site (VA Pacific Islands Health Care System)
----------------------------------------------------------------------------------------------------------------
                         Facility                            FY 2006    FY 2007       FY 2008      FY 2009 (YTD)
----------------------------------------------------------------------------------------------------------------
Honolulu..................................................        298        253             186             230
Maui......................................................         53         65              60             272
                                                                                       (includes       (includes
                                                                                      Molokai 5)     Molokai 17)
Kauai.....................................................         70         71              73             100
Hilo......................................................        128         59              65              96
Guam......................................................          0         18              40             117
Kona......................................................          6          1              14              33
Am Samoa..................................................          0          0               0               7
                                                           -----------------------------------------------------
    TOTAL.................................................        555        467             438             855
----------------------------------------------------------------------------------------------------------------

    The total numbers of VA's patients using telehealth decreased in FY 
2007 when VA received permission to begin sending patients to TAMC, 
rather than using telemedicine to support patient transfers to 
California. Some of this change can also be explained in part by 
additional staff hires, particularly in mental health, at some of these 
facilities. We anticipate a growth in telehealth in FY 2010 as 
dedicated telehealth nurses are added to our facilities this fall.
                            oahu facilities
    VA operates the Spark M. Matsunaga VA Medical Center in Oahu, 
located on the campus of TAMC at 459 Patterson Road, Honolulu, HI, 
96815. The VAMC consists of the Ambulatory Care Center (ACC), a 60-bed 
Community Living Center (CLC) and administrative space (located in the 
E Wing of TAMC). Additionally VA operates both a 20-bed acute 
psychiatry inpatient unit and a 16-bed PRRP within TAMC. A Veterans 
Benefits Administration (VBA) Regional Office is co-located with VHA on 
this campus. The Honolulu Vet Center is located nearby at 1680 
Kapiolani Boulevard in Honolulu.
    VA estimates the Veteran island population for Oahu in FY 2008 was 
73,000. In FY 2008, 27,000 Veterans on Oahu were enrolled for care, and 
of these 14,070 received VA care (``users''). The market penetrations 
for enrollees and users are 37 percent and 19 percent, respectively and 
compare favorably with rates within VISN 21 and VHA.
    The average FTEE level on Oahu in FY 2008 is 468. With this staff, 
VAPIHCS provides a wide range of outpatient services, including primary 
care, several medical subspecialties (e.g., cardiology, 
gastroenterology, geriatrics, nephrology, orthopedics, pulmonary and 
women's health), mental health, and dental care. In addition, VAPIHCS 
provides diagnostic services such as laboratory, echocardiography and 
radiology. If Veterans require services not available at the ACC or 
CLC, VAPIHCS arranges and pays for care at TAMC, local community 
providers, or VA facilities in California; for those referred to a 
facility in California, VA can cover the costs of transportation if the 
veteran is eligible for beneficiary travel.
    In FY 2008, VA facilities in Oahu recorded about 162,000 clinic 
stops. In the face of increasing demand for primary care services in 
Honolulu, VAPIHCS unexpectedly lost the services of two primary care 
physicians, resulting in a large number of Veterans being placed on our 
wait list. To address this need, we have identified potential 
replacements for our primary care provider vacancies and established 
several new primary care positions, including a physician solely 
dedicated to women's health care and another for spinal cord injuries. 
We believe these steps will eliminate our primary care appointment wait 
list by October 1, 2009. In FY 2008, the combined average daily census 
(ADC) in the mental health ward was 11 and was 53 at the CLC. VAPIHCS 
spent about $15 million for clinical services for Veterans at TAMC and 
another $30 million for non-VA care in the community.
          va resources available to the hawaii national guard
    VAPIHCS has served the needs of almost 3,400 total Operation 
Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans through 
July 2009, including 1,089 Hawaii National Guard members, 800 of whom 
reside on Oahu, with the rest residing throughout the Hawaiian neighbor 
islands. Experience to date has shown that about one in four OEF/OIF 
Veterans avail themselves of VA enrollment and health care.
    VAPIHCS has a dynamic OEF/OIF Program led by a Program Manager who, 
along with three staff including two Care Managers and one Transition 
Patient Advocate, partner effectively with the Hawaii National Guard, 
the Army Reserve, and active duty military to serve the Veterans' 
health care needs related to these organizations.
    These program staff members coordinate care and services for OEF/
OIF Veterans and their families throughout the VAPIHCS. Specifically, 
they ensure comprehensive preventive mental and physical health 
evaluations are performed, provide outreach services to Veterans who 
are not currently VA users, and assist in the case management of 
severely injured Veterans who require complex care. VA program staff 
also work collaboratively with Army Wounded Warrior staff to coordinate 
care and services for these individuals.
    VAPIHCS OEF/OIF staff members meet and communicate frequently with 
Hawaii National Guard leadership and exchange data and information 
about troop status, including force deployment and return. VA is 
presently anticipating the health care needs from an estimated 1,158 
returning members of the Guard during August 2009.
    The program is also decentralizing its staff during this period of 
time, locating them on a full and part time basis as appropriate to 
work on military bases on Oahu including Ft. Shafter, Kaneohe Marine 
Air Station, Schofield Barracks, and with the Hawaii National Guard at 
Kalaeloa. We expect that integrating VA staff with these military units 
will increase the visibility and level of service VA provides to 
individuals within these units and supports continued seamless 
transition activities between the organizations.
    In addition, VA program staff members regularly attend and 
participate in Guard Post Deployment Health Assessment Screenings and 
Yellow Ribbon Events, organized for servicemembers and their families.
    As mentioned previously, VAPIHCS has the resources to provide 
members of the Hawaii National Guard quality primary and mental health 
care, and specialized medical care. The PRRP, TBI and SCI team 
capability further enhances the services available to all Veterans.
                               conclusion
    In summary, with the support of the Senate Committee on Veterans' 
Affairs and the Hawaiian Congressional delegation, VA is providing an 
unprecedented level of health care services to Veterans residing in 
Hawaii and the Pacific region. VA has state-of-the-art facilities and 
enhanced services in Honolulu, as well as robust staffing on the 
neighbor islands along with expanded or renovated clinics in many 
locations. VA continues to enhance its staff with added mental health 
providers and specialists to meet Veterans' needs. These services are 
also available to Veterans who are Hawaii National Guard members
    VAPIHCS still faces several challenges including timely access to 
health care services (in part due to the topography of its catchment 
area and lack of an acute medical-surgical hospital), an aging Veteran 
population, and the special needs of our newest Veterans. VAPIHCS will 
meet these challenges by working with DOD and community partners, 
activating an ambulatory surgery center, utilizing telehealth 
technologies, and opening new clinics as necessary. I am proud of what 
VA has accomplished in Hawaii and the Pacific Islands region and look 
forward to our future endeavors on behalf of Veterans.

    Again, Mr. Chairman, mahalo for the opportunity to testify at this 
hearing. My colleagues and I would be delighted to address any 
questions you may have for us.

    Chairman Akaka. Thank you very much, Ms. Cullen, for your 
testimony.
    And now, I will call on General Ishikawa for his statement.

    STATEMENT OF BRIGADIER GENERAL GARY M. ISHIKAWA, DEPUTY 
               ADJUTANT GENERAL, STATE OF HAWAII

    General Ishikawa. Chairman Akaka, mahalo and aloha.
    Chairman Akaka. Aloha.
    General Ishikawa. I appreciate this opportunity to testify. 
I am Brigadier General Gary Ishikawa, the Deputy Adjutant 
General for the State of Hawaii. I bring you greetings from 
Major General Bob Lee, of course.
    You should have my written testimony submitted earlier, so 
as such, I would just like to summarize and share with you an 
observation and an event that I just experienced, both of which 
I believe are relevant.
    Before I get into that, I would also like to enter into the 
record--I have here the testimony of Mark Moses, who is the 
Director of the State Office of Veterans Services. They are a 
very important partner with all the agencies in the outreach, 
as we have counselors in every county, including periodic 
visits to Molokai and Lanai. So, I think his testimony--I ask 
that it be entered into the record.
    Chairman Akaka. Thank you very much. It will be included in 
the record, without objection.
    [The prepared statement of Mr. Moses is in the Appendix.]
    General Ishikawa. Mahalo. The first and most important are 
the services to our veterans, especially on the neighbor 
islands and our Pacific Island veterans from Tinian, Rota, and 
Saipan. I know that on August 14, Secretary Shinseki announced 
that 28 additional Vet Centers will be established next year. 
This is in addition to the existing 232 community-based centers 
across the 50 States. I further note that two of the additional 
centers will be in Western Oahu. I think they mean Leeward 
Coast and American Samoa. After listening to Secretary Shinseki 
during his most recent visit, I am extremely optimistic that we 
will be seeing marked improvements in care to our veterans.
    It is also a great pleasure of mine to share with a former 
fellow Deputy Director, the Secretary Ray Jefferson. And I 
welcome him back to Hawaii.
    The key, I feel, to a lot of these good things that are 
going on in what I call remote locations is collaboration and 
partnerships. All too often, we get into our silos. We are the 
State, so we only work with State. We are the Federal, so we 
only work with Federal. If we are going to really address the 
problem of remote locations for service to our veterans, then 
we really need to get together and sit down and have a good 
discussion how Federal, State, county, and even non-government 
organizations can somehow partner. We have got a lot of smart 
lawyers. I am certain that we can get there if that is what we 
are determined to do.
    Then an event I would like to share with you, Senator. 
Early this month--actually, I left on August 11--I had the 
opportunity to welcome back to the U.S. Hawaii's own 29th 
Brigade Combat Team, including Lieutenant Tamayo. During my 
briefing about the demobilization, or what we call Reverse SRP, 
or Reverse Soldier Readiness Program, I was pleasantly 
surprised--and this is in Fort Hood, Texas--to learn that two 
new stations had been added to the demobilization. I am not 
sure this is occurring nationwide, but it did occur in Fort 
Hood. They were dental and hearing.
    When I asked the doctors there why they were doing this, 
they were very clear to me how difficult it was for Reserve 
soldiers in remote locations to get those type of services. I 
was really happy to hear that kind of thinking in the 
demobilization station. When I inquired how they defined remote 
locations, however, they answered, places like Saipan, Tinian, 
Rota, and American Samoa. While this is a giant step to 
addressing care to our veterans in remote locations, this type 
of thinking has to be extended, and we will figure out how to 
do this within the Department of Defense to all remote 
locations, because as we know, soldiers from locations like 
Molokai and Keaau on Hawaii Island fits what I would define as 
remote locations.
    So, I am pleased that the conversation has started. We will 
continue to push that conversation to all remote locations, 
even within the continental United States. I think this is very 
important. You have to get to where the veterans are. It has to 
be grass roots. And I like these two things, hopefully as 
indicators that things are moving in the right direction.
    Senator, thank you again for your attention, and I will be 
available for questions after.
    [The prepared statement of General Ishikawa follows:]
   Prepared Statement of Brigadier General Gary M. Ishikawa, Deputy 
                   Adjutant General, State of Hawaii
    Chairman Akaka and members of the Senate Committee on Veterans' 
Affairs, I am Brigadier General Gary Ishikawa, the Deputy Adjutant 
General for the State of Hawaii.
    Within the State Department of Defense, there are four major 
divisions: the Hawaii Army and Air National Guard, State Civil Defense, 
and the Office of Veterans' Services. Mr. Mark Moses, a retired Marine 
and former state legislator, is our Director of the Office of Veterans' 
Services.
    The Office of Veterans' Services is responsible for the welfare of 
our veterans and their families. They also act as an intermediary 
between our veterans and the Department of Veterans' Affairs.
    Hawaii veterans make up more than ten percent of our total 
population. The majority of them--about 72%--live on the island of 
Oahu. About 13% live on the island of Hawaii, 10% are on one of the 
three islands that comprise Maui County, and 5% live on the island of 
Kauai. However, our veteran population continues to grow as Hawaii 
continues to support our Nation's war on terrorism. Since September 11, 
2001, call to active duty have involved nine out of every ten Hawaii 
Army National Guard and Army Reserve soldiers. They have served 
honorably in Iraq Afghanistan, and other locations; and have returned 
to Hawaii after their 12-15 month 
deployments.
    Members of the Hawaii Air National Guard have supported and 
continues to support Operations Iraqi Freedom and Enduring Freedom.
    It is important that these veterans return to their communities in 
good health. The Office of Veterans' Services partners with the 
Veterans' Administration here during the soldier's demobilization 
process. This partnership works to ensure that no veteran or no benefit 
is forgotten.
    The United States government has an obligation to our military 
members from enlistment, through their years of service, and to 
veterans' benefits. We must ensure that all veterans receive all 
entitled benefits now and tin the years to come.
    The National Guard Bureau recently authorized the Army and Air 
National Guard to release medical records to the Department of 
Veterans' Affairs without the veteran's signature. This new procedure 
speeds the Department of Veterans' Affairs adjudication of veterans' 
claims and provides medical care to National Guard 
members.
    I come to you with two concerns. First and most important is 
Veterans' Affair services to all our veterans, especially on the 
neighbor islands and our Pacific Islander veterans form Tinian, Rota, 
and Saipan. In July 2007, a VA clinic opened in American Samoa that 
supports our veterans there. However, veterans from other Pacific 
islands must pay the high cost of airline and hotel accommodations to 
receive follow-on medical treatment. In Hawaii, a similar situation 
occurs when a neighbor island veteran must come to Tripler Army Medical 
Center/Matsunaga VA Hospital in Honolulu for treatment. We must find a 
solution to this situation. One thought would be to establish a 
partnership between the Department of Veterans' Affairs and existing 
medical/health care facilities on the neighbor islands to provide 
medical treatment for our veterans.
    Second concern is the staffing at VA hospitals. For example, the 
Post Deployment Health Reassessment Program (PDHRA) requires an initial 
appointment with 30 days for VA registration.
    On average, the VA hospital schedules initial appointments as much 
as 90 to 120 days from the registration date. Our local VA hospital 
staff has been doing their best to provide services to all of our 
veterans. They have stretched their limited health care provider 
resources to support their mission requirements to all veterans in the 
Pacific Basin.

    In closing, I want to thank the Committee for their continuing 
support of our veterans. Thank you for coming to Hawaii to conduct 
these hearings. Are there any questions?

    Chairman Akaka. Thank you very much, General Ishikawa.
    Now, we will receive the statement of our friend, the 
Honorable Raymond Jefferson.

STATEMENT OF RAYMOND JEFFERSON, ASSISTANT SECRETARY, VETERANS' 
       EMPLOYMENT AND TRAINING, U.S. DEPARTMENT OF LABOR

    Mr. Jefferson. Aloha.
    Chairman Akaka. Aloha.
    Mr. Jefferson. Chairman Akaka, brethren, distinguished 
members in the room today who serve the veterans community, it 
is an honor and a pleasure to be back home. Let me just share a 
few thoughts.
    I am a veteran. I was injured in October 1995 with Special 
Forces, lost my hand in the line of duty. I was medevaced here 
to Tripler, Hawaii, and through the support of Hawaii, of the 
Department of Veterans Affairs, the Vocational Rehabilitation 
Program, all of those partnerships allowed me to get my life 
back, to move forward, and to ultimately today have the 
privilege of serving our veterans through the Department of 
Labor's Veterans' Employment and Training Service.
    Senator, we have the mission of helping veterans and 
transitioning servicemembers have the best possible services 
and resources to succeed in the 21st century workforce. We have 
five aspirations that we are aiming toward achieving that.
    The first is serving as a national focal point for veterans 
employment and training. That will involve increasing 
awareness, access, and participation in all of our programs, 
and improving the employment outcomes for those participants.
    Second, convening, collaborating, and communicating with 
all of our stakeholders so that we can work seamlessly 
together.
    And third, from that first aspiration is ensuring that we 
serve all of those populations with special needs, especially 
homeless veterans, women veterans, veterans in rural areas, and 
veterans who have been ill or injured. During this week here in 
Hawaii, we are also, Senator, going to be reaching out to Maui 
and the Big Island and spending time with the veteran 
populations there.
    We also want to further engage with the private sector, 
make sure they are involved with our programs and processes 
because they have the jobs. We want to work with them, and we 
are going to meet with private sector leaders tomorrow here on 
Oahu and on Thursday and Friday with private sector leaders on 
the Big Island and Maui.
    We also want to boost USERRA's impact and the commitment to 
USERRA. We are very pleased that right now Hawaii has a very 
low rate of USERRA incidents--only four in 2007 and four in 
2008.
    We also want to help transitioning servicemembers to 
transition seamlessly into meaningful employment and careers, 
and to have a particular emphasis on what we call green jobs 
and jobs of the future.
    And finally, we want to invest in our people. I believe 
that the rising tide lifts all boats. We want to help each of 
our team members achieve his or her potential and also improve 
their ability to better serve our veterans.
    Thank you, Senator, and we look forward to your questions.
    [The prepared statement of Mr. Jefferson follows:]
 Prepared Statement of Hon. Raymond M. Jefferson, Assistant Secretary, 
      Veterans' Employment and Training, U.S. Department of Labor
    Chairman Akaka, Ranking Member Burr and distinguished Members of 
the Committee: Aloha! Thank you for inviting us to appear before you 
today to discuss the employment assistance and outreach services 
provided to the National Guard and Reserve in Hawaii.
    The mission of the Veterans' Employment and Training Service (VETS) 
is to provide Veterans and transitioning Service Members with the 
resources and services to succeed in the workforce by maximizing their 
employment opportunities, protecting their employment rights, and 
meeting labor market demands with qualified veterans.
    We accomplish our mission through three distinct functions: (1) 
conducting employment and training programs; (2) enforcing relevant 
Federal laws and regulations; and (3) providing transition assistance 
services.
    VETS administers two programs through formula grants to States that 
directly meet the goals of its mission: (1) the Disabled Veteran 
Outreach Program (DVOP) and (2) the Local Veterans Employment 
Representatives (LVER) program. DVOP specialists provide outreach 
services, and intensive employment assistance to meet the employment 
needs of eligible veterans. LVER staff conduct outreach to employers 
and engage in advocacy efforts with hiring executives to increase 
employment opportunities for veterans, encourage the hiring of disabled 
veterans, and generally assist veterans to gain and retain employment. 
To meet the needs of homeless veterans and help reintegrate them into 
the workforce, VETS administers the Homeless Veterans' Reintegration 
Program. Veterans with significant barriers to employment or service-
connected disabilities are also served through the Veterans' Workforce 
Investment Program, a focused and innovative training program that 
coordinates services available through other VETS administered 
programs. Both the homeless and workforce investment veterans programs 
are funded through a competitive grant process.
    Our enforcement programs investigate complaints filed by Veterans 
and other protected individuals under the Uniformed Services Employment 
and Reemployment Rights Act (USERRA), assess complaints alleging 
violation of statutes requiring Veterans' Preference in Federal hiring, 
and implement and collect information regarding Veteran employment by 
Federal contractors.
    VETS' transition assistance services are offered through the 
Transition Assistance Program (TAP), which provides employment 
workshops and direct services for separating military members, 
including those who are seriously wounded and injured.
                     transition assistance program
    TAP is a Department of Defense (DOD) program that partners with the 
Department of Labor (DOL), the Department of Veterans Affairs (VA), and 
the Department of Homeland Security (DHS). TAP has four components:

    1. Pre-separation counseling--this is mandatory for all 
transitioning Service Members and is provided by the military services;
    2. TAP employment workshops--these are voluntary on the part of the 
transitioning Service Member and are administered through DOL and its 
state partners;
    3. VA benefits briefing--these briefings are also voluntary and 
administered by the VA; and
    4. Disabled Transition Assistance Program--also voluntary and 
administered by the VA.
                        dol employment workshops
    Since 1991, when DOL began providing employment workshops pursuant 
to section 502 of the National Defense Authorization Act for Fiscal 
Year 1991 (P.L. 101-510), over one million separating and retiring 
military members and their spouses have been provided employment and 
job training assistance and other transitional services. DOL was 
further directed to provide these services at overseas locations by 
section 309 of the Veterans Benefits Act of 2003 (P.L. 108-183).
    VETS began facilitating TAP workshops at overseas military 
installations where, by previous interagency agreement, the DOD had 
provided TAP workshops since the program's inception. We are currently 
conducting TAP employment workshops at 55 sites overseas including 
Germany, Japan, Italy, Korea, Guam and the United Kingdom. Our mission 
is to provide TAP at every location requested by the Armed Services or 
National Guard and Reserve Component.
    VETS provides employment search workshops based on projections made 
by each of the Armed Services and the DHS (for the U.S. Coast Guard). 
DVOPs and LVERs are the primary source for TAP Employment Workshop 
facilitation stateside. However, because of the distance between many 
state employment offices and the military installations, as well as the 
rapid increase in Workshop participants, contract facilitators were 
added in early FY 1992 and supplemented by Federal staff in FY 1996. 
Hawaii currently uses contract facilitators.
    The Department of Defense recently set a goal for TAP Employment 
Workshop participation of 85 percent of separating servicemembers. 
Eighty-one percent of active-duty transitioning Service Members 
currently attend the DOL TAP employment workshops, a 30% increase in 
participation since 2001. TAP employment workshop participation is 
expected to increase over the next year, and we plan to target workshop 
delivery to spouses and family members of separating servicemembers, 
including those with limited English proficiency. .
    In an effort to provide the same high level of instruction to all 
servicemembers and spouses attending TAP Employment Workshops, VETS 
requires that all TAP facilitators receive training conducted by the 
National Veterans Training Institute (NVTI) at the University of 
Colorado in Denver. NVTI provides competency based training to further 
develop and enhance the professional skills of veterans' employment and 
training service providers throughout the United States.
    The current course curriculum covers two and one-half days of 
classroom instruction and provides information on a variety of topics 
including:

     Career exploration;
     Resume preparation;
     Strategies for an effective job search;
     Interview techniques;
     Reviewing job offers;
     Prevention of homelessness;
     Entrepreneurship information; and
     Other available support and assistance.
        reserve component and national guard employment workshop
    Global military commitments have necessitated a mobilization of 
Guard and Reserve members that is unprecedented in modern times. The 
longer mobilization periods result in these Service Members now being 
eligible for Veterans' benefits, including TAP. The employment workshop 
is available for Guard or Reserve Members, along with all other Service 
Members, at one of the 215 transition offices located on military 
installations in the United States as well as overseas locations.
    However, Reserve and National Guard members usually transition at 
fewer locations, referred to as demobilization sites. Typically the 
demobilization process is rapid, taking a matter of days once the 
Service Members arrive back in the United States from overseas. During 
demobilization, Service Members may be expected to participate in many 
separate briefings and activities. This leaves little or no time for a 
full two and one-half day employment workshop. Nevertheless, we have 
found that many National Guard and Reserve Service Members would 
benefit from such transition assistance. Our State Directors have 
coordinated with each State Adjutant General and they work directly 
with the individual Reserve and National Guard commanders to make 
special arrangements following demobilization in order to present a 
modified TAP employment workshop to Guard and Reserve Service Members. 
Based on requests from Reserve Component Commanders or Adjutant 
Generals and through coordination with our VETS' state directors and 
local VA staff, VETS has offered to tailor the workshops to the 
identified needs of the transitioning Reserve and National Guard 
members.
    In fact, since 2001 VETS has provided transition services to over 
146,000 National Guard and Reservists. These transition services range 
in size and content from mobilization and demobilization briefings to 
the full scale TAP employment workshops. They are provided in 43 states 
and the District of Columbia. In some states, National Guardsmen and 
Reservists have been allowed to attend the regular TAP for Active 
Component Service Members. The services provided to the National Guard 
and Reserve are tailored to the needs and requests by the DOD.
    To meet the transition needs of the National Guard and Reserves, in 
FY 2007, DOL directed the NVTI to develop a modular version of the TAP 
employment workshop. The traditional TAP employment workshop was turned 
into a 15-module menu that Reserve and National Guard commanders may 
choose from in providing these services to their unit members. This 
training includes a mandatory module that covers local labor market 
information, USERRA, the One-Stop Career Center system, small business 
opportunities, and the risks of homelessness. The other 14 modules 
consist of the current TAP employment workshop curriculum broken down 
into logical and connected blocks of instruction. This is not a new or 
separate curriculum for the Reserves and National Guard; rather it has 
been packaged to better serve this community.
                           programs in hawaii
    I have provided information on what is being done to assist those 
Service Members transitioning from the military to civilian life. I 
would now like to focus on what we are doing in the state of Hawaii.
    Hawaii averages more than 100 TAP workshops annually with nearly 
4,000 transitioning Service Members in attendance. There are five TAP 
sites, all on the island of Oahu, Honolulu County, encompassing all 
military service branches including the U.S. Coast Guard.
    A DVOP or LVER representative attends each workshop session to 
discuss their respective roles and responsibilities in providing job 
search assistance. Since most transitioning Service Members return to 
the mainland, this information is provided to help the Service Member 
contact the DVOP and LVER representative in their respective states to 
assist them directly with their re-integration into the local job 
market in their areas.
    Our VETS Director in Hawaii meets quarterly with all TAP site 
managers, a VA representative, and a representative from the State of 
Hawaii National Guard to discuss the TAP program and how it can be 
improved. Guest speakers have included the garrison commander at 
Schofield Barracks and the U.S. Attorney for Hawaii.  
    National Guard and Reserve personnel in Hawaii are informed that 
they can attend TAP for up to 180 days after completion of their active 
duty commitment. LVER and DVOP staff assigned to the counties of 
Honolulu, Maui, Kauai, and Hawaii have all been formally trained and 
can facilitate TAP employment workshops either individually or on a 
unit basis.
    Periodic USERRA briefings are conducted upon request and through 
outreach by VETS staff. State of Hawaii Army and Air National Guard 
units as well as Army Reserve have received briefings and USERRA 
outreach within the last six months. National Guard units on the 
neighboring islands of Hawaii (Big Island) and Maui have received 
briefings within the last 45 days. Briefings will be conducted in 
conjunction with the Operation Yellow Ribbon Reintegration Program for 
the return of the State of Hawaii Army National Guard's 29th Brigade. 
These welcome home activities are planned for Oahu on September 20, 
2009, followed by September 26, 2009, in the counties of Hawaii and 
Kona, and October 3 and 4, 2009, for Maui and Kauai counties.
                                closing
    In closing, I again thank you for allowing me to address you today 
on this very important issue. I would be pleased to respond to any 
questions you may have. Mahalo.

    Chairman Akaka. Thank you very much, Ray. We are so happy 
to have you here.
    I have a question for all the members of the panel. How do 
you currently communicate at the local level with one another 
about how to meet the needs of returning servicemembers? Let me 
first call on Tracey Betts for her response.
    Ms. Betts. Here in Honolulu, we meet--myself and Dr. 
Hastings, as well as other folks--on a regular basis or even 
sometimes on a case-by-case basis, but we meet to discuss 
issues. A lot of times, the discussion starts with what can we 
do or what can we improve upon.
    I meet with the folks in the community. We have our service 
organizations who are in the facility with us. We meet with 
them regularly. Basically, it is a revolving door, and as a 
need comes up, we address it, and on a regular basis.
    We have a lot of what I would consider--we do a lot of 
collaboration. We meet with not only the medical side, we have 
the benefit side. We also work with the Vet Centers.
    One of the issues, of course, that is coming up here in 
this hearing today is outreach. We have created a coordinator 
in the VBA side who is starting to network and to develop 
communication with everyone out there in the community, to let 
us know when we are needed for outreach and where are we 
needed, and then we schedule. And what we do is we communicate 
internally with everyone to participate and to ensure that the 
presence of the VA is there during the session or event in 
which we attend.
    Chairman Akaka. Is there a regular schedule for meetings on 
Lanai and other Neighbor Islands?
    Ms. Betts. When dealing with outreach, currently, the State 
of Hawaii has representatives who are out there every month. 
Mark Moses's group goes out and meets with veterans and does 
counseling. When I came out, the VA benefits, they were meeting 
twice a year, and we are looking at increasing that time 
element. On the medical side, they do--can I defer to Dr. 
Hastings?
    Chairman Akaka. Yes, you may. Let me say that we are 
accompanied here by Dr. Hastings, as well, and we are glad to 
hear from you, Dr. Hastings.
    Dr. Hastings. Thank you, Senator. Again, I want to thank 
you very much for all the support you have given us and our 
veterans here over a many-year period of time.
    We have, I think, a very sophisticated informal 
communication system between the groups that support veterans 
here on Oahu and in the Pacific Islands. We are fortunate in 
being all co-located on the Tripler campus. Very importantly, 
we have developed many lines of communication between VA, VHA, 
and Tripler, and they provide us inpatient services and 
outpatient services. But we also are involved with any 
servicemen who are coming back who are going to go into the 
Warrior Transition Unit. As you heard, we now have 
representatives from our organization located in the Warrior 
Transition Unit, both at Schofield Barracks and at Kaneohe. So 
we have developed a very good communication system.
    Also very importantly, as Tracey mentioned, we work 
collaboratively, and Tracey is essentially a member of our 
staff and we are a member of her staff. That is the way it 
works. So she can work with me, but she also can work with 
other members of my staff if the issue is something that they 
are more conversant with. Also they can work with Mark Moses. 
He is right downstairs, and we also have open communication 
with him.
    We also are very fortunate in that the Veterans Service 
Organizations are also housed in our complex, so they have open 
communication with us, as well.
    So, I think we are doing very, very nicely. We have regular 
meetings together and we have a Veterans Advisory Council, and 
both Mark and Tracey sit on our Veterans Advisory Council. So 
we have a lot of open communication with them.
    Now, you asked specifically a question about the sort of 
meeting that you witnessed yesterday in Lanai. I have to tell 
you that we have not had an open forum meeting like that with 
them in some time. But it is clear as I listened to that 
meeting yesterday that this is something we are going to have 
to start doing, and we do have plans to do regular town halls, 
open town halls on the other islands and we will include Lanai 
in that plan. So, we will open up communications with the 
veterans. That is where we sort of stand today.
    Chairman Akaka. Thank you very much, Dr. Hastings.
    The other member I wanted to pose this to is Sheila Cullen. 
Do you have anything to add?
    Ms. Cullen. Thank you, Senator. Just a few. There is not 
much to add to what you have already heard from Dr. Hastings 
and from Tracey Betts.
    I would reemphasize the enormous benefit of having VHA, 
VBA, and DOD co-located here in Honolulu. That affords them the 
opportunity not only to have formal meetings to discuss common 
issues, but to readily have informal sessions, as well.
    Dr. Hastings and Tracey Betts have resolved together that 
when the opportunity presents itself in the future, they will 
be looking to locate some component of VBA along with any 
expansions that we might have for any of our community-based 
outpatient clinics.
    I would also add that some of the outreach efforts that you 
have heard about are joint outreach efforts, and I had seen 
that firsthand last Friday at the convention center for the 
50th commemoration of Statehood. One of the booths was an 
outreach effort manned by VHA and VBA staff and they worked 
together very, very well answering the questions that came from 
some people in the military as well as some civilians and were 
jointly able to pass out information about eligibility and to 
refer some questions each to the other whenever one might have 
more specialized knowledge.
    It is not just at that outreach effort, but at the many 
other Yellow Ribbon and Welcome Home events that we have joint 
participation from the VA to assure a common understanding of 
what the issues are that we face.
    Chairman Akaka. Thank you very much, Sheila.
    Let me ask General Ishikawa to respond to that question. 
General Ishikawa?
    General Ishikawa. If I understand the question correctly, 
it is how we communicate with our veterans. Actually, we have a 
family support group and we have a full-timer. Any information 
that we need to move to the spouses or the family members, 
really, we pass it through them.
    Just because I was curious with a personal reason, I joined 
the Family Support Group for Bravo Troop First of the 299th. 
There was a commander, his name was Captain with the same last 
name as mine, Ishikawa, so I saw it from two sides. The witness 
that said we should try to maintain that Family Support Group 
Network, I think they have it spot-on.
    We put information on the top and I caught it coming back 
at me. There are a lot of volunteers out there, and a constant 
e-mail traffic flow. That is a very strong method of 
communications with the grassroots that I would like to say 
that we relied upon a lot.
    One of the things that was real clear to me, and that is 
why we are really pushing hard for what we call the Yellow 
Ribbon Reintegration, while it is not mandatory, it is a 30-, 
60-, 90-day program where, again, we will talk to not so much 
the veterans themselves but the families. Because they 
demobilized in Fort Hood, Texas, the families were not with 
them. It is actually the families, the spouses and the 
grandpas, like that, they are the ones that are really curious. 
They are the ones that pick up all that information. Talking to 
the soldiers themselves, basically, no matter how much we tell 
them to pay attention, they just want to get back to L&L and 
have a plate lunch. [Laughter.]
    So, we found that getting to the families and using the 
Family Support Network is probably going to be the key to the 
future for us, anyway, for especially our veterans in remote 
locations.
    Thank you, sir, for the opportunity to respond.
    Chairman Akaka. Thank you very much for that. Since our 
troops have been returning as of last week, this becomes very, 
very important. I do understand that when they do come home, 
they want to just rest and do what they want to do and not 
worry about whether they are having any problems at this time. 
You are correct that the family is the one that can really help 
them at this point. But we still need to develop these 
relationships between the different units of the National Guard 
and Reserves as well as the VA for services.
    Let me ask Ray for any comments he may have in this 
particular area. I know we just confirmed you a few weeks ago 
in your position and that you have been working hard to set up 
services for our veterans across the Nation.
    Mr. Jefferson. Yes, Senator. Well, thank you. So in terms 
of coordination at the local level, let me touch on a few of 
the areas there. I want to thank my friend here and colleague, 
General Ishikawa, from our time in service, because in the 
Transition Assistance Program, we meet quarterly with the 
Department of Defense representative, the Veterans Affairs 
representative, and also with the State of Hawaii National 
Guard representative, and so that is a very effective 
collaboration at the transition assistance and program level 
for that resource and service.
    Also, our State Director, who is here today--Tom 
Rosenswike--is co-located at the Department of Labor Industrial 
Relations on Punchbowl. We are very grateful for the support we 
get from DLIR--the Director and the Deputy Director there. So 
we have a very close relationship and that co-location is very 
helpful in that.
    We also partner, Senator, with the Department of Veterans 
Affairs in our Homeless Veterans Reintegration Program. I would 
like to talk more about that later, if it would be helpful, and 
also about the Vocational Rehabilitation Program.
    We additionally have a REAL Lifelines program, and we 
actually have a Disabled Veteran Outreach Program Specialist 
located right at Tripler Army Medical Center. That individual 
works with the veteran when he or she is on active duty and 
helps them develop a plan for their life and to have a seamless 
transition as they move from active duty to their status as a 
veteran, whether they remain in Hawaii or whether they were to 
go on to the mainland.
    Finally, our State director participates in a variety of 
forums and councils, such as the Oahu Veterans Council, and is 
very involved with the VSOs here. I am very thankful for the 
support that the Department of Labor's Veterans Employment and 
Training Service gets from the VSOs. I just want to 
particularly acknowledge the American Legion and the Navy 
League.
    So, there is a tremendous amount of cooperation and 
communication that takes place and that assures we provide the 
most effective service possible to veterans and transitioning 
servicemembers. At the same time, I am down here to look at how 
things can be further improved.
    Chairman Akaka. Thank you very much for that, Ray. I would 
like for you to expound on what you just suggested, but let me 
ask this question to General Ishikawa. I am concerned that the 
efforts of commands to identify and help those who may be 
suffering from psychological trauma may not be entirely 
focused. The approach seems to be one of providing information 
to a large gathering rather than working to identify those in 
need so as to reach them in a more appropriate setting, which 
could be down to one-to-one. I would add that sometimes these 
sweeping approaches can hurt overall morale while still not 
reaching those in need. A unit's tempo and elements of the 
military culture create a wall that is hard for servicemembers 
to breach.
    What can be done to create an open and private environment 
in which servicemembers will be able to ask for help?
    General Ishikawa. That is a very double-sided, double-edged 
question, because we work in a macho environment where we have 
to be strong. I think we have done a lot of work with education 
for our soldiers. I do see some breakthroughs. The last mission 
which the brigade just came back from, basically, two of the 
units, the 100th and the First of the 299th, had convoy duty 
into Iraq. It was normal policy when any of the units 
encountered an IED or something like that, they would 
automatically send the whole group to a resident mental health 
specialist.
    I think those types of positive things which the 29th 
Brigade did, will play well into the future. So what happened 
was that it doesn't become stigmatized. You had an IED. Your 
whole team goes there. It is to help you. If you catch it right 
after the incident occurs and follow it through--because we 
know who they are now--it should be easier to keep it from 
being stigmatized and easier for us to find it.
    Now, I think it starts right there on the battlefield. If 
we can start it there for all units, I think it will pay big 
dividends. I think it is going to be time before we can shift 
the cultural mindset, but we have just got to keep up our 
education programs. It is OK. It doesn't show weakness. We can 
help you.
    I don't have a magic bullet, Senator. These are just some 
ideas and techniques I think that possibly could lead down the 
road to the ultimate solution. Thank you.
    Chairman Akaka. Thank you very much. What the General is 
referring to, as he said, you can talk to families, but when it 
comes to the troops, they are looking at when they are going to 
eat----
    [Laughter.]
    Chairman Akaka [continuing]. Which is true. I am glad to 
hear that--and you are correct. It starts where it happened, on 
the field. That will certainly make a difference to the troops.
    Ms. Betts and Ms. Cullen, access to health care and other 
benefits and services are ongoing challenges for veterans in 
Hawaii and Guam. I am especially concerned that when our 
National Guard members turn to VA, that the appropriate 
services will not be easily accessible when needed. What 
advances have been made to reduce the burden on veterans as 
they seek VA health care and benefits in areas served by the 
Pacific Islands Health Care System and the Honolulu Regional 
Office? Ms. Betts?
    Ms. Betts. Yes, Senator. In developing and improving 
access, one of the road maps that we developed--one is to 
increase our presence and attend more outreach, as well as to 
utilize the structure. Right now, as we had alluded to earlier 
or discussed earlier, was the placement of a benefit person 
where the medical assistance is in all of the CBOCs. The 
medical facilities are growing and they are relocating to have 
easier access to the veterans, and with that we have worked 
out, or they have committed to us to allow for space because 
that is always an issue--we can put people out there. Finding 
the space that they will occupy is a challenge, so, we have 
been looking toward that.
    The challenge for us is obviously the geography of the 
jurisdiction that we have, such as places in Guam, Tinian, 
Rota, American Samoa, and particularly here in the islands. All 
of the outer islands, we have those kind of challenges.
    The discussion came up yesterday of when do you--what are 
the requirements to have a full-time person sitting there in a 
chair 8 hours a day? The reality of it is, when there is a 
need, when the veterans are present, and so the outreach 
approach is to try to get them to identify themselves and tell 
us where they are. Once we know where they are we can then 
provide those services and reach out to them, whether it is 
through periodic visits and/or if we need to be there on a more 
permanent basis.
    So, what we are doing right now is looking--we are working 
on a very collaborative effort in understanding where these 
veterans are, what their needs are, and how we can together 
provide full, comprehensive services for them both on the 
benefits as well as the medical side.
    As far as getting information out there, of course, 
everybody assumes that now that we are online, it is easier for 
people to apply for their benefits. The part that is missing is 
that veterans, or what we call the end users, don't all have 
computers or access to them; so we are trying to look at that 
part of it--the technology side of how can we better improve 
access for them. Although we have the methodology, we need to 
look at the actual veterans, see where they are at and see how 
can we help them. Ideally, the non-government entities or the 
service organizations or other veterans and volunteer folks can 
help us to determine how can we get those people access to the 
structure that we placed out there.
    Chairman Akaka. Thank you.
    Ms. Cullen?
    Ms. Cullen. Thank you, Senator Akaka. What we have done, is 
made improvements in bringing health care to the veterans in 
remote areas such as American Samoa and Guam. In late 2007, we 
opened a new CBOC on American Samoa and that has been very well 
received by veterans. I don't have the numbers in front of me 
of how many veterans we have seen there, but the numbers have 
increased very dramatically from the numbers who had been seen 
when we had a part-time presence on the island.
    In Guam, we will be replacing the current CBOC with an 
expanded clinic and it will be located on the perimeter of the 
Naval Hospital in Guam, which we think will be an improvement 
for veterans. Right now, they need to go through the security 
process at the Naval Hospital in order to access the clinic, 
which is within the hospital there. So, in March of next year 
we will have an expansion of services in Guam.
    We have both primary care and mental health services 
available at both clinics. As Tracey Betts referenced, we are 
looking to accommodate benefits counselors in both locations, 
as well. With those great distances and the challenge it 
presents, we are hoping to expand our utilization of telehealth 
and tele-mental health services. We look forward to providing 
you with a demonstration of how we utilize that technical 
capability later on this week at the hearing on Friday.
    Chairman Akaka. Thank you for that.
    Let me just ask Dr. Darkins whether he has any comments to 
make.
    Dr. Darkins. Thank you, Mr. Chairman. Telehealth uses 
information communication technologies to make health care 
accessible. Certainly, the distances involved and the services 
required in Hawaii and the Pacific Islands lend themselves very 
much to the use of telehealth. The Pacific Islands Health Care 
System has been an innovator and a leader in developing 
telehealth in partnership with the military, and also with 
links across to the mainland.
    I think that the services here are really poised to take 
advantage of many new things in the future. The real challenge, 
I think, is to go from what are called point-to-point 
connections to develop a network of care; and to do that, there 
are various issues that need to be addressed.
    First, there are telecommunications issues to be able to 
ensure there is that connectivity.
    Second, it is necessary to have the culture. We heard 
earlier about the importance of relationships. Despite using 
technology, it doesn't work unless it fosters those kind of 
relationships. So, visiting some of the clinics, which I have 
had the opportunity to do this week, shows just some of the 
ways in which that needs to take place.
    I certainly commend what is being done here and look 
forward to seeing the further growth of telemedicine as a way 
to deliver the kind of services which we are hearing are 
required.
    Chairman Akaka. Thank you, Dr. Darkins.
    This name has been mentioned here, and I want to take the 
time to mention that Mark Moses is here. He is with the Office 
of Veterans Services, Department of Defense, for the State of 
Hawaii, and he is available to veterans for veterans services. 
He is another one that veterans can call on for help.
    Ray, I am delighted that you could be here on what must be 
one of your first engagements since becoming Assistant 
Secretary for Veterans' Employment and Training at the 
Department of Labor.
    Mr. Jefferson. My first one.
    [Laughter.]
    Chairman Akaka. Very good. As a disabled veteran who has 
utilized VA services and who is now in a position to make 
positive contributions for those who have worn this Nation's 
uniform, can you please share some areas in which you believe 
that transition services can be improved, as well as some 
things that DOD, VA, and Labor are doing right, and expand on 
what you had suggested you would do.
    Mr. Jefferson. Thank you. Senator, let me first just share 
maybe a picture of the journey of how the Department of Labor's 
Veterans Employment and Training Service can help 
servicemembers and veterans.
    When the active-duty servicemember, to include National 
Guard and Reserve who were mobilized and now are being 
demobilized, when they are transitioning out, we have the 
Transition Assistance Program, which is conducted in 
collaboration with the Department of Defense, Department of 
Veterans Affairs, and the Department of Homeland Security. So, 
we provide a 2\1/2\-day employment workshop through that 
Transition Assistance Program. So, that is the first service 
and resource that we can provide to servicemembers.
    Second, when they return, either when they have been 
mobilized and they are being demobilized, if they come back and 
realize that their job or employment has been given away as a 
result of that deployment, we have the USERRA program that 
helps guarantee their rights and we go ahead and work to ensure 
that those rights are maintained. And if there is a situation 
of employment discrimination, we investigate that and work to 
resolve that. So that is the second area and service that we 
can provide for servicemembers and veterans.
    Third, once a servicemember has transitioned to being a 
veteran, we have what we call our Disabled Veterans Outreach 
Program Specialists, or DVOPS. It is a long phrase, but a very 
important role. We also have our LVERS, Local Veterans 
Employment Representative Services. Here is the bottom line: 
these people work with veterans one-on-one to get them jobs. 
Our Disabled Veteran Outreach Program Specialists--we have one 
here on Oahu, one on the Big Island, and one on Maui--I will be 
meeting with them this week to get their insights on how things 
can be further improved.
    We also have four local Veterans Employment 
Representatives: three on Oahu, one on Kauai, and one of them 
on Oahu is co-located at Tripler to help the seriously disabled 
and injured veterans there.
    There are two more areas in which we can help veterans. 
One, we have a Homeless Veterans Reintegration Program. We have 
on this island a rural location that I visited yesterday, 
Kalaeloa; and we have an urban location where I will be this 
afternoon called Network Enterprises. Rene Berthiaume is here 
today and I am very appreciative of his support, and we are 
looking forward to spending time together. We are getting very 
good feedback on the impact these programs are having to help 
homeless veterans get back on their feet and to get jobs.
    And finally, for those servicemembers who are seriously, 
seriously injured, we have a REAL Lifelines program where we 
help them develop a life map to move from being injured in the 
military to going through whatever retraining is necessary to 
create a meaningful life and career. There are things which are 
working well. There are also things that can be improved, and 
if you would like me to comment on those, I would be very 
willing and eager to do so.
    Chairman Akaka. Thank you very much, Ray, for that. It is 
good for Hawaii to know what you are doing here. Thank you.
    Mr. Jefferson. Thank you, Senator.
    Chairman Akaka. Ms. Betts, your testimony touches on the 
Hawaii Beyond the Yellow Ribbon Exposition that the Military 
Services Coordinators and other Honolulu Regional Office 
employees will participate in during September. Can you expand 
on the information that will be provided at this exposition and 
detail any other efforts that are underway to inform Guard 
members of benefits and services for which they are eligible?
    Ms. Betts. The function itself--what will happen is the 
Department of Veterans Affairs will have a booth there with 
representation from all of the components, and those components 
are from the medical staff, from the benefits staff, as well as 
the Vet Center staff. The expectation is that all information 
that we have for them will be available and will be provided at 
that time. We will have brochures for all the different benefit 
programs. We will have representatives from the different 
benefit programs, such as a loan guarantee representative, the 
voc rehab representative, as well as the compensation-pension 
program. What we plan to do is be there to answer questions, to 
take inquiries, and if necessary, to take claims.
    As far as what else we are doing out there: we have been 
involved with the Yellow Ribbon Program that the Guard and the 
Reserves have. As I had indicated earlier, we have an Outreach 
Program Coordinator, and their job is to get into the network 
of the needs of both veterans--those in the Guard as well as in 
the Reserve, and even in the active service, anyone out there 
who needs to know about benefits--about VA and what we have to 
offer. We have been trying to get the word out there, contact 
that individual and let them know and it will be on our 
schedule.
    Right now we participate in the Guard's 30-, 60-, 90-day 
reintegration program. We have counselors who go in for every 
one of those. Of course, we have the normal TAP briefings, but 
right now, it is if you call, we will come. So, we have been 
trying to get out there to get the word out and to find out 
what information is needed and how to better improve our 
presence as well as access they have to benefits.
    Chairman Akaka. Thank you very much, Ms. Betts.
    General Ishikawa and Ms. Betts, one issue that we hear of 
time and time again from VA and servicemembers is the 
difficulty VA has in gathering Guard and Reserve records. This 
is regarding records for the claims process. Obviously, this 
impedes the timeliness of receiving compensation.
    My question is, what can be done to improve this particular 
process? General Ishikawa, followed by Ms. Betts.
    General Ishikawa. I think right now, and even in the really 
difficult times that we are having in the State of Hawaii 
economically, Mark Moses and his folks are on the tip of the 
spear. They meet with the veterans out there, especially more 
so in our remote locations, and they actually help them fill 
out the forms. And Mark can probably talk a lot more about 
this, but I think when I talk about partnerships and 
collaborations, I think all the agencies need to get together--
the VA clinics, the Vet Centers, and all of that--because we 
are servicing the same folks in these remote locations.
    So, I cannot see why we cannot take the meetings and 
communications we do here on that one campus to the neighbor 
islands where we have the services. I challenge Director Moses 
to start collaborating with the various agencies out there. I 
think if we start pushing that more and more, we will see a lot 
better input, and I think that is the key. A lot of times we 
see the records--applications--go in and they get returned, 
missing this, missing that, and that is where Mark and his 
great team steps in. They actually 
sit down with the veterans and help them fill out the forms. I 
think more work on collaboration and partnerships is the 
ultimate answer.
    Ms. Betts. One thing I can say is here in Hawaii, we do not 
have the same or similar issues that you see in other stations, 
and that is access to the records. I do know that what we have 
started to do is we have started the conversation with the 
Guard in how to get better access or how to better secure this 
information.
    One of the things we found out in this conversation was 
that they do centralize their records here in Hawaii, which 
makes it a little bit easier for us. So, what we have done is 
one of my staff has entered into conversation with the records 
manager and discussed access to points of contact. So, we have 
set up a structure and we have managed--as he said, the 
collaboration of the agencies and finding the right people and 
continuing the conversation has improved the process, but it 
also is not as--this issue here is not as prevalent as it is 
other places because of this. And I think it will definitely 
improve just because we have started that conversation.
    Chairman Akaka. Thank you very much, Ms. Betts.
    I want to ask Ray----
    General Ishikawa. Senator, if I could, my apologies----
    Chairman Akaka. Oh, sorry. General Ishikawa?
    General Ishikawa. In my written testimony, and I apologize 
for not mentioning this, the National Guard Bureau recently 
authorized the Army and the Air National Guard to release 
medical records to the Department of Veterans Affairs without 
the veterans' signature. So if that is the medical records we 
need, then we have that authority to do that now.
    Chairman Akaka. Thank you, General.
    Ray, you understand the unique needs of Hawaii and Hawaii's 
veterans. You did mention what you are doing now. I just want 
to give you an opportunity to expound on any other programs 
that you may have to provide to veterans as they return home to 
the islands, given Hawaii's unique geographical challenges that 
we have.
    Mr. Jefferson. Sure. Well, Senator, let me first begin by 
thanking Lieutenant Tamayo for your comments and Sergeant First 
Class Tuimalealiifano, my fellow Special Forces man, because 
one of the things that was very important for me--and we 
discussed this at my confirmation hearing--is to get out of 
Washington, get out into the field, out of the urban areas and 
into the rural areas to see what is really happening with the 
veterans.
    So, Senator, there are some things working very well. There 
is tremendous interagency cooperation among the Federal 
agencies and the State agencies. Everyone cares deeply and is 
tremendously committed. The TAP Council, where we meet four 
times a year, has a significant impact to improve that program 
for the participants. The Homeless Veterans Reintegration 
Program brings a lot of best practices to help homeless 
veterans make that journey to employment and to deal with the 
issues that can prevent employment, such as substance abuse and 
addiction.
    But there is additional room for improvement. I don't have 
all the answers, and so one of the reasons I am here and one of 
the things we are going to do this week is to get out to the 
different islands to talk to the veterans and to talk to the 
Veterans Service Organizations to find out specifically what 
their needs are and how they would like to see the programs 
improved.
    But let me share two thoughts. First, we have the 
responsibility to provide coverage to all veterans throughout 
Asia Pacific--Guam, Saipan, Tinian, Palau, Federated States of 
Micronesia. We presently don't have any Disabled Veterans 
Outreach Program Specialists or local veterans employment 
representatives in those areas. So, that is something I need to 
look at, to find how we provide adequate coverage for them.
    Senator, I also want to share briefly with you a story and 
ask for help from you and from the other members who are in the 
room today. Yesterday, I had the chance to go out to Kalaeloa. 
We have a Homeless Veterans Reintegration Program out there 
called U.S. Vets. They are doing fantastic work. They have 
about 98 veterans out there right now. I met with the veterans 
alone, without any staff around, and was really impressed by 
the tremendous feedback they had on how successful they felt 
the program was. It was helping them deal with addiction, break 
those cycles of dependency, helping them to create meaningful 
lives for themselves, and to find employment.
    But here is the challenge I learned about. There is a one-
mile distance from where the site is located to the nearest 
city and county public transportation, and evidently the 
ridership level is not a significant amount to change that. I 
believe that if nonprofit, private sector leaders work 
creatively in Hawaii, we might be able to help those 45 to 50 
veterans who are out there to find some kind of shuttle service 
to span that one-mile distance.
    I was really surprised to learn that this has been a 
challenge ongoing for about 5 years. Now, I know that we can 
send these men and women thousands of miles away to put 
themselves in danger for the benefit of our Nation. I believe 
that, collectively and creatively, we can find a way to span a 
distance of one mile and get them a shuttle so these 50 
veterans who found jobs can actually get to their jobs.
    So, I am here asking for help. Tom, raise your hand, 
please. This is my State Director. If anyone has ideas, if 
anyone would like to be part of the solution, there are 50 
veterans who found jobs and can't get to them. More 
importantly, something that really annoyed me, Senator, some of 
these veterans have actually been attacked and assaulted going 
or coming on that one-mile walk. So, I think that is something 
that we can do a much better job at and it is just one of those 
things that if I stayed in my office in Washington, DC, I 
wouldn't have known about. But I have full confidence that with 
the aloha spirit here, we can find a solution to help those 
veterans. Thank you.
    Chairman Akaka. Thank you very much, Ray.
    I want to thank the second panel. But before I close this 
hearing, I want to invite those on the panel to make any final 
comments about today's hearing topic or what they have on their 
hearts. I will begin from that side of the room, since the 
microphone is there, and ask each of you to make any final 
statements you may want to make.
    Mr. Jefferson. Senator, I was reflecting this morning on a 
quote by a tremendous leader, an inspirational figure, Eleanor 
Roosevelt, and she said that the future belongs to those who 
believe in the beauty of their dreams. And when our 
servicemembers come back, each of them has unique dreams, 
unique aspirations, unique needs. I just believe that by 
working together, we can do everything we can to help 
Lieutenant Tamayo and Sergeant First Class Tuimalealiifano make 
sure that they achieve their dreams and their aspirations. And 
thank you for your service.
    [Applause.]
    Chairman Akaka. General?
    General Ishikawa. In closing, I want to quote what I 
consider to be a great patriot--General Eric Shinseki--when he 
talked about the G.I. Bill--which I thank you so much for 
passing. He said, ``Lightning is about to strike twice.'' I 
firmly believe that when I go and talk to our soldiers, our 
airmen, our Marines, I see the next great generation. So, thank 
you for all the work you do and thank you to all the veterans 
in the audience.
    Chairman Akaka. Yes?
    Dr. Darkins. Could I make a quick comment, which is also to 
quote General Shinseki. He mentioned a few days ago his belief 
in telehealth and telemedicine as part of the solution to the 
challenges. With his support and with the support of Congress, 
I see it as one of the solutions and look forward to a future 
in which we will provide solutions to the challenges we have 
heard today.
    Chairman Akaka. Ms. Cullen?
    Ms. Cullen. Thank you, Mr. Chairman. I would say that we in 
the VA appreciate your longstanding support for veterans and we 
count on your future support for veterans. We also thank you 
for coming out here and having this panel where you hold us 
personally accountable for taking care of the needs of, as 
Abraham Lincoln said, he who has borne the battle. So thank you 
for that and thank you for coming here with Secretary Shinseki 
last week to also hold us accountable.
    Chairman Akaka. Thank you.
    Dr. Hastings?
    Dr. Hastings. Thank you, Mr. Chairman. It is very 
important, I think, for the VA to recognize the low-density 
populations that they have responsibility for, that we have 
responsibility for, in the islands and the Pacific. We have low 
density, so we don't have the big numbers, and this is home. As 
we heard today, all of us want to be taken care of as near home 
as we can; and certainly when we are stressed and have 
significant challenges in life, we want to be near our homes. 
That is where we can get the best cures, and we have ample 
evidence that that is the case.
    At the VA, we have heard now that the VA is changing its 
focus and putting resources into care in low-density, rural and 
very rural areas, so I think the VA is taking on a new role in 
its obligation to care for veterans, and that is the world that 
we live in. You saw some of it yesterday on Lanai. I can tell 
you that I have been to Tinian, I have sat with a veterans 
group in Tinian and talked to them about their frustrations 
with health care, and I have talked to the veterans in Saipan, 
and on our next trip, we are going to Rota, where the 
concentration is even smaller.
    But, I think these are veterans who have been underserved 
by the VA and I think I am very proud to be in an organization 
that is recognizing this obligation and building in a direction 
using all of the modern technology and all the modern science 
that we know. We have learned to deliver care to veterans who 
earned the care in their home. Thank you.
    Chairman Akaka. Ms. Betts?
    Ms. Betts. Yes, Senator. I would like to make a general 
statement on my behalf that I am committed with the position 
that I have here, to ensure that the employees that work under 
me start to look and take advantage of what we refer to as 
opportunities, and each opportunity that occurs every day is 
when a veteran walks into our door. The way I would like to see 
it develop over time is that they recognize it as an 
opportunity when a veteran comes to us--an opportunity to help 
to improve their life--to just experience and discuss or be a 
part of that moment in time that we are part of for them.
    What we are working on, as I know you had discussed with me 
when I first met you, what you had told me was you would like 
to see the VA have a motto, and I said, yes, sir, I will work 
on that motto, and I am still working on it. But I do know that 
one thing that comes to mind, and that is that every employee 
who works at the VA when a veteran walks in the door or when 
the veteran calls on the phone, is the first thing they should 
think about is what we can do, and that might be my motto if I 
work on it hard enough.
    But it is something that we need to get back to realizing--
that the reason we are here is for the veteran--and we need to 
remember what we can do when they walk in that door and ask for 
our assistance and expect the services that they do. Because a 
lot of it has to do--in our outreach program right now, my goal 
and objective is to help change the perspective of the 
individuals we visit, meaning their perspective of what the VA 
is.
    As I heard the three witnesses earlier, their perspective 
of the VA out there as a servicemember--as a veteran, whether 
it is a Vietnam veteran, World War II, or even the latest OEF/
OIF veteran--is not very good. It is not a very good picture 
that they paint of us. But I am sure that we can improve on it. 
Just as they said, the communications, developing those 
relationships, and here in Hawaii, being Hawaiian, I believe it 
is a place where it can start. The ohana is definitely a part 
of the daily relationships and the building of those 
relationships to bring more grayness to those lines of the 
bureaucracy and the services that we provide.
    I want you to know that the commitment is here to help to 
improve and to develop that thought process of what we as VA 
employees can do for those veterans that we service, and I 
thank you very much for the time.
    Chairman Akaka. Well, thank you. I think you have said much 
in closing.
    I want to thank all of our witnesses for being here, for 
your responses. No question, it is going to be helpful to what 
we are trying to do. We know there is much to be done in order 
to improve the effectiveness of VA's outreach to servicemembers 
returning from overseas. Members of the Guard and Reserve that 
we are focusing on today face unique challenges. It is 
necessary that VA recognize and overcome those obstacles so 
that these veterans receive the highest quality of care. This 
is our challenge today.
    So, I want to thank all of you again for being here today. 
This hearing is adjourned.
    [Whereupon, at 1 p.m., the Committee was adjourned.]
                            A P P E N D I X

                              ----------                              





                  STATE OF VA SERVICES ON MAUI, HAWAII

                              ----------                              


                       THURSDAY, JANUARY 7, 2010

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                          Maui, HI.
    The Committee met, pursuant to notice, at 2 p.m., in the 
Maui Arts and Cultural Center, Maui, Hawaii, Hon. Daniel K. 
Akaka, Chairman of the Committee, presiding.
    Present: Senator Akaka.

     OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 
                    U.S. SENATOR FROM HAWAII

    Chairman Akaka. Well, I want to say again mahalo to Danny 
for leading the pledge and Mitch for offering the prayer, and 
now it is pono. We are ready to go.
    Let me tell you that we as a Committee have held similar 
hearings on Maui before, as you know. Much has improved in 
recent years, for which I am grateful, but it is important for 
us to understand the present challenges. I think you know what 
our country is going through at this time and we must be ready 
to come up with the kind of help that our country needs. Both 
the clinic and Vet Center on Maui are tremendously busy and 
must be available to those Maui veterans who rely on VA for 
their care and to veterans living on Lanai and Molokai as well.
    I applaud the efforts of the VA employees in Hawaii. These 
men and women work hard to help the veterans who seek their 
assistance, and there are many things that VA does well in 
Hawaii, as you know. Hawaii has done, I think, pretty well, but 
we need to continue to do better. There is always room for 
improvement. Indeed, our unique geography, diversity, and our 
kind of way of life require that VA develop a unique strategy 
to care for our island's veterans and to care for it through 
our cultural activities as well.
    Ensuring timely access to mental health services for 
veterans living on Maui has been a challenge due to reported 
shortages of VA and community health providers on the island. 
However, VA has established new mental health positions at the 
Maui Clinic and has expanded telehealth capabilities to other 
islands. There has also been some indication of a desire to 
create a single location on the island for veterans' services 
in lieu of the existing three locations. I hope to discuss 
these and other important issues with veterans and VA today.
    Back in Washington, we have worked hard to ensure that VA 
has the resources to provide the best possible care. In my 
years as Chairman, Congress provided record-breaking funding 
increases to VA. Last year, I introduced the Veterans Health 
Care Budget Reform and Transparency Act to secure funding for 
veterans' health care 1 year in advance of the regular 
appropriations process. And we have followed up that success 
with passage of our Caregivers bill, which would help wounded 
warriors and the families who care for them. This bill, which 
also improves care for women veterans, those who reside in 
rural areas, and those who are homeless, has been sent to the 
House of Representatives. I expect to finalize this bill in the 
coming months.
    Finally, I note that there are many veterans here today who 
would like to testify. While we cannot accommodate everyone's 
request to speak, we do want to hear your views. The Committee 
is accepting written testimony which will be reviewed and made 
part of the record of today's hearing. If you have brought 
written testimony with you, please give it to Committee staff 
who are located outside on the patio. If you do not have 
written testimony but would like to submit something, Committee 
staff will assist you in doing that. In addition, the Committee 
staff is joined by VA staff who can respond to the questions, 
concerns, and comments that you raise.
    A special mahalo nui to Dr. Hastings, Dr. JangDhari, and 
their team who are here to help us as well. Will you raise your 
hands, Dr. Hastings and Dr. JangDhari? [Applause.]
    Once again, mahalo nui loa. Mahalo to all of you who are in 
attendance today, and I look forward to hearing from today's 
witnesses.
    I want to welcome members of our first panel; and I just 
want to pass this on: as far as feelings are concerned, I feel 
real cool. [Laughter.]
    I want to welcome members of the first panel. Our first 
witness is Karl Calleon.
    Our second is Rogelio Evangelista, Advisory Board Member 
for VA Pacific Islands Health Care System; followed by Larry 
Helm, the Commander of Molokai Veterans Caring for Veterans.
    After Mr. Helm will be Clarence Kamai, Jr., a VA Advisory 
Council Member, and his fellow Council Member Danny Kanahele.
    Next will be Paul Laub, the President of the Maui County 
Veterans Council; and Terry Poaipuni, the wife of a veteran. 
Ms. Poaipuni will be followed by Mitch Skaggerberg, who offered 
the prayer and who is President of the Vietnam Veterans of Maui 
County.
    Our final witness on the panel will be Lloyd Sodetani, the 
Maui Representative to the Hawaii Office of Veterans Services.
    I thank all of you for being here today on this panel. Your 
full testimony will, of course, appear in the record of this 
hearing.
    I would like to ask you to begin, Mr. Evangelista--oh, Mr. 
Calleon. E kala mai i'au.

   STATEMENT OF KARL CALLEON, VIETNAM VETERAN AND COMMANDER, 
   C H A P T E R 2, M A U I, D I S A B L E D A M E R I C AN 
                            VETERANS

    Mr. Calleon. My name is Karl Calleon. I am the Commander 
for DAV Chapter 2 in Maui.
    Audience Members. We can't hear.
    Chairman Akaka. Oh.
    Mr. Calleon. Can you hear me now?
    Audience Members. No.
    Chairman Akaka. Pull the mic closer.
    Mr. Calleon. My name is Karl Calleon. I am the Commander 
for DAV Chapter 2 in Maui. First of all, I want to thank you, 
Senator Akaka, on behalf of all the Hawaii veterans for being 
our most vocal and powerful voice for veterans ranked in our 
State.
    As part of the DAV here, I have most often heard the 
following complaints about VA services on Maui.
    First, we need your help to remedy the ongoing loss of so 
many of our best VA doctors and other key veteran service 
personnel. For example, it is extremely disruptive to quality 
and continuity of our veterans' medical care to keep losing our 
primary care providers. They have to wait months then are 
scheduled to start all over again with a new doctor, by then 
they are already overwhelmed with the VA system. Related to 
this ongoing turnover is that we cannot rely on the Maui CBOC 
staff to schedule, reschedule, or set up referrals for outside 
medical appointments because they seem to always be so 
disorganized. As a result, we advise all those veterans getting 
services to follow up with the clinic to make sure they are 
doing what they are supposed to do. But that should not be our 
responsibility.
    The real cause of this ongoing VA staff turnover and clear 
disorganization is that the VA systems under which they work 
are so incredibly inefficient that they get fed up and leave. 
VA management are either not listening to them or they are 
completely ignoring them because they too often do not believe 
change is possible.
    This is why we strongly urge you and the VA Secretary, Eric 
Shinseki, to go and talk directly to our long-time front line 
professionals like Dr. Maurice Kramer, Kathleen McNamara, 
William McMichaels, James Lockyear, Richard McDonald, social 
worker Laurie Aoki and Tamicko Jackson in the State. If given 
the opportunity and support, they can tell you very clearly 
what changes need to be made.
    Another concern we have is that we have a lot of older vets 
here whose doctors are prescribing them grab bars and other 
safety devices. However, after receiving them, they are told 
they have to install them, and they cannot--many cannot. It 
should not be the veteran's responsibility.
    Something also needs to be done about our veterans who seek 
emergency care on weekends or after hours at Maui Memorial 
Medical Center. Too often these veterans start receiving huge 
bills and threatening letters for the services they received. 
This is because the VA refuses to pay these bills since they 
were not preapproved, even though it was impossible for the 
veteran to do so at the time. While most of these veterans 
choosing to challenge these actions eventually do get them paid 
by the VA, this whole process is very distressing to these 
veterans, adds insult to injury, and seems so needless. This 
same problem also occurs too frequently with payments for 
outside medical referrals and consultations.
    The Independent Living Program here has helped hundreds of 
severely PTSD-disabled veterans like myself finally pull out of 
decades of ugliness, depression, and isolation to reconnect 
with our families and communities. However, too many veterans 
are waiting too long to receive these services. I myself had to 
wait 2 years to get my independent living plan written and 
approved. The biggest problem is that only Hawaii veterans are 
required to have their independent living plans approved all 
the way to the VA's Central Office. It just does not seem right 
that only Hawaii veterans are being singled out this way, 
especially when these services have proven to be so helpful to 
so many.
    The incredible workload demands faced by our Office of 
Veterans Services officers are enormous; however, the VA and 
the State cannot seem to come up with whatever is needed to 
secure two full-time staff which are minimally needed to meet 
this demand. As a result, we already lost one long-time OVS 
officer. We just lost another part-time staff person, and the 
remaining officer, Tamicko Jackson, is impossibly overloaded. 
Again, it is our veterans' services that are suffering because 
no one seems to have the power to remedy this matter.
    Maui veterans have been complaining about these related 
problems for some time--the ongoing burnout and loss of VA 
health care service providers and the resulting disruption 
means loss of effective care to our veterans--will not improve 
without significant changes in our VA system and management. 
Thankfully, we have really good VA staff serving us here on 
Maui; however, these remaining diehard professionals are still 
being severely hindered in their jobs to effectively and 
efficiently serve our veterans by unresponsive VA systems and 
management.
    In conclusion, on behalf of all Maui veterans, we sincerely 
thank you for your time and kokua. We also thank you for your 
efforts to make the VA more responsive to our veterans' needs.
    [There is no prepared statement for Mr. Calleon.]
    Chairman Akaka. Mahalo. Mahalo, Karl, for your testimony.
    And now we will hear from Rogelio Evangelista.

STATEMENT OF ROGELIO G. EVANGELISTA, ADVISORY BOARD MEMBER, VA 
               PACIFIC ISLANDS HEALTH CARE SYSTEM

    Mr. Evangelista. Honorable Chairman, Distinguished Members 
of the Senate Veterans' Affairs Committee, and fellow veterans, 
being on the Veterans Administration Pacific Islands Health 
Care System, I thank you for giving me the opportunity to 
testify, especially you, Senator, for all the personal 
sacrifices and unending time you have spent helping with our 
veterans.
    The uniqueness of the Hawaiian Islands, separated from the 
United States by miles of ocean, makes it hard to provide for 
more than 120,000 veterans living here. When I first testified 
back in the year 2007, and again in 2008, there have been great 
strides in health care with the leadership of James Hastings 
and his team of professionals, but a lot still needs to be done 
to assure the best health care to our veterans.
    Unfortunately, unlike the Mainland, there are no bridges or 
tunnels and we need to fly to Tripler. And because of 
disability and cost of the insurance, we incur all those 
expenses. Due to the illnesses and injuries that these veterans 
have received in wartime, many of these veterans have limited 
incomes. To choose between taking care of their families, 
themselves, and flying to Oahu for health care is a choice that 
should not even be an issue for these veterans who have served 
so selflessly.
    I think it is only fair for the specialized services of 
each island to cover any and all the transportation costs that 
I receive that are offered by the Spark Matsunaga Clinic and 
Tripler on Oahu. The VA health care system should take care of 
us 100 percent because the problems that are happening in our 
later years are all part of the cost of war; and when we served 
in the military we did not give only a certain percent, but we 
gave our full 100 percent. In Hawaii, we need to think how we 
can geographically place the best delivery of care, or we will 
deny our veterans quality medical care which they rightfully 
deserve.
    As our WWII, Korean, and Vietnam veterans age, they are now 
faced with more ailments that affect their health, problems 
that were not visible when they were younger. Not only are they 
faced with their health concerns, but also the issues that 
cannot be corroborated due to red tape between the VA and the 
records.
    Senator Akaka, you also know that when a military person 
finishes, their problems are just beginning to start with their 
visible scars and invisible physical and mental scars. These 
issues have not been dealt with, and most of our veterans are 
at that time contemplating committing suicide. Part of the 
billions spent overseas in Iraq and Afghanistan need to be 
spent on the men and women who relive this war on a daily 
basis.
    Senator, we the veterans ask you, the Senate Veterans' 
Affairs Committee, to right what is wrong and to say to the 
veterans, ``Thank you for your service to our country.''
    May God bless our Nation, those in uniform and our 
veterans, and in closing, we the veterans ask for our country 
to love us as we loved our country in keeping it the land of 
the free and the home of the brave.
    Thank you.
    [Applause.]
    [The prepared statement of Mr. Evangelista follows:]
 Prepared Statement of Rogelio G. Evangelista, VAPIHCS Advisory Board 
      Member and President Emeritus, Maui County Veterans Council
    Honorable Chairman, Distinguished members of the Senate Veterans' 
Affairs Committee, and Fellow veterans, being on the Veterans 
Administration Pacific Islands Health Care System Advisory Board, I 
thank you for giving me this opportunity to testify on behalf of the 
Veterans of Maui County. I would like to commend the Committee, 
especially Senator Akaka, for all the personal sacrifices and unending 
time spent on helping our veterans cope with their disabilities.
    The uniqueness of the Hawaiian Islands, separated from the United 
States by 1500 miles of ocean makes it very extra ordinary to provide 
health care to the more than 120,000 veterans living here. When I first 
testified before this panel in 2007 and again in 2008 there have been 
great strides done with our health care here in Hawaii with the 
leadership of Gen. James Hastings and his team of professionals BUT A 
LOT STILL NEEDS TO BE DONE TO ASSURE THE BEST HEALTH CARE TO OUR 
VETERANS.
    Unfortunately, unlike the mainland of the United States, these 
islands are not joined by bridges or tunnels, therefore to obtain the 
necessary medical services needed from Tripler, the veterans need to 
fly, and due to the lack of disability insurance, the veterans incur 
most of the cost of these flights to receive their rightful medical 
services. Due to the illness and injuries that these veterans have 
received during wartime, many of these veterans are on limited incomes. 
Having to choose between taking care of their families and themselves 
and flying to Oahu to receive healthcare, is a choice that should not 
even be an issue for these veterans who have served the United States 
so selflessly. The promises made by the military offer education for 
the betterment of the soldier for life, the ability for home loans on 
the GI bill for the betterment of the soldier's life, and medical care 
for the betterment of the soldier's life. What we are asking for is 
that the medical services be available and not have to be a financial 
liability to the veteran in need of medical services. We ask that the 
transportation costs of those veterans who do not live on Oahu be 
covered fully. Until the time that there are specialized services 
available on each island, it is only fair and just to cover any and all 
the transportation costs to receive these medical services that are 
only offered at Tripler or the Spark Matsunaga Clinic on Oahu. If we 
use the VA health care system, the VA should take care of us 100 per 
cent, cause the problems that are happening to us now in our later 
years in life are all part of the cost of war and also when we served 
in the military we did not give only a certain percent but we gave our 
full 100 per cent. In Hawaii we need to think how we can geographically 
place the best delivery of care or we will deny our veterans quality 
medical care that they so rightfully deserve.
    As our WWII, Korean, and Vietnam veterans age, they are now faced 
with more ailments that affect their health, problems that were not 
visible when they were younger, with the possibility of being service-
connected. Not only are they faced with their health problems, but also 
the issues of getting to prove with collaborating evidence, records 
which the VA cannot provide due to all the red tape between the 
military records and the VA when you need copies of your records.
    As we deal with the incredible injuries and mental health needs of 
our veterans we simply have to do it right in taking care of those that 
borne the battle and we can start by reducing the number of backlog on 
claims, especially those on disability claims. If there is any 
probability that it could be service-connected, it should be approved.
    Senator Akaka, you also know that when a person finishes his 
military obligation and he goes home it does not end there, but their 
problems are just starting, in trying to get health care, getting a 
job, fitting in with the community, reuniting with the family and 
coping with visible and invisible physical and mental scars.
    Senator Akaka, another issue is the families of these veterans. For 
a lot of families the men or women who have left to serve their country 
have come back broken both mentally and physically and this is often 
traumatic to the families to not only welcome back a changed person, 
but to learn how to deal with their disabilities. These families need 
the support of the VA also to deal with needs of the veteran in the 
home situation. The veteran may have been exposed to situations to 
which the average family cannot even fathom much less give support to. 
What options do these families have on their home islands? For the 
families on the outer islands often the costs of transportation to 
receive these services are a deterrent to receiving these services.
    We have done our duty, so now we ask the Senate Veterans' Affairs 
Committee along with the Veterans Administration to do their duty in 
helping the Veterans and their families. There are incredible issues 
that we have to face not only for our newer veterans but also those 
that have served in previous wars, be it World War II, Korea, Vietnam, 
Etc. Caring for our veterans means providing the best health care 24/7 
and rehabilitation and compensating veterans for their injuries.
    We have to honor our returning troops, as you know what happens 
when we don't. Like in the case of the Vietnam Veterans, due to the 
opposition against the war, the men and women who served were not 
honored on their return, they were disrespected. For these men and 
women to endure wartime and come home to be dishonored by society, 
caused tremendous psychological issues resulting in suicides, 
homelessness etc. These issues have not been dealt with and our 
veterans of this current war are committing suicide in large numbers. 
Dealing with these issues is very much part of the cost of war. Part of 
the billions spent overseas in Iraq and Afghanistan need to be spent on 
the men and women who relive this war on a daily basis.
    With hundreds of our troops returning home in dire need of health 
care let us show our appreciation and commitment to the men and women 
who have worn the military uniform in defense of this Nation, let us 
say thank you by asking for unlimited funding to deal with the crisis 
that we are facing to get the veteran soldiers back into society and 
their families, even in this hard economic times we need to know and 
show that the care for the veteran and their families are the 
continuing cost of war.
    The VA is a premier Health Care System, but here in Hawaii, 
specifically the outer islands, the healthcare services are limited. In 
fact, the VA does not have a hospital anywhere here in the Hawaiian 
islands. With the increasing population of veterans here in the 
islands, is it possible that there would be plans for a VA hospital in 
the near future.
    Let me also mention that the Maui County Veterans Council and the 
more than 20 veteran organizations it represents wholeheartedly support 
the aspect of the proposed facility in Kahului at Maui High School of 
which one of our panelists Col. Lloyd Sodetani Ret. will address.
    Last but not the least is the honors that veterans earned while 
serving in the military which is basically the last respect regarding 
the veterans service to his country during his burial rites. We are 
being faced with different issues in providing these various services--
services that were earned and promised when we wore the uniform. Things 
like new memorandums for different branch of service, no available 
personnel, due to deployment for the war, economic hardship on travel 
for the full honor guard, time constraints, etc; WE, THE VETERANS, ask 
you and the Senate Veterans' Affairs Committee TO RIGHT WHAT IS WRONG 
and say to the Veterans ``THANK YOU'' for your service to our country.

    May God Bless Our Nation, those in uniform, our veterans and their 
families and in closing, WE, THE VETERANS, ASK, ``FOR OUR COUNTRY TO 
LOVE US AS WE LOVED OUR COUNTRY'', IN KEEPING IT THE LAND OF THE FREE 
AND THE HOME OF THE BRAVE.

    Chairman Akaka. Thank you very much for your testimony.
    Now I would like to call on Larry Helm.
    Mr. Helm. Senator, if you do not mind, I would like to 
allocate three of my minutes to our Molokai representative.
    Chairman Akaka. I do not mind.
    Mr. Helm. Because he is from out of island and we must be 
helpful to our guests.
    Chairman Akaka. Thank you. Let me repeat that the full text 
of your testimony will be included in the record, but we do 
have a time limit for the presentation of this. So, Larry, you 
have an additional 3 minutes.

STATEMENT OF LARRY HELM, COMMANDER, MOLOKAI VETERANS CARING FOR 
                            VETERANS

    Mr. Helm. Thank you, Senator. Before I start my testimony, 
I would like to give personal thanks to the Molokai vets who 
got up at 4 o'clock this morning, jumped on a boat----
    [Applause.]
    Mr. Helm. I would just to say to you in advance, Senator, 
that when I get through testifying, because we have to get back 
on the ferry we're going to hele on.
    Good afternoon, Chairman, Senator Daniel Akaka, staff, all 
the angels that work for the betterment of veterans and their 
families, fellow veterans and to the audience, aloha.
    Participants. Aloha.
    Mr. Helm. Mahalo, Senator Akaka, for your time to hear 
veterans testify on behalf of veterans. There are lots of 
advocates. You are our number 1 advocate. For that I say mahalo 
nui loa. [Applause.]
    Six years ago, an organization was formed on Molokai called 
Molokai Veterans Caring for Veterans. Today there are 
approximately 600 Molokai veterans. Three hundred veterans from 
all wars and conflicts have joined our organization called 
``Koa Kahiko''--ancient warriors, wise warriors. Services to 
Molokai vets then were sparse and limited. Today, thanks to 
you, Dr. Hastings, Dr. Steve McBride, who helped to hire our 
own resident, Dr. Hefferman, regular visits from our VA angel 
Dr. McNamara, Dr. Springer, Benefit Counselor Joe Thompson, 
Ernie Matsukawa, and many others, beginning next week, we will 
have a home care nurse on-island to fulfill an overwhelming 
need. Today seven veterans qualify for home care, and she is 
here today, and she starts next week. [Applause.]
    Molokai has had the highest percentage of Vietnam vets per 
capita in this country. Many of them have died. Many have been 
in the valleys, the bars, and the crevices of Molokai for a 
long time. Finally, many of these veterans are getting their 
due benefits. And because of the VA services and counselors, 
they are at least having some quality-of-life. Mahalo plenty.
    I come today, of course, with some honey, but also I have 
some lemonade that needs some sugar in it.
    Recently, a Molokai retired Navy lieutenant, Richard Smith, 
who served 33 years in the Korean and Vietnam conflicts and 
received many commendations, died. One of the benefits promised 
to vets like Richard is that they have a full military burial 
when they are on their last rite from Earth. Because his home 
was on Molokai, Richard had a watered-down detail of three and, 
in my opinion, if we cannot own up to our promises made to 
veterans, then how are we going to own up to the rest of the 
world?
    Some veteran organizations like the VFW, et cetera, provide 
burial details. This ought not to happen. It ought to be 
mandatory that all military branches honor these vets with full 
military burials as they promised.
    There are two crypts left in Molokai Veterans Cemetery. Mr. 
Mark Moses, Director of the State Veteran Services, is aware of 
this issue. However, he is constrained by State budget 
problems. Give the veterans on Molokai the materials, and we 
will build the needed addition.
    We acquired official property to build a Vet Center. We are 
in the process. It is a simple building. Needless to say, we 
have been jumping through hoops with the County of Maui to get 
our permit. It's been a 3-year process.
    My suggestion is from the top down give priority status to 
all veteran groups in this country that are advocating and 
helping in the advancement and the betterment of all veterans 
and their families. Many times just going through this process, 
I still think I am in the woods in Vietnam. We are still 
fighting.
    Senator, if you can find it in a little piggy bank stashed 
away, we can use $20,000 to $30,000 to furnish our Vet Center.
    There are many veterans whose records have been lost from 
the Korean and Vietnam era for one reason or another. Some of 
them have legitimate service-connected claims. There ought to 
be a system to give them the benefit of the doubt. Because of 
State budget woes, there was a mental health counselor position 
cut on Molokai. The counselor had over 100 clients, and some 
are veterans. What can we do to help them? Because of privacy 
issues, the VA can find out from the State and get them 
enrolled in the system if not already enrolled.
    On Molokai, we have approximately 60 residents who have 
served in the Mideast conflicts. Some are still serving. Some 
are home now. There ought to be a method of issuing a heads-up 
that these soldiers are returning home so they can be 
identified to be provided needed service before they have major 
problems. I personally have had three different late-night 
calls from parents concerned about erratic, threatening 
behavior from young vets that could have been very volatile. 
Mahalo to the VA, Dr. McNamara, and others who served these 
veterans immediately, and they are moving forward.
    Another personal issue. My nephew served three tours in 
Iraq, wanting to make a career in the army. His paternal 
grandmother, who raised him, died. He was denied to come home 
to her funeral. As the military says, ``only immediate 
family.'' Suggestion: VA, work with the military on exceptions. 
My nephew left the army.
    Molokai has 30 or more Native Hawaiian veterans. Many are 
disabled--service-connected--living on homestead land. There 
ought to be a more efficient process for Native Hawaiian 
veterans to refinance their homes through the VA or other loan 
people. The Department of Hawaiian Homes process is a 
hindrance. They ought not to be. Native Hawaiians served this 
country and deserve equal treatment. In my opinion, the system 
discriminates against qualified disabled Native Hawaiian 
veterans.
    Suggestion: The VA, first, in administering services to 
veterans, if the State is involved with the State counselors 
for veterans, that they be required to use the criteria of the 
Federal VA standards. Many times it is redundant, time-
consuming, and not cost-effective.
    Veterans ought to have: a veteran credit union--easy to do, 
piggyback or a subsidiary like the Pentagon Credit Union; a 
veteran low fixed interest credit card, easy to do. Work with 
major credit cards--Visa, American Express, et cetera. Veterans 
set up the rules.
    Again, on behalf of the Molokai veterans, to Senator Daniel 
Akaka and staff, mahalo for your kokua and your continued 
advocacy for all veterans. Veterans are the soul of America. 
There are citizens and there are veterans. Without veterans, 
there would be no citizens.
    Akua bless you. Mahalo.
    [Applause.]
    Chairman Akaka. Mahalo. Mahalo, Larry, for your testimony.
    And now I call on Clarence Kamai, Jr., for your testimony.

   STATEMENT OF CLARENCE KAMAI, JR., MOLOKAI REPRESENTATIVE, 
                  VETERANS CARING FOR VETERANS

    Mr. Kamai. Thank you, Senator. Now let me turn this thing 
on.
    OK. There is no sound. Let's change mics.
    OK. Can you hear me?
    Participants. Yes.
    Mr. Kamai. Amen. Good morning, Senator, Honolulu VA 
executives, staff of the State Veterans Office, Maui CBOC 
staff, members of panels one and two, and, most important, 
aloha and mahalo to my fellow veterans and comrades.
    Chairman Akaka. Aloha.
    Participants. Aloha.
    Mr. Kamai. Senator, I do concur with my fellow constituents 
here, and I would just like to say thank you for being here and 
for bringing a second round to us.
    I would also like to make mention and really applaud Dr. 
Kathy McNamara for her dedication and work. [Applause.]
    I know Dr. McNamara is working with one of our veterans--
this guy Rodney Ricken. He needs a lot of help. He has put in 
all of his paperwork, and so far to this date and time, we have 
not heard anything from anyone regarding his status. And he is 
looking for his disability and whatnot. So, prayerfully, 
something can happen for Mr. Ricken. Hopefully, we can get 
something going for him.
    But I would like to thank each and every one of you for 
helping us, and my question right now to the Senator is: What 
can we do to help you? How can we help you to help us to get 
what we need? Because we are here. We have been training as 
soldiers, and we will continue being soldiers. We will fight 
for you and become your soldiers. Tell us what you want, 
because we are telling you what we need, not what we want. God 
bless each and every one of you. Aloha. Thanks.
    [Applause.]
    Chairman Akaka. Mahalo. Thank you very much, Mr. Kamai, for 
your statement, and I want to thank you again for your offer 
for us to work together. That is the key. We have got to work 
together to try to get these things done. So, mahalo.
    And now we will hear from Mr. Kanahele for your testimony. 
Please proceed.

                 STATEMENT OF DANNY KANAHELE, 
                   VA ADVISORY COUNCIL MEMBER

    Mr. Kanahele. Thank you, Senator. Thanks to everybody for 
being here.
    My testimony is slightly different. My testimony is about 
thanking everybody for what they do. Senator, I want to thank 
you and your professional team for the hard work they do, the 
time they put in, the hours they sleep--which is not much. 
Senator, I also want to tell you about the staff at Spark 
Matsunaga Veterans Administration under the direction of Dr. 
Hastings. With his professional team, Dr. Hastings' 
administration and his direction have helped Maui. They do the 
best they can, which I am one of them who makes sure they do 
the best they can because that is also my job. Thank you, 
General.
    Again, I would like to thank, Dr. Hastings. I want you to 
know your staff on Maui, under the hands of Kathy Hass and her 
professional team--again, doctors, nurses, administrators, and 
their directors--deserve thanks for everything they do, and 
share and put up with--headaches and sometimes hard times, 
which I am one of them at times. I am honest about that.
    I would also like to thank Dr. McNamara for the Education 
and Independent Living Program, which I think is very much 
needed, and I have been on it. I love it and I am still doing 
it. I like that. I enjoy that.
    Again, I would like to thank Mr. Ernie Matsukawa for 
everything he does with his counselors: family counseling, 
individual counseling, and group counseling. They have made 
advances over there, which I join in once in a while. He shares 
a lot of information with everybody and he shares it and more. 
But, again, you cannot please everybody.
    With this testimony, like I said, it is short, brief, and 
very direct. I thank you, Senator, Dr. Hastings, Kathy, Ernie, 
and Tamicko . I want to thank everybody who puts in time and 
helps us today.
    Thank you.
    [Applause.]
    Chairman Akaka. Mahalo nui loa, Danny, for your gracious 
mahalos to those who have been working hard. We really 
appreciate that.
    And now we will hear the testimony of Paul Laub. Please 
proceed.

              STATEMENT OF PAUL LAUB, PRESIDENT, 
                  MAUI COUNTY VETERANS COUNCIL

    Mr. Laub. Aloha auinala and aloha kakou.
    Chairman Akaka. Aloha.
    Mr. Laub. I am Paul Laub and I have the honor of being the 
President of the Maui County Veterans Council.
    First, I would like to read a letter from County Council 
member Bill Kauakea Medeiros, who is or was here. It says:

          ``I am writing this letter to you as a concerned 
        veteran and a Maui County council member that feels 
        that we veterans are not receiving the most efficient 
        and cost-effective facilities and services for the 
        funds that the Veterans Administration spends on Maui. 
        Our second proposal would be more efficient and cost-
        effective because it would bring all the veterans' 
        services to one location rather than having the 
        services at three different locations as it exists 
        today. Currently, insufficient parking at all three 
        locations is a problem. Additionally, confusion and 
        frustration results when a veteran goes to the wrong 
        location and needs to drive 20 or 30 minutes to another 
        location. In the long term, the costs for VA would be 
        substantially less than the total amount the VA will 
        have paid for these three--and will pay in the 
        future.''
          ``The State of Hawaii's Departments of Defense and 
        Education are also providing fair-share contributions 
        to make this a reality. The VA will continue to own its 
        facilities and be able to upgrade its facilities as 
        technology and operational needs change. Being rent-
        free will result in substantial savings to the VA. This 
        complex will benefit all of our veterans and, with 
        proper coordination, provide immeasurable benefits to 
        our students and our neighboring communities. As a 
        faithful constituent and member of our local government 
        legislative body, I humbly ask that you favorably 
        consider the proposal and to initiate funding for that 
        purpose. Mahalo for your kokua.
        Bill Kauakea Medeiros.''

    I also happen to have a letter from Council member Jo Anne 
Johnson, who is the wife of a World War II veteran who is in 
difficult straits at this time. It says:

          ``As the wife of a veteran of World War II, as a 
        member of the Aging with Aloha coalition, not to 
        mention my public service as an elected official, I am 
        acutely aware of the needs of our veterans here in Maui 
        County. Partially due to our isolation, but also 
        because of the increasing number of veterans who 
        require services, we are facing a crisis here in our 
        county. With funding being limited for programs that 
        help support our veterans and their families at both 
        the State and county levels, we face diminished 
        services at a time when demand is on the rise. Programs 
        that provide for the needs of veterans such as medical 
        care, dental treatment, and mental health counseling 
        are critical to our community. Also, rehabilitation for 
        our disabled veterans, caregiver support services, 
        reimbursement for relatives who care for loved ones, 
        and educational retraining must be considered as key 
        components of any health care delivery system for those 
        who have served our country.''
          ``Our veterans trusted that while they were caring 
        for our country that their families and themselves 
        would be cared for in return. That assumption has 
        proven over time to fall short of expectations of our 
        vets and family members. Many servicemen and women 
        cannot get simple counseling to find out what services 
        are available to them and their families or what the 
        requirements are for eligibility. We need to provide a 
        one-stop service center that is accessible, that is--
        and that is adequately staffed to support the needs of 
        veterans and their loved ones.''

    Our members, our veterans, who were once strong, 
resourceful, and independent men--the heroes of yesteryear--
have now found that they have aged. This aging has robbed them 
of their strength, and many of their abilities have been 
diminished. Now these men are stooped with age and need the 
great services that our Government can offer to these warriors 
of our history.
    The problem is that getting these services has been 
unnecessarily difficult due to the random locations of each 
service. It appears that this problem can be resolved by 
building a Veterans Campus on the 4\1/2\ acres of land at Maui 
High School that has been offered to us by the State of Hawaii. 
Please give this possibility your soonest attention.
    We now have no burial facilities in West Maui. The very 
generous Ka'anapali Land Company has offered us 15 acres of 
land for this purpose. May I urge you to assist in whatever way 
possible to ensure that we receive and properly utilize this 
great gift.
    The Veterans Cemetery at Makawao is almost at full 
capacity. I understand that there is a proposal to expand it 
through purchase of neighboring property. May I also urge you 
to help effect this transaction.
    We, the veterans of Maui County, greatly appreciate and 
wish to thank you for your many, many assistances to us.
    Thank you.
    [Applause.]
    [The prepared statement of Mr. Laub follows:]
   Prepared Statement of Paul Laub, President, Maui County Veterans 
              Council and Member, West Maui Veterans Club
    Senator Akaka, thank you for coming home to Maui. As the youngest 
member of the West Maui Veterans club, of which you are listed as a 
member, and President of the Maui County Veterans Council, it has 
fallen to me to bring some issues to your kind attention.
    Our members, once strong resourceful and independent men, the 
heroes of yesteryear, have now found that they have aged. This aging 
has robbed them of their strength and many of their abilities have been 
diminished. Now these men are stooped with age and need the great 
services that our Governments afford to these warriors of our history. 
The problem is that getting these services has been unnecessarily 
difficult due to the random locations of each service. It appears that 
this problem can be resolved by building a Veterans Campus on the 4\1/
2\ (four and one-half) acres of land at Maui High School that has been 
offered to us by the state of Hawaii. Please give this possibility your 
soonest attention.
    We now have no burial facilities in West Maui. The VERY generous 
Ka'anapali Land Company has offered us 15 (fifteen) acres of land for 
this purpose. May I urge you to assist in whatever way possible to 
ensure that we receive and properly utilize this great gift?
    The Veterans Cemetery at Makawao is almost at full capacity. I 
understand that there is a proposal to expand it through purchase of 
neighboring property. May I also urge you to help effect this 
transaction?
    We, the Veterans of Maui County greatly appreciate, and wish to 
thank you for your many assistances to us.
    If there is any way I can be of assistance to any Veteran endeavors 
please do not hesitate to ask.

    Thank you, again.

    Chairman Akaka. Thank you. Thank you very much, Mr. Laub, 
for your testimony and your idea of consolidation.
    And now we will hear from Ms. Poaipuni. Terry, will you 
please proceed with your statement?

                 STATEMENT OF TERRY POAIPUNI, 
                   WIFE OF A VIETNAM VETERAN

    Ms. Poaipuni. Aloha, Senator Akaka and Members of the U.S. 
Senate Committee on Veterans' Affairs. My name is Terry Lee 
Poaipuni, and I am the wife of a Vietnam veteran. I was born 
and raised on the east side of Maui in a place called Hana. I 
have worked for Maui's Native Hawaiian Health Care System, Hui 
No Ke Ola Pono, for 19 years. I will refer to Hana as East Maui 
because the district encompasses a bigger area than Hana. The 
number of veterans in East Maui is 75-plus, and this is not 
counting the National Guard and Coast Guard veterans. I am sure 
there are more veterans out there that I have missed.
    Nearly 5 years ago, the State Office of Veterans Services 
would send William Staton to Hana once a month to assist the 
veterans living in East Maui. Ten years ago, a registered nurse 
from the Veteran Clinic used to come to Hana Medical Center to 
see veteran patients. Presently, the State Office of Veterans 
Services does not come to East Maui. I have spoken to our State 
representative, and due to the State economic constraints, 
services by the State Office of Veterans Services were cut. 
Tamicko Jackson, who has taken William Staton's place, is the 
only person employed by the State who is able to assist 
veterans from Maui, Molokai, and Lanai. Tamicko Jackson sees 
several of our East Maui veterans who drive out to Central Maui 
for their appointments, and I am not sure how long Tamicko 
Jackson will be there. The unfortunate thing is the veterans 
become familiar--or ``ma`a,'' as we say in Hawaiian--to someone 
like Tamicko, and then she or he gets replaced. This 
replacement only makes it harder and more frustrating for the 
veterans.
    The accessibility of services to East Maui veterans is a 
major problem. Counselors Ernie Matsukawa and Ipo Messmore have 
made the Vet Center in Lunalilo Building a safe place for 
veterans wanting to gather and share experiences. Ernie and Ipo 
do an awesome job of counseling our veterans, and we need more 
people like them.
    I find the veterans who gather there have a lot of 
knowledge and information that they are willing to share. This 
is what is missing in the system. That willingness to share 
with the veteran of his or her benefits without them guessing 
and feeling like they need to beg, maybe this is what the 
system is set up to do.
    Hui No Ke Ola Pono, the Native Hawaiian Health Care System 
with an office in Central Maui and a satellite office in East 
Maui, has recently begun working with veterans on the island of 
Maui. Hui No Ke Ola Pono have included on our organization 
intake form a portion for the veteran to fill in. This will 
identify the veteran and give us the opportunity to advocate 
for them. Clay Park, of Papa Ola Lokahi, has been instrumental 
for starting the veteran advocate services at Hui No Ke Ola 
Pono. Clay Park has been helping the veterans on Maui to 
explain how to fill out the Veterans Benefit Administration 
forms and applications, and Clay Park does come to Hana.
    In closing, I would like to know how East Maui can get 
assistance from the Veteran Benefits Administration. My 
understanding is that Joseph Thompson can assist veterans with 
the application process. Can Joseph Thompson come to East Maui? 
Is there a way that a telecommunications site can be set up so 
veterans can access services from East Maui? The veterans need 
to feel like they are part of the system that they fought for 
and not a burden to it.
    Mahalo and thank you for your time.
    [Applause.]
    [The prepared statement of Ms. Poaipuni follows:]
  Prepared Statement of Terry Lee Poaipuni, Wife of a Vietnam Veteran
    Aloha Mr. Chairman and Members of the U.S. Senate Committee on 
Veterans Affair, My name is Terry Lee Poaipuni and I am a wife of a 
Vietnam Veteran. I was born and raised on the East side of Maui, in a 
place call Hana. I have worked for Maui's Native Hawaiian Healthcare 
System, Hui No Ke Ola Pono for 19 years. I will refer to Hana as east 
Maui because the district encompasses a bigger area than Hana. The 
number of Veterans in east Maui is seventy five plus and this is not 
counting the National and Coast Guard Veterans. I'm sure there are more 
Veterans out there that I've missed.
    Nearly five years ago the State, Office of Veteran Services would 
send William Staton to Hana once a month to assist the Veterans living 
in east Maui. Ten years ago, a Registered Nurse from the Veteran Clinic 
used to come to Hana Medical Center to see Veteran patients. Presently 
the State, Office of Veterans Services does not come to east Maui. I've 
spoken to our State representative and due to the State economic 
constraints services by the State Office of Veterans Services were cut. 
Tamicko Jackson, who has taken William Staton's place is the only 
person employed by the State who is able to assist Veterans from Maui, 
Molokai, and Lanai. Tamicko Jackson sees several of our east Maui 
Veterans who drives out to Central Maui for their appointments and I'm 
not sure how long Tamicko Jackson will be there. The unfortunate thing 
is the Veterans become familiar (or ma`a as we say in Hawaiian) to 
someone like Tamicko and then she gets replaced. This replacement only 
makes it harder and frustrating for the Veteran. The accessibility of 
services to east Maui Veterans is a major problem.
    Counselors Ernie Matsukawa and Ipo Messmore has made the Veteran 
Center in Lunalilo Building a safe place for Veterans wanting to gather 
and share experiences. Ernie and Ipo Messmore does an awesome job of 
counseling our Veterans and we need more people like them. I find the 
Veterans, who gather there, have a lot of knowledge and information 
they are willing to share. This is what is missing in the system. That 
willingness to share with the Veteran of his or her benefits without 
them guessing and feeling like they need to beg. Maybe this is what the 
system is set up to do.
    Hui No Ke Ola Pono, the Native Hawaiian Healthcare System with an 
office in Central Maui and a satellite office in east Maui have 
recently began working with Veterans on the island of Maui. Hui No Ke 
Ola Pono, have included on our organization intake form a portion for 
the Veteran to fill. This will identify the Veteran and give us the 
opportunity to advocate for them. Clay Park, of Papa Ola Lokahi, has 
been instrumental for starting the Veteran advocate services at Hui No 
Ke Ola Pono. Clay Park has been helping the Veterans on Maui to explain 
how to fill out the Veterans Benefit Administration forms.
    In closing, I would like to know how East Maui can get assistance 
from the Veteran Benefits Administration. My understanding is that 
Joseph Thompson can assist Veterans with the application process. Can 
Joseph Thompson come to east Maui? Is there a way that a 
telecommunication site can be set up so Veterans can access services 
from east Maui?

    The Veterans need to feel like they are part of the system that 
they fought for and not a burden to it. Mahalo and thank you for your 
time.

    Chairman Akaka. Mahalo nui, Terry, for your testimony.
    And now we will receive the testimony of Mitch Skaggerberg, 
President of the Vietnam Veterans Association.

          STATEMENT OF MITCH SKAGGERBERG, PRESIDENT, 
                VIETNAM VETERANS OF MAUI COUNTY

    Mr. Skaggerberg. Daniel, thank you for coming. Your 
tireless work has really spawned a tremendous number of 
veterans here in Maui to step forward to represent the 12,000 
veterans in Maui and Maui County. You continue to inspire us, 
and we are always amazed at the new benefits that you enact on 
our behalf and the budget increases for the VA to do their job 
more effectively. You are in our hearts always.
    The thing that I think has become apparent is how our 
families cherish what is going on in this community. They are 
probably--they have more benefit than we do because families 
are healing, children fall back in love with their fathers. So, 
truly you represent the ohana of so many veterans, and we want 
you to know that. We never want to stop telling you that, so 
thank you.
    Also, an overwhelming appreciation in the last 2 years 
since you held--we had a pretty tumultuous meeting 2 years ago 
here. I want to give you and your staff credit for giving us 
the extra money, especially in terms of mental health care and 
additional doctors. It has improved the ability of our staff 
here--our doctors and our nurses--to provide us with good care, 
very good care overall. Now, there are some improvements that I 
will address in a minute, but like Danny and Clarence, there 
are a lot of good things to report because of what you have 
done and what our VA director has done. They have rolled up 
their sleeves. It is not easy when you hear criticism and still 
broaden your horizons, and we hope that they could do that 
again today.
    There are three areas that I am going to briefly make 
recommendations on, and the first is voc rehab. I was 
privileged to be the first Voc Rehab Veteran of the Nation in 
1995. I remember you sent me a letter, and that has continued 
to follow through all these years with me, so I have a fond 
heart for that.
    Why has D.C. reinstituted a policy to have all independent 
living programs go up to them for review? There has got to be a 
better way. It is hurting the veterans. I want them and I want 
you to really have them reevaluate that system. Many of the 
veterans are waiting 1\1/2\ to 2 years. Now, these are veterans 
60 years old. It is not like they are 30 or 40 and they have 
the time, and their families are waiting, too. There has got to 
be a better way to get things done like when you were going 
through it in the 90's--6 months to get it approved. They have 
also reduced the limit, I understand, to 15,000 from 25,000. I 
am not quite clear why that is, especially with the cost here. 
So that--I mean, I know the system can be improved. It was--for 
years, and I am not blaming those people from D.C. They 
probably had a good reason, but they have got to understand 
that they are hurting the veterans. They are not hurting any of 
the VA employees or whatever is going on. So, that is one 
recommendation, and I know we have heard that from other people 
before. It is a huge problem, maybe not only here, but across 
the State. Ms. Joy Gavigan would know that.
    The second area is the benefits counselor. We are 
recommending that the VA actually install a full-time benefits 
counselor in the Vet Center to do outreach to Hana and Molokai. 
Joe Thompson is fantastic, but he can only get here once or 
twice a month. The reason I am saying that is the State has 
refused over the last 10 years to add another counselor through 
the State Office of Veterans Services, and they have burned out 
about three of those people on the neighbor islands because of 
it. Pat Pavao, Bill Staton, and Manuel Brigadora on Kauai, they 
are not nurturing their people, they are wearing them out 
because we need more counselors on the neighbor islands.
    Sparky Matsunaga is the one that got the Governor in 1987 
to start the Office of Veterans Services for Hawaii. He 
understood the critical need. They have done nothing since, and 
the workload has gone up tremendously. So, Maui sees the same 
number of veterans as Oahu. Oahu has three. We have been trying 
to get it through the State for 10 years. It falls on deaf 
ears. They give us less than $1 million a year to service 
125,000. The best tip that the veteran leader said was let's 
get a full-time benefits counselor in Maui County, and outreach 
especially for the Iraq and Afghanistan vets coming home. We 
have got 900 to 1,000 in Maui that are going to be leaving 
their units or be back for good in the next year. So, that is a 
high priority.
    [The recording got cut off and resumes with another 
speaker.]
    [The prepared statement of Mr. Skaggerberg follows:]
Prepared Statement of Mitch Skaggerberg, President, Vietnam Veterans of 
                              Maui County
    Dear Senator Daniel Akaka, Our Aloha to you, Senator Akaka, for 
coming back to Maui to listen to our current experiences and additional 
suggestions to improve about our VA Medical Clinic, Vet Center, and 
Vocational Rehab Programs and Services.
    We want to start with our Overwhelming Appreciation for the 
additional Nurses, Mental Health Doctor's, and administrative staff at 
our Maui Clinic over the last 18 months. Our veterans are very thankful 
for your support, Senator Akaka, in getting us the additional funding 
for these much needed personnel to serve the 2,000+ Maui Veterans using 
our VA Clinic.
    We have seen a big improvement in shorter wait times to access 
mental health support for our 1,000 Maui PTSD Veterans because the 
hiring of an additional mental health psychologist and a mental health 
clinical nurse. Again, thank you, Senator Akaka, for procuring and 
advocating for the funds to get these two additional Mental Health 
providers into the Maui clinic.
    A PTSD psychologist on Maui, Dr. Richard Sword, together with 
Professor Zimbardo of Stanford University, has been using another new 
PTSD treatment method to treat some Maui Veterans that effectively 
reduce PTSD symptoms and treatment times. It's called ``Time Therapy.'' 
We would encourage the VA mental health providers to look at this 
method for possible use in our VA PTSD programs.
    Our Vietnam Veterans also overwhelming support the current proposal 
to house all our VA Facilities at the Maui High School complex; being 
spearheaded by Our Maui County Veterans Council; and its Chairperson 
for this Proposal, Lloyd Sodetani.
    And our wounded Veterans seeking disability compensation need much 
more timely and consistent help in submitting and being provided with 
ongoing help to get their Claims adjudicated. We would like to 
recommend a Full Time Benefits Counselor be added to our VA Maui Vet 
Center. Currently we have a benefits counselor come twice a month from 
our Honolulu VA Regional headquarters; which slows the process and, in 
our experience, can cause unnecessary frustration with the Veteran. 
This could also help the VA reduce its Compensation Claims backlog, 
which is a top priority with our VA.
    Many of our combat veterans who have their disability claim still 
being adjudicated (called CV in the system) cannot get their travel to 
Honolulu paid for by the VA. For much needed medical care. This results 
in withholding critical medical care for them since the care is not 
available on Maui. We believe they are entitled to travel. Travel 
reimbursement is also being withheld for non service-connected veterans 
needing critical care only available at Honolulu VA or Tripler. These 
veterans cannot drive to Oahu and are entitled to care and the travel 
cost to get there! In both situations our doctors tell us these 
Veterans are needlessly suffering because of this policy. Can you get 
us travel for all these deserving Veterans Senator Akaka!
    We have also heard from Combat Disabled Veterans (many with ratings 
of 50-100%) that some of the medical treatment being recommended by our 
Maui VA Doctors is not being approved by our Honolulu VA/Utilization 
board. This has been an ongoing source of frustration with our Veterans 
care on Maui. Why have doctors if the Financial folks on Honolulu have 
the final SAY for our medical care. We would like our Doctors to have 
the Final Say on their Patients care.
    We need help also in getting our Guam Clinic a Mental Health 
Doctor. Because the budget for this position is 60% less than the pay 
in Las Vegas the VA cannot fill the position. Is there any way the VA 
can fix this wide pay difference to fill the position? We have already 
lost a highly qualified Applicant due to this pay issue!
    Last, Maui Veterans seeking vocational rehab, specifically, the 
Independent Living Program, are upset at the procedure set up by the 
Washington, DC, Voc Rehab Office to review and approve all Voc Rehab 
Program Applications by Maui Veterans. We find this policy has resulted 
in major delays in getting Maui Veterans their programs; many times up 
to two years.

    Again, Senator Akaka, we want to thank you for your Tireless and 
ongoing assistance in the overall improvement of our Maui VA health 
care in the last two years. Without your help this would not have been 
possible.

  STATEMENT OF LLOYD K. SODETANI, MAUI REPRESENTATIVE, HAWAII 
                  OFFICE OF VETERANS SERVICES

    Mr. Sodetani [In progress]. I would like to introduce 
individuals who were instrumental in assisting us as a team in 
planning, organizing, and directing this proposed project. I 
would like to begin with a person who represents the Department 
of Defense, State of Hawaii, Brigadier General Gary Ishikawa. 
If he would stand to be recognized, please.
    [Applause.]
    Chairman Akaka. Welcome to our hearing, General.
    Mr. Sodetani. Representing the Department of Education is 
Maui High School Principal Randy Yamanuha. Randy.
    [Applause.]
    Chairman Akaka. Thank you for being here, Randy.
    Mr. Sodetani. The architect who has done pro bono work 
throughout this period of time is Stanley Gima.
    [Applause.]
    Chairman Akaka. Mahalo, Stanley.
    Mr. Sodetani. And through the generosity of Austin, 
Tsutsumi & Associates, Ken Kurokawa, who is a Vietnam veteran, 
an engineer, and a cancer survivor, I would like to introduce 
the surveyor, Tim Lapp.
    [Applause.]
    Chairman Akaka. Mahalo.
    Mr. Sodetani. This was all manuahi, OK? Above all, I would 
like to recognize the organizations within the community, 
including the veterans groups and veterans who are present here 
today, and I would like to thank all of them for all their 
kokua.
    My testimony. Regarding the proposed multi-service complex, 
submitted herewith is a copy of a survey--and I am submitting 
that also--that was conducted by the Hawaii Health Systems 
Corporation on the island of Hawaii. The results of the survey 
indicate similar problems and challenges appearing in East 
Hawaii. It has shown that systemic problems exist relative to 
Hawaii, as it was voiced during your visit with the Hawaii 
veterans last August 2009, and this testimony is being 
presented today. In each geographical location, the consensus 
has been loud and clear that multi-service complexes as 
proposed are needed. It is the contention of the veteran 
advocates that continuing to provide services in the current 
manner would not be in the best interest of veterans, 
particularly since dissatisfaction continues to grow. Creating 
multi-service complexes would benefit all users, employees, and 
the community. By providing a user-friendly facility with ample 
parking in close proximity to all related services, it will be 
cost-effective, efficiently operated, and achieve greater 
satisfaction from veterans.
    It is with sincere appreciation that I express my gratitude 
to you for having this forum. You have provided an immense 
amount of projects and programs for Hawaii and Maui County. For 
those we are truly grateful. We continue to ask for your 
support in our endeavor to have a better quality-of-life for 
all veterans in Hawaii nei.
    Thank you.
    [Applause.]
    [The prepared statement of Mr. Sodetani follows:]
  Prepared Statement of Lloyd K. Sodetani, COL, USA (Ret.), Chairman, 
           State Advisory Board, Office of Veterans Services
    Dear Senator Akaka: Submitted herewith is a copy of a survey that 
was conducted by the Hawaii Health Systems Corporation on the island of 
Hawaii. The results of the survey indicate similar problems and 
challenges experienced in East Hawaii. It confirms that systemic 
problems exist throughout the State of Hawaii as it was voiced during 
your visit with the Kauai veterans last August, 2009.
    It is the contention of the veteran advocates that multi-service 
complexes will benefit all users, employees and the community. To 
continue providing services in the current manner would not be in the 
best interest of veterans, particularly since dissatisfaction continues 
to grow. By providing a user friendly facility with ample parking, in 
close proximity to all related services, it will be cost-effective, 
efficiently operated and achieve greater satisfaction from the 
veterans.
    It is with sincere appreciation that I express my gratitude to you 
for having this forum. You have provided an immense amount of projects 
and programs for Hawaii and Maui County. For those, we are truly 
grateful. We continue to ask for your support in our endeavor to have a 
better quality of life for our veterans in Hawaii nei.
                                 ______
                                 
                               Attachment




    Chairman Akaka. Thank you very much, Lloyd, for your 
testimony and your concerns, as well as your offerings of how 
we can help to improve the system.
    And now, as you know, this is the time for questions. I 
have a question here for all of the witnesses, so what I will 
do--you all do not have to answer. I will just go down the 
line. If you want to answer it, please do. And this has to do 
with the accessibility of service. Can you hear me?
    Audience. We cannot hear.
    Chairman Akaka. OK. This question has to do with the 
accessibility of service, and this is for all the witnesses 
here, and here is the question: Do you feel that VA services on 
Maui are readily available to all veterans? And then if not, 
what improvements do you feel are necessary to ensure access to 
services for all of Maui's veterans? That is the question. 
Maybe I will just open it to anyone who wants to start. Larry 
Helm?
    Mr. Helm. Mahalo, Senator Akaka. As far as here on Maui, 
there probably could be some improvement, but in my opinion, 
10, 15 years ago there was some. Today there is more. Molokai, 
10, 15 years ago, there was none. Today we have a lot thanks to 
you. Mahalo.
    Of course, there is a lot more to do to improve, and that 
is why we are here, to try to--and if I sound sharp sometimes, 
E kala mai, but I am trying to find the right way and a right 
day to make it better for the veterans. I think dialoguing with 
guys that use the services and being more efficient, more 
effective, less time-consuming, finding ways to do that would 
improve accessibility and service to the veterans.
    Chairman Akaka. Mahalo.
    Anyone else?
    Ms. Poaipuni. I think I would like to answer some of 
those----
    Chairman Akaka. Terry Poaipuni.
    Ms. Poaipuni [continuing]. Those questions. As far as 
accessibility to East Maui--and I am saying East Maui because 
that encompasses Kanaio too. It seems like we are on the flip 
side of Molokai. We used to have services, and I do not mean a 
lot of services. We had services; now we don't have any. We 
have been working--I have been talking with Dr. McNamara and we 
meet with Dr. McNamara and Clay Park, we have been talking 
about giving telecommunication a try to find a solution, 
anything, so we could begin to get more services--or get 
services into the community. Oftentimes, our veterans of many 
wars need to take off from their work time, and with the 
cutback of jobs and so forth, that is difficult. So what 
happens is they have got to come up to Central Maui for their 
appointments. So, it would be nice if someone would come to 
East Maui or Hana or Keanae, and if someone could come there it 
would be a lot easier. That way they could come in and do that 
for us, even via telecommunication.
    You know, we have been without for so long, oftentimes in 
East Maui we feel like we are like Molokai--out of sight, out 
of mind--and we've gotten ma`a (used to it), but we do not want 
to be in that same state of mind. We want to be able to 
continue getting in because we have a lot of veterans and we 
need the services.
    Chairman Akaka. Mahalo.
    Mr. Sodetani. Senator, may I comment on that, please?
    Chairman Akaka. Yes, Mr. Sodetani.
    Mr. Sodetani. In my recent testimony to you, I addressed 
part of this. I believe that by combining services or jointly 
providing services through the public health clinic, for 
example--and I believe General Shinseki also spoke about 
telemedicine, using telemed facilities to be able to do 
communications, among other things.
    The Hana Clinic, for example, can be used as an initial 
examination station for veterans, and then rather than the 
veteran coming all the way out here to the clinic for initial 
visits or being sent to Tripler, for that matter. I believe 
that by having a veteran attend the facilities at Hana Clinic 
it would make it more convenient to the veteran and also 
probably make it more efficient and cost-effective as well.
    I believe the Wailuku Clinic that just opened would also be 
another alternative facility for veterans to attend in the 
event the VA clinic here would not be able to support all of 
the needs of the veterans. I am sure they have a lot of 
specialists at the community health clinic that can provide 
additional services to our veterans before our veterans are 
being transported to Tripler. I think we should try to avoid 
that transportation matter as much as possible or try to 
provide a more convenient environment for our veterans so that 
it will be less stressful for them.
    But these are some of the things that I suggested in there, 
and it brought to my mind when I served my last tour at Camp 
Smith in a joint level, that we worked together with Army, 
Navy, Air Force, Marine Corps, and we had to pool our resources 
in order to ensure that we had the best experts and the most 
cost-effective way of operating our mission requirements.
    So, I would like to suggest that Public Health Service 
clinics could be an option for us to consider, especially in 
these remote communities. Thank you.
    [Applause.]
    Chairman Akaka. Thank you.
    Any other comments? Mitch? Mr. Skaggerberg?
    Mr. Skaggerberg. It is amazing how many calls the leaders 
got in the last few months, but one of the big things that we 
have been hearing is that many service-connected veterans are 
not getting the full range of services our VA doctors are 
prescribing, such as chiropractic and massage. There are a lot 
of inconsistencies. They are very frustrated. They need these 
services. And we do not know who it is, whether it is the Board 
of Utilization in Honolulu. I know I have gone through it 
before, and a lot of times they say, well, that is not really 
necessary. And they almost--I do not know if they use doctors 
there, but they take our doctors and they override us. I do not 
know if it is money or what, but I know one thing: a lot of 
service-connected veterans are suffering because of that and 
they are angry. And a lot of these veterans have been serving 
Maui for 40 years.
    So, I would ask our VA reps and you to see if they can 
correct that because that denies them access to certain 
services their doctors want them to have--our doctors. Thank 
you.
    [Applause.]
    Chairman Akaka. Mr. Laub?
    Mr. Laub. Thank you. I want to read part of a letter here 
that came to me from Pastor Daniel Merritt, who is in the back 
with his father. He wrote a letter to the editor because he 
could not get the services that he needed for his father.
          ``I want to just first say thank you for responding 
        to my letter to the editor regarding care of my veteran 
        father. It is very discouraging to have to write such 
        letters, but it has become painfully apparent that 
        things like this must be done. My name is Pastor Daniel 
        Merritt. I am a pastor for the Salvation Army and the 
        chaplain for Maui Community Correctional Center here on 
        Maui. Over the past several months, I have noticed the 
        lack of due care in the health practitioners for my 
        father who did two tours in Vietnam in the U.S. Marine 
        Corps. My Dad was diagnosed with Agent Orange exposure, 
        and as a result, he has leukemia, non-Hodgkin's 
        lymphoma, and diabetes, along with several other 
        crippling diseases.''
          ``I have called VA on several occasions with concerns 
        regarding my Dad's health only to get treated with 
        anything but respect. I followed up with them for over 
        a month for a walker as his feet have become so bad he 
        can barely walk. Only after this letter to the editor 
        was he offered a diabetes specialist which I have been 
        requesting for months. I also asked for an increase of 
        his pain medication, which has never been done. He had 
        to go to a pain doctor as the VA would not supply him 
        with adequate medication for his pain, which he had to 
        pay for out of his pocket. He was prescribed pain 
        patches, shower handles for his shower, and hand 
        controls for his car, but I was told they were too 
        expensive and the VA would not cover them. Can we put a 
        price tag on the vets who fought to keep the country 
        the United States of America? Have we lost the 
        understanding that without them we would be speaking 
        another language?''
          ``It saddens me to know that I have to call the VA 
        and when I ask who I am speaking to, I am told `RP 64.' 
        As I was concerned with all these issues, I called the 
        patient advocate, Alma, and asked her help regarding 
        the situation and was told, `There is nothing to 
        investigate.' I then called the Inspector General, who 
        would only identify himself as `RP 64,' and was told 
        that there was nothing to the claim and they refused to 
        investigate.''
          ``Have we lost our system of checks and balances? 
        These are the veterans of the United States military 
        and need to be treated as such. On this day, my father 
        is sitting at home, alone, in excruciating pain, with 
        no pain pills because he cannot afford to keep 
        purchasing them on his own and is waiting for another 
        empty promise from the VA that his prescription is in 
        the mail. Why can't they fill them at the VA pharmacy 
        or local drug store? I don't understand. Today, as the 
        son of a strong man who has been reduced to nothing for 
        his country, I am humbly asking for your assistance. 
        Pastor Daniel Merritt.''

    Chairman Akaka. Thank you very much, Paul, for your 
response here to the question.
    Any other responses? Rogelio Evangelista.
    Mr. Evangelista. Senator Akaka, due to the economic times, 
we need to honor the veteran because they went out there to do 
what was needed. And if honoring the veteran is just a minute 
thing that we need, we need a VA hospital within the islands 
that will take some of the pressure off, not just with Spark 
Matsunaga but some hospital itself. And the part is we need to 
lift the restriction of the Millennium Act sending the 
veterans--although they are only 10 percent or whatever--send 
them to get specialized medical care also.
    Thank you.
    Chairman Akaka. Thank you very much, Rogelio Evangelista.
    Are there any other further responses? Before we continue, 
I want to say mahalo to the veterans from Molokai.
    [Applause.]
    Mr. Helm. Thank you, Senator Daniel Akaka. This is a fine 
time for Maui, Molokai, Lanai, with President Paul Laub. The 
power is in the veterans. We form a coalition and get 
politically active. For those who are veteran-friendly get them 
in, and those who are not get them out.
    [Laughter.]
    Audience Member. Imua!
    Mr. Helm. And that is the direction. I think we have got 
enough numbers there. We have got 12,000. And although we are 
aware, Senator Akaka, we'll keep you posted. Thank you again.
    Chairman Akaka. Mahalo.
    [Applause.]
    Mr. Helm. Thank you. I want to invite you guys over to 
Molokai when we have our building dedication, OK?
    Chairman Akaka. Mahalo. Are there any other responses to 
that question? If not, let me go back particularly to Lloyd 
Sodetani, because you mentioned and there were some others who 
mentioned it, too. And let me say to Mr. Sodetani that I 
appreciate the efforts you have made to develop a plan to 
consolidate services for Maui veterans. [Applause.]
    And so my question to you, Lloyd, is: How would this 
improve efficiencies and services for veterans?
    Mr. Sodetani. Well, first of all, if you look at the 
current situation, the parking is inadequate at all three 
facilities. There is inadequate advertising or ability to 
locate the facilities. The signage is poor, and the locations 
are not in the best areas for and on behalf of veterans. So, 
physically it becomes a burden for the veterans. There are 
inadequate handicapped stalls in all three locations.
    If you look at the clinic, it is a walk-up or it requires 
elevator services. It is not conducive to serving veterans, 
especially those who are handicapped. The greater majority of 
them--a whole bunch of them are. And so we need to be aware 
that, you know, the ADA requirements should be even more 
pronounced. We need to be sure that our veterans are provided 
this type of care.
    By consolidating it to one location, we can have in the 
plan--our plan shows 200 parking stalls, and it is all mostly 
located through the buildings so that they will be easily 
accessible for the veterans. We have more than adequate 
handicapped stalls. It is on a 4\1/2\-acre campus that Maui 
High School is willing to give up so that they can also start a 
program for the students, a health care, social services, and 
community service type of internship that would be more 
acceptable to the student programs there.
    We would also have everything on one level. I am sure 
everyone--because it is so centralized, all of our veterans 
will be able to locate that facility easily. It can be easily 
identifiable. It can be advertised accordingly. But right now 
we advertise three different locations for veterans services. A 
guy goes to Wailuku, Ernie's place, and Ernie tells him, No, 
you are at the wrong location. You have got to go down to 
Kahului. You know, that is demoralizing for the veteran. I 
think that having that one-stop service would eliminate that 
type of confusion. So these are some of the benefits that we 
would gain from having something like that.
    In addition to that, I know that I received a letter from 
you with regard to this matter early last year when I submitted 
it to you. The concern that you had was the ownership of the 
land. Well, the State owns the land here. The facility would be 
provided by VA, veterans' facilities, the clinic, Vet Center, 
et cetera, things that would--areas that would be occupied by 
VA. On the other hand, OVS would pay for their own structure or 
improvements.
    In the National Guard, there is not a problem with 
ownership of land. The State owns the land. The Federal 
Government pays for the armory. And if I recall correctly, and 
if this system has not changed over the years, the building 
remains under the ownership of the National Guard Bureau for 27 
years. Thereafter, if the National Guard Bureau wants to turn 
that building over, they say, ``We have no further need for 
this structure,'' turns it over to the State, and just like 
here at Charlie Company Armory and Wailuku Armory, Wailuku 
Armory has been converted to part of a school. Charlie Company 
Armory is now being used by the Land and Natural Resources' 
Enforcement Division. So these are continuous government uses.
    So, the concern that has been expressed--and I believe 
General Shinseki also expressed that--with regard to the 
ownership of the land with a Federal structure on it should not 
be really a concern because we have means of coming to an 
understanding. We have already submitted a draft between the 
Memorandum of Agreement between the Department of Defense, the 
State Office of Veterans Services, and the Department of 
Education to show that, you know, whatever VA needed--30-, 50-, 
100-year use of the land--would be accommodated. And it would 
be rent free. There would be no rent whatsoever.
    I believe that we are prepared and committed to go forth 
with this project if we can receive the proper funding for it. 
And I believe that by what we have submitted so far to date, 
the phasing of it would be such that it would not require a 
total lump sum budgeted amount one time. It will be over a 
period of 3 or 4 years. I believe that we, the veterans, would 
be able to enjoy a facility more or better than what we have 
now.
    Thank you.
    Chairman Akaka. Thank you very much for that.
    [Applause.]
    Mr. Laub. May I answer that, sir?
    Chairman Akaka. Paul Laub.
    Mr. Laub. Sir, we also need long-term elder care, and this 
property would provide us with space for that.
    Chairman Akaka. Thank you.
    Any other comments on--Terry Poaipuni.
    Ms. Poaipuni. Senator, we talked about accessibility, and 
another one is, like I mentioned, the ability to fill out the 
applications; and oftentimes our vets go out to Ernie's 
thinking they can get the help. He just counsels and the only 
other one that we know of--I just found out--which is Tamicko . 
I just recently found out that Mr. Thompson does it, too. So we 
need that type of assistance for our vets to be helped through 
that process to understand the applications and work with them 
at that point, because right now they are lost and they are 
confused. They do not know, and then when they get the reply, 
they think that--you know, they stop. It is all right for the 
VA that they do stop, but I think the veterans just do not have 
to and should not give up because they do not understand the 
system--the process of the application system.
    Chairman Akaka. Well, mahalo--oh, Mitch Skaggerberg.
    Mr. Skaggerberg. One of the things about having a 
centralized location for all the services is being able to 
attract a lot more veterans. It is going to give them a 
tremendous visibility in the community and a sense of 
confidence and comfort when they go there.
    One of the things I think is going to happen, it is going 
to make life a lot easier for them, the VA nurses and doctors, 
Dr. Hastings, the director, because when the veterans do want 
drugs, they leave the clinic denied, they feel, of services 
they are entitled to. With everything there, they have access 
to other people in there, like a counselor, to say, hey, I am 
never coming back to the VA. We hear this all the time. They 
can stay on the property and get other help. A patient advocate 
or a counselor solves their problem right there, where they go 
back to the family with some sense of comfort and peace.
    The other thing is that it would be a rallying point for 
all the veteran organizations. It will be a place of honor in 
our community and visible; and that will help us get more 
services from the county and other places where veterans are.
    Thank you.
    Chairman Akaka. Well, mahalo.
    Mr. Sodetani. Senator, I would like to announce that----
    Chairman Akaka. Mr. Sodetani.
    Mr. Sodetani [continuing]. If anyone would like to see the 
site plan and aerial photo of what has been done so far, please 
do not hesitate to consult with Mr. Stanley Gima. He has a 
blown-up aerial photo, I believe, and also the site plan of the 
proposal. If any others would like to discuss it with him or 
with any of the people that I mentioned, including Paul or 
those who have been involved in this project for the longest 
period of time, I am sure they are well versed on what we would 
like to do. And, please, by all means, I am sure that they 
would welcome your request, Senator.
    Thank you.
    Chairman Akaka. Thank you very much, Lloyd.
    Now I would like to move to the next question. This 
question is to Mitch Skaggerberg. I have heard from many 
veterans across Hawaii that there is a need for a full-time 
veterans counselor at each Vet Center to help with, among many 
issues, the filing of claims for compensation. Mitch, why do 
you feel a full-time benefits counselor at the Maui Vet Center 
is important? And if he answers that, to the rest of the panel, 
do any of you have any thoughts or opinions on this issue after 
Mitch is finished with his response? Mitch.
    Mr. Skaggerberg. Many Maui veterans--and we have 12,000--
never apply for compensation, disability, or even the medical 
benefits. A benefits counselor who has outreach capability will 
be able to adequately let all our veterans know what their 
entitlements are and encourage them to apply for them.
    I think the most important reason why we need a full-time 
benefits counselor is for years the State did that role, and 
they did it well. But we have quadrupled the number of veterans 
using veterans care now, which means we have quadrupled the 
number of people that have to fill out applications. They need 
counseling and they need coordination. Here is step one, step 
two, check into the clinic to see your doctor, step three. They 
cannot come close to doing that right now. Joe Thompson was a 
full-time member of our Vet Center for years, and he will be 
much more valuable, I think, in helping us--he comes over, I 
believe, once a month. And so that is the reason why I believe 
we need a full-time benefits counselor. Again, we tried to get 
another one through the State. Their attitude, by the way, is 
that that is the VA's job. And they turned us down. I have 
heard that from the county Mayor. I have heard that from the 
Governor's office, even the OVS, behind closed doors. Really, 
the VA needs to do that. So, we need tremendous support in 
reaching all those veterans that we need to reach.
    Thank you.
    Chairman Akaka. Thank you very much.
    Are there any other responses from the panel? Yes, Terry 
Poaipuni.
    Ms. Poaipuni. Let me say--because I think that is exactly 
what we are trying to mention to you, Senator, because there is 
a great need. I think when we say counselor, maybe there should 
be a counselor/application process officer; and I think a full-
time person. Right now, as I am looking at Ernie, I see they 
are the ones that do the application work, and other ones do 
not. And so it is important because what we are doing right now 
is we are doing that job at home. So, I think it is very 
important that the VA comes to all areas and not only Central 
or Lahaina, but should travel the tri-isle of these islands.
    Chairman Akaka. Are there any more responses to that 
question?
    Mr. Sodetani. Yes, Senator. I would like to respond.
    Chairman Akaka. Yes, Lloyd Sodetani.
    Mr. Sodetani. You know, Tamicko has been a tireless worker, 
and it is a very thankless job, and she is overwhelmed. And we 
miss you, Terri. In any event, I wanted to state that, you 
know, one solution to this would be to fund it through VA, 
allocating the funds through another position to the State of 
Hawaii through the Department of Defense Office of Veterans 
Services, and mandating that that fund will be for another 
counselor here. And I think that might work. I am not sure how 
the whole politics of it would be, but I would think that if we 
could have that funding allocated specifically for that 
position, we would be able to create that position here. But it 
will be funded through the Federal Government providing 
assistance to Maui County. Hopefully that is the solution.
    Chairman Akaka. Fine. Well, mahalo nui loa. You know, I 
want to thank all of you on this panel very much for your 
testimony, for your responses, and without question, this is 
going to be helpful to what we are trying to do to improve the 
accessibility, services, and the quality of care for veterans. 
And this is the reason we are having this hearing. I have got 
to tell you at this point I am so glad we are having this 
hearing because we have learned a lot.
    So, I want to say mahalo nui loa to all on this panel for 
what you have added to our hearings and to the work that we 
need to do. But I want to take some suggestions from you folks, 
too, that this is something that we all have to work together 
to do, and I really, really appreciate what you have said. And 
this does not end. You can continue to express as we go along, 
as you have ideas about what we need to do. So I want to say 
mahalo nui loa to all of you again for being members of this 
panel. Thank you. [Applause.]
    And now I would like to invite those who are standing. 
There are seats that are available, or maybe the panelists will 
be moving--and then I would like to welcome the second panel.
    First is Tracey Betts, Honolulu Regional Office Director.
    Next is Sheila Cullen, Director of the Veterans Integrated 
Service Network 21. She is accompanied by Dr. James Hastings, 
Director of the VA Pacific Islands Health Care System, and Dr. 
Darkins from VA as well.
    Next we have Linda Halliday, Deputy Assistant Inspector 
General for Audits and Evaluations for VA's Office of Inspector 
General. Ms. Halliday is accompanied by Walter Stucky, who is 
an audit manager in the Seattle Audit Division.
    I want to thank our panelists for being here today, and 
your full testimony will, of course, appear in the record. So, 
may I ask you, Ms. Betts, to proceed with your testimony. 
Welcome, Ms. Betts.

   STATEMENT OF TRACEY BETTS, DIRECTOR, HONOLULU VA REGIONAL 
          OFFICE, U.S. DEPARTMENT OF VETERANS AFFAIRS

    Ms. Betts. Thank you, Chairman. Chairman Akaka, it is my 
pleasure to be here today to discuss our efforts to meet the 
needs of veterans residing in the Pacific Region. Today I will 
specifically discuss important benefits and outreach services 
provided to veterans living on Maui.
    The Honolulu Regional Office serves the veteran population 
in Hawaii and the Pacific Region. The Honolulu facility also 
provides outreach to veterans residing in the Insular Islands 
of the Republic of Palau, Federated States of Micronesia, and 
Republic of the Marshall Islands.
    The Honolulu Regional Office administers the following 
benefits and services: disability compensation; vocational 
rehabilitation and employment assistance; home loan guaranty, 
specially adapted housing grants, and Native American direct 
home loans; and outreach for all veteran and survivor benefits. 
Our goal is to deliver these benefits and services in a timely, 
accurate, and compassionate manner. This is accomplished 
through the administration of comprehensive and diverse benefit 
programs.
    The Honolulu facility is responsible for delivering non-
medical VA benefits and services to over 118,000 veterans and 
their families. Approximately 19,000 of these veterans receive 
disability compensation benefits from the Honolulu facility.
    In fiscal year 2009, Honolulu provided more than 5,400 
veterans with decisions on their disability claims. The 
Honolulu office conducts an average of 3,000 telephone 
interviews and 1,300 personal interviews per month. In 
addition, the Honolulu RO conducted 171 Transitional Assistance 
Program briefings to approximately 5,000 servicemembers in 
Hawaii in fiscal year 2009.
    The Maui Vet Center hosts a traveling veterans service 
representative from Honolulu to provide services to the 
veterans living on Maui. During fiscal year 2009, 132 veterans 
personally met with the traveling counselor to file claims and 
obtain information regarding benefits.
    In October 2009, we have implemented a program in which our 
decision review officer hearings are being conducted on all of 
the six Hawaiian Islands, which includes Maui. To date, the 
Honolulu facility has conducted two decision review officer 
hearings here in Maui, and as they are received, they will be 
conducting more in the future.
    The Honolulu Regional Office also has a vocational 
rehabilitation counselor collocated in the Maui Community Based 
Outpatient Clinic. The vocational rehabilitation counselor 
provides educational and vocational counseling to 
servicemembers, veterans, and eligible dependents. The 
counselor met with 1,276 veterans in fiscal year 2009 and is 
currently working with over 100 veterans here on Maui. The 
counselor is also a member of the Maui Veterans Association and 
attends their regular meetings to provide general vocational 
rehabilitation and educational information.
    Veterans residing on Maui can receive assistance with their 
claims and benefits information through the nationwide toll-
free number, which is answered by the Honolulu Regional Office 
employees. The Honolulu office and the State Office of Veterans 
Services here on Maui work as partners to ensure that the 
veterans on Maui receive access to all VA benefits for which 
they are eligible.
    The Native American Direct Loan Program administered by VA 
is very active on Maui, in part because of the temporary 
increase in the maximum guaranty amount, as enacted by Public 
Law 110-389. Another reason for this success is attributable to 
our ongoing partnership with the Department of Hawaiian 
Homelands. The Department of Hawaiian Homelands serves as our 
partner in assisting with loan packaging, appraisals, and 
construction-related inspections, as well as providing crucial 
communication links between our staff and the veterans that we 
serve. A Honolulu Regional Office employee in the Loan Guaranty 
Division travels to Maui on a regular basis to assist in 
servicing Maui loans, meet with the Department of Hawaiian 
Homelands, and conduct appraisals.
    I myself am a member of various advisory councils, such as 
the Advisory Board on Veterans Services chaired by the Director 
of the State of Hawaii Office of Veterans Services and the VA 
Pacific Island Health Care System Advisory Council. Board and 
council members are local veterans and advocates representing 
their communities from six of the Hawaiian Islands, to include 
Maui. During these meetings, board and council members express 
concerns, discuss veteran issues and receive general 
information on VA benefits.
    The Honolulu Regional Office is and remains committed to 
providing timely benefits and services to the veteran 
population residing here on Maui.
    Mr. Chairman, this concludes my testimony. I greatly 
appreciate being here today and look forward to answering your 
questions.
    [The prepared statement of Ms. Betts follows:]
     P r e p a r e d S t a t e m e n t o f T r a c e y B e t t s , 
 D i r e c t o r , H o n o l u l u VA R e g i o n a l Office, Veterans 
      Benefits Administration, U.S. Department of Veterans Affairs
    Chairman Akaka, it is my pleasure to be here today to discuss our 
efforts to meet the needs of Veterans residing in the Pacific Region. 
Today I will specifically discuss important benefits and outreach 
services provided to Veterans living on Maui.
                        honolulu regional office
    The Honolulu Regional Office (RO) serves the Veteran population in 
Hawaii and the Pacific Region. The Honolulu RO also provides outreach 
to Veterans residing in the Insular Islands of the Republic of Palau, 
Federated States of Micronesia, and Republic of the Marshall Islands.
    The Honolulu RO administers the following benefits and services:

     Disability Compensation
     Vocational Rehabilitation and Employment Assistance
     Home Loan Guaranty, Specially Adapted Housing Grants, and 
Native American Direct Home Loans
     Outreach for all Veteran and survivor benefits

    Our goal is to deliver these benefits and services in a timely, 
accurate, and compassionate manner. This is accomplished through the 
administration of comprehensive and diverse benefit programs.
    The Honolulu RO is responsible for delivering non-medical VA 
benefits and services to over 118,000 Veterans and their families. 
Approximately 19,000 of these Veterans receive disability compensation 
benefits from the Honolulu RO. In fiscal year 2009, Honolulu provided 
more than 5,400 Veterans with decisions on their disability claims. The 
Honolulu RO employees conduct an average of 3,000 telephone interviews 
and 1,300 personal interviews per month. In addition, the Honolulu RO 
conducted 171 Transitional Assistance Program (TAP) briefings to 
approximately 5,000 servicemembers in Hawaii in fiscal year 2009.
                            services on maui
    The Maui Vet Center hosts a traveling Veterans Service 
Representative (VSR) from Honolulu to provide services to Veterans 
living on Maui. During fiscal year 2009, 132 Veterans personally met 
with the VSR to file claims and obtain general benefit information.
    In October 2009, the Honolulu RO began conducting Decision Review 
Officer (DRO) hearings on six of the Hawaiian Islands, to include Maui. 
To date, the Honolulu RO has conducted two DRO hearings on Maui.
    The Honolulu RO also has a Vocational Rehabilitation Counselor 
(VRC) co-located in the Maui Community-Based Outpatient Clinic. The VRC 
provides educational and vocational counseling to servicemembers, 
Veterans, and eligible dependents. The VRC met with 1,276 Veterans in 
fiscal year 2009 and is currently working with over 100 Veterans on 
Maui. The VRC is also a member of the Maui Veterans Association and 
attends their regular meetings to provide general vocational 
rehabilitation and educational information.
    Veterans residing on Maui can receive assistance with their claims 
and benefits information through the nationwide toll-free number, which 
is answered by the Honolulu RO. The Honolulu RO and State Office of 
Veterans Services on Maui work as partners to ensure the Veterans on 
Maui receive access to all VA benefits for which they are eligible.
    The Native American Direct Loan Program administered by VA is very 
active on Maui, in part because of the temporary increase in the 
maximum guaranty amount, as enacted by Public Law 110-389. Another 
reason for this success is attributable to our ongoing partnership with 
the Department of Hawaiian Homelands. The Department of Hawaiian 
Homelands serves as our partner in assisting with loan packaging, 
appraisals, and construction-related inspections, as well as providing 
crucial communication links between our staff and the Veterans we 
serve. A Honolulu RO loan guaranty employee travels to Maui on a 
regular basis to assist in servicing Maui loans, meet with the 
Department of Hawaiian Homelands, and conduct appraisals.
    I participate on various advisory councils, such as the Advisory 
Board on Veterans Services chaired by the Director of the State of 
Hawaii Office of Veterans Services and the VA Pacific Island Healthcare 
System Advisory Council. Board and Council members are local Veterans 
and advocates representing their communities from six of the Hawaiian 
Islands, to include Maui. During these meetings, board and council 
members express concerns, discuss Veteran issues and receive general 
information on VA benefits.
                               conclusion
    The Honolulu RO is and remains committed to providing timely 
benefits and services to the Veteran population residing on Maui.

    Mr. Chairman, this concludes my testimony. I greatly appreciate 
being here today and look forward to answering your questions.

    Chairman Akaka. Thank you very much, Ms. Betts.
    And now we will receive the testimony of Sheila Cullen.

STATEMENT OF SHEILA CULLEN, DIRECTOR, VA SIERRA PACIFIC NETWORK 
 (VISN 21), VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
                        VETERANS AFFAIRS

    Ms. Cullen. Mr. Chairman, mahalo for the opportunity to 
appear before you today to discuss the state of VA health care 
in Maui.
    Chairman Akaka. Thank you for being here.
    Ms. Cullen. It is a privilege to be here in Maui to speak 
and answer any questions you may have pertaining to the 
services we provide veterans in Maui County.
    First, Mr. Chairman, I would like to thank you for your 
leadership and advocacy on behalf of veterans. Your vision and 
support have led to an unprecedented level of health care 
services for veterans, construction of state-of-the-art 
facilities in Honolulu, and remarkable improvements in access 
to health care services for veterans residing on the Hawaiian 
neighbor islands, American Samoa and Guam.
    My written statement, which I request be submitted for the 
record, reviews the VA Sierra Pacific Network; provides an 
overview of the VA Pacific Islands Health Care System; offers 
information regarding telehealth programs; and discusses the VA 
clinic in Maui, as well as issues of interest to veterans 
residing in Maui County. During my time before you today, I 
would like to focus on what VA is doing to improve services and 
care for Maui veterans.
    VA operates a community-based outpatient clinic located in 
Kahului and expanded the clinic space by an additional 4,400 
square feet during fiscal year 2008 to a total today of 9,700 
square feet. Since the hearing you held here 2 years ago, the 
Maui Clinic has recently increased its staffing and currently 
is authorized to have 28 staff at the clinic to provide a broad 
range of primary care and mental health services.
    In fiscal year 2008, the clinic implemented a home-based 
primary care program supported by a nurse practitioner and 
received over a quarter of a million dollars in VA rural health 
funding this fiscal year.
    As you know, Mr. Chairman, Congress has provided several 
hundred million dollars to VA specifically to enhance mental 
health services. These funds have been used to hire about 35 
new mental health staff in VA facilities across Hawaii and the 
Pacific Region, including seven staff here at the Maui Clinic. 
In addition, the Maui Vet Center also successfully recently 
recruited another psychologist.
    VA provides part-time outreach clinics on the islands of 
Molokai and Lanai, and VA Pacific Islands Health Care System is 
assessing options to increase and enhance services in both of 
those locations. The VA Clinic on Molokai is located in shared 
space near Molokai General Hospital and operates two half-day 
primary clinics per week. VA also sends mental health staff 
from the Maui Clinic to Molokai to provide care.
    In addition, VA purchases non-VA care in the community for 
eligible veterans there. Veterans residing in Molokai also are 
seen at DOD and VA facilities in other locations.
    Since June 2007, a VA primary care provider from Maui and 
more recently, since late fiscal year 2009, a mental health 
clinical nurse specialist travels to Lanai once a month to 
provide needed primary care and mental health services. VA has 
used space adjacent to the Lanai Community Hospital and last 
year finalized an agreement with the Straub Outpatient Clinic 
for visiting VA providers to use space and support the clinic 
there. In addition, VA purchases non-VA care in the community 
and pays beneficiary travel for eligible veterans. VA is 
exploring other options to improve access, including adding an 
automated pharmacy dispensing machine and increasing telehealth 
capabilities.
    In summary, with your support, Mr. Chairman, and with the 
support of other Members of Congress, VA is providing an 
unprecedented level of health care services to veterans 
residing in Hawaii and here in Maui. We look forward to a 
growth of new patients at the Maui Clinic, and we will meet the 
expectations of veterans for quality and timeliness of care.
    Again, Mr. Chairman, mahalo for the opportunity to testify 
at this hearing. My colleagues and I would be happy to address 
any questions that you may have for us. Thank you.
    [The prepared statement of Ms. Cullen follows:]
 Prepared Statement of Ms. Sheila Cullen, Director, VA Sierra Pacific 
 Network (VISN 21), Veterans Health Administration, U.S. Department of 
                            Veterans Affairs
    Mr. Chairman and Members of the Committee, Mahalo for the 
opportunity to appear before you today to discuss the state of VA 
health care in Maui. It is a privilege to be here in Maui to speak and 
answer any questions you may have pertaining to the services we provide 
Veterans in Maui County. I am accompanied today by Dr. James Hastings, 
Director of the VA Pacific Islands Health Care System (VAPIHCS), and 
Dr. Adam Darkins, Chief Consultant, Care Coordination, Office of 
Patient Care Services, Veterans Health Administration.
    First, Mr. Chairman, I would like to thank you for your leadership 
and advocacy on behalf of our Nation's Veterans. During your tenure as 
Ranking Member and Chairman of this Committee, you have consistently 
demonstrated your commitment to Veterans by introducing legislation 
designed to meet the needs of Veterans. As I will highlight later, your 
vision and support have led to an unprecedented level of health care 
services for Veterans, construction of state-of-the-art facilities here 
in Honolulu, and remarkable improvements in access to health care 
services for Veterans residing on the Hawaiian neighbor islands, 
American Samoa and Guam. In addition, I appreciate your interest in and 
support of the Department of Veterans Affairs (VA).
    Today, I will briefly review the VA Sierra Pacific Network that 
includes Hawaii and the Pacific islands region; provide an overview of 
the VA Pacific Islands Health Care System (VAPIHCS); provide national 
and local information regarding telehealth programs; discuss the VA 
clinic in Maui; and highlight issues of particular interest to Veterans 
residing in Maui County, including capacity at the VA clinic in Maui 
and VA services on the nearby islands of Molokai and Lanai.
                  va sierra pacific network (visn 21)
    The VA Sierra Pacific Network (Veterans Integrated Service Network 
[VISN] 21) is one of 21 integrated health care networks in the Veterans 
Health Administration (VHA). The VA Sierra Pacific Network provides 
services to Veterans residing in Hawaii and the Pacific region 
(including the Philippines, Guam, American Samoa and Commonwealth of 
the Northern Marianas Islands), northern Nevada, and central/northern 
California. There were an estimated 1.1 million Veterans living within 
the boundaries of the VA Sierra Pacific Network in Fiscal Year (FY) 
2009.
    The VA Sierra Pacific Network includes six major health care 
systems based in Honolulu, HI; Palo Alto, CA; San Francisco, CA; 
Sacramento, CA; Fresno, CA; and Reno, NV, as well as an Independent 
Outpatient Clinic in Manila, PI. In FY 2009 the Network provided 
services to over 250,000 unique Veterans out of 350,000 enrolled 
Veterans. There were about 2.7 million clinic visits and 28,079 
inpatient discharges. The cumulative full-time employment equivalents 
(FTEE) level was 9,740, and the operating budget was about $2.2 
billion.
    The VA Sierra Pacific Network is committed to ensuring the care 
Veterans receive is of the highest quality. All six health care systems 
within the Network have major academic affiliations. The Network hosts 
a significant number of Centers of Excellence in VHA and supports a 
large and broad research portfolio. It also has expansive and 
collaborative relationships with the Department of Defense (DOD). The 
VA Sierra Pacific Network has not only exceeded patient satisfaction 
goals (inpatient and outpatient), but its employee satisfaction scores 
are among the top five Networks for overall job satisfaction in VHA. As 
reflected in the most recent employee satisfaction survey, the Network 
had the highest scores in VHA in several categories including 
leadership, supervisory support, customer service, conflict resolution, 
praise, and rewards.
    Given the large and diverse geographic nature (i.e. rural or 
frontier lands and remote islands) of VISN 21, access to care is a 
priority. In FY 2010, the Network will activate nine new sites of care 
including the Pacific (Hawaii and the Northern Mariana Islands), 
California, and Nevada. Finally, VISN 21 is proud to operate one of 
four Polytrauma Rehabilitation Centers in VHA dedicated to addressing 
the clinical needs of the most severely injured Veterans.
            va pacific islands health care system (vapihcs)
    As noted above, VAPIHCS is one of six major health care systems in 
VISN 21. Dr. James Hastings is the director and a practicing 
cardiologist at VAPIHCS. VAPIHCS is unique in several important 
aspects: its vast catchment area covers 2.6 million square-miles 
(including Hawaii, Guam, American Samoa and Commonwealth of the 
Northern Marianas); its remote island locations create access 
challenges; and it enjoys the cultural richness of the Pacific Islands 
with an ethnically diverse patient and staff population. In FY 2009 
there were an estimated 118,000 Veterans living in Hawaii, and at least 
10,000 additional Veterans located beyond Hawaii in the VAPIHCS 
catchment area.
    VAPIHCS currently provides care in ten locations, with two more 
soon to be added. Our current facilities include an Ambulatory Care 
Center (ACC) and a Community Living Center (CLC) on the campus of the 
Tripler Army Medical Center (TAMC) in Honolulu; community-based 
outpatient clinics (CBOCs) in Lihue (Kauai), Kahului (Maui), Kailua-
Kona (Hawaii), Hilo (Hawaii), Hagatna (Guam) and Pago Pago (American 
Samoa); and outreach clinics in Molokai and Lanai. Two new facilities 
planned include a new CBOC to serve Leeward Oahu Veterans (approved in 
FY 2008 with an expected opening in late FY 2010) and a new rural 
outreach clinic in Saipan set to open this winter. A mental health 
provider (psychologist) has begun seeing patients part-time in Saipan 
but the clinic has not yet been activated. The inpatient Post Traumatic 
Stress Disorder (PTSD) residential rehabilitation unit is in its 
interim location on the campus of TAMC, pending construction and 
activation of a new VA-funded facility ($9.56 million), also at TAMC, 
during FY 2011.
    VAPIHCS is also constructing a new replacement CBOC in Guam that 
will offer expanded capacity. It will be located along the perimeter of 
the Guam Naval Hospital, and we expect it to open in May 2010. VHA 
operates a total of six Vet Centers in Honolulu, Lihue, Wailuku, 
Kailua-Kona, Hilo and Guam. These facilities provide counseling, 
psychosocial support, and outreach. A Vet Center staff member was also 
added in American Samoa during FY 2008.
    In FY 2009 VAPIHCS provided services to more than 24,000 Veterans, 
an increase of five percent from FY 2007. Of these Veterans, 19,000 
reside in Hawaii. VAPIHCS provided 175,000 outpatient visits during FY 
2009. The cumulative VAPIHCS FTEE in FY 2009 was 619 employees, with an 
operating budget increase from $139.1 million in FY 2008 to $155.1 
million in FY 2009, an increase of 12 percent.
    VAPIHCS provides or contracts for a comprehensive array of health 
care services. VAPIHCS directly provides primary care, including 
preventive services and health screenings, and mental health services 
at all locations. VAPIHCS does not operate its own acute medical-
surgical hospital and as a result faces some challenges in providing 
specialty services. VAPIHCS has hired specialists in orthopedics, 
cardiology, endocrinology, ophthalmology, nephrology, infectious 
disease and inpatient medicine (``hospitalist''), and makes use of 
University of Hawaii faculty to provide specialty care services in 
pulmonary disease, rheumatology, allergy, and hematology in Honolulu 
and to a lesser extent at CBOCs. Veterans with spinal cord injuries 
receive care from VAPIHCS dedicated staff, which provides a 
multidisciplinary approach to care. The team, located on Oahu, is 
planning to travel and care for patients on the neighbor islands during 
FY 2010. Veterans requiring other specialty care continue to be 
referred to DOD and community facilities.
    Inpatient long-term and acute rehabilitation care is available at 
the Community Living Center (CLC). Inpatient mental health services are 
provided by VA staff on a 20 bed ward within TAMC and at the 16 bed 
Post Traumatic Stress Disorder (PTSD) Residential Rehabilitation 
Program (PRRP). VAPIHCS contracts for care with DOD (at TAMC and Guam 
Naval Hospital) and community facilities for inpatient medical-surgical 
care.
                 national and local telehealth programs
National Telehealth Programs
    Telehealth involves the use of information and telecommunication 
technologies as a tool in providing health care services when the 
patient and practitioner are separated by geographical distance. The 
benefits of telehealth to health care systems include: improving access 
to care, making specialist services available in rural and remote 
locations, and supporting patients to live independently in their own 
homes and local communities. Because of the support of telehealth by VA 
and Congressional leadership, more Veterans are able to realize these 
benefits.
    Over the past six years telehealth in VA has transitioned from use 
in a range of discrete local projects and programs toward a unified, 
enterprise level approach that provides routine telehealth services 
that are mission critical to the delivery of care to Veterans. In 2009 
over 260,000 Veteran patients received care via VA's telehealth 
programs. Telehealth takes many forms. VA's enterprise telehealth 
programs deliver care to Veteran patients in their homes via home 
telehealth; telehealth care is also provided in VA medical centers 
(VAMCs), CBOCs and Vet Centers via clinical videoconferencing. In 
addition, VA routinely exchanges clinical images via ``store and 
forward'' telehealth.
    I would like to briefly highlight some of the direct benefits these 
services are providing to Veterans. More than 40,000 Veterans are 
receiving home-telehealth-based care that supports care delivery to 
them in their own homes. These care coordination/home telehealth (CCHT) 
services have reduced hospital admissions by 25 percent, hospital stays 
by 25 percent, and have high levels of patient satisfaction (86 percent 
mean score). In 2009 more than 58,000 Veterans received care via 
clinical videoconferencing, the majority receiving mental health care 
services that reduced hospital admissions by 24 percent. In 2009 almost 
150,000 Veterans were screened to prevent avoidable blindness by VA's 
teleretinal imaging programs (CCSF).
    The successful implementation of robust and sustainable telehealth 
services that VA entrusts to provide care to Veteran patients must 
satisfy stringent clinical, technological and business requirements 
that ensure they are appropriate, effective and cost-effective. These 
requirements include acceptance by patients and practitioners as well 
as staff training and quality management systems. Mr. Chairman, you and 
the Committee understand how the geography of Hawaii and the Pacific 
region poses particular challenges in implementing telehealth that are 
not encountered on the U.S. mainland. Services to Guam and American 
Samoa not only need to bridge a physical distance of 3,820 and 2,300 
miles respectively, they also need to bridge between patients and 
clinical communities that are distant and distinct from one another. 
Bridging these distances and linking these communities to enable them 
to integrate requires telecommunications bandwidth. VA is currently 
seeking to embrace Hawaii and the Pacific region within its clinical 
enterprise video conferencing network (CEVN) and in doing simplify the 
linkage to specialist services from medical center assets on the U.S. 
mainland.
    VA recognizes the pioneering role that Hawaii and the Pacific 
region have played in the development of telehealth solutions that 
range from teleretinal imaging to home telehealth. These innovations 
have included partnerships with DOD and the University of Hawaii within 
the collaborative framework of the Pacific Telehealth and Technology 
Hui. VA appreciates the support of Congress in supporting rural health 
initiatives that enable us to focus on extending current enterprise 
telehealth solutions as well as developing new telehealth solutions to 
serve Veterans, not only those in Hawaii and the Pacific region 
Islands, but also Veterans elsewhere in the Nation for whom 
geographical distance from VA's physical health care assets presents a 
challenge to receiving care. In considering future innovation for local 
and enterprise portfolios of telehealth services, VA is looking toward 
new iterations of a familiar technology--the telephone. Currently the 
telephone has meant that eight patients a month from Hawaii and the 
Pacific region have been able to access VA's suicide hotline and 
receive support from Canandaigua, New York. The transition of health 
applications onto mobile technologies such as cell phones promises to 
further revolutionize how telehealth can serve Veterans in areas such 
as Hawaii and the Pacific region.
    Mr. Chairman, I used the word Hui earlier. As you know, Hui 
describes a partnership, a union or a gathering. All health care is 
ultimately local, and my discussion so far has focused on the clinical, 
technological and business issues of implementing telehealth across the 
VA health care system. My attention will now turn to local telehealth 
initiatives that support Hawaiian Veterans and those living on other 
Pacific Islands.
Local Telehealth Programs
    In partnership with DOD, specifically TAMC, VAPIHCS began to 
develop this capability in 2001 with the support of Senator Daniel K. 
Inouye. The Hui allows joint development of telemedicine technologies 
for both organizations in the Pacific. This partnership has fielded 
many demonstration projects that have enabled both Departments to 
develop ongoing telehealth activity for our beneficiaries.
    For VAPIHCS, this partnership allowed us to begin developing 
telemedicine capabilities in collaboration with the local information 
technology (IT) department that developed the telecommunications 
network infrastructure and supported the deployment of video 
teleconferencing to VA CBOCs on the islands of Hawaii, Maui, Kauai, 
Guam, and American Samoa. Connectivity to Molokai and Lanai is also 
available, and we are presently studying connectivity for our newly 
approved Outreach Clinic in Saipan. Additionally, this initial 
investment allowed the development of procedures, practices, and 
protocols to support video teleconference clinical visits for primary 
care, mental health, and subspecialty care. Funds were provided for 
purchasing telemedicine ``carts'' that allow the use of peripheral 
medical equipment (stethoscopes, otoscopes, cameras and other 
attachments), as well as teleretinal imaging equipment to permit 
screening for diabetic eye disease. Automated Drug Dispensing System 
(ADDS) machines were installed in CBOCs in 2003 allowing pharmacists in 
Honolulu to dispense medications and, through the use of video 
conferencing, to provide medication counseling to Veterans at the time 
of their clinic visits. The VAPIHCS also began tele-home care projects 
in 2003 by deploying home telemedicine units. This partnership and 
initial funding has helped us establish a foundation of experience upon 
which we continue to build to enhance the medical care provided in our 
facilities throughout the Pacific Region. Additionally, this early 
experience has allowed our facilities to compete for research dollars 
to further develop telemedicine and tele-mental health activities.
    The Hui also provided support for TAMC projects, including support 
for ``store and forward'' telemedicine for adult and pediatric care to 
the Western Pacific, cardiac sonography from TAMC to Guam and Japan, 
intensive care unit telemetry and consultation from TAMC to Guam Naval 
Hospital and Korea, speech therapy and other projects.
    Beyond the Hui, VAPIHCS and TAMC are working together to develop 
joint telemedicine capabilities in American Samoa to support co-
location of TAMC personnel at a VA CBOC. This arrangement would extend 
clinical expertise from TAMC to American Samoa to serve Veterans and 
active duty servicemembers, as well as members of the National Guard 
and Reserve who have experienced a Traumatic Brain Injury (TBI).
    Recently, VA expanded mental health programs, including significant 
growth in tele-mental health activities. VA recruited a clinical 
psychologist to fill a new position for a dedicated tele-mental health 
coordinator based in Maui. This new position expanded tele-psychology 
services equitably throughout the CBOC. Additionally, VA has begun 
conducting tele-mental health Compensation and Pension (C&P) 
examinations to expedite the assessment of Veterans for appropriate 
benefits.
    During fiscal year (FY) 2009, telehealth has been extremely helpful 
in delivering mental health services and dispensing medications to 
Veterans. A snapshot of relevant data, current through September 2009, 
includes:

     Over 2,500 telehealth patient encounters in VAPIHCS, 1,500 
of which were for mental health and 52 of which were for mental health 
C&P evaluations for patients in Guam or the Commonwealth of the 
Northern Mariana Islands; and
     Over 12,500 prescriptions filled at CBOCs on Kauai, Maui, 
Hilo, Kona, American Samoa and Guam using Automatic Drug Dispensing 
System (ADDS) machines.

    VAPIHCS has other Telehealth services that are available to 
Veterans, including:

     Clinical Video Telehealth clinics (CVT), which offer
          o Individual and group psychology and psychiatry support;
          o PTSD group research clinic;
          o Individual and family nutrition information;
          o Mental health C&P examinations;
          o Geriatric psychiatry;
          o General surgery and neurosurgery through the San Francisco 
        VAMC;
          o Treatment for spinal cord injury through the Palo Alto 
        VAMC;
          o Wound care;
          o Nephrology care; and
          o Participation in VA's `MOVE!' (weight loss) program;

     Care Coordinated Store Forward clinics (CCSF):

          o Teledermatology through the San Francisco VAMC;
          o Teleretinal Imaging; and
          o Care Coordination Home Telehealth, utilizing home 
        telehealth devices to support the care of Veteran patients in 
        their own homes on Oahu, Maui and Hilo.

    Our expanding and diverse experience with telehealth has provided 
many ``lessons learned'' to further shape the development of our 
VAPIHCS Telehealth Program. For example, numbers (i.e. encounters) 
alone do not tell the complete story of how technologies may be used to 
improve the health care of Veterans. In addition to increasing access 
to specialty services for Veterans, VAPIHCS has found telehealth 
technologies also allow CBOC providers to learn from telemedicine 
experiences (with distant providers), which can improve the skills of 
local physicians. VAPIHCS continually evaluates the use of telehealth 
services that are provided to Veterans within our service area and 
changes the program as necessary to meet the needs of the Veterans we 
serve. There is a new opportunity to expand the use of telehealth as we 
develop new outreach clinics to meet the needs of Veterans in highly 
rural areas.
    This increased ``hands-on'' care allows us to pursue new telehealth 
opportunities in even more remote locations to benefit Veterans. We are 
providing more care in the home, using VA's Care Coordination Home 
Telehealth (CCHT) protocols. This will provide us with patient data and 
information from the home that can be used to maximize our ability to 
manage medically complex patients in conjunction with our chronic 
disease team to improve the quality of life for Veterans.
    There are some local challenges with telehealth. We are adding 
additional staff, including telehealth nurses, to our sites so our 
clinics can both provide direct patient care and staff telehealth 
clinics as well. We anticipate that by this fall, we will have 
sufficient support for telehealth activities at each CBOC in the area.
    This table provides data about telehealth usage in the following 
facilities:


   Number of Unique Patients by Site  (VA Pacific Islands Health Care
                                 System)
------------------------------------------------------------------------
                      Facility                         FY 2008   FY 2009
------------------------------------------------------------------------
Honolulu............................................        74       159
Maui................................................       153       287
Molokai.............................................         6        17
Kauai...............................................        96       124
Hilo................................................        66        62
Guam................................................        58       143
Kona................................................        17        43
American Samoa......................................        14         8
                                                     -------------------
    TOTAL...........................................       425       669
------------------------------------------------------------------------

    The total numbers of VA's patients using telehealth increased in FY 
2009 over FY 2008. Some of this change is attributed to additional 
telehealth nurse positions added in FY 2009, and a telehealth 
Psychologist who serves veterans throughout the VA Pacific Islands 
locations. We anticipate further growth in telehealth in FY 2010 as 
additional VA specialty care visits, such as Nephrology, make greater 
use of the capability.
                               maui cboc
    VA operates a CBOC located in Kahului (203 Ho'ohana, Suite 303, 
Kahului, HI, 96732) and expanded the clinic's space by an additional 
4,400 square feet during FY 2008 to a total of 9,700 square feet. The 
building that currently houses the Clinic cannot be certified as having 
met Federal seismic structural requirements. If the current building 
cannot be modified to meet these requirements, as required by the 
renewal lease process, we will need to identify a new location. VISN 21 
and VAPIHCS have requested VA Central Office approval to seek an 
alternate location as a contingency should the modifications not be 
feasible.
    In addition to the CBOC, VA operates on Maui a Vet Center, which is 
located in nearby Wailuku.
    In FY 2009, the Maui CBOC served an estimated island Veteran 
population of 9,900 Veterans. Approximately 2,400 Veterans residing on 
Maui were enrolled for care, and 1,749 Veterans received VA care. This 
is a 21 percent increase over FY 2007. The market penetration rates for 
enrollees and users within the Veteran population are 24 percent and 17 
percent, respectively. These rates are lower than rates elsewhere in 
Hawaii. In FY 2009 the Maui CBOC recorded 9,976 clinic visits, which 
represent an increasing trend largely attributed to increased capacity 
and enhanced services.
    At the time of the hearing here in August 2007, the Maui CBOC was 
authorized to have 15 FTEE; the Maui CBOC has recently increased its 
staffing and currently is authorized to have 25 staff at the clinic. 
This includes two full time primary care physicians, a physician 
assistant and a social worker to support primary care services, two 
psychiatrists, two psychologists (one of whom provides tele-mental 
health services to other CBOCs), one social worker, one clinical nurse 
specialist, one substance abuse counselor, and one telehealth 
technician and one administrative officer are also available to address 
Veterans' mental health needs. This staff provides a broad range of 
primary care and mental health services. In FY 2008 the clinic also 
implemented a Home-Based Primary Care (HBPC) program supported by a 
nurse practitioner. During FY 2010, HBPC will be initiated this month 
on Molokai, and we expect to activate Lanai's HBPC program later this 
year.
    The size of the Veteran population and the number of VA patients in 
Maui limit the feasibility of having a large number of medical and 
surgical specialists based in the Maui CBOC. Nonetheless, VA recognizes 
that some Veterans in Maui County have needs beyond primary care and 
mental health. VAPIHCS provides specialty care services at the clinic 
by sending VA staff from Honolulu and other VA facilities in California 
to the CBOC. Services provided by clinicians traveling to Maui include 
cardiology, gastroenterology, geriatrics, nephrology, neurology, 
orthopedics and rheumatology. If Veterans require services not 
available at the Ambulatory Care Center (ACC) or CLC, VAPIHCS arranges 
and pays for care at TAMC, local community providers, or VA facilities 
in California; for those referred to a facility in California, VA can 
cover the costs of transportation if the veteran is eligible for 
beneficiary travel. In FY 2009, VA spent over $4 million for non-VA 
care in the private sector (i.e. not including costs at other VA or DOD 
facilities) for residents of Maui. Treatment of many non service-
connected Veterans requiring off island referrals continues to be a 
challenge, because VA Beneficiary Travel support is unavailable for 
these patients. The Maui CBOC also utilizes telehealth technologies to 
provide specialty services, as described above.
                             special issues
    Capacity at Maui CBOC. As noted earlier, in FY 2009 VA provided 
health care services to 1,749 Veterans who reside in Maui. However, 
market penetration rates for enrollees and users suggest there is 
additional demand for VA health care. VAPIHCS has significantly 
increased the authorized staffing at the Maui CBOC to keep pace with 
the growth in numbers of Veterans seeking care, in particular Operation 
Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. This 
population increased from 56 in FY 07 to a cumulative total of 270 
unique Veterans at the close of FY 09. The Clinic's two full time VA 
primary care physicians and one full time physician assistant, based 
upon VA primary care panel size criteria, gives the clinic a potential 
capacity for over 3,000 primary care patients (i.e. 1,200 patients for 
each full-time physician and 800 for each physician assistant). Even 
considering the special circumstances at the Maui CBOC (e.g., lack of 
VA inpatient facility and limited community health care resources on 
the island), the VA clinic will be able to provide high quality and 
accessible primary care to more than 2,000 patients.
    In addition, during FY 2008, the Maui CBOC began delivering HBPC 
services for Veterans residing in Maui. HBPC is also delivered by VA in 
Oahu, Kauai and the Big Island. HBPC is an important component of VA's 
non-institutional long-term care program designed to provide care in 
the least restrictive setting for Veterans. Earlier this year, VAPIHCS 
was approved for $256,000 in rural health funding to expand the Maui 
HBPC program and to begin providing home care services on the islands 
of Lanai and Molokai. VA will add staff to serve these islands, with 
service delivery anticipated this month on Molokai and later this year 
in Lanai.
    There is also a significant demand for mental health services at 
the Maui CBOC. About 32 percent of all patients currently seen at the 
clinic have a documented mental health illness (compared to 19 percent 
for VHA). This includes a high prevalence of PTSD. In response to this 
need, VA has substantially increased its authorized mental health 
capacity at the Maui CBOC. As you know, Mr. Chairman, Congress has 
provided several hundred million dollars to VA to specifically enhance 
mental health services. Since FY 2006, and each subsequent year 
thereafter, VAPIHCS has received nearly $3 million of these funds. 
These funds have been used to hire about 35 new mental health staff in 
VA facilities across Hawaii and the Pacific region, including seven 
staff here at the Maui CBOC. In addition, the Maui Vet Center also 
successfully recruited another psychologist.
    Molokai and Lanai. The islands of Molokai and Lanai are part of 
Maui County. VA provides limited services (i.e. part-time outreach 
clinics) on these islands with permanent staff (on Molokai) and 
visiting VA staff (to both islands). VAPIHCS is assessing options to 
enhance services in both locations.
    Molokai. VA estimates the Veteran population on Molokai to be 649, 
with 203 Veterans from Molokai enrolled for VA care and 150 Veterans 
receiving VA services. VA formally established an outreach clinic on 
Molokai in FY 2005 with the assistance of you and your staff, Mr. 
Chairman. The VA clinic on Molokai is located in shared space near 
Molokai General Hospital and operates two half-day primary care clinics 
per week. The clinic is staffed with a part-time VA physician and 
contract support staff. VA has access to videoconferencing equipment at 
this facility. VA also sends mental health staff from the Maui CBOC to 
Molokai to provide care. The Clinic's psychologist travels twice a 
month and the psychiatrist once a month. In addition, VA purchases non-
VA care in the community (e.g., Molokai General Hospital) for eligible 
Veterans residing in Molokai. Veterans residing in Molokai also are 
seen at DOD and VA facilities in other locations. VA pays for travel 
expenses for those Veterans eligible for beneficiary travel.
    Lanai. VA estimates the Veteran population on Lanai to be 229, with 
57 Veterans enrolled for VA care, and 30 Veterans receiving VA 
services. Since June 2007, a VA primary care provider from Maui travels 
to Lanai once a month to provide needed primary care services. 
Additionally, in FY 2009 a Mental Health Clinical Nurse Specialist 
began accompanying the primary care provider. VA has used space 
adjacent to the Lanai Community Hospital, and most recently finalized 
an agreement with Straub Outpatient Clinic for visiting VA providers to 
use space and support the Clinic. In addition, VA purchases non-VA care 
in the community and pays beneficiary travel for eligible Veterans. VA 
is continually exploring other options to improve access.
                               conclusion
    In summary, with your support, Mr. Chairman, and with the support 
of other Members of Congress, VA is providing an unprecedented level of 
health care services to Veterans residing in Hawaii and here in Maui. 
We look forward to a growth of new patients at the Maui CBOC and will 
meet the expectations of Veterans for quality and timeliness.
    VAPIHCS still faces several challenges, in part due to the 
topography of its catchment area, the lack of an acute medical-surgical 
hospital, limited community resources in rural areas, and difficulties 
recruiting staff. VAPIHCS will meet these challenges by utilizing 
telehealth technologies, hiring specialists, working with community 
partners and developing new delivery models. I am proud of the 
improvements in VA services in Hawaii, but recognize that our job is 
not done.

    Again, Mr. Chairman, mahalo for the opportunity to testify at this 
hearing. My colleagues and I would be delighted to address any 
questions you may have for us.

    Chairman Akaka. Thank you very much, Ms. Cullen.
    And now we will hear from Linda Halliday. Please proceed 
with your testimony.

STATEMENT OF LINDA HALLIDAY, DEPUTY ASSISTANT INSPECTOR GENERAL 
 FOR AUDITS AND EVALUATIONS, OFFICE OF INSPECTOR GENERAL, U.S. 
                 DEPARTMENT OF VETERANS AFFAIRS

    Ms. Halliday. Mr. Chairman, thank you for the opportunity 
to testify on the results of our report, ``Review of 
Availability of Mental Health and Orthopedic Services at the VA 
Pacific Islands Health Care System.'' Accompanying me today is 
Mr. Walter Stucky, Audit Manager in our Seattle Audit and 
Evaluations Office in the OIG.
    Veterans living on Maui and the other islands face similar 
issues as veterans living in rural communities in obtaining 
timely access to health care services, especially mental health 
services and specialty care such as orthopedics. Not only has 
the health care system faced difficulties in providing these 
services, they have also been limited by the short supply of 
community health providers.
    In early June 2009, we conducted on-site work at the health 
care system's main ambulatory care center in Honolulu and the 
Maui CBOC. We found that since fiscal year 2006 the health care 
system has made significant strides in reducing wait times for 
elective orthopedic surgery procedures. Furthermore, although 
the health care system has experienced challenges in providing 
mental health services to veterans on Maui and other islands, 
it is effectively using VA's Mental Health Enhancement 
Initiative funding to recruit additional staff and expand 
telehealth services.
    In 2006, the OIG assessed the timeliness of orthopedic 
surgeries at the health care system. We found that the average 
wait time for elective orthopedic procedures was 182 days with 
wait times for individual cases ranging between 14 to 379 days. 
I am happy to say our more recent work found significant 
improvement in elective surgery wait times. Both VA and Tripler 
orthopedic surgeons treat health care system patients who 
require orthopedic care, and the surgical procedures are 
performed at Tripler TAMC by VA and Tripler orthopedic surgeons 
under an interagency sharing agreement.
    We reviewed 15 elective orthopedic surgeries performed at 
Tripler in April and May 2009 and found that the time between 
the decision to operate and the surgery date ranged from 11 to 
210 days and averaged 82 days. We attribute the improvements in 
timeliness since 2006 to three factors:
    Since February 2007, the health care system has hired two 
orthopedic surgeons. Prior to this, it relied on surgeons from 
Tripler and other VA facilities in the continental United 
States.
    Tripler dedicated one operating room day each week to VA 
orthopedic patients, in addition to its normal integrated 
scheduling of VA and Tripler patients for surgery.
    And, third, the health care system and Tripler have 
improved their coordination of orthopedic surgery care.
    In 2007, the State of Hawaii task force reported community 
health resources in Maui were stretched to meet mental health 
needs resulting from veterans returning from Iraq and 
Afghanistan, an aging population, and prevalent drug use. The 
health care system has also been stretched by the scarcity of 
mental health resources on Maui. Mental health staff at the 
Maui CBOC told us that they have been meeting emergency needs 
of patients, but they are challenged in ensuring the timely 
follow-up care due to staff shortages. For example, in May 
2009, the psychiatrist reported that his earliest available 
follow-up appointment was 7 weeks away.
    Despite these challenges, we found that the health care 
system leadership has been proactive in securing funding 
through VA's Mental Health Enhancement Initiative to hire 
additional staff at the Maui CBOC and to expand telehealth 
capabilities to assist other CBOCs. In the past year, the 
health care system has received approximately $4.7 million in 
Mental Health Enhancement Initiative funding and used a portion 
to hire additional staff. They expect to meet both the urgent 
and the follow-up mental health care needs of veterans served 
by the Maui Clinic.
    In summary, Mr. Chairman, our review found that the health 
care leadership continues to identify gaps and improve 
availability of orthopedic and mental health services to 
veterans on Maui and other islands. However, as with any rural 
health care system, VA Pacific Islands Health Care System 
leadership must make difficult choices as to how to best use 
the resources to most effectively meet the needs of veterans in 
a large, geographically diverse area, while also addressing 
difficulties in recruiting qualified health care professionals.
    Mr. Chairman, I thank you for the opportunity today. We 
would be pleased to answer any questions you have.
    [The prepared statement of Ms. Halliday follows:]
   Prepared Statement of Linda Halliday, Deputy Assistant Inspector 
  General, Audits and Evaluations, Office of Inspector General, U.S. 
                     Department of Veterans Affairs
                              introduction
    Mr. Chairman and Members of the Committee, Thank you for the 
opportunity to testify today on the availability of mental health and 
orthopedic services for veterans served by the VA Pacific Islands 
Health Care System (VAPIHCS), with special emphasis on the Island of 
Maui. I will focus on the results of our recently issued report, Review 
of Availability of Mental Health and Orthopedic Services at the VA 
Pacific Islands Health Care System (attached). Accompanying me today is 
Mr. Walter Stucky, Audit Manager, Seattle Audit Operations Division, 
Office of Inspector General (OIG), Department of Veterans Affairs.
                               background
    Veterans living on Maui and the other Hawaiian islands face similar 
issues as veterans living in rural communities throughout the country 
obtaining timely access to all services, especially mental health 
services and specialty care services such as orthopedics. Not only has 
VAPIHCS faced difficulties providing the services, they have also been 
limited by the short supply of community health providers.
    In May 2006, the OIG issued a report titled, Review of Access to 
Care in the Veterans Health Administration, which included an 
assessment of the timeliness of orthopedic surgeries at the VAPIHCS. 
Because no related Veterans Health Administration or other American 
medical timeliness standards were available at the time, the review 
used a foreign orthopedic surgery timeliness goal of 6 months. This 
standard was based on evidence that suggested that deterioration of 
patients' health occurs when they wait more than 6 months for joint 
replacement surgeries. The OIG's review found that the average wait for 
elective orthopedic procedures at the VAPIHCS was 182 days, with wait 
times for individual cases ranging from 14 to 379 days.
    In November 2007, a task force commissioned by the State of Hawaii 
found that community mental health resources on Maui were stretched to 
meet increasing mental health needs resulting from veterans returning 
from Iraq and Afghanistan, an aging population, and prevalent drug use. 
VAPIHCS is also challenged in recruiting staff especially on the outer 
islands due to the high cost of living, both for housing and 
commodities; high relocation costs; and a cost of living adjustment 
that is not comparable to locality pay rates used in the continental 
United States and is not used in calculating Federal retirement 
benefits.
                                results
    In late May/early June 2009, we conducted onsite work in Honolulu 
and Maui at VAPIHCS, Veterans Integrated Service Network 21, Tripler 
Army Medical Center (TAMC), and the Maui Community Based Outpatient 
Clinic (CBOC). We interviewed managers and administrative and clinical 
staff and reviewed scheduling and workload data, recruitment 
information, and other pertinent documents related to patient 
complaints and wait times. We found that:

     Since fiscal year (FY) 2006, VAPIHCS has made significant 
strides in reducing wait times for elective orthopedic surgery 
procedures, most notably by hiring two orthopedic surgeons.
     Although VAPIHCS has experienced challenges in providing 
mental health services to veterans on Maui and the other outlying 
islands, it is effectively using VA's Mental Health Initiative funding 
to recruit additional staff and expand telehealth services.
Orthopedic Care
    Our recent work noted significant improvement in elective surgery 
wait times since FY 2006. Both VA and TAMC orthopedic surgeons evaluate 
and treat VAPIHCS patients requiring orthopedic care. Because VAPIHCS 
is not fully staffed or equipped to perform orthopedic surgeries, 
surgical procedures are performed at TAMC by VA and TAMC orthopedic 
surgeons under an interagency sharing agreement. If TAMC cannot 
accommodate a VA patient, VAPIHCS Utilization Management staff refers 
the patient to a community provider on a fee-for-service basis.
    Our discussions with VAPIHCS clinicians and TAMC managers indicated 
that TAMC has sufficient staff and resources to consistently 
accommodate VA patients without significant delays, but that some 
patients prefer later surgery dates or they are not medically ready to 
undergo surgery on the scheduled dates. Our review of 15 elective 
orthopedic surgeries performed at TAMC in April and May 2009 found 
significant improvement in average wait times. The time between the 
decision to operate and date of surgery ranged from 11 to 210 days and 
averaged 82 days. We attribute the improvement in timeliness to three 
factors:

     VAPIHCS officials hired two orthopedic surgeons--one in 
February 2007 and the other in October 2008. Prior to hiring these 
surgeons, VAPIHCS relied on orthopedic surgeons from TAMC and other VA 
facilities in the continental United States to provide services. With 
these recruitments, VAPIHCS has established its own orthopedic clinics 
at both the Ambulatory Care Center and CBOCs. Furthermore, one of the 
orthopedic surgeons also performs surgery at TAMC.
     TAMC dedicated one operating room day each week to VA 
orthopedic patients, in addition to its normal integrated scheduling of 
VA and TAMC patients for surgery.
     VAPIHCS and TAMC have improved their coordination of 
orthopedic surgery care. For example, TAMC provides VAPIHCS monthly 
reports on availability of services and holds monthly coordination 
meetings with VAPIHCS Utilization Management officials to resolve 
problems and improve services. In addition, a VAPIHCS orthopedic 
surgery nurse tracks the status of VA patients scheduled for surgery at 
TAMC to ensure patients meet all pre-operative requirements.
Mental Health
    Mental health staff at the Maui CBOC told us that they have been 
meeting the emergency needs of patients; yet, they continue to 
acknowledge challenges ensuring timely follow-up care due to staff 
shortages. For example, in May 2009, the psychiatrist reported that his 
earliest available follow-up appointment was 7 weeks away and that he 
often worked additional hours to see patients.
    Despite these challenges, we found that VAPIHCS leadership has been 
proactive about securing funding through VA's Mental Health Enhancement 
Initiative to hire additional staff at the Maui CBOC and expand 
telehealth capabilities to assist other CBOCs. In the past year, 
VAPIHCS has received approximately $4.7 million in Mental Health 
Enhancement Initiative funding and has used a portion of this amount to 
improve the availability of services at the Maui CBOC by hiring 
additional staff. In February 2009, VAPIHCS officials hired a mental 
health social worker. In addition, a clinical nurse specialist and a 
second staff psychiatrist joined the CBOC in late July/early August of 
this year. VAPIHCS leadership and clinicians told us that, with this 
additional staff, they expect to meet both the urgent and follow-up 
mental health care needs of veterans served by the Maui CBOC.
                                summary
    Our review found that VAPIHCS leadership continues to identify gaps 
and improve availability of orthopedic and mental health services to 
veterans on Maui and the other islands. However, as with any rural 
health care system, VAPIHCS leadership must make difficult choices as 
to how best to use its resources to most effectively meet the needs of 
veterans in a large, geographically diverse area, while also addressing 
difficulties in recruiting qualified health care professionals.

    Mr. Chairman, thank you again for this opportunity. We would be 
pleased to answer any questions that you or other Members of the 
Committee may have.

                               Attachment



    Chairman Akaka. Thank you. Thank you all very much for your 
testimony. Again, I want to thank this panel for bringing us up 
to date and especially what we are anticipating will happen, 
providing the supports come through.
    Dr. Hastings, I want to pose the first question to you. 
What is the status of the proposal to build a new veterans 
multi-use building on the campus of the Maui High School? And 
what is VA's role in this partnership? And have you heard from 
the State regarding this proposal?
    Dr. Hastings. Well, Mr. Chairman, first I want to thank you 
very much for coming out and having this hearing and providing 
all of us with an opportunity to review how we provide services 
to our veterans. This proposal that we heard so much about 
today we have heard of, and we have talked to several of the 
people that have worked on this proposal. The fundamental 
problem that we have is the issue of the Federal Government not 
being able to build on land that it does not own, and it seems 
that is the core issue that we are faced with. And we certainly 
have talked to the capital assets managers of the VA about this 
proposal. We have looked at it, and we have worked with the Vet 
Center that proposed this. But as we understand it right now, 
the issue is that the VA does not have the authority to build 
on land that it does not own. I think that is the fundamental 
problem.
    Chairman Akaka. Well, thank you for that technicality. We, 
of course, need to look into that and see what we can do next 
on this. I thank you very much for what you have been trying to 
do and get done, and even to the point of maybe making other 
suggestions. Thank you for your response.
    Ms. Betts, how often does the traveling veterans service 
representative from Honolulu provide services to veterans 
living on Maui? How often does that happen? How would you 
characterize that representative's schedule while on Maui? Do 
veterans seeking services from that representative receive them 
in a timely manner?
    Ms. Betts. With regards to the traveling schedule of the 
counselor, currently we have a counselor who travels to every 
island once a month, and they do come on. It is a set schedule, 
the same day of the week every month. The Vet Center hosts the 
counselor, and they take--they actually take appointments, so 
they know who they are coming to see. And they usually come in 
the morning and then leave on the last flight out. And they see 
all of the people who are scheduled for appointments plus walk-
ins.
    We also have a program in which the counselor--and it is 
not always the same one, but a benefit counselor also goes to 
Molokai every other month, and they go to Maui--I mean, to 
Lanai apparently once a quarter. The counselor is able to 
assist and provide as much information as they can while they 
are here, and they take the information back to Oahu.
    We are currently working on outreach to all of the islands 
in collaboration with Dr. Hastings and myself. We are working 
on an outreach program to visit each of the islands with an 
outreach team because one of the issues we have, and that is, 
what is the need and what is the veteran population in the 
areas. What we are trying to do in this program--we started 
this month, in January--is to start to get the veterans who are 
residing in all of these rural remote areas to register. We 
need them to register with the health care system so that we 
can document how many veterans are there, and, therefore, we 
can provide the services for the veteran population. Currently, 
the populations who are registered are a lot less than the 
numbers that people keep putting out to us. Although the State 
has a number of veterans on this island, the number that are 
registered in the VA system are a lot less than what they are 
saying is actually residing.
    So what we are doing is, as far as access to a benefit 
counselor, I work collaboratively also with the State Office of 
Veterans Services, Mr. Moses, and we are looking at what is 
needed, and we are looking at the possibility of having a full-
time counselor here on Maui, and that, again, is a 
collaborative effort with Dr. Hastings because he had worked on 
a program where he would provide the actual space, which would 
be in the CBOC. We are working toward, as we say, the one-stop 
shop where all of the VA services are provided in one area. So, 
right now we are working with the clinic to see when they come 
up with the space for us, then we will put a full-time 
counselor there.
    Currently, the Vet Center is hosting us. Again, it is an 
issue of space to put a permanent full-time person in.
    Chairman Akaka. Ms. Betts, as you heard from the first 
panel, some veterans believe that Vet Centers should be staffed 
with a veterans service representative full-time. What is your 
opinion on this matter?
    Ms. Betts. Currently, where the veteran counselor sits, I 
do not have an opinion on that at this time. My issue is that 
we get a veteran counselor, and they need to be full-time out 
here on Maui. At this time, just from my exposure to 
everything, I would say it appears that it would be more 
beneficial to put a counselor into a CBOC. But whether it goes 
into a Vet Center or a CBOC, I don't have an opinion there. It 
is just getting the counselor out to----
    Chairman Akaka. Thank you very much.
    Ms. Cullen, I understand that some veterans are able to 
receive specialty care through a telehealth link with Palo Alto 
in California. Are you providing incentives to providers in 
Palo Alto to provide those services to veterans in Hawaii? And 
if so, what are they?
    Ms. Cullen. Over the last 2 to 3 years, we have moved away 
from the reliance that we had at one point of utilizing 
clinical providers from both the VA medical centers in Palo 
Alto and in San Francisco. Dr. Hastings has made significant 
inroads in hiring some specialists to be on staff at VA Pacific 
Islands Health Care System. As you heard from part of the IG 
report, having brought on two orthopedists who are now in place 
in Honolulu, I believe that they are now able to provide a lot 
of the specialty services via telehealth.
    I would like to look to Dr. Hastings just to see if we 
still have any regular services via telehealth from California, 
but I think that they are all provided from providers out of 
Honolulu, a combination of telehealth as well as those clinical 
providers traveling to the other islands, though I would turn 
to Dr. Hastings.
    Chairman Akaka. Dr. Hastings?
    Dr. Hastings. Senator, I would like to tell you that our 
contact with the other facilities in the VISN has been very, 
very supportive, and whenever we have needed something, they 
have been willing to come and help us.
    The two areas that we are using them extensively right now 
is--I guess there are three areas that we use them. One is 
spinal cord injury patients, paraplegic patients, and we are 
using facilities at Palo Alto telemedicine support there. And 
then we are using teledermatology where we get dermatology 
consultations from providers in California, and this is very 
helpful to us. And then the third area that I would tell you 
about is in electrocardiograms for cardiac patients. We have 
been able to set up a relationship so that we have been able to 
get regions in California to help in that area.
    Now, we are not going to have to use that in the future 
because we have been successfully hiring our own cardiologists, 
so we will not use that one. But, as we identify areas that we 
feel there is something that they can help us with, they have 
always been very responsive to the needs that we identify.
    Thank you, Senator.
    Chairman Akaka. Thank you.
    Ms. Cullen. If I can perhaps add, I had a few more thoughts 
since Dr. Hastings began to elaborate. Just to tell you of two 
developments within VA that will certainly benefit veterans in 
the Pacific Islands and will benefit them nationally as well.
    One is that within VA there is now a greater incentive to 
provide health care services via telehealth. At one point 
within VA, its own internal reimbursement mechanism did not 
recognize a cost transfer for services provided by telehealth, 
and that has been changed effective this fiscal year, so I 
anticipate that will help increase telehealth services 
nationwide.
    A second development that may be of interest to you is VA's 
National Teleradiology Program. That began in California, in 
Northern California, starting at the San Bruno Clinic, which is 
linked to the San Francisco VA medical center, and 
transitioning to a larger program at Palo Alto. They have now 
begun a second center here in Honolulu and have two to three 
radiologists on board who are available to read radiology films 
at the facilities that are experiencing either recruitment 
difficulty with radiologists or who might have a temporary 
problem.
    So, they have already touched based with Dr. Hastings, and 
I am assured that he will have first availability of any 
services that they can provide should he have any need, but I 
think both of those developments will greatly help provide 
services to veterans throughout the country.
    Chairman Akaka. Thank you.
    Also, Dr. Darkins, this relates to you and your work in 
telemedicine. Please give us an update on how telemedicine is 
improving which might make getting on a plane less necessary.
    Dr. Darkins. Aloha, Chairman.
    Chairman Akaka. Aloha. Thank you for being here, Doctor.
    Dr. Darkins. I would like again, like the others, thank you 
for the opportunity to be here. This meeting and also the one 
back in August really help highlight some of the importance of 
telehealth, so I thank you for that.
    VA really has shown over the last 7 or 8 years a sustained 
growth in telehealth, and we completed fiscal year 2009 with 
just over 260,000 cases nationally, which was up from just over 
230,000 the year before. Of those 260,000 cases, 58,000 were 
doing videoconferencing with VA medical centers and clinics, 
and 150,000 were providing teleretinal imaging, screening the 
eyes of veteran patients with diabetes and blindness. And as we 
sit here, some 41,000 veteran patients are currently managing 
to live in their own homes independently because of having 
telehealth devices in their homes.
    We have looked at the benefits of this in terms of the 
reductions of admissions to hospital where the reductions are 
on the order of about 25 percent reductions in the need to go 
to the hospital. And we look across the board at the 
satisfaction of veteran patients because we are obviously 
concerned that with changing the location of care, this is 
indeed their preference. We have found very high levels of 
patient satisfaction. So, I think it is good news to be able to 
report that we are seeing a systematic growth year on year, and 
we look forward to the same happening again.
    We have some new programs which we anticipate coming online 
this year. One particularly notable one is going to be the use 
of the weight reduction program, the MOVE program that VA has. 
It is now possible to provide that by telehealth devices.
    I was talking to Dr. Hastings before. This is something in 
preliminary discussions, but certainly it makes sense to be 
able to discuss its applicability out in the islands. We are 
looking at the use of Internet protocol video in the home to be 
able to reach out into the home more commonly to provide 
services. So, we are really seeing, as I said, this kind of 
sustained growth.
    We are piloting teledermatology. You have heard about its 
link between Northern California and Hawaii. We are looking 
toward--we have piloted it in seven VISNs and are looking 
toward rolling that out more widely. So, I hope to be able to 
report at the end of this next fiscal year further sustained 
growth.
    The issue very much for telehealth, particularly with 
regard to rural and remote areas, such as--I welcome the 
opportunity to be here and to see many of the issues evolve, 
though I have been here before as well.
    The issue of telehealth is not just about care in the 
remote areas that is important. It is also the access to care 
from urban areas----
    I would just like to finish by saying in the end it really 
comes down to peoples and communities. My ability back in 
August with others to go around and see Hawaii, especially on 
the Big Island, and just over yesterday to be here on Maui to 
see the enthusiasm of the staff involved, which I think there 
are some exemplary services. Having seen Dr. Pierce and what is 
taking place in telemedical health I think is really something 
we can work elsewhere.
    So, I must say, I think one can certainly see improvements 
in growth here and seeing the effects of both yourself and 
Secretary Shinseki really focusing on the importance of 
telehealth. I have had some very good discussions with Ms. 
Cullen and also Dr. Hastings, and we look forward to being able 
to serve more veterans in more timely ways in the future. That 
is really why I am here, and I look forward to being able to 
bring forth some of the ideas we have for that benefit.
    Chairman Akaka. Well, thank you very much, Dr. Darkins.
    Ms. Halliday, are other clinics in the health care system 
encountering the same challenges that the Maui Clinic has 
encountered serving veterans with mental health care needs?
    Ms. Halliday. We did not specifically review the staffing 
issues outside of Maui. However, we did talk with the health 
care system clinicians and staff and believe that the other 
CBOCs are experiencing similar issues. Some of the common 
problems include lack of community mental health resources, 
difficulty in recruiting medical providers, and the geographic 
separation from the main health care facility in Honolulu.
    Chairman Akaka. Ms. Cullen, you are in charge of several 
large VA hospitals and clinics, mostly in California. Would it 
help if you had a Deputy Network Director here in Hawaii?
    Ms. Cullen. Well, funny you should ask because we will be 
getting a new Deputy Network Director, but that person will be 
based in Northern California. She will be arriving the 
beginning of February. And one of the things that we are doing 
is setting--while we are setting some goals for all of our 
facilities during the course of this year, we are also setting 
some goals for our home office, and one that we are assigning 
to ourselves is to ensure that our VISN staff get out to each 
element of our organization; that is, not just the large 
medical center but to each CBOC, at least one VISN staff person 
would be at each VA site, a VHA site, within the VISN annually. 
It is not quite the same as having a Deputy Network Director 
based in Hawaii, but I believe that--but sometimes I think that 
our Hawaii colleagues think they perhaps see a little more of 
us than they would like.
    I come with Jeannie Daily, the quality manager who is with 
me and with our chief medical officer to have regular 
performance reviews with our facility in Hawaii. And thanks to 
your invitation in August to come to almost all of the islands, 
and the opportunity here today, we feel we see the value in 
having regular contact with each VA location. So while we do 
not have a staff person--a VISN staff person--based here, I 
think, though you will have to ask them, that they perhaps get 
to see at least as much of us as they might like. But, again, I 
will leave that for them to respond to perhaps after they are 
on the official record.
    Chairman Akaka. Yes. [Laughter.]
    Well, thank you very much for that. We look forward and 
anticipate the best happening here.
    Ms. Betts, I am very pleased to hear that the Native 
American Direct Loan Program is very active on Maui. Will you 
please tell me approximately how many Maui veterans benefited 
from this program in 2009?
    Ms. Betts. I do not have that number specifically for Maui. 
I do know that we had 121 Native American direct loans for the 
State of Hawaii.
    Chairman Akaka. Well, you can provide that specific for the 
record.
Response to Request Arising During the Hearing by Hon. Daniel K. Akaka 
to Tracey Betts, Director, Honolulu VA Regional Office, U.S. Department 
                          of Veterans Affairs
    Question. Of the 121 Native American direct loans for the State of 
Hawaii, how many are specifically for Maui?
    Response: Nine of the 121 Native American Direct Loans in Hawaii 
are in Maui.

    Chairman Akaka. Dr. Hastings, what barriers do you see to 
expanding telehealth services on Maui? Do you see any barriers, 
including potentially connecting VA to the community health 
clinic in East Maui?
    Dr. Hastings. Thank you, Senator. We have looked at the 
issue of East Maui and are trying to connect with them, and our 
staff people who view telehealth have been over to Maui, have 
been over to Hana, and they have surveyed the equipment and 
facilities that were available over there. At the moment we 
have--we are unable to connect VA equipment with the existing 
equipment there.
    On the other hand, as we are continuing to explore the 
expansion of this technology in the Pacific, I believe that we 
will be able to figure out how to end up really providing 
better services there.
    I can tell you that in the Pacific the challenges that we 
have had have been with connectivity growing. Look at American 
Samoa and, more recently, our expansion into Saipan. And, of 
course, the problem of getting into American Samoa was getting 
cable--getting bandwidth--there. It has been within the past 
year, I believe, that we were able to get cable into American 
Samoa. And what has happened is we now have wide bandwidth 
connectivity to our clinic there, and so we have been able to 
expand our telehealth connectivity to that area, and we are 
doing it to support the Department of Defense in their TBI 
evaluations on our Reservists that are in the area, as well as 
for supporting our veterans.
    I think that has not been a problem for us here in Hawaii. 
I think we have adequate bandwidth connectivity capabilities 
here in our clinics, but we have had some problems with 
equipment, and I think we are going to be able to have all of 
those soon.
    You asked about the things that prevent us from being able 
to exploit this technology. Part of it is just the very system 
that we work in. A lot of our providers--for instance in our 
fee-based system--they're people from the university, 
practitioners in the community, specialists, and we can set up 
a telemedicine capability where we can transmit with an 
individual, but we also have to have--on the other end of the 
connection--we have to have a provider who is trained, 
experienced, and willing to use the technology. And if that 
person does not work full-time for VA, then it becomes a little 
bit of a challenge.
    So, I have been successful, we have been very successful in 
getting some of these people who are not as familiar with the 
technology to use it, but we are more successful when we have 
the specialists inside our own organization.
    Chairman Akaka. Ms. Halliday, for elective orthopedic 
surgeries, you stated that the wait time was decreased to an 
average of 82 days. This still seems excessive given that the 
time ranged from 11 to 210 days. What challenges does the 
health care system continue to encounter to ensure timely 
orthopedic surgeries?
    Ms. Halliday. The 82-day average in our sample included 
three surgeries that were delayed because patients were not 
healthy enough for surgery to be completed. When you factored 
those three instances that the auditors found, the average time 
would come down to 62 days. That is approximately 2 months.
    The main challenges that were brought to our attention were 
getting the patients ready for surgery, and sometimes their 
health issues--they have to have certain things cleared up 
before surgery. Now that they have a nurse, a VA nurse tracking 
the patients' needs, it is improving dramatically. I think it 
is just a matter of timing to see an even more significant 
improvement.
    Chairman Akaka. Thank you.
    Mr. Stucky, would you like to share more information about 
the waiting times?
    Mr. Stucky. Sure. There are no VHA or industry standards 
for timeliness of elective orthopedic surgeries. We found that 
the desired waiting time in scheduling the surgeries varies 
depending on the patient's medical condition and the patient's 
preferences, in addition to some cases where the surgery was 
scheduled within 60 days it was delayed either because of the 
patient's preference or because the patient was not ready for 
surgery.
    Chairman Akaka. Ms. Betts, in his prepared testimony, Mitch 
Skaggerberg of the Vietnam Veterans of Maui County notes that 
requiring Central Office review and approval of applications 
for VA's Independent Living Services Program results in ``major 
delays, many times up to 2 years.'' Would you please comment on 
this statement?
    Ms. Betts. Apparently, there was a time period when the 
requirement for the Central Office review, as he stated, was an 
outcome of a site visit, and it was more of an oversight of the 
program itself. That was conducted here in Hawaii.
    Since then, that requirement is no longer in place. 
Currently, there are only four cases pending that have gone up 
into--and the normal process for the Independent Living 
Program--this is for everyone--is that the counselor once 
determined through the group assessment that the individual is 
eligible and was put into the Independent Living Program, all 
of that information does go up into the Washington office, and 
it is in our vocational rehabilitation and employment service, 
and they actually do the final approvals on all of the cases.
    So, the counselor would not--what was happening before, 
where his statement came from is based on this site visit and 
an audit that was done previously. We were asking him to look 
at the independent living cases prior to the actual application 
and the submission of requirement, and I think that is where 
there is a discrepancy in the understanding of what actually 
transpired.
    So, currently, there is no specific thing that we do any 
different from any other facility, and it does--and it is just 
the program itself. They do have an oversight, and that 
oversight does go up to--once the counselor puts their program 
together and everyone concurs, I also see it and concur. We do 
send them up because the program reserves the right--and that 
is at the Central Office level--to approve and to review all 
independent living programs.
    Chairman Akaka. Would you be able to tell me the national 
average time to approval for an application for independent 
living services and the average time for approvals in Maui?
    Ms. Betts. Not at this time. Could I send you that 
information?
    Chairman Akaka. Yes, thank you.
Response to Request Arising During the Hearing by Hon. Daniel K. Akaka 
to Tracey Betts, Director, Honolulu VA Regional Office, U.S. Department 
                          of Veterans Affairs
    Question. What is the average time to approve an application for 
independent living services in Maui and nationwide?
    Response. The average number of days to enter an independent living 
(IL) program nationally, based on active workload, is 188 days. The 
average number of days to enter an independent living (IL) program for 
the Honolulu Regional Office, based on cases that entered independent 
living status fiscal year to date, is 415 days.
    The Honolulu Regional Office (RO) faces the unique challenge of 
serving a vast geographic area, which impacts timeliness of VR&E 
services. The RO's geographic jurisdiction encompasses the following 
areas: Asia, American Samoa, Guam, Republic of Palau, Republic of the 
Marshall Islands, Federated States of Micronesia, and the Commonwealth 
of the Northern Mariana Islands. The RO has implemented several 
initiatives to ensure that IL services are used appropriately and to 
improve timeliness of the development of IL plans. Specifically, the 
Honolulu VR&E division implemented a workload management plan with an 
emphasis to improve the timelines of IL claims. The VR&E division 
revised the local training program to focus on IL planning. In 
addition, there is a multi-level approval process for all IL plans. To 
that end, the VRC develops the plan, the VR&E Officer reviews the 
appropriateness of the plan, and then it is forwarded to the Director 
for final approval. The tiered approval process ensures that all plans 
are developed appropriately. Honolulu has improved timeliness by 24% so 
far in fiscal year 2010, as a result of these initiatives.

    Chairman Akaka. Now, I have further questions, but I want 
to give each of you a chance to give a summary or a statement 
that you have got to give at this time about what you are 
doing. And I, of course, want to thank you for your responses 
that you have given. It will be helpful for the people of Maui 
to have heard from you what you have done already and what we 
can probably expect to be done. So, if you have a statement you 
would like to close with, I want to give you that opportunity 
now.
    Let me begin with Ms. Betts.
    Ms. Betts. Thank you, Chairman. What I would like to say to 
the veterans of Maui is we do have--right now I am working on--
basically I have three initiatives going. One of them is to 
increase the outreach. I have been hearing this across the 
State and across the Pacific Region because my responsibilities 
are to deal with the benefits. I have been working 
collaboratively with Dr. Hastings from the medical side, and we 
also work with the Vet Centers as well as the Office of 
Veterans Services from all of Hawaii, American Samoa, and Guam. 
And what we are looking at is one, to increase our outreach and 
appearances on every island. The objective there is to do just 
that: to let the veterans know that we are here; to hear what 
they need; and one of our focuses is going to be on getting 
them enrolled. It is very important and they need to understand 
that.
    I heard the conversation about Hana, and we do not have a 
benefit counselor who goes to Hana. Those are the kinds of 
things that I need to know about. Those are the kinds of things 
we need to look into, and we are going to start by doing 
outreach.
    From January to June of this year, we will take an outreach 
team to every island, and that is the kind of thing we are 
going to be looking to address their concerns and to determine 
if the population there requires not only the benefits but also 
the medical care. So, we need to get everyone to register. It 
is very important that they register with the VA, and the 
registration is with the VA medical centers and the medical 
clinics. Once we get that, we can then do our assessments and 
put our people out there.
    Another thing is that in working in collaboration with Dr. 
Hastings and the medical centers, they are planning in their--
as they are growing, they are planning to have space for a 
benefit counselor. So, with that commitment, as he grows and as 
he starts to--because currently in the facility they have, 
there is no extra space to put us. But once they do become 
available, we will be putting counselors in those areas.
    In the meantime, what I'm looking at is we have a current 
counselor who comes once a month, and if it is determined 
because there is a need to have him go out more than once a 
month, we will do that. Right now I am trying to do assessments 
of what the need is, and this is for all of the islands and for 
all of the Pacific Region that we are responsible for. So, that 
was one thing.
    Another thing is I know there is a lot of conversation 
about the vocational rehabilitation and employment, 
particularly the Independent Living Program. Just something for 
more of what is the program itself. The Vocational 
Rehabilitation and Employment Program offers benefits for 
vocationally rehabilitating veterans for employment. VA has 
what we call 5 Tracks, and independent living is just one of 
the five tracks available: to try to rehab the veteran for 
employment purposes. In some instances they are not employable; 
therefore, we work with them. Independent living is just that. 
It is a program that helps them become more independent in 
their daily life. So, it is a program out there. It has not 
gone away. I hear from time to time people asking why did it go 
away. It has not gone away.
    I heard a comment about the dollar value being changed, and 
that has not happened either. It is an entitlement. It is a 
benefit. The purpose of the vocational rehabilitation 
counselor, who works in conjunction with the medical folks, 
they make the determinations medically and psychologically, 
where does the veteran sit at that time, what is the best 
program for them. And, again, independent living is just one of 
many tracks that the rehab-to-employment program takes care of.
    The last thing I would like to say is, again, you know, we 
are out here to service veterans, and the important thing is we 
need to know what--we need to hear from them, but we also need 
to know what is it that we need to do better, and we are 
working on that. It does not happen overnight. Some things take 
time. Some things can happen instantaneously, but a lot of 
these particular issues we are working on. I am hearing them. I 
am committed to improve the services to the veterans. And, 
again, I must keep saying as we do outreach, they must register 
with the VA system.
    Chairman Akaka. Thank you very much, Tracey.
    Dr. Darkins?
    Dr. Darkins. Thank you very much, Mr. Chairman. It is a 
privilege to work for the VA and to be able to serve veterans, 
and that is not just as an entitlement, but also our way of 
life, and as we have heard, is dependent upon the service they 
have given to our country. Therefore, the ability to do that 
and to help serve veterans is a great privilege, not just for 
myself but everybody I work with.
    I look forward--having heard distinctly some of the issues 
in terms of access to care, in terms of how timely that care 
is, and the trouble that will be avoided by telehealth, I think 
we have one of the solutions to some of the problems. I would 
not suggest that telemedicine is going to do everything, but I 
think there are ways it can appreciably enhance services here 
in Maui.
    I look forward to working with Dr. Hastings, with his 
staff, and Ms. Cullen to see what we can do to be able to 
address some of the issues that we have heard and to deal with 
those and to come back in the future with what we have achieved 
and solutions and to hear that we have met some of these 
challenges and helped them.
    Chairman Akaka. Thank you very much.
    Ms. Cullen?
    Ms. Cullen. Thank you, Mr. Chairman. I appreciate hearing 
today from veterans on the first panel their expression that 
they have seen improvements in the services available to the 
veterans in Maui County over the course of the last 2 years. I 
am very encouraged by their declarations to that effect.
    We have national programs in the VA that you are certainly 
very familiar with which will allow us to provide opportunities 
to further improve care for veterans in the Pacific Islands--
the rural health initiative, the women's health initiative, the 
telehealth initiative, and Native Hawaiian initiatives. They 
are all priorities that Secretary Shinseki has identified, and 
our VISN staff will be working very closely with Dr. Hastings' 
staff to exploit--and I mean that in a very positive way--how 
those programs can further benefit veterans in the Pacific 
Islands.
    I am also very impressed, as I come to each of the 
community-based outpatient clinics--and certainly here the last 
couple of days in Maui--with the dedication, the 
professionalism, the commitment, not to mention the enthusiasm 
of the VA staff here and their willingness to embrace more 
programs and more opportunities to serve the veterans that they 
have been caring for over the last few years. That dedication 
and enthusiasm is something that I think will help us further 
expand and include services.
    We look forward to the Saipan outreach clinic this fiscal 
year, also the new expanded replacement clinic in Guam, and our 
own collaborations that Dr. Darkins referred to while here have 
identified some other potential areas for improvement that we 
need to do a little bit more work on. But we certainly look 
forward to reporting back to you at some point in the future 
with what those improvements will be.
    So, once again, thank you for all of your support and your 
encouragement to all of us to not settle for improvements that 
we have made, but to realize that there is still a lot more to 
be done.
    Chairman Akaka. Thank you.
    Let me call on Ms. Halliday and call on Mr. Stucky and 
finally Dr. Hastings. Ms. Halliday?
    Ms. Halliday. Well, thank you, Senator Akaka, for being so 
proactive and asking the OIG to look at certain accessibility 
and gaps that are occurring out on Maui.
    One of our main concerns was with the performance measure 
of mental health services in wait times to the initial and 
follow-up appointments. We have found that both the ambulatory 
care center in Honolulu and Maui were meeting this VHA 
performance measure. What we did see, though, is that the Maui 
CBOC was experiencing slippage in ensuring timely follow-up for 
current care.
    VHA does not track this performance. We would encourage VHA 
to track and collect this data so we can see it really truly 
measure whether improvements are happening in the future.
    Chairman Akaka. Thank you.
    Mr. Stucky?
    Mr. Stucky. Thank you, Senator. The main focus of our 
limited review of availability of services to the veterans in 
Hawaii was on mental health services. What was clear was that 
the mental health initiative funding has had a significant 
positive impact on the availability of services there.
    Chairman Akaka. Thank you.
    Dr. Hastings?
    Dr. Hastings. Thank you, Senator. I think what you have all 
heard is that the VA has significantly improved its ability to 
deliver services to our veterans here on Maui, and indeed 
throughout our system. We are not finished. This is a journey 
that we are on. We have come a long ways.
    I have to say that in large part it is support from you and 
from your Committee and from our representatives that has 
allowed the VA to improve the quality of care and the access to 
our veterans. We have a lot of challenges. Developing a complex 
health care system in the isolated areas that we face out here 
in the Pacific is a challenge, and I think that we have a long 
way to go. I think we have some very, very dedicated 
individuals and have been able to recruit more. For us in 
isolated areas, we have been successful.
    Now, there are areas that we need to improve, clearly. One 
of the ones that you heard today, we all heard today, is the 
East Maui issue. East Maui represents a small pocket of 
veterans who are in a very isolated area with limited resources 
for health care. We have other areas like that, and we have 
been able to begin to address those areas.
    Now, I think we are doing it very successfully. I think you 
heard that today. We have been successful on Molokai. We have 
been successful on Lanai. We have been successful in American 
Samoa. We have been successful in Guam. We have been successful 
in Saipan. I think we can be successful in East Maui as well.
    It is not something we can do overnight. It is going to 
take us a while to work on the problem, but I think we can be 
successful. And we will use the technologies that we heard 
about. We will use telemedicine, and we will use partnerships 
with existing health care facilities. You know, those are the 
tools that we end up using. We need to use the tools and the 
people that we have.
    I think there are other areas that we are improving on that 
are not so available, they do not stand out. But we are 
improving the efficiency of our organization. One of them that 
I would mention is laboratory support. We have come a long way 
in being able to get laboratory support for our CBOCs 
throughout our system in our area, and we are going to continue 
to do that. That is going to improve the ability of our 
providers to make accurate and rapid decisions about our 
patients.
    That is not something you measure, but it is there. I saw 
it today in the clinic that I went to. I remember going through 
that clinic 2 years ago, and we had a part-time person that was 
there one half or two half-days a week to draw blood, something 
like that. That was it. Today we have a full-time individual in 
nicely equipped, small laboratory, able to do some functions 
right when the patient came in. That improves the quality of 
care for our patients. They were doing that kind of thing.
    We started improving women's health. We have expanded our 
women's health clinic. We have brought on some more 
subspecialists into our system, and we will continue to do 
that. We will continue to build up that kind of support system 
that would support our whole thing.
    So, I think with the continued support that you have given 
us and that we have gotten from the big VA and from our VISN, 
all the help that we have gotten--and we have gotten help when 
we have asked for it, when we identified problems. We have been 
able to get support. We will continue to be able to improve 
access and quality of care for the veterans in Maui County and 
throughout the Pacific.
    Chairman Akaka. Thank you very much, Dr. Hastings.
    I want to thank our panelists. We know that there is much 
to be done in order to ensure that veterans on Maui receive VA 
benefits that they are entitled to. Given Hawaii's unique 
features, VA must implement its method of delivery of these 
services in a unique way. As Chairman, I am committed to 
overseeing that all veterans, especially those in my home State 
of Hawaii, receive the highest quality of care, and this is 
also for the rest of our country.
    Again, to all of you, thank you for being here, and at this 
time I would like to adjourn this hearing. This hearing is 
adjourned.
    [Applause.]
    [Whereupon, at 4:30 p.m., the Committee was adjourned.]
      

                                  
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