    [Senate Hearing 111-866]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 111-866

    OVERSIGHT HEARING ON TRAUMATIC BRAIN INJURY (TBI): PROGRESS IN TREATING
                 THE SIGNATURE WOUNDS OF THE CURRENT CONFLICTS

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                         ONE HUNDRED ELEVENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                  MAY 5, 2010

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

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

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                         COMMITTEE ON VETERANS' AFFAIRS

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

                                C O N T E N T S

                                  ----------

                                  May 5, 2010
                                    SENATORS

                                                                       Page
    Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........     1
    Burr, Hon. Richard, Ranking Member, U.S. Senator from North
      Carolina.......................................................     2
    Tester, Hon. Jon, U.S. Senator from Montana......................     4
    Murray, Hon. Patty, U.S. Senator from Washington.................    28
    Isakson, Hon. Johnny, U.S. Senator from Georgia..................    31
    Begich, Hon. Mark, U.S. Senator from Alaska......................    35
    Brown, Hon. Scott, U.S. Senator from Massachusetts...............   144

                                   WITNESSES

    Beck, Lucille B., Ph.D. Chief Consultant, Office of
      Rehabilitation Services, Office of Patient Care Services,
      Veterans Health Administration, U.S. Department of Veterans
      Affairs; accompanied by Karen Guice, M.D., Director, Federal
      Recovery Coordination Program; Joel Scholten, M.D., Associate
      Chief of Staff for Physical Medicine and Rehabilitation,
      Washington, DC, VA medical center; and Sonja Batten, Ph.D.,
      Deputy Director, U.S. Department of Defense Center of
      Excellence for Psychological Health and Traumatic Brain Injury.     6
        Prepared statement...........................................     7
        Response to written questions submitted by:
          Hon. Daniel K. Akaka.......................................    13
          Hon. Sherrod Brown.........................................    16
        Response to request arising during the hearing by:
          Hon. Patty Murray..........................................    29
          Hon. Jon Tester..........................................34,41,42
          Hon. Mark Begich...........................................    36
    Jaffee, Col. Michael S., M.D., National Director, Defense and
      Veterans Brain Injury Center (DVBIC), Traumatic Brain Injury
      Program, U.S. Department of Defense; accompanied by Katherine
      Helmick, Interim Senior Executive Director for TBI, Defense
      Centers of Excellence for Psychological Health and Traumatic
      Brain Injury...................................................    16
        Prepared statement...........................................    19
        Response to post-hearing questions submitted by Hon. Daniel
          K. Akaka...................................................    22
    Bohlinger, Karen L., Second Lady, State of Montana...............    43
        Prepared statement...........................................    46
    Barrs, Jonathan W., Operation Iraqi Freedom Veteran..............    47
        Prepared statement...........................................    49
    Gans, Bruce M., M.D., Executive Vice President and Chief Medical
      Officer, Kessler Institute for Rehabilitation..................    50
        Prepared statement...........................................    53
        Response to post-hearing questions submitted by Hon. Daniel
          K. Akaka...................................................    57
    Dabbs, Michael F., President, Brain Injury Association of
      Michigan.......................................................    59
        Prepared statement...........................................    61
            Attachment 1--CARF Statistics Table for Michigan.........    65
            Attachment 2--State of Michigan map identifying CARF
              accredited providers...................................    66
        Response to post-hearing questions submitted by Hon. Daniel
          K. Akaka...................................................    67
            Enclosure--TBI-ROC Brain Injury Navigator................    70
    LaPlaca, Michelle C., Ph.D., Associate Professor, Wallace H.
      Coulter Department of Biomedical Engineering, Georgia Institute
      of Technology and Emory University, Institute of Bioengineering
      and Bioscience, Laboratory of Neuroengineering, Atlanta, GA....    73
        Prepared statement...........................................    75
        Response to post-hearing questions submitted by Hon. Daniel
          K. Akaka...................................................    78
            Attachments..............................................    80

                                    APPENDIX

    Wade, Sarah, Wounded Warrior Project; prepared statement.........   151
    National Association of State Head Injury Administrators;
      prepared statement.............................................   156
    Poe, Charles M. ``Mason'', SSGT USMC (Ret.); prepared statement..   159
    Poe, Kristin M.; letter..........................................   161

    OVERSIGHT HEARING ON TRAUMATIC BRAIN INJURY (TBI): PROGRESS IN TREATING
                 THE SIGNATURE WOUNDS OF THE CURRENT CONFLICTS

                                  ----------

                             WEDNESDAY, MAY 5, 2010

                                           U.S. Senate,
                                Committee on Veterans' Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 9:30 a.m., in
    room 418, Russell Senate Office Building, Hon. Daniel K. Akaka,
    Chairman of the Committee, presiding.
        Present: Senators Akaka, Murray, Tester, Brown of
    Massachusetts, Begich, Burr, and Isakson.

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

        Chairman Akaka. This hearing will come to order. Aloha and
    welcome to all of you here today.
        Today we will be discussing the progress that has been made
    in providing care and services to veterans with Traumatic Brain
    Injury. Differences in tactics, such as the use of IEDs, and
    significant advances in battlefield medicine and protective
    equipment from prior wars have resulted in an unprecedented
    number of servicemembers sustaining and surviving TBIs, making
    this the signature physical wound of the conflicts in Iraq and
    Afghanistan. It is estimated that up to 360,000 servicemembers
    have sustained a brain injury in Iraq or Afghanistan. The
    Government must do all it can to treat these wounded veterans.
        In 2007, in response to this trend, I convened a hearing of
    this Committee on diagnosing and treating TBI. That hearing led
    to the introduction and ultimate passage of legislation I
    authored to enhance TBI services in VA. Today we revisit this
    topic to determine how completely that law is being implemented
    and how effective the steps we have taken have been in making
    sure veterans with TBI are receiving necessary and appropriate
    care.
        Today, we will explore the relationship between VA and
    outside entities in providing treatment and rehabilitation
    services for TBI. I have visited the Richmond, Virginia,
    polytrauma center, and was very impressed with what I saw, but
    I believe that there is a need to expand the geographic
    availability of care. It is a burden for family members to have
    to travel several hours to visit their loved ones in the
    hospital or to take them to rehabilitation appointments.
        In addition to partnering with community and other non-VA
    providers, VA must do more to involve family members in
    providing care for their wounded veterans. We must recognize
    and support family members appropriately, as they are our
    partners in this shared mission.
        The Legislation I authored to provide a comprehensive
    program of services and support to family members who wish to
    care for their veterans at home, instead of placing them in an
    institution, is to be signed by President Obama this afternoon.
    This caregiver program will be another tool we can use to
    provide a seamless and effective continuum of care for veterans
    with TBI.
        I am pleased to have witnesses from both VA and the
    Department of Defense here today. Effectively addressing the
    issue of TBI requires the full efforts of both Departments;
    neither can do it alone. I encourage both Departments to
    continue to break down barriers in their processes and find new
    ways to work more seamlessly, which ultimately results in the
    best outcomes for servicemembers and veterans.
        One of the most critical challenges remaining is properly
    diagnosing mild and moderate TBI. Reliance on self-reporting,
    the misdiagnosing of symptoms, and sometimes the lack of an
    easily identifiable traumatic event are all elements that make
    it more difficult to get the proper care to these veterans and
    servicemembers. An aggressive and proactive approach to
    screening using the latest innovations is necessary.
        I thank our witnesses for being here today, and I look
    forward to your testimony. Veterans suffering with TBI have
    demonstrated courage on the battlefield, and they continue to
    do so in their recovery. Together we can improve the care and
    services available to them.
        Thank you very much, and now I ask our Ranking Member,
    Senator Burr, for his statement. Senator Burr.

            STATEMENT OF HON. RICHARD BURR, RANKING MEMBER,
                    U.S. SENATOR FROM NORTH CAROLINA

        Senator Burr. Aloha, Mr. Chairman.
        Chairman Akaka. Aloha.
        Senator Burr. Thank you for calling this hearing. I want to
    take a moment, if I can, to recognize several North Carolinians
    who are in attendance at the hearing today. They each have
    important stories, and one will share that story with us.
        First, we have on our second panel Jonathan Barrs. Jonathan
    retired from the Marine Corps last year after two tours in
    Iraq. He experienced two improvised explosive device blasts in
    1 week while serving as a turret gunner in his Humvee and was
    later diagnosed with a TBI in 2008. Jonathan, thanks for
    agreeing to share your story with these Members and this panel
    today and, more importantly, for your service to the country.
        Also joining us is Mason Poe and his wife, Kristen. Mason
    was in a coma for 1 month following an IED blast in Iraq.
    Thirty surgeries later, he is walking and has started his own
    small business. Both Mason and his wife have submitted
    testimony for the record today.
        [The prepared statements of both Mr. and Mrs. Poe are in
    the Appendix.]
        Senator Burr. Next, Vincent Gizzerelli served two tours in
    Iraq before his separation from service last year. He took
    shrapnel in his leg and has moderate to severe TBI following an
    IED blast in 2004. Vincent, thank you for being here.
        Last, I want to acknowledge two individuals that are not
    here, Mr. Chairman, and I had hoped they would have been--Sarah
    and Ted Wade--for their work within the Wounded Warrior
    Project. Ted sustained a severe brain injury while in Iraq, and
    Sarah has been at his side ever since. Later today, the
    President will sign into law a bill that will direct the
    creation of a program of assistance for family caregivers.
    Without the bravery and support of loved ones like Sarah, many
    of our wounded warriors would be forced to live in nursing home
    settings. Sarah and Ted have submitted testimony for the record
    today, and they have already been an invaluable asset in
    helping Congress, the VA, and the Department of Defense on new
    ways to improve and coordinate care and its delivery to our
    servicemembers and veterans with TBI. Their efforts were
    critical in shaping the family caregiver legislation that the
    President will sign.
        [The prepared statement of Mrs. Sarah Wade is in the
    Appendix.]
        Senator Burr. To all of you, I thank you for your service
    to our country. I thank you for your willingness to continue
    that service by working with us to improve the system of care
    and the benefits for all our servicemembers.
        Mr. Chairman, just over 3 years ago, the Committee held a
    hearing on VA's ability to respond to the health care needs of
    returning servicemembers, the care provided to what is known as
    the signature wound of the current war. TBI was the main focus.
    What we learned from that hearing led to provisions enacted
    within the 2008 Defense Authorization Act. Specifically, the
    law directed or authorized actions on the following points:
    one, providing to each of our TBI wounded an individual plan of
    rehabilitation and reintegration into the community; two, using
    rehabilitation services outside of VA where appropriate,
    particularly for newly injured veterans; three, research on the
    diagnosis and treatment of TBI; four, providing assisted living
    services in veteran communities; and, finally, the provision of
    age-appropriate nursing care to younger veterans with severe
    TBI whose needs are vastly different than a typical nursing
    home patient.
        I hope to learn from both VA and DOD the progress they have
    made in each of these areas.
        Furthermore, I am interested to learn whether one of the
    key recommendations of the Dole-Shalala Commission, the
    creation of Federal recovery coordinators, is helping
    servicemembers and their families navigate systems of care and
    benefits that in many cases are overwhelming. From those who
    work or do research on TBI issues on a day-to-day basis, I hope
    to learn how we might continue to improve our past efforts.
        Mr. Chairman, our Nation faces extraordinary domestic
    challenges, but we must never forget the sacrifices our men and
    women and their families make in the defense of our freedom.
    Meeting their needs is our highest priority as a Nation. I
    remain committed to work with you and with this entire
    Committee to fulfill our obligation to them. I am confident we
    can do better than we have.
        I thank the Chair.
        Chairman Akaka. Thank you very much, Senator Burr.
        Senator Tester?

                     STATEMENT OF HON. JON TESTER,
                       U.S. SENATOR FROM MONTANA

        Senator Tester. Thank you, Mr. Chairman. I want to thank
    you for holding this hearing today. I also want to welcome the
    witnesses, especially Karen Bohlinger, of Helena, MT. Karen is
    the wife of Montana's lieutenant Governor, but first and
    foremost, she is the mother of an American soldier. Her son,
    Jeremy, has been in a VA polytrauma network site for nearly 5
    years. During that time, she has been one of the most vocal,
    passionate advocates for veterans and their families that I
    have ever met. She is going to talk about Jeremy's story in
    great detail, so I am not going to steal her thunder, except to
    say that she has a powerful story to tell about what the VA is
    doing right and what the VA is doing wrong. So, Karen, I want
    to thank you so very, very much for being here today. You have
    a critically important story to tell, and we all look forward
    to hearing it.
        Much is made of how Traumatic Brain Injury is the signature
    wound of the Iraq and Afghanistan conflicts. By now, many of us
    know the statistics and the challenges facing the doctors and
    nurses in the DOD facilities and VA hospitals who have been
    tasked with treating hundreds of thousands of men and women.
    These are gut-wrenching, life-changing challenges, and it is
    critical that the spouses and the parents are a meaningful
    voice in patient care and treatment.
        But all too often, I hear about folks who have a loved one
    that come into the DOD health system or the VA with serious
    TBI. The parents and the spouses of these servicemembers then
    have to wage a battle against the bureaucracy when someone that
    they care about is not getting the treatment that they deserve.
        I met with a number of folks from Montana who have come
    through Walter Reed and Bethesda Naval. Most of them have been
    fortunate to have a spouse or a parent who has been able to
    drop everything and fight full time for their soldier or
    Marine. One of the things that I have heard frequently was that
    the individual care from doctors and nurses was outstanding,
    but fighting with the bureaucracy to schedule an appointment
    with a doctor or to have medications changed is nothing short
    of a full-time job.
        What happens to a soldier or a veteran when he does not
    have a full-time advocate? What happens when a young person
    from rural Montana is brought to Seattle or Minneapolis with
    serious TBI? Who is looking out for that young woman or man?
    This is the area where we need to do better.
        Mr. Chairman, I know we have got a busy agenda, but I want
    to say one more thing. Recently, I joined Senator Murray on a
    letter to the Secretary of the Army asking some questions about
    the Army's Warrior Transition Units. I have been told that most
    of these questions are beyond the scope of this Committee's
    jurisdiction. I do believe that we should consider another
    round of joint hearings with our friends from the Armed
    Services Committee to find out about what we can do to make
    sure the WTUs work better for the soldier who will eventually
    become a veteran and, thus, will be in our jurisdiction.
        With that, thank you again, Mr. Chairman, for the hearing.
    I look forward to the testimony from our participants.
        Chairman Akaka. Thank you very much, Senator Tester.
        Senator Brown, your statement, please.
        Senator Brown of Massachusetts. Thank you, Mr. Chairman. It
    is a pleasure to be here again. Being from Massachusetts, we
    have, Mr. Chairman, a statewide head injury program that we
    have implemented, for which we receive State funds. Obviously,
    it is funded by the State, and there are some Federal grants
    tied into it. It is an issue that we have identified and tried
    to work with the appropriate treatment authorities.
        As you know, Mr. Chairman, I am in the Guard as a JAG. I
    notice regularly the transformation from a soldier who is
    raring to go to somebody who is not functioning quite right.
    Before, we never really knew why, and I think we have
    identified it through the research and treatment opportunities
    in Massachusetts and throughout the country. It is something
    that I want to thank you for holding another hearing about.
    Being new, it is something that we have taken very seriously
    back home because we are trying to find out how to help, you
    know, what types of tools and resources do we need to provide
    our men and women who are serving to get better and get back to
    their families and be the person they once were.
        So I am going to defer. I look forward to the testimony
    though I will be bouncing back and forth to the Armed Services
    Committee. And, Senator Tester, I am happy to work with you on
    that letter and move that through the food chain. So thank you.
        Chairman Akaka. Thank you very much, Senator Brown.
        Now I want to welcome our witnesses. Would you please come
    up to the dais? First we have Dr. Lucille Beck, who is Chief
    Consultant for Rehabilitation Services at the Department of
    Veterans Affairs. She is accompanied by Dr. Karen Guice, the
    Director of the Federal Recovery Coordination Program; Dr. Joel
    Scholten, Associate Chief of Staff for Physical Medicine and
    Rehabilitation at the Washington, DC, VA medical center; and
    Dr. Sonja Batten, Deputy Director of the Department of Defense
    Center of Excellence for Psychological Health and Traumatic
    Brain Injury.
        We also have Col. (Dr.) Michael Jaffee, National Director
    of the Defense and Veterans Brain Injury Center. Katherine
    Helmick, Interim Senior Executive Director for TBI at the
    Defense Centers of Excellence for Psychological Health and
    Traumatic Brain Injury, is sitting there.
        I thank you all for being here this morning. Your testimony
    will appear in the record. Dr. Beck, will you please proceed
    with your statement?

    STATEMENT OF LUCILLE B. BECK, PH.D. CHIEF CONSULTANT, OFFICE OF
       REHABILITATION SERVICES, OFFICE OF PATIENT CARE SERVICES,
      VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
     AFFAIRS; ACCOMPANIED BY KAREN GUICE, M.D., DIRECTOR, FEDERAL
     RECOVERY COORDINATION PROGRAM; JOEL SCHOLTEN, M.D., ASSOCIATE
       CHIEF OF STAFF FOR PHYSICAL MEDICINE AND REHABILITATION,
     WASHINGTON, D.C., VA MEDICAL CENTER; AND SONJA BATTEN, PH.D.,
         DEPUTY DIRECTOR, U.S. DEPARTMENT OF DEFENSE CENTER OF
     EXCELLENCE FOR PSYCHOLOGICAL HEALTH AND TRAUMATIC BRAIN INJURY

        Ms. Beck. Yes, thank you. Good morning, Mr. Chairman,
    Ranking Member Burr, and Members of the Committee. Thank you
    for inviting me here to update the Committee on VA's progress
    in implementing the wounded warrior provisions in the Veterans
    Traumatic Brain Injury and Health Programs Improvement Act of
    2007. I would like to thank the Committee for its work, which
    has enabled VA to establish landmark programs and initiatives
    to meet the provisions of the Wounded Warrior Act.
        I would also like to thank the members of the second panel
    for their advocacy on behalf of severely injured veterans. We
    appreciate these opportunities where we can listen to our
    stakeholders because they know the system and they can help us
    improve.
        Polytrauma is a new phenomenon, and, unfortunately,
    medicine has not yet caught up in every regard. At the outset
    of the current conflicts, it is fair to say we were unprepared
    for the complexity of injuries we were seeing because
    servicemembers would not have survived these types of injuries
    in previous conflicts. While VA had established TBI centers,
    Traumatic Brain Injury centers, in 1992, it was in 2005 that we
    established the Polytrauma System of Care and the four
    Polytrauma Rehabilitation Centers. We know there were
    challenges during those early days in providing seamless care
    that could treat all of the veterans' needs. Care for complex
    injuries was limited to the four polytrauma centers. Some
    veterans with severe TBI were not regaining consciousness, and
    care was not optimally coordinated.
        Today the Polytrauma System of Care has direct patient care
    available at 108 locations across the country. There are 48
    polytrauma points of contact at other facilities who can refer
    veterans and family members to the specialists they need.
    Twenty Federal Recovery Coordinators support the transition and
    care of the severely injured. We worked with 1,573 facilities
    and providers in the private sector to provide care for more
    than 3,700 veterans at a cost of more than $21 million in
    fiscal year 2009. We have an Emerging Consciousness treatment
    approach that we developed after consulting with the best
    clinicians across the country that sees better than 70 percent
    of patients recover.
        VA provided more than $23 million in fiscal year 2010 to
    support 106 research projects related to TBI, and we are
    screening every OEF/OIF veteran who comes to us for care for
    Traumatic Brain Injury. We have the systems in place and the
    resources we need to care for our veterans. In addition, we
    have made our programs veteran centric. We have modified the
    physical environment at our Polytrauma Rehabilitation Centers
    to be family friendly, and we have added liaisons at the major
    military treatment facility to improve patient transfers. We
    use teams of clinicians to achieve our goal of returning
    veterans to the maximum level of independence and
    functionality.
        Let me provide you with an example of how this benefits
    veterans. A 28-year-old servicemember was injured in a blast in
    2007. He sustained moderate TBI, eye injuries, burns, and
    fractures in his hands. Within 12 hours, he was flown to
    Landstuhl for surgery and stabilization, and within 72 hours,
    he was sent to Walter Reed.
        Ten days after the injury, the Richmond Polytrauma
    Rehabilitation Center was on a videoconference receiving a
    medical update and information about the family. Eleven days
    after that, the family toured the Richmond PRC with a case
    manager from Walter Reed. Less than a week later, 4 weeks from
    his injuries, the servicemember was admitted to the Richmond
    Rehabilitation Center and was recovering from his burns and
    fractures.
        By the 120th day following his injuries, we were
    transferring him to the Polytrauma Transitional Rehabilitation
    Program, and he was also receiving services from blind
    rehabilitation and community rehabilitation. On the 210th day
    after his injuries, he returned home. VA continues providing
    outpatient care through the polytrauma network site as well as
    vocational rehabilitation and family counseling. Today he is
    living at home with his spouse, exploring work and volunteer
    opportunities, and continuing close case management with VA.
    This is one of many stories that we are proud of, and this
    Committee should also take pride in helping to make it
    possible.
        Although we have accomplished much since we established
    these programs, we recognize that there are still challenges to
    overcome. For example, we need to improve the availability of
    services in rural areas. One way we are pursuing this goal is
    through the use of telemedicine. Four of our facilities,
    including Denver, now offer TBI screening and evaluation to
    veterans in rural areas. In addition, we are always looking to
    establish new relationships with high-quality local care
    providers and strengthen the more than 300 local agreements
    that are already in place.
        In closing, let me thank you again for your support and the
    opportunity to appear before you today. I look forward to our
    continued partnership on this issue. Thank you.
        [The prepared statement of Ms. Beck follows:]
        Prepared Statement of Lucille B. Beck, Ph.D., Chief Consultant,
     Rehabilitation Services and the Director of the Audiology and Speech
     Pathology Program, Veterans Health Administration, U.S. Department of
                                Veterans Affairs
        Good morning, Mr. Chairman, Ranking Member Burr, and Members of the
    Committee. Thank you for inviting me here to update the Committee on
    the Department of Veterans Affairs' (VA) progress in implementing the
    wounded warrior provisions in the Veterans Traumatic Brain Injury and
    Health Programs Improvement Act of 2007. I would like to thank the
    Committee for its work in passing important legislation, which has
    enabled VA to establish landmark programs and initiatives to meet the
    provisions of the title XVI, referred to as the Wounded Warrior Act,
    and title XVII of Public Law 110-181.
        I am accompanied today by Dr. Karen Guice, Director of the Federal
    Recovery Coordination Program; Dr. Joel Scholten, Associate Chief of
    Staff for Physical Medicine and Rehabilitation at the Washington, DC,
    VA Medical Center; and Dr. Sonja Batten, Deputy Director at the
    Department of Defense (DOD) Centers of Excellence for Psychological
    Health and Traumatic Brain Injury. I will describe the current state of
    VA care and services for Veterans and Servicemembers with Traumatic
    Brain Injury (TBI), as well as discuss the interagency collaborations
    with DOD to improve the care, management and transition of recovering
    Servicemembers.
                                   background
        VA has developed and implemented numerous programs that meet
    legislative requirements and ensure the provision of world-class
    rehabilitation services for Veterans and active duty Servicemembers
    with TBI. VA has enhanced its integrated nationwide Polytrauma/TBI
    System of Care. The VA Polytrauma/TBI System of Care consists of four
    levels of facilities, including 4 Polytrauma Rehabilitation Centers, 22
    Polytrauma Network Sites, 82 Polytrauma Support Clinic Teams, and 48
    Polytrauma Points of Contact. The System offers comprehensive clinical
    rehabilitative services including: treatment by interdisciplinary teams
    of rehabilitation specialists; specialty care management; patient and
    family education and training; psychosocial support; and advanced
    rehabilitation and prosthetic technologies.
        In 1992, VA designated four lead TBI Centers as part of the Defense
    and Veterans Brain Injury Center (DVBIC) collaboration to provide
    comprehensive rehabilitation for Veterans and active duty
    Servicemembers. In 1997, VA designated a TBI Network of Care to support
    care coordination and access to services across VA's system. In
    recognition of the high survival rate of severely injured
    Servicemembers in Iraq and Afghanistan, Congress passed two laws that
    underscored the need for a specialized system of care that meets the
    complex rehabilitation needs of Servicemembers and Veterans injured in
    combat: Public Law 108-422, the Veterans Health Programs Improvement
    Act of 2004, and Public Law 108-447, the Consolidated Appropriations
    Act, 2005 (in accompanying Reports S. Rep. 108-353 and H.R. Rep. 108-
    792 (Conf. Rep.)). These laws directed VA to ensure that severely
    injured Veterans would benefit from the best of both modern medicine
    and integrative therapies for rehabilitation. In addition, these laws
    furthered the development of specialized, interdisciplinary
    rehabilitation programs to handle the complex medical, psychological,
    and rehabilitative needs of these individuals. In 2005, VA expanded the
    scope of services at existing VA TBI Centers, and accordingly renamed
    them Polytrauma/TBI Rehabilitation Centers, to establish an integrated,
    tiered system of specialized, interdisciplinary care for polytrauma
    injuries and TBI.
        ``Polytrauma'' is a new word in the medical lexicon that was termed
    by VA to describe the complex, multiple injuries to multiple body parts
    and organs occurring as a result of blast-related injuries seen from
    Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF).
    Polytrauma is defined as two or more injuries to physical regions or
    organ systems, one of which may be life threatening, resulting in
    physical, cognitive, psychological, or psychosocial impairments and
    functional disability. TBI frequently occurs in polytrauma in
    combination with other disabling conditions such as amputation,
    auditory and visual impairments, spinal cord injury (SCI), Post
    Traumatic Stress Disorder (PTSD), and other medical problems. Due to
    the severity and complexity of their injuries, Servicemembers and
    Veterans with polytrauma require an extraordinary level of coordination
    and integration of clinical and other support services.
        The VA Polytrauma System of Care currently provides specialty
    rehabilitation care across 108 VAMCs to create points of access along a
    continuum, and integrating services available at 4 regional Polytrauma/
    TBI Rehabilitation Centers (PRC), 22 Polytrauma Network Sites--one in
    each Veterans Integrated Service Network (VISN) and one in San Juan,
    Puerto Rico--and 82 Polytrauma Support Clinic Teams.
        PRCs provide the most intensive specialized care and comprehensive
    rehabilitation care for Veterans and Servicemembers with complex and
    severe polytrauma. PRCs maintain a full staff of dedicated
    rehabilitation professionals and consultants from other specialties to
    support these patients. Each PRC is accredited by the Commission on
    Accreditation of Rehabilitation Facilities, and each serves as a
    resource to develop educational programs and best practice models for
    other facilities across the system. The four regional Centers are
    located in Richmond, VA; Tampa, FL; Minneapolis, MN; and Palo Alto, CA.
    A fifth Center is currently under construction in San Antonio, TX, and
    is expected to open in 2011.
        VA's Polytrauma System of Care strongly advocates family
    involvement throughout the rehabilitation process, and VA strives to
    ensure that patients and their families receive all necessary support
    services to enhance the rehabilitation process while minimizing the
    inherent stress associated with recovery from TBI and polytrauma. VA
    offers multiple levels of clinical, psychosocial and logistical support
    to ensure a smooth transition and continuous care for patients and
    their families. VA assigns a dedicated case manager to each patient and
    family at a PRC. These case managers maintain workload levels of six
    patients each. Families can access this case manager for assistance 24
    hours a day, 7 days a week.
        Since 2007, VA has placed Polytrauma Nurse Liaisons at Walter Reed
    Army Medical Center and National Naval Medical Center (at Bethesda, MD)
    to support coordination of care, patient transfers, and shared patients
    between DOD and VA PRCs. Whenever an injured Veteran or Servicemember
    requires specialized rehabilitative services and enters VA health care,
    the Polytrauma Nurse Liaison maintains close communication with the
    admissions nurse case manager at the VA PRC, providing current and
    updated medical records. Before transfer, the Center's
    interdisciplinary team meets with the DOD treatment team and family by
    teleconference as another way to ensure a smooth transition.
        The four VA Centers typically have between 12- and 18-inpatient
    beds staffed by specialty rehabilitation teams that provide acute
    interdisciplinary evaluation, medical management and rehabilitation
    services. Occupancy rates at these Centers fluctuate over time and
    location. The average length of stay is currently 30 days, but the
    average for the most severely injured is 67 days. Upon discharge from a
    VA PRC, patients may be transferred to another facility, although over
    70 percent are discharged to their home.
                               va accomplishments
        A total of 1,736 inpatients with severe injuries have been treated
    at these Centers from March 2003 through December 2009; 879 of these
    patients have been active duty Servicemembers, of which 736 were
    injured in OEF or OIF. VA continues following these patients after
    their discharge from a VA PRC to assess their long-term outcomes. Data
    available for 876 former patients indicate:

         781 (89 percent) are living in a private residence;
         642 (73 percent) live alone or independently;
         413 (47 percent) report they are retired due to age,
    disability or other reasons;
         206 (24 percent) are employed;
         90 (10 percent) are in school part-time or full-time; and
         59 (7 percent) are looking for a job or performing
    volunteer work.

        As patients recover and transition closer to their homes, the
    Polytrauma/TBI System of Care provides a continuum of integrated care
    through 22 Polytrauma Network Sites, 82 Polytrauma Support Clinic
    Teams, and 48 Polytrauma Points of Contact, located at VAMCs across the
    country.
        The Polytrauma Network Sites develop and support a patient's
    rehabilitation plan through comprehensive, interdisciplinary,
    specialized teams; provide both inpatient and outpatient care; and
    coordinate services for Veterans with TBI and polytrauma throughout the
    VISN.
        In 2008, the Polytrauma Support Clinic Teams expanded to 82 VA
    facilities. These interdisciplinary Teams of rehabilitation specialists
    provide dedicated outpatient services closer to home and manage the
    long-term or changing rehabilitation needs of Veterans. These Teams
    coordinate clinical and support services for patients and their
    families, conduct comprehensive evaluations of patients with positive
    TBI screens, and develop and implement rehabilitation and community
    reintegration plans.
        VA Polytrauma Points of Contact are available at 48 VAMCs without
    specialized rehabilitation teams. These Points of Contact, established
    in 2007, are knowledgeable about the VA Polytrauma/TBI System of care
    and coordinate case management and referrals throughout the system.
        Throughout the Polytrauma/TBI System of Care, we have established a
    comprehensive process for coordinating support efforts and providing
    information for each patient and family member. Specialized
    rehabilitation initiatives at the PRCs include:

         In 2007, VA developed and implemented Transitional
    Rehabilitation Programs at each PRC. These 10-bed residential units
    provide rehabilitation in a home-like environment to facilitate
    community reintegration for Veterans and their families, focus on
    developing standardized program measures, and investigate opportunities
    to collaborate with other entities providing community-based
    reintegration services. Through December 2009, 188 Veterans and
    Servicemembers have participated in this program spending, on average,
    about 3 months in transitional rehabilitation. Almost 90 percent of
    these individuals return to active duty, or transition to independent
    living.
         Beginning in 2007, VA implemented a specialized Emerging
    Consciousness care path at the four PRCs to serve those Veterans with
    severe TBI who are slow to recover consciousness. Patients with
    disorders of consciousness (e.g., comatose) require high complexity and
    intensity of medical services and resources in order to improve their
    level of responsiveness and decrease medical complications. To meet the
    challenges of caring for these individuals, VA collaboratively
    developed this care path with subject matter experts from DVBIC and the
    private sector. VA and DVBIC continue to collaborate on research in
    this area, and incorporate improvements to the care path in response to
    advances in science. From January 2007 through December 2009, 87
    Veterans and Servicemembers have been admitted in VA Emerging
    Consciousness care. Approximately 70 percent of these patients emerge
    to consciousness before leaving inpatient rehabilitation.
         In October 2008, all inpatients with TBI at VA PRCs began
    receiving special ocular health and visual function examinations based
    upon research conducted at our Palo Alto PRC. To date, 840 inpatients
    have received these examinations.
         In April 2009, VA began an advanced technology initiative
    to establish assistive technology laboratories at the four PRCs. These
    facilities will serve as a resource for VA health care, and provide the
    most advanced technologies to Veterans and Servicemembers with ongoing
    needs related to cognitive impairment, sensory impairment, computer
    access, communication deficits, wheeled mobility, self-care, and home
    telehealth.
         VA continues to optimize its Polytrauma Telehealth Network
    to facilitate provider-to-provider and provider-to-family coordination,
    as well as consultation from PRCs and Network Sites to other providers
    and facilities. Currently, about 30 to 40 videoconference calls are
    made monthly across the Network Sites to VA and DOD facilities. New
    Polytrauma Telehealth Network initiatives in development include home
    buddy systems to maintain contact with patients with mild TBI or
    amputation, and remote delivery of speech therapy services to Veterans
    in rural areas.
         The PRCs have been renovated to optimize healing in an
    environment respectful of military service. Military liaisons located
    at the centers help to support active duty patients and to coordinate
    interdepartmental issues for patients and their families. Working with
    the Fisher House Foundation, we are also able to provide housing and
    other logistical support for family members staying with a Veteran or
    Servicemember during their recovery at one of our facilities.
         In fiscal year (FY) 2009, 22,324 unique outpatients had
    83,794 total clinic visits across the Polytrauma Support Clinic Team
    sites; an increase of over 30 percent from FY 2008.

        In addition to improvements in the Polytrauma/TBI System of Care,
    VA developed and implemented the TBI Screening and Evaluation Program
    for all OEF/OIF Veterans who receive care within VA. From April 2007
    through February 2010:

         397,904 OEF/OIF Veterans have been screened;
         54,675 who screened positive have been evaluated and
    received follow-up care and services appropriate for their diagnosis
    and their symptoms;
         29,819 have been confirmed with a diagnosis of having
    incurred a mild TBI;
         Over 90 percent of all Veterans who are screened are
    determined not to have TBI, but all who screen positive and complete a
    comprehensive evaluation are referred for appropriate treatment.

        VA developed and implemented a national template to ensure that it
    provides every Veteran receiving inpatient or outpatient treatment for
    TBI, who requires ongoing rehabilitation care, an individualized
    rehabilitation and community reintegration plan, as required by section
    1702 of Public Law 110-181 (38 U.S.C. Sec. 1710C). VA integrates this
    national template into the electronic medical record, and includes
    results of the comprehensive assessment, measurable goals, and
    recommendations for specific rehabilitative treatments. The patient and
    family participate in developing the treatment plan and receive a copy
    of the plan. Since April 2009, 8,373 of these plans have been completed
    and documented for Veterans who receive ongoing rehabilitative care in
    VA.
        Section 1703 of Public Law 110-181 (38 U.S.C. Sec. 1710E) permits
    VA, in implementing and carrying out Sec. 1710C of title 38, to provide
    hospital care and medical services through cooperative agreements with
    appropriate public or private entities that have established long-term
    neurobehavioral rehabilitation and recovery programs. VA continues to
    increase collaborations with private sector facilities to successfully
    meet the individualized needs of Veterans and complement care in cases
    when VA cannot readily provide the needed services, or cases where the
    required care is geographically inaccessible. VA medical facilities
    have identified private sector resources within their catchment area
    that have expertise in neurobehavioral rehabilitation and recovery
    programs for TBI. In FY 2009, 3,708 enrolled Veterans with TBI received
    inpatient and outpatient hospital care and medical services from public
    and private entities, with a total disbursement of over $21 million.
        VA has developed, and continues to enhance, policies regarding
    comprehensive long-term care for post-acute TBI rehabilitation that
    includes residential, community and home-based components utilizing
    interdisciplinary treatment teams. In 2007, VA chartered the Polytrauma
    Rehabilitation and Extended Care Task Force, to address the long-term
    care needs of seriously injured OEF/OIF Veterans, including
    rehabilitative care. As a result of this Task Force, VA developed
    approaches to meet the long-term care needs of Veterans with TBI
    through enhancements to the current spectrum of long-term care programs
    and services. Changes implemented include expansion and age-appropriate
    modifications in Home-Based Primary Care (HBPC) and Adult Day Health
    Care, development of volunteer home respite, geographic expansion and
    staff training for HBPC, implementation of Medical Foster Home for
    Veterans with TBI, and integration of home Telehealth. Last, TBI was a
    Select Program in VA's budget request, as directed in H.R. Report No.
    110-775, accompanying Pub. L. 110-329, and VA has noted Congress'
    direction to continue this designation. In FY 2010, $231.9 million has
    been programmed for TBI care for all Veterans; $58.2 million is
    programmed for OEF/OIF Veterans.
                             va/dod collaborations
        VA and DOD have shared a longstanding integrated collaboration in
    the area of TBI through the Defense and Veterans Brain Injury Center
    (DVBIC). Since 1992, DVBIC staff members have been integrated with VA
    Lead TBI Centers (now Polytrauma Rehabilitation Centers) to collect and
    coordinate surveillance of long-term treatment outcomes for patients
    with TBI. Other significant initiatives that have resulted from the
    ongoing collaboration between VA and DVBIC include: developing
    collaborative clinical research protocols; developing and implementing
    best clinical practices for TBI; developing materials for families and
    caregivers of Veterans with TBI; developing integrated education and
    training curriculum on TBI, and joint training of VA and DOD heath care
    providers; and coordinating the development of the best strategies and
    policies regarding TBI for implementation by VA and DOD.
        In addition to the longstanding affiliation with DVBIC, since 2007,
    VA has collaborated with DOD to develop implementation plans for
    Defense Centers of Excellence (DCoE) and the associated injury
    registries, including Centers for Psychological Health and Traumatic
    Brain Injury, Extremity Injuries and Amputation, Hearing Loss and
    Auditory System Injuries, and Vision. VA has assigned personnel at the
    Center for Psychological Health and TBI, and at the Vision Center. VA
    continues to be involved in working groups with DOD representatives to
    assist in developing concepts of operations and plans for the Hearing
    Loss and Auditory System Injuries Center and the Center for Extremity
    Injuries and Amputation.
        VA has also collaborated with DOD to develop and implement several
    unprecedented initiatives that are improving care and services for
    those with TBI. VA, in collaboration with DOD and DVBIC, implemented a
    5-year pilot program to assess the effectiveness of providing assisted
    living (AL) services to Veterans with TBI, as required by section 1705
    of Public Law 110-181. The AL-TBI pilot program is being administered
    through contracts with brain injury residential living programs that
    provide individualized treatment models of care to accommodate the
    specialized needs of patients with TBI. Currently, four Veterans with
    moderate to severe TBI have been placed in private facilities that
    specialize in providing rehabilitation services for TBI (residing in
    Virginia, Wisconsin, Kentucky and Texas). Up to 26 Veterans are
    projected to be enrolled in the program in FY 2010 and 14 more in FY
    2011. We are collecting and assessing outcome data on health
    information, functional status, satisfaction with care, and quality of
    life. VA will submit a final report to Congress at the conclusion of
    the program in 2013.
        VA, in collaboration with DVBIC, developed a uniform training
    curriculum for family members in providing care and assistance to
    Servicemembers and Veterans with TBI: ``Traumatic Brain Injury: A Guide
    for Caregivers of Servicemembers and Veterans.'' The final version of
    the curriculum was approved by the Defense Health Board, and
    dissemination of the curriculum is pending final approval from the
    Secretaries of DOD and VA. In 2009, VA and DOD collaboratively
    developed clinical practice guidelines for mild TBI and deployed this
    to health care providers, as well as recommendations in the areas of
    cognitive rehabilitation, drivers' training, and managing the co-
    occurrence of TBI, Post Traumatic Stress Disorder (PTSD), and pain.
        In 2009, the VA-led collaboration with DOD and the National Center
    for Health Statistics produced revisions to the International
    Classification of Diseases, Clinical Modification (ICD-9-CM) diagnostic
    codes for TBI, resulting in significant improvements in the
    identification, classification, tracking, and reporting of TBI and its
    associated symptoms.
        Finally, VA maintains ongoing collaborations with other Federal
    agencies to leverage resources and collective efforts in advancing the
    care and services for those with TBI. The most recent notable
    collaborations include:

         In 2009, VA began collaborating with the National
    Institute on Disability and Rehabilitation Research TBI Model Systems
    to collect and benchmark VA rehabilitation and longitudinal functional
    outcomes and establish a TBI Veterans Health Registry, as required by
    section 1704 of Public Law 110-181.
         Since 2009, VA has collaborated with the Centers for
    Disease Control (CDC), National Institutes of Health (NIH), and DOD in
    accordance with section 3(c) of Public Law 110-206 (42 U.S.C.A.
    Sec. 280b-1d), the Traumatic Brain Injury Act of 2008 to: (1) determine
    how best to improve the collection and dissemination of information on
    the incidence and the prevalence of TBI among persons who were formerly
    in the military; and (2) make recommendations on the manner in which
    CDC, NIH, DOD, and VA can further collaborate on the development and
    improvement of TBI diagnostic tools and treatments. A report to
    Congress is being prepared regarding this collaborative effort.
                   the federal recovery coordination program
        The Federal Recovery Coordination Program (FRCP) serves an
    important function in ensuring that severely injured Veterans and
    Servicemembers receive access to the benefits and care they need to
    recover. Beginning in 2008, FRCP has helped coordinate and access
    Federal, state and local programs, benefits and services for severely
    wounded, ill and injured Servicemembers, Veterans, and their families
    through recovery, rehabilitation, and reintegration into the community.
    The Program is a joint program of DOD and VA, with VA serving as the
    administrative home.
        The Program has grown since enrolling the first client in
    February 2008. Not every individual referred to the Program meets
    enrollment criteria or needs the full services of FRCP. Some
    individuals are enrolled for a period of time and then determine that
    they no longer need the Program's services. Currently, 513 clients are
    enrolled and another 41 individuals are being evaluated for enrollment,
    and another 451 have received assistance. Anyone can return for re-
    enrollment or additional assistance if the problems are not resolved or
    if new problems develop.
        Recovering Servicemembers and Veterans are referred to FRCP from a
    variety of sources, including from the Servicemember's command, members
    of the interdisciplinary treatment team, case managers, families or
    clients already in the Program, Veterans Service Organizations and
    other non-governmental organizations. Generally, those individuals
    whose recovery is likely to require a complex array of specialists,
    transfers to multiple facilities, and long periods of rehabilitation
    are referred.
        FRCP outreach efforts include brochures, a presence on VA's OEF/OIF
    Web site, participation and presentations at local, state and national
    events. Our 1-800 number, new in April 2009, provides another avenue
    for referral or assistance. When a referral is made, a Federal Recovery
    Coordinator (FRC) conducts an evaluation that serves as the basis for
    problem identification and determination of the appropriate level of
    service.
        FRCs coordinate benefits and services for their clients through the
    various transitions associated with recovery and return to civilian
    life. FRCs work with military liaisons, members of the Services'
    Wounded Warrior Programs, Service recovery care coordinators, TRICARE
    beneficiary counseling and assistance coordinators, VA vocational and
    rehabilitation counselors, military and VA facility case managers, VA
    Liaisons, VA specialty care managers, Veterans Health Administration
    (VHA) and Veterans Benefits Administration (VBA) OEF/OIF case managers,
    VBA benefits counselors, and others.
        Each enrolled client receives a Federal Individual Recovery Plan
    (FIRP). The FIRP, based on the goals and needs of the Servicemember or
    Veteran and upon input from their family or caregiver, is designed to
    efficiently and effectively move clients through transitions by
    identifying the appropriate services and benefits. The FRCs, with input
    and assistance from interdisciplinary team members and case managers,
    implement the FIRP by working with existing governmental and non-
    governmental personnel and resources.
        FRCP staffing has grown to meet the Program's needs. Eight FRCs
    were initially hired in January 2008. We are adding 5 additional FRCs
    to the 20 current positions in order to meet the growth, and success,
    of the Program. Most of these new hires will be placed at VA PRCs
    adding additional support for severely wounded, ill and injured
    Servicemembers and Veterans. The table below shows the current
    locations, as well as the locations for the new FRCs.
    ------------------------------------------------------------------------
                 Facility Name and Location                   Total FRCs
    ------------------------------------------------------------------------
    Walter Reed Army Medical Center, Washington, DC.....                  3
    National Naval Medical Center, Bethesda, MD.........                  3
    Brooke Army Medical Center, San Antonio TX..........                  4
    Naval Medical Center, San Diego, CA.................                  3
    Camp Pendleton, CA..................................                  1
    Eisenhower Army Medical Center, Augusta, GA.........                  2
    James A. Haley VAMC, Tampa, FL......................                  1
    Providence VAMC, Providence, RI.....................                  1
    Michael E Debakey VAMC, Houston, TX.................                  1
    USSOCOM Care Coalition, Tampa, FL...................                  1
    Richmond VAMC Polytrauma, VA........................       2 (new hire)
    Palo Alto VAMC Polytrauma, CA.......................       2 (new hire)
    Navy Safe Harbor, DC................................       1 (new hire)
                                                         -------------------
      Total (FRC) FTE...................................                 25
    ------------------------------------------------------------------------

        Administrative staff includes an Executive Director, two Deputies
    (one for Benefits and one for Health), an Executive Assistant, an
    Administrative Officer and two Staff Assistants.
        The FRCP is VA's lead for the National Resource Directory (NRD), an
    online partnership of the U.S. Departments of Defense, Labor and
    Veterans Affairs for wounded, ill or injured Servicemembers, Veterans,
    their families, caregivers, and supporting providers. The NRD is a
    comprehensive online tool available worldwide with over 10,000 Federal,
    state and local resources organized into nine easily searchable topic
    areas including: benefits and compensation, families and caregivers,
    employment, education and training, health care, housing,
    transportation and travel, and homeless assistance. The NRD has an
    average of 1,500 visitors a day where they access an average of 15,000
    page views. Over 300,000 other Web sites now link to the NRD.
        FRCP's success rests in its extraordinary and well-trained problem
    solving professional staff. We have learned a great deal over the past
    2 years and have been able to respond quickly to developing needs or
    problems. We are looking forward to the results from a current
    Government Accountability Office program evaluation and those from our
    satisfaction survey. This input will guide the Program's future
    development and adaptation.
                                   conclusion
        In conclusion, thank you again for the opportunity to speak about
    VA's efforts to support injured transitioning Servicemembers and
    Veterans. This concludes my prepared statement.
                                     ______

    Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to
    Lucille B. Beck, Ph.D., Chief Consultant, Rehabilitation Services, U.S.
                         Department of Veterans Affairs
        Question 1. The Institute of Medicine's (IOM) Preliminary
    Assessment on the Readjustment Needs of Veterans, Servicemembers and
    their families notes that there is a critical shortage of health care
    specialists. Given that the Mohonk Report on Disorders of Consciousness
    (DoC) notes that some 40% of persons with DoC are misdiagnosed, and
    that there are few rehabilitation facilities in the U.S. that
    specialize in the assessment and treatment of patients with DoC, how is
    the VA able to educate and train TBI specialists to provide accurate
    diagnosis and appropriate treatment?
        Response. VA proactively maintains capacity for the treatment of
    Veterans and Servicemembers with TBI, including development of the
    health care specialists who serve this population. Steps taken to
    achieve this goal include establishment of Emerging Consciousness (EC)
    Programs at the four Polytrauma Rehabilitation Centers (PRC),
    collaborations with specialists from DOD, academia, and the private
    sector to develop the EC programs and clinical guidance, and ongoing
    efforts to educate and train current and future clinicians.
        VA partnered with specialists from the Defense and Veterans Brain
    Injury Center and from academia to develop the EC care pathways at the
    PRCs. This is a clinical algorithm that details the main elements of
    the specialized medical, nursing, therapy, technology, and family
    education and support services deployed for the care of patients in an
    emerging consciousness state. Participating in the development of the
    care pathways were some of the main authors of the Mohonk Report,
    including Dr. John Whyte, Director Moss Rehabilitation and Research
    Center, and Dr. Joseph Giacino, Spaulding Rehabilitation Network. More
    recently, the EC Programs have partnered with the VA Neurology Service
    to perform diagnostics and active monitoring of brain activity during
    the recovery phase. The care pathways and technologies are continually
    updated in response to advances in science.
        EC Programs at the PRCs maintain the highest standards of
    accreditation and certification for rehabilitation facilities awarded
    by the Commission on Accreditation of Rehabilitation Facilities (CARF).
    CARF is an independent, nonprofit accreditor of health and human
    services in the area of medical rehabilitation, and VA EC programs are
    CARF accredited for Brain Injury Rehabilitation. CARF accreditation
    certifies that the provider meets internationally recognized standards
    and is committed to continually improving services through the quality,
    value, and optimal outcomes of services that are delivered.
        VA is also a proven leader in recruiting, education, and training
    of healthcare providers. VA has made great strides in attracting and
    retaining high quality clinicians and researchers with specialization
    in such areas as diagnosis, rehabilitation, and treatment of Traumatic
    Brain Injury and disorders of consciousness. VA's recruitment efforts
    include hiring incentives, school loan forgiveness plans, performance
    based advancement opportunities, ample opportunities for professional
    growth, and strong ties with the academic and research communities.
        Specifically, in the area of emerging consciousness, VHA's Office
    of Rehabilitation Services organizes yearly conferences dedicated to
    this topic and invites clinicians from the PRCs and experts from
    academic programs to share knowledge and experience. Clinicians have
    the opportunity to attend grand rounds and continuing education
    programs to stay current with new developments in the field.
    Rehabilitation specialists at the PRCs actively train the next
    generation of health professionals (i.e. fellows and allied health
    professionals) through the EC Program. The leadership of the EC
    Programs confer at least monthly about consistency of clinical care,
    outcomes management, and research projects. In conjunction with the
    non-VA EC Consortium, the VA EC Programs work on the latest innovations
    of the Mohonk Report and on planning ongoing collaborations in this
    area of expertise.

        Question 2. How many Veterans with severe TBI are currently being
    treated in the Polytrauma sites and how many Veterans with TBI are
    currently living in VA Community Living Centers?
        Response. Through the second quarter of Fiscal Year (FY) 2010, the
    Polytrauma Rehabilitation Centers (PRC) treated 145 patients in their
    inpatient bed units; 40 patients are currently being treated at the
    PRCs. Through the second quarter of FY 2010, 376 Veterans with TBI were
    served in one of the VA Community Living Centers (CLC); 26 of those
    were Veterans of Operation Enduring Freedom or Operation Iraqi Freedom
    (OEF/OIF). At the end of Q2 FY 2010, 9 Veterans with TBI were treated
    in a CLC bed unit; none of those were OEF/OIF Veterans.
        Additionally, during the first five months of FY 2010, 11,376
    unique outpatient Veterans had 30,720 total clinic visits for
    interdisciplinary outpatient rehabilitation services across the
    Polytrauma Support Clinic Team sites.

        Question 3. The Secretary's report notes that the VA developed an
    Emerging Consciousness Program at the four Polytrauma centers. How many
    Veterans have been served? What have the outcomes been?
        Response. Beginning in 2007, VA implemented a specialized Emerging
    Consciousness (EC) clinical care pathway at the four PRCs to serve
    those Veterans with severe TBI who are slow to recover consciousness.
    From January 2007 through December 2009, 87 Veterans and Servicemembers
    were treated in the VA EC Programs. Approximately 70 percent of these
    patients emerged to consciousness before leaving inpatient
    rehabilitation. Of the remaining 27 patients, 5 emerged at a later date
    and 5 are deceased. The majority of the patients (70.3 percent)
    continue to receive services in the VA; 11 Veterans are at home with
    family and home health support; 4 are in VA Community Living Centers;
    and 5 are hospitalized in rehabilitation facilities (2 at the PRCs, and
    3 at the Kessler Institute).

        Question 4. What is the status of the research being conducted on
    neutral adaptation for Emerging Consciousness?
        Response. The study centered at the Hines VA in Illinois is active
    and still accruing patients. Since the study is still ongoing, no data
    analysis have been performed.

        Question 5. What is the status of the research on the effectiveness
    of methylphenidate therapy during early TBI recovery?
        Response. The existing research knowledge on the early use of
    methylphenidate (brand name Ritalin) in individuals with moderate to
    severe TBI reveals that it has no demonstrable effect on individuals
    with a DoC, but it does improve specific areas of cognitive functioning
    (attention, arousal) in individuals who have emerged from coma.
    Methylphenidate is used commonly, but judiciously, in the VA polytrauma
    system of care at both the early and late phases of recovery after TBI.
    VA is collaborating through the Defense and Veterans Brain Injury
    Consortium on a randomized, controlled trial of the effect of
    methylphenidate in individuals with early TBI, which will be continuing
    for at least the next 2-3 years.

        Question 6. There have been reports in the media about research and
    new findings about the value of functional imaging techniques to
    improve communication and rehabilitation for persons with DoC. Has the
    VA used these techniques?
        Response. Functional neuroimaging for TBI, particularly for
    individuals with DoC, remains a research tool. Advances in technology,
    technique and knowledge have greatly added to our understanding of
    brain injury. However, the specific clinical correlation of functional
    neuroimaging to real world activities is not well defined. There is no
    specific functional neuroimaging technology that has been used to
    enhance communication in individuals with a TBI/DOC. An ongoing VA
    Rehabilitation Research & Development research project utilizes
    functional neuroimaging (fMRI) as an outcome tool to assess the impact
    of ``familiar voice'' (repeated spoken paragraphs by family members) on
    Veterans with a DOC; results are not anticipated for at least 2 to 3
    years.

        Question 7. Please provide information, including the name and
    address, on local contract providers or VA medical centers which
    provided neuropsychological evaluations for Veterans claiming service-
    connected compensation due to TBI during FY 2009.
        Response. In order to collect the information requested, VHA will
    survey the field facilities. We estimate that the time to survey the
    field and to consolidate responses will require additional time and we
    will provide this information later in July.

        Question 8. Please provide data on the number of Veterans who
    received a VHA or VHA local contract compensation and pension
    examination for TBI and the number of those who received a
    neuropsychological evaluation and testing at each location during FY
    2009 and the first two quarters of FY 2010.
        Response. In order to provide the data requested, VHA will need
    additional time and will provide this information also in July .

        Question 9. What is the status of VA's transformational activities
    pertaining to improving age-appropriate care in the Community Living
    Centers (CLC)?
        Response. VA has and continues to embed the provision of age-
    appropriate care in all major VA CLC conferences and education. VA has
    and will continue to work with all CLC disciplines in facilitating the
    design of care plans and activities to accommodate the specific
    interests and needs of the younger Veteran. For example, the care
    planning process itself has changed to what is known as the ``I Care
    Plan''. This has been implemented in many VA CLCs and was recently a
    major presentation at a CLC education conference. In this approach, the
    Veteran is identified by name, age, and interests prior to the
    discussion of the Veteran's medical diagnosis. The plan of care then,
    is designed around personal preferences for sleep/wake cycles, food
    preferences, times for personal care, and includes the resident and
    family in the formulation of care goals.

        Question 10. What additional resources does VA require in order to
    improve the quality or availability of TBI care and rehabilitation?
        Response. VA has adequate resources to meet the needs of Veterans
    with TBI, and TBI continues to be a Select Program in VA budget
    submissions. In FY 2010, $231.1 million has been programmed for TBI
    care for all Veterans and $58.2 million is programmed for OEF/OIF
    Veterans. There are three specific areas where VA can benefit from
    support to improve TBI care and rehabilitation. This does not require
    ``additional resources'', as much as a better understanding and support
    of VA in its current collaborations and initiatives:

         An increased utilization of the VA Telehealth Network to
    allow for advanced access to a greater number of Veterans, in
    particular those from rural areas.
         Continued efforts to proactively provide education on Post
    Deployment issues including TBI, mild TBI, polytrauma (including
    amputation), and Co-Morbid conditions such as pain, Post Traumatic
    Stress Disorder, and other mental health issues. Ongoing support to
    educate clinicians across VA on advances in care, as well as training
    new VA clinicians, is necessary.
         VA must sustain the TBI treatment and rehabilitation
    capabilities that have been developed in recent years by continuing to
    develop its future workforce. Rehabilitation clinicians are necessary
    to support expanded efforts to provide timely evaluations and needed
    ongoing rehabilitation care for the wide range of symptoms commonly
    seen following TBI and polytrauma.

        Question 11. What is the average daily census for the Polytrauma
    facilities or network sites, and are there wait times for admission to
    the facilities?
        Response. Occupancy rates at the four Polytrauma Rehabilitation
    Centers (PRC) fluctuate over time and location. The occupancy rate
    across the PRCs was 68 percent for FY 2009. The four VA Centers operate
    between 12- and 18-inpatient beds staffed by specialty rehabilitation
    teams that provide acute interdisciplinary evaluation, medical
    management and rehabilitation services.
        At no time since the beginning of conflicts in Afghanistan or Iraq
    has there been a ``wait time'' for admission to the VA Polytrauma
    Centers. Capabilities and capacity is maintained, and patients are
    admitted immediately upon medical referral and consistent with the
    patient's medical condition.

        Question 12. What progress has been made on the proposed VHA
    Handbook 1172.02 Physical Medicine and Rehabilitation Transitional Bed
    Section, which was originally scheduled to be released in March 2010?
        Response. The VHA Handbook 1117.02 Physical Medicine and
    Rehabilitation Transitional Bed Section was signed and issued by VA
    Under Secretary for Health on May 14, 2010. The document has been
    published on both the VHA Intranet and Internet Web sites.

        Question 13. What is the status of the report required to be
    submitted to Congress, on the pilot program for assessing the
    feasibility of assisted living services for Veterans with TBI?
        Response. The report to Congress on the Assisted Living Pilot for
    Veterans with TBI is due August 30, 2013. In anticipation of this
    report, VA continues to enroll eligible Veterans into the Pilot. These
    Veterans have TBI and require supervision and assistance with
    activities of daily living in order to enhance their rehabilitation,
    quality of living and community re-integration. Veterans are being
    placed in brain injury residential living programs in the private
    sector near their home communities. These programs provide
    individualized treatments to accommodate the specialized needs of
    patients with TBI. Case management services are provided by VA case
    managers with expertise in TBI. Outcome data are being collected that
    include demographic and health information, functional status, quality
    of life and satisfaction indices, and cost of care.
                                     ______

     Response to Post-Hearing Question Submitted by Hon. Sherrod Brown to
    Lucille B. Beck, Ph.D., Chief Consultant, Rehabilitation Services, U.S.
                         Department of Veterans Affairs

        Question. What is VA doing regarding the Eye Trauma Registry and
    when can we expect it to be up and functional?''
        Response. VA and DOD continue to develop a Joint Defense and
    Veterans Eye Injury and Vision Registry (DVEIVR). VA has completed
    development of a data store to collect clinical data on Veterans with
    eye injuries and visual symptoms related to TBI. Initial testing was
    completed March 2010. DOD will implement a project similar to the VA
    functional data store by the end of the third quarter of FY 2010. This
    will be accomplished through use of the Joint Theater Trauma System.
        Approval was granted to begin the acquisition phase for development
    of the DVEIVR Phase 1 Pilot in May 2010. The DVEIVR is expected to be
    operational by June 2011.

        Chairman Akaka. Thank you. Thank you very, very much.
        Now we will hear from Colonel Jaffee.

     STATEMENT OF COL. MICHAEL S. JAFFEE, M.D., NATIONAL DIRECTOR,
      DEFENSE AND VETERANS BRAIN INJURY CENTER (DVBIC), TRAUMATIC
     BRAIN INJURY PROGRAM, U.S. DEPARTMENT OF DEFENSE; ACCOMPANIED
      BY KATHERINE HELMICK, INTERIM SENIOR EXECUTIVE DIRECTOR FOR
    TBI, DEFENSE CENTERS OF EXCELLENCE FOR PSYCHOLOGICAL HEALTH AND
                         TRAUMATIC BRAIN INJURY

        Colonel Jaffee. Mr. Chairman, Members of the Committee,
    thank you for the opportunity to discuss the progress that has
    been made in the diagnosis and treatment of Traumatic Brain
    Injury (TBI), and the highly collaborative and fruitful
    relationship between the Department of Defense and the
    Department of Veterans Affairs.
        The high rate of TBI and blast-related concussion events
    are felt within each branch of the service and throughout both
    the DOD and VA health care systems. We have been providing
    acute management for the entire spectrum of Traumatic Brain
    Injury--mild, moderate, and severe. The vast majority of the
    Traumatic Brain Injuries in the Department of Defense are mild
    TBIs, also known as concussion. Almost 90 percent of
    individuals who sustain mild TBI will have a complete
    resolution of their symptoms within days or weeks of the
    incident. We have focused a lot of effort on the appropriate,
    safe management of these patients to avoid recurrent injuries
    during their recovery.
        Both the DOD and the VA have dedicated significant
    resources for the prevention, early detection, treatment, and
    rehabilitation of servicemembers and veterans with TBI. I will
    describe our efforts in these areas and how they support the
    direction of this Committee and the Veterans Traumatic Brain
    Injury and Health Programs Improvements Act of 2007.
        Prevention of TBI is a critical component of our overall
    strategy. Central to the preventative approach is the continued
    development of state-of-the-art personal protective equipment,
    along with a broad-based awareness campaign to provide
    servicemembers with strategies to mitigate risks both in a
    deployed location and at home.
        After prevention, we ensure our early detection efforts are
    directed at identifying potential TBI as close to the time of
    injury as possible. Mandatory concussion screening occurs at
    four levels: in-theater; at Landstuhl Regional Medical Center
    in Germany for all medically evacuated personnel; during the
    post-deployment health assessments and reassessments; and at VA
    facilities where veterans present for treatment.
        DOD has developed and proliferated--with the input of VA
    and civilian subject matter experts--a systematic method for
    conducting these screenings. The Military Acute Concussion
    Evaluation, or MACE, has been used for in-theater screening
    following an incident. DOD and VA also jointly developed and
    are using a screening tool in the post-deployment health
    assessment and reassessment and the VA's TBI clinical
    Assessment. Both of these tools have been recommended to the
    DOD by the Institute of Medicine.
        Once TBI is identified, DOD, in collaboration with VA
    subject matter experts, developed guidelines for the management
    of concussion in mild TBI in-theater. These initiatives have
    been adapted by several of our NATO allies.
        For providers delivering care in the combat theater, we
    have introduced an electronic consult service for use by all
    service providers that connects them with a TBI expert--jointly
    manned by DOD and VA specialists. For care in the U.S., the DOD
    and VA partnered to develop evidence-based guidelines for the
    management of mild Traumatic Brain Injury. The Defense and
    Veterans Brain Injury Center, DVBIC, a congressionally-mandated
    collaboration between the DOD and VA, has facilitated or led a
    number of TBI conferences, including focused approaches to
    managing minimally-conscious TBI patients, TBI patients with
    other clinical conditions to include PTSD, and efforts at
    cognitive rehabilitation.
        We have worked with the VA on the Assisted Living for
    Veterans with TBI project, and we helped establish a pilot age-
    appropriate TBI-specific assisted living program at one of nine
    State-owned comprehensive rehabilitation facilities. Simply
    put, the DOD and VA collaboration could not be stronger and
    more results oriented than what we have accomplished in this
    area. An independent article published by the Journal of Head
    Trauma Rehabilitation cited that DVBIC collaboration between
    DOD and VA as the most fully-developed system of care in the
    U.S. for brain injury. Still, much remains unknown about the
    short- and long-term effects of blast injury on the brain, and
    so our research continues.
        Last year, DVBIC published the largest randomized-
    controlled trial of cognitive rehabilitation for moderate to
    severe patients. The DOD is leveraging the latest advances in
    stem cell regenerative medicine through a collaboration between
    the Uniformed Services University and NIH. The DOD has been
    recognized for innovative research utilizing the latest
    advances in neuroimaging. The DOD is leveraging national
    expertise and resources in TBI research through more than $200
    million allocated through the congressionally directed Medical
    Research Program.
        Servicemember and family outreach is an equally strategic
    element of our educational efforts. At Congress' direction, we
    assisted the development of a Family Caregiver Program to meet
    the needs of family members, and this included a panel with
    members from the VA and civilian subject matter experts. We
    have developed a number of award-winning multi-media
    educational initiatives to include partnerships with public
    television, Brainline.org. Finally, we have established a
    National Care Coordination Network identifying all personnel
    with TBI who have been evacuated from theater. They get regular
    follow-ups upon their return home, and this program is closely
    linked with the VA's Polytrauma Federal Care Coordination
    System.
        We have had the benefit over the past several years of
    significantly increasing the number of civilian providers who
    are eligible to care for patients in our TRICARE network. We
    have been implementing a number of pilot initiatives to enhance
    our telemedicine projects in the rural outreach.
        The DOD, VA, and our civilian colleagues have performed
    extraordinary work across this country to advance our
    understanding of TBI, particularly as it relates to the unique
    nature of combat. Substantive progress has been made to
    implement the provisions of the 2007 law, and we are very
    pleased to have worked with the VA as colleagues in this
    endeavor.
        Mr. Chairman, Members of the Committee, I want to again
    thank you for your steadfast support of our Military Health
    System and your ongoing investment in Traumatic Brain Injury
    research and care. I look forward to your questions.
        [The prepared statement of Colonel Jaffee follows:]
    Prepared Statement of Col. Michael S. Jaffee, M.D., National Director,
       Defense and Veterans Brain Injury Center (DVBIC), Traumatic Brain
                   Injury Program, U.S. Department of Defense
        Mr. Chairman, Members of the Committee, Thank you for the
    opportunity to come before you today to discuss progress made in the
    diagnosis and treatment of Traumatic Brain Injury (TBI), and the highly
    collaborative and fruitful relationship between the Department of
    Defense (DOD) and the Department of Veterans Affairs (VA) in this vital
    area of medical research and treatment. Accompanying me today is Ms.
    Katherine Helmick, Interim Senior Executive Director for TBI at the
    Defense Centers of Excellence for Psychological Health and Traumatic
    Brain Injury (DCoE).
        I am honored to be able to represent DOD, and the men and women who
    serve in our Military Health System. I am the National Director of the
    Defense and Veterans Brain Injury Center (DVBIC), a congressionally
    mandated collaboration between DOD and VA which is organized as a
    network of excellence across 17 DOD and VA sites with more than 225
    professionals representing more than 20 different clinical disciplines.
    For the past two and a half years, the DVBIC has also operated as the
    primary operational TBI center of DCoE. Through these collaborations, I
    have been fortunate to work closely and collaboratively with our
    colleagues across DOD and VA for the last several years. I am proud of
    what we have accomplished together to advance the prevention,
    diagnosis, and treatment of Servicemembers and veterans with TBI.I am
    confident in our organization's ability to serve as a national asset
    for helping Servicemembers and veterans maximize their functional
    abilities and decrease or eliminate their TBI-related disabilities.
        The high rate of TBI and blast-related concussion events resulting
    from current combat operations directly impacts the health and safety
    of individual Servicemembers and subsequently the level of unit
    readiness and troop retention. The impacts of TBI are felt within each
    branch of the Service and throughout both the DOD and VA health care
    systems. Since January 2003, over 134,000 Servicemembers have been
    identified within our surveillance system as having sustained a
    clinician-confirmed TBI, most of which are considered mild TBI or a
    concussion ( mTBI). It is important to note almost 90 percent of
    individuals who sustain mTBI will have complete resolution of their
    symptoms within days or weeks of the incident. Our in-theater
    management guidelines for TBI emphasize safety and prevention of
    recurrent injuries until recovery has occurred.
        With the support of Congress, both Departments have dedicated
    significant resources to the prevention, early detection, treatment,
    and rehabilitation of Servicemembers and veterans with TBI. Ongoing
    medical research continues to contribute to our understanding of each
    of these activities. I will describe our efforts in these areas. I will
    also highlight the comprehensive professional medical education and
    family outreach undertaken to ensure our military and VA practitioners
    and the families who must help with managing this condition are aware
    of the most current findings and tools to assess and treat TBI. All of
    these activities support the direction of this Committee as reflected
    in the Veterans Traumatic Brain Injury and Health Programs Improvements
    Act of 2007.
                                   prevention
        Prevention of TBI is a critical component of our overall strategy.
    Central to the preventative approach is the continued development of
    state-of-the-art personal protective equipment (PPE). The army combat
    helmet/light weight helmet was developed for today's battlefield
    environment, and a next generation enhanced combat helmet is under
    development. The Headborne System--a joint Service future initiative--
    is being engineered to provide added protection from blast injury.
        Along with PPE investments, the Department has engaged in a broad-
    based awareness campaign to provide Servicemembers with strategies to
    mitigate risks both in a deployed location and at home to include
    ballistics protection and adherence to use of seatbelts.
                                early detection
        Our early detection efforts are focused on identifying potential
    TBI as close to the time of injury as possible. Mandatory concussion
    screening occurs at four levels to maximize treatment opportunities for
    Servicemembers who may have sustained a concussion: in-theater; at
    Landstuhl Regional Medical Center, Germany (for all medically evacuated
    personnel); during Post Deployment Health Assessments and
    Reassessments; and at VA facilities when veterans are treated.
        DOD has developed and proliferated--with the input of the Services,
    VA, and civilian subject matter experts--a systematic method for
    conducting these screenings with the appropriate tools. The Military
    Acute Concussion Evaluation (MACE) has been used for in-theater
    screening following an incident. This evaluation tool has been
    independently reviewed by the Institute of Medicine and recommended for
    continued use in assessing combat-related TBI. We continue a cycle of
    process improvement for in-theater screening and management. The latest
    proposed guidelines include a transition to mandatory evaluation of all
    Servicemembers involved in an incident considered associated with risk
    of concussion. DOD and VA jointly developed and are using a screening
    tool in the Post-Deployment Health Assessment and Reassessment and the
    VA TBI Clinical Reminder. This tool is an adaptation of the Brief TBI
    Screen and has been recommended to DOD by the Institute of Medicine for
    this purpose.
                                   treatment
        DOD has published clinical practice guidelines for both in-theater
    and CONUS-based management of mTBI (``Mild TBI Clinical Guidelines in
    the Deployed Setting'' and ``Mild TBI Clinical Guidance''), and
    developed tailored algorithms for use by medics/corpsmen, an initial
    evaluation, and a more comprehensive evaluation. NATO countries have
    used adaptations of the MACE and DOD clinical guidelines as a template
    for their own militaries.
        For providers delivering care in the combat theater, we have
    introduced an electronic consult service for use by all Service
    providers to connect them with a TBI expert--jointly manned by DOD and
    VA specialists. This consult service has proven to be a useful tool to
    deployed medical staffs.
        DOD and VA worked closely on developing and issuing evidence-based
    CONUS guidelines for management of mTBI. We issued these guidelines in
    April 2009, to providers in both organizations, assisting them with
    patients having subacute or chronic (more than 90 days) mTBI. These
    guidelines allow Servicemembers to receive care from their primary care
    providers, closest to home and family support. When required, referrals
    are made to TBI specialists at designated facilities.
        For more severe categories of TBI, we have disseminated several
    guidelines for use in theater, and have sponsored the development of
    specialist guidelines such as those from the American Association of
    Neuroscience Nurses. We have also provided consultation in the
    development of civilian guidelines such as those developed by the
    American College of Emergency Physicians.
        To advance our understanding of changes in neurocognitive
    abilities, we have implemented a program of baseline, pre-deployment
    cognitive evaluation. Introduced in 2008, this baseline test better
    informs return-to-duty determinations in theater following a concussion
    injury.
        The DVBIC also facilitated a consensus conference on programs for
    minimally conscious TBI patients which included DOD, VA, and civilian
    subject matter experts. This conference was instrumental in helping
    inform further development of relevant programs to manage this
    population.
        Finally, our clinical guidelines recognize there are often co-
    morbidities with TBI cases, to include depression, post-traumatic
    stress and substance use disorders, and other extremity injuries. To
    better understand this, the DVBIC co-sponsored with the Congressional
    Brain Injury Task Force, an international symposium on behavioral
    health and TBI. TBI case management demands an interdisciplinary
    endeavor that must incorporate and meld various clinical elements
    including neurology, neurosurgery, psychiatry, neuropsychology, and
    physical medicine and rehabilitation. DOD and VA have worked to ensure
    our TBI clinical guidelines represent the input from this diverse set
    of medical specialists.
        An independent article published by the Journal of Head Trauma
    Rehabilitation cited the DVBIC collaboration between DOD and VA as the
    most fully developed system of care in the United States for brain
    injury.
                     rehabilitation/recovery/reintegration
        Rehabilitation is an essential component of our TBI program, with a
    focused approach on cognitive rehabilitation. In 2009, we hosted the
    leading experts in this country--from DOD, VA, and the civilian
    sector--to develop and issue clinical guidance for cognitive
    rehabilitation programs based on available evidence. Fourteen DOD
    military treatment facilities will use these guidelines in a
    controlled, step-wise process to assess the effectiveness of these
    guidelines on patient outcomes.
        The DVBIC has worked with VA on the Assisted Living for Veterans
    with TBI project. We have collaborated with VA in their exploration of
    means to contract with civilian facilities to serve veterans. We helped
    establish a pilot age-appropriate TBI-specific assisted living program
    with multidisciplinary rehabilitation and assistive technology at one
    of nine state-owned comprehensive rehabilitation facilities. I was
    pleased to see VA issuance of a Request for Information from the
    industry just last month to continue to move forward with this
    initiative.
                                ongoing research
        The short and long-term effects of blast injury on the brain are
    still not completely known. DOD has made important contributions to the
    medical literature with our own research, to include a history of
    published, successful randomized-controlled clinical trials and several
    awards from national professional organizations.
        The Medical Research and Materiel Command and DVBIC convened a
    consensus conference with 75 experts identifying scientific evidence
    supporting the importance of blast injury. Last year, DVBIC published
    the largest randomized controlled trial of cognitive rehabilitation for
    moderate-severe patients. The Department's TBI research contributions
    were recognized in the external technical report on mTBI in DOD
    conducted by the Survivability/Vulnerability Information Analysis
    Center which stated in its conclusion:

            ``Even within the limited existing literature, it is evident
            that researchers are now making use of screening criteria,
            instruments, and other resources developed and made available
            through DVBIC. The DVBIC now plays a central role in performing
            and advancing research that will directly benefit military
            Servicemembers and veterans with TBI.''

        With the support of Congress, DOD is leveraging national expertise
    and resources in TBI research through the Congressionally Directed
    Medical Research Program by investing more than $200 million to
    academic researchers after a process of scientific and programmatic
    review that included our VA colleagues.
        We are working on innovative ways to enhance our system to fast-
    track promising research initiatives and findings, and rapidly identify
    gaps such as the paucity of research findings regarding clinical
    outcomes from cognitive rehabilitation in the concussion population, as
    well as direct resources to address these gaps.
        DOD and VA are collaborating further with other Federal agencies on
    translational biophysics, proteomics, and other blast-related projects.
                   professional education & patient outreach
        DOD and VA have worked closely to ensure our research into best
    practices and evidence-based medical guidance is rapidly distributed to
    the field. Since 2007, we have held annual conferences to educate our
    providers on the most current research and evidence-based clinical care
    guidelines for TBI. Our most recent conference in 2009, was attended by
    over 800 DOD and VA clinicians. In addition, DOD and VA have developed
    a series of educational modules for providers of all skill levels,
    which is accessible via our internal web-based educational platform,
    MHS Learn.
        Servicemember and family outreach is an equally strategic element
    of our educational efforts. DOD has developed TBI education modules
    appropriate for all Servicemembers, and include self-help materials for
    dealing with a range of post-concussive symptoms. At Congress'
    direction, DVBIC facilitated a panel of the Defense Health Board to
    oversee development of a Family Caregiver Program to meet the needs of
    family members, providing them with consistent health information and
    tools to cope with daily challenges of caregiving.
        A recent RAND report recognized DOD and DVBIC educational products
    for their clinical accuracy and effective risk communication.
        Brainline.org is a multimedia project that provides information on
    preventing, treating, and living with TBI. Funded by DVBIC and
    delivered by WETA, the public radio and television network in
    Washington, DC, Brainline.org has reached a very broad audience of TBI
    patients and families. Additionally, we are using social networking
    media to connect family members with others who have gone through
    similar experiences.
        Finally, DVBIC has established a national care coordination
    network, identifying all personnel with TBI who have been evacuated
    from theater. A care coordinator contacts the Servicemember at 3, 6,
    12, and 24 months following injury, and determines what, if any,
    additional resources are needed to meet the Servicemember's needs.
    DVBIC Regional Care Coordinators (RCCs) work to ensure optimal care and
    recovery for Servicemembers and veterans with TBI whose rehabilitation
    and return to community do not always follow a strict linear path, or
    whose injury may result in cognitive, social, behavioral, or physical
    deficits which prevent them from accessing available systems of care.
    RCCs also follow Servicemembers and veterans with TBIs longitudinally
    to help avert poor outcomes and improve our understanding of the many
    factors related to outcome following TBI. This program is linked with
    the VA Polytrauma Federal Care Coordination System and with DCoE's
    Outreach Center, providing 24 hours a day/7 days per week support to
    patients, family members, and providers.
                          other federal collaboration
        While our brain injury collaborative efforts with VA have spanned
    two decades, we have worked across the Federal health sector on
    important national efforts to advance our research base. We worked
    closely with the Centers for Disease Control and Prevention (CDC) to
    select the appropriate International Classification of Disease codes
    for TBI surveillance. We are also working with the CDC to extend our
    education to rural and medically underserved areas for providers in
    these communities who may be treating Guard and Reserve members.
        DOD, VA, and the Department of Education's TBI Model Systems of the
    National Institute for Disability Rehabilitation Research are
    collaborating to coordinate the important TBI registry initiatives we
    have underway. DOD is collaborating with the Department of Labor's
    ``America's Heroes at Work'' initiative providing education to
    employers enhancing incorporation of veterans with TBI into the
    workforce.
                                   conclusion
        DOD, VA, and civilian colleagues have performed extraordinary work
    across this country to advance our understanding of TBI, particularly
    as it relates to the unique nature of combat.
        DOD and VA experience has been one of intense collaboration--
    typified by open, fact-driven analysis, research, and dissemination of
    evidence-based findings. I am proud the DVBIC has been at the center of
    this collaboration--facilitating and deepening our joint efforts,
    inspired by the sacrifices of the Servicemembers, veterans, and
    families we serve. We are developing a system that allows for a more
    rapid and proactive approach to optimizing our systems of care for our
    wounded warriors with TBI.
        Substantive progress has been made to implement the provisions of
    the 2007 law, and we are pleased to work with our VA colleagues in this
    endeavor.

        Mr. Chairman, Members of the Committee, I want to thank you again
    for your steadfast support of our Military Health System and your
    ongoing investment in Traumatic Brain Injury research and care. I look
    forward to your questions.
                                     ______

    Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to
     Col. Michael S. Jaffee, M.D., National Director, Defense and Veterans
                Brain Injury Center, U.S. Department of Defense
                         early diagnosis and treatment
        Question 1. Early diagnosis and treatment is key to having positive
    outcomes after TBI. What is DOD doing to enforce adherence to the
    screening and rest standards after a servicemember is exposed to a TBI
    causing event.
        Response. The Department of Defense currently does not enforce
    adherence to screening and rest standards. However, DOD must continue
    improving our processes to ensure that every Servicemember exposed to a
    TBI event received the appropriate diagnosis and treatment. To this
    end, we will continue to review how we can best enforce standards
    across Services and in theater.
        DOD is currently re-evaluating revisions to current guidelines,
    originally developed in 2006, for the acute management of concussion/
    mild Traumatic Brain Injury in the deployed setting to reinforce the
    importance of early diagnosis and treatment as well as a recovery
    period to prevent further injury. Currently, the Department conducts
    baseline cognitive tests used to inform post-concussion evaluations.
    DOD employs evidence-based tools for concussion screening acutely
    following injury and during mandatory post-deployment evaluation.
    Current screening tools assess multiple symptoms in addition to
    cognition and the assessments are incorporated into the Post Deployment
    Health Assessment and the VA TBI Clinical assessments.
        We are also developing clinical practice guideline for rest
    standards for those who are diagnosed with any symptoms concussion or
    TBI. While guidelines are not adequate to enforce adherence, we are
    educating and training Servicemembers, including the medical community
    and line leadership, regarding approaches to screening and treatment
    for concussion/mild TBI.
                            dod data sharing with va
        Question 2. How is DOD making data, such as predeployment cognitive
    baseline screenings, available to VA for use in their treatment of
    servicemembers and veterans?
        Response. DOD will provide TBI data, such as predeployment
    cognitive baseline screenings, to VA for use in their treatment of
    Servicemembers and veterans by December 2010. To date, more than
    500,000 multiservice baseline assessments have been collected using the
    Automated Neuropsychological Assessment Metrics, a Government off-the-
    shelf product, to collect baseline cognitive data on deploying
    Servicemembers. According to the VA, they will begin implementing
    technical solutions to enable VA providers to view DOD
    neuropsychological assessment data by June 30, 2011.
                       comorbidities associated with tbi
        Question 3. Multiple comorbidities are associated with TBI,
    including vision impairment, hearing loss and tinnitus, and the
    frequency with which servicemembers suffer amputations or other severe
    extremity injuries. Despite substantial funding provided for the
    purpose, why has there been virtually no discernable progress in
    establishing the vision, amputation and extremity injury, and hearing
    loss centers of excellence, as mandated by the FY 2008 and FY 2009
    NDAAs?
        Response. The Department has made progress in establishing the
    vision, traumatic extremity injury and amputation, and hearing loss
    centers of excellence (COE). Although progress toward establishing
    these centers of excellence has been slow, the Department has never
    lost its focus on the care of the wounded warriors. Working in
    coordination with our VA and private-care partners, we continue to
    provide high quality care for wounded warriors in multiple clinical
    centers in the US and overseas. Milestones for establishment of the
    centers of excellence are provided below:

         Feb 2010--Deputy Secretary of Defense delegated authority
    to Under Secretary of Defense (Personnel & Readiness) to establish
    centers of excellence.
         May 2010--Under Secretary of Defense (Personnel &
    Readiness) established the centers and assigned each center to lead
    Service Component:

              - Vision--Navy
              - Hearing--Air Force
              - Traumatic extremity Injuries/Amputations--Army

         In May 2010, the VCE sponsored Vision Research Program
    awarded $10M for Vision Research primarily focused on the management of
    visual dysfunction with TBI.
         In April 2010, $1.86M was provided to the Hearing COE to
    be used for contracts, equipment and information management solution to
    electronic networking. The Hearing COE is also focusing on developing
    the Joint Hearing Registry with VA and the Services. The Registry will
    used for the tracking of the diagnosis, surgical intervention or other
    operative treatment for each case of hearing loss and auditory system
    injury incurred by a member of the Armed Forces while serving on active
    duty.
         The Traumatic Extremity Injuries and Amputations COE had
    not received funding in FY 2009 or FY 2010. However, in collaboration
    with the VA, DOD is fully engaged with continuing the DOD and VA
    programs for extremity injuries and amputations.
         Funding profile for each of CoEs provided in table below:
    ------------------------------------------------------------------------
       Center of Excellence (CoE)           FY 2009             FY 2010
    ------------------------------------------------------------------------
    Vision CoE
      DOD O&M.......................             $3.00M              $6.84M
      VA O&M........................             $0.38M              $1.10M
      DOD MILCON....................             $4.05M
                                     ---------------------------------------
        O&M /MILCON Total...........             $7.43M              $7.94MHearing CoE
      DOD O&M.......................             $0.00M              $1.86MTraumatic Injuries/Amputations
      DOD O&M.......................             $0.00M              $0.00M
    ------------------------------------------------------------------------

        Chairman Akaka. Thank you very much, Colonel Jaffee.
        Colonel, one Marine who returned from Afghanistan in
    December 2009 was in a lightly armored vehicle that struck an
    IED. The incident was fatal for other occupants of the vehicle
    and amputated the legs of the turret gunner. The Marine in
    question was knocked unconscious.
        After seeking treatment from his corpsmen, having the
    incident documented in his medical record, and making the
    proper indication on his PDHA, he has since received no follow-
    up care. He has not been contacted by anyone about his PDHA. He
    has even sought care from several different military medical
    sites and has been turned away.
        Can you comment on what the Department is doing to ensure
    servicemembers actually receive the treatment that is outlined
    in the policy?
        Colonel Jaffee. Thank you, Mr. Chairman. There are a couple
    of ways that we are trying to increase the penetration and
    ensure that people get the appropriate treatments, one of which
    is we are in the process of transitioning our system for
    evaluations from a subjective, voluntary approach where a
    servicemember would have to raise their hand and say that they
    have a problem and access care, to one in-theater, which is
    more of a mandatory--if you have been involved in an incident
    that is associated with a blast, even if you are being stoic
    and denying that you have symptoms, you would still receive a
    mandatory evaluation. And the current protocol for that also
    includes that that gets appropriately documented in-theater,
    which can help facilitate further follow-up. And your
    particular case mentioned assuring more robust care and follow-
    up in the post-deployment aspects throughout all of the
    facilities.
        One of the things that is very important to the Department
    of Defense is providing the appropriate education and resources
    to all of our primary care providers in the military health
    care system on the systems and resources and guidelines that
    are in place to care for this very important population. To
    that end, we have been investing a lot of resources in
    providing appropriate education to all members of our military
    health care system. This includes having instituted for the
    past 3 years annual training events, which have trained more
    than 800 DOD and VA providers to make them aware of these newer
    developments and guidelines.
        We have put in a system, a network of education
    coordinators throughout the country. We have 14 of these people
    throughout the country whose job is outreach to make sure that
    they are providing appropriate education and resources to our
    primary care providers at all of our military facilities. We
    recently are very pleased by the collaboration that we have
    with our line commanders.
        So the medical community does not feel like we are doing
    this alone in the military, we have the unmitigated support of
    our line commanders who want to help us get the appropriate
    education out to all of our servicemembers. Part of that
    education campaign includes not just education to the patients,
    not just the providers and the family members, but actually
    involves the commanders and the line, so that if they are aware
    that one of the servicemen or servicewomen under their command
    is not getting the appropriate services, they will have an
    awareness of the types of resources available and can also
    assure that they will get the appropriate referrals and
    treatments.
        The other aspect that we have is that immediate screening,
    that post-deployment health assessment. And we are aware that
    some people may not have problems that develop until several
    months after they return home. To address that challenge, we
    have implemented the post-deployment health reassessment, which
    occurs 90 to 100 days after they return home. We have found
    that that system can sometimes identify individuals with
    problems that were not identified initially, which also helps
    expedite getting them transitioned to the appropriate care
    network.
        Chairman Akaka. In this particular case where this person
    has claimed that he has been turned away, what alternative does
    this person have?
        Colonel Jaffee. There is a number--we have a network of
    those regional care coordinators who can certainly reach out
    and help facilitate--assuring that that individual can get to a
    facility that can provide the appropriate resources, be it a
    Federal facility or a local facility within the TRICARE
    network. That is the purpose of that program, to try and reach
    out to individuals like that, because the goal is to keep
    anyone from falling through the cracks.
        Chairman Akaka. Thank you.
        Dr. Beck, as you know, Congress recently passed legislation
    I introduced that would create a comprehensive program of
    caregiver support services. If you could make any changes you
    wanted, how would you implement this program for veterans with
    TBI?
        Ms. Beck. Thank you. We at the VA are very pleased that
    Congress has recognized the significant sacrifices that are
    made by caregivers and that there is support and legislation
    for the expansion of benefits and services to meet their needs.
        The additional benefits outlined in the legislation will be
    of great value to families and to veterans with Traumatic Brain
    Injury who require a primary caregiver in the home. VA looks
    forward to working with Congress and other key stakeholders on
    the implementation of the plan. We think the legislation is
    comprehensive and will address the needs that our caregivers
    have.
        Chairman Akaka. Dr. Beck, the Secretary's March 23, 2010,
    report to the Committee says that, and I quote,
    ``Collaborations with private sector facilities are regularly
    used to successfully meet the individualized needs of veterans
    and complement VA care.''
        Can you cite examples of private facilities providing care
    for veterans with the most severe TBIs?
        Ms. Beck. Yes, sir. I would think first of hospitals like
    Kessler Hospital in New Jersey, Casa Colina in California, the
    Rehabilitation Institute in Chicago, Spaulding Hospital in
    Boston, Marianjoy in Wheaton, the National Rehabilitation
    Hospital here in the District of Columbia. I am aware of
    active-duty servicemembers who have been treated or where we
    have shared treatment with those facilities.
        I would also like to point out that at the military
    treatment facilities, our servicemembers have a choice. They
    may choose the private sector at the military treatment
    facility. That is their choice. Some of them do use the private
    sector, but many of them choose to transfer to Polytrauma
    Rehabilitation Centers. And since the beginning of conflicts in
    Afghanistan and Iraq, our polytrauma centers have been
    available to take patients. We have not denied admission, and
    we have had rehabilitation services available to the
    servicemembers and their families.
        Chairman Akaka. Thank you very much.
        Senator Burr, your questions.
        Senator Burr. Colonel, I heard you mention that every
    servicemember who might be exposed to a blast has a mandatory
    evaluation. Let me just ask you, is Severe Traumatic Brain
    Injury pretty identifiable?
        Colonel Jaffee. Yes.
        Senator Burr. What we are really concerned with is people
    on the margins. Even with a mandatory evaluation, how in the
    world are we going to catch it if we do not have a baseline to
    compare? I think you are talking about a quiz that we send
    servicemembers through, and yet we know that this is a problem
    that is going to affect a lot of people. Why aren't we taking a
    baseline on these folks before they are deployed so we have got
    some comparison?
        Colonel Jaffee. Well, sir, I am happy to report that
    actually the DOD does have a program to do cognitive
    baselining. To date, since that program was implemented, we
    have baselined more than 500,000 servicemembers prior to their
    deployment. The purpose of that program is that we can better
    inform and make the safest determination for when it is safe to
    return them to duty in theater following an injury so that we
    can access that baseline information and compare it to their
    post-injury evaluation when we think we are preparing to send
    them back into the fight.
        Senator Burr. So how does that baseline follow that
    servicemember from medical facility to medical facility or in-
    theater?
        Colonel Jaffee. Well, the baseline is meant to help inform
    those decisions in-theater, so currently it is in a system
    which the in-theater providers reach back to a help desk to
    access, and we are in the process of enterprising the execution
    of a system through our Defense Health Information Management
    System to tie those results directly into the theater computer
    systems where the providers there can directly access it from
    their computer.
        Senator Burr. And do you know how many people in-theater
    know that that exists?
        Colonel Jaffee. I know that there has been a steady
    increase in utilization of that help desk since it was
    implemented.
        Senator Burr. OK. Dr. Beck, Dr. Gans with the Kessler
    Institute appeared 3 years ago, and 3 years ago he sort of
    brought to the Committee's attention that we were doing little
    to reach outside. Now, you quoted all these places that we go,
    but let me quote from Dr. Gans' testimony today. ``It appears
    that little has changed since 2007 regarding the use of local
    care providers for TBI care.'' Would you like to comment on
    that?
        Ms. Beck. Yes, sir. Thank you. As I noted in my testimony,
    during fiscal year 2009 the VA treated 3,700 veterans in the
    private sector and spent over $21 million. There were 1,500,
    approximately, either facilities or individuals who provided
    that care to the Nation's veterans.
        Senator Burr. What is the VA's criteria for determining
    whether you use a local provider?
        Ms. Beck. The criteria are that the care is either--number
    1, that we cannot provide the care at the VA; we do not have
    the services available at the VA.
        Senator Burr. But define that for me. If the nearest VA
    facility is 90 miles away and they provide the care, is that
    their point of delivery?
        Ms. Beck. What we do in those cases is, we have a
    geographically accessible statement, and that is a medical
    decision that is made by our physicians who manage the care,
    and that is related to distance from the facility, condition,
    and the specialty care needs. So the geographic accessibility
    decision is implemented based on those three conditions under
    the direction of a physician.
        Senator Burr. What is the DOD criteria, Colonel?
        Colonel Jaffee. Basically it is up to the--if a certain
    resource or specialty is available at the military treatment
    facility, then that is where the servicemember would receive
    their treatment. If a particular specialty or need is not
    available, then we would go to the TRICARE network looking at
    the number of facilities and providers.
        Senator Burr. Do you also have a geographical area for the
    DOD facility?
        Colonel Jaffee. This is done more local and regional by the
    facility, so it is at the facility itself, if you have the
    resources; if not, then you try and utilize the expertise as
    close to the area as possible. That is why we have local
    TRICARE networks, and each MTF sort of keeps track of those
    local providers by specialty who are involved in the TRICARE
    network.
        Senator Burr. Dr. Beck, in late 2007, we passed the Wounded
    Warrior Act, and in that legislation we created a pilot program
    that provided residential living options.
        Now, in your testimony, you say that we currently have
    ``four veterans with moderate to severe TBI that have been
    placed in private facilities that specialize in providing
    rehabilitation services for TBI (residing in Virginia,
    Wisconsin, Kentucky, and Texas.) Up to 26 veterans are
    projected to be enrolled in the program in 2010 and 14 more in
    2011.''
        Let me just ask you, why are so few being served under this
    pilot?
        Ms. Beck. We have the capacity to serve more under the
    model. So far----
        Senator Burr. Let me just point out, this is 2010. We
    passed this in 2007. To date, we have four veterans--and I
    appreciate your projections of 26 in 2010 and 14 in 2011. But
    based upon the 3-year ramp-up to get four in, I am somewhat
    skeptical about the ability to meet those. What has been the
    problem?
        Ms. Beck. We have done extensive outreach, and many of our
    veterans prefer to get their care in their homes with their
    families.
        Second, I also referred in my testimony to our Transitional
    Rehabilitation Centers. We have those at our four regional
    centers, and we frequently use those centers for community
    reintegration, which is a type of care, community-based
    reintegration, that we would use before we would go to assisted
    living.
        We are doing extensive outreach to make this program known,
    and we have identified 267 private sector facilities who can
    provide assisted living for TBI, and we are----
        Senator Burr. Have you identified how many servicemembers
    this might be appropriate for?
        Ms. Beck. We have reached out to our veterans through our
    OEF/OIF case management programs. We initially identified--they
    reported to us a possible universe of 168 veterans who were
    interested and might at some point consider assisted living.
        What we are finding is that this is going to be an option
    we think further out in the recovery period as we look at the
    stressors that may occur for patients, for our veterans and
    families when they are at home or in the community.
        Senator Burr. Thank you. My time has expired, and I thank
    the Chairman for his indulgence.
        Chairman Akaka. Thank you very much, Senator Burr.
        Senator Murray?

                    STATEMENT OF HON. PATTY MURRAY,
                      U.S. SENATOR FROM WASHINGTON

        Senator Murray. Thank you very much, Mr. Chairman and
    Senator Burr, for holding this really important hearing.
    Clearly, we all know that we have to get this approach to
    treating patients with TBI right. I continue to be concerned as
    we have a number of veterans returning from Iraq and
    Afghanistan, and we know that IED explosives continue to be a
    problem on the ground. At the same time, the VA is having
    trouble still hiring enough mental and health care
    professionals to meet the needs that we have not only today but
    for tomorrow.
        So, I am concerned about our long-term plan and making sure
    we continue to do what we need to do from our end to ensure we
    have the resources to meet it. I am very concerned that the VA
    is underestimating the number of patients who are going to seek
    VA health care as a result of the wars in Iraq and Afghanistan.
    Like I said, clearly the VA has to be able to hire enough
    professionals, including mental health care professionals, if
    it is to maintain the quality of care that we expect.
        I wanted to ask today if the DOD and VA casualty prediction
    models are accurate, in your opinion. Dr. Beck or Colonel
    Jaffee, either one.
        Ms. Beck. I would like to take that for the record. I
    cannot comment on that at this time.
        Dr. Guice is our Federal recovery coordinator and works
    with our severely injured. I----
        Senator Murray. So we do not know if they are accurate?
        Ms. Beck. I cannot comment on it at this time. Colonel
    Jaffee?
        Colonel Jaffee. What we are most confident in is the number
    of servicemembers who, after having received a screen, got a
    clinical evaluation and got diagnosed as having had symptoms
    thought to be due to a Traumatic Brain Injury. So they get the
    appropriate clinical evaluation and use an ICD code. There is a
    very positive initiative over the past 2 years between the VA,
    DOD, and the Centers for Disease Control to come to a consensus
    and a revision of the ICD-9 codes that are being used by
    clinicians to evaluate these patients. So we have a--I think we
    are confident in clarifying the number of patients who get
    diagnosed and coded.
        One of the things that I alluded to in my earlier statement
    is we are also trying to very much encourage our servicemembers
    who may be suffering but not coming forward who we may not know
    about. That is why we are transitioning from the system where
    it is a voluntary symptom-based approach, requiring them to
    raise their hand, to this mandatory evaluation which we hope
    and believe will capture more individuals who may be having
    symptoms and suffering yet may not be raising their hand. This
    will allow us to get a more accurate prediction and planning
    for these servicemembers.
        Senator Murray. OK. Well, I would like you then to answer
    for the record because we need to look long term for our
    budget. And we know that it is not just care the day they get
    home or even 3 months later, but far into the future. The kinds
    of facilities or treatment that we will need 5, 10, 15, 20
    years from now are important, so I would like to have you
    respond to that.

        [The information requested during the hearing follows:]
    Response to Request Arising During the Hearing by Hon. Patty Murray to
     Lucille Beck, Ph.D., Chief Consultant, Rehabilitation Services, U.S.
                         Department of Veterans Affairs
        Response: There is no modeling activity by VA regarding this issue.
    Casualty Projection modeling is a DOD issue.

        Senator Murray. Let me turn to another question then. In
    2008, the GAO raised concerns about the screening tool that was
    used by the VA to assess TBI. Now, I understand that the VA is
    currently examining its TBI screening tools because of that,
    and I am interested to know where that research stands right
    now because it is unacceptable for veterans with TBI, whether
    it is blatant or unreported, to go undiagnosed because of lack
    of training of someone or medical equipment at the VA.
        So can someone describe to me where we are with the
    screening tool assessment?
        Ms. Beck. Yes, Senator Murray, we have three research
    projects now which are evaluating the screening tool and
    assessing its reliability and validity. We expect the first of
    those studies to be completed in fiscal year 2011.
        Senator Murray. Sometime next year.
        Ms. Beck. Sometime next year. And I would like to provide
    for the record the details as to the status of the other
    studies.

        [The information requested during the hearing follows:]
    Response to Request Arising During the Hearing by Hon. Patty Murray to
     Lucille Beck, Ph.D., Chief Consultant, Rehabilitation Services, U.S.
                         Department of Veterans Affairs
        Response. Currently, VA has three studies that are evaluating the
    TBI Screening and Evaluation Tool (below). Two are underway, and a
    third study is beginning. Results from these are expected beginning in
    2011.
    1. SDR 08-377: Evaluation of VA's TBI Clinical Reminder and Secondary
            Level Evaluation
        Judi L Babcock-Parziale PhD
        Southern Arizona VA Health Care System, Tucson, AZ
        Funding Period: May 2009-April 2011
    http://www.hsrd.research.va.gov/research/
    abstracts.cfm?Project_ID=2141699528
        Current Status: Active; recruiting subjects.
        Background: Traumatic Brain Injury (TBI) is a leading injury among
    military personnel serving in the Operation Enduring Freedom/ Operation
    Iraqi Freedom (OEF/OIF) combat theaters due largely to improvised
    explosive devices. While TBI severities range from mild to severe, mTBI
    is particularly difficult to identify, diagnose and treat. The VA
    modified a version of the Defense and Veterans Brain Injury Center
    (DVBIC) tool, which is used to screen returning OEF/OIF servicemembers.
    The VA's modified screen, the TBI Clinical Reminder, is used to screen
    a slightly different population. Therefore, results of the validity
    study for the DVBIC tool are not directly applicable. As a result, the
    General Accounting Office (GAO) recommended the VA expeditiously
    evaluate the clinical validity and reliability of its TBI screening
    tool. The VA's Second Level Evaluation will also be evaluated to
    determine the sensitivity and specificity of the diagnostic criteria.

        Objective(s):
        (1) Develop expert-derived mTBI Diagnostic Standards (i.e., proxy
    gold standards).
        (2) Evaluate and compare the performance characteristics of the TBI
    Clinical Reminder and the Second Level Evaluation using the expert-
    derived Diagnostic Standards.

        These objectives will be realized via: (a) An examination the
    performance characteristics (diagnostic validity) of the TBI Clinical
    Reminder and the Second Level Evaluation relative to the expert-derived
    Diagnostic Standards to determine sensitivity and specificity, (b)
    Determining whether false positives and/or false negatives are related
    to Post Traumatic Stress Disorder (PTSD) and how the performance
    characteristics of the tests differ for PTSD, (c) Ascertaining the
    concordance among measures of functional impairment, the TBI Clinical
    Reminder and the Second Level Evaluation, (d) Establishing the
    concurrent validity between the diagnosis of presence or absence of
    post-concussion syndrome due to mTBI and measures of functional
    impairment, (e) Verifying the test/retest reliability for the TBI
    Clinical Reminder and the Second Level Evaluation and (f) Identifying
    whether clusters of symptoms or subjects reporting similar patterns of
    symptoms correspond with any of the eight clinical sub-groups (e.g.,
    mTBI with PTSD, PTSD alone).

        Methodology:
        The project includes a mixed methods approach with a total sample
    of 720 OEF/OIF veterans recruited over 12-months at three VA Polytrauma
    Network Sites. The subjects will have either symptoms consistent with
    post-concussion syndrome thereby due to mTBI (True Positive) or
    symptoms not consistent with post-concussion syndrome thereby not due
    to mTBI (True Negative). All subjects will be assessed by research
    clinicians using the TBI Clinical Reminder and the Second Level
    Evaluation, the Diagnostic Standards, and two measures of functional
    impairment to determine a true diagnosis of mTBI and/or PTSD.
        Diagnostic Standards will be derived from experts using an online
    Delphi process and will be used to compute sensitivity and specificity
    for the TBI Clinical Reminder and the Secondary Level Evaluation. Test
    re-test reliability of the TBI Clinical Reminder and cluster analyses
    of the Secondary Level Evaluation will be conducted. Cluster analyses
    will be conducted to further our understanding of how the clinical
    presentation of patients with mTBI might be classified.

        Results:
        There are no findings, as the project began May 2009.

        Impact:
        Anticipated Impact: Determining the clinical validity of the VA's
    TBI Clinical Reminder and Second Level Evaluation is critical because
    valid screening and evaluation of mild Traumatic Brain Injury (mTBI)
    leads to accurate diagnosis and timely treatment. Accurate screening
    improves clinical efficiency and ensures that resources are provided to
    those who need them most. The project findings are expected to advance
    the science of screening and diagnosis by clarifying whether symptoms
    are consistent with post-concussion syndrome thereby due to mTBI. The
    anticipated findings will also improve the field's ability to measure
    mTBI outcomes.
    2. C7055-I: Objective Diagnosis of Mild Blast-Induced TBI
        Joseph F. Rizzo
        Funding Period: 1/1/2010-12/31/2012
        Objective(s): This proposal presents a novel plan to develop a
    diagnostic tool to diagnose TBI.
        Research: This proposal seeks to develop a new tool to diagnose
    mild TBI.
        Methodology: We propose to modify existing laboratory-based methods
    to record eye movements to create a new portable device with similar
    capabilities. This new test will be developed and validated in the
    first year of this proposal. Thereafter, this test will be administered
    to a small number of veterans with blast-induced Traumatic Brain Injury
    to judge the feasibility of giving this test to blast victims. The
    blast-victims will be selected by Neurocognitive scientists at the
    Boston VA.
        Current Status: Active; anticipate data collection beginning
    August 2010, and preliminary data before the end of fiscal year 2011.
    3. SDR 08-411: TBI Screening Instruments and Processes for Clinical
            Follow-Up
        Rodney D. Vanderploeg Ph.D.
        James A. Haley Veterans Hospital, Tampa, FL
        Funding Period: October 2009-September 2011
        Objective(s): The goal is to evaluate the reliability and validity
    of the existing Traumatic Brain Injury (TBI) Clinical Reminder Screen
    for OEF/OIF Veterans. There are four objectives:

        1. Operationalize a gold standard semi-structured interview for TBI
    identification using a national panel of experts.
        2. Identify VHA system factors and patient characteristics
    predicting delay in or failure to complete the TBI Clinical Reminder
    screen (e.g., patient characteristics and VA System levels of
    Polytrauma care).
        3. Using the gold standard semi-structured interview, evaluate the
    validity (sensitivity and specificity) and reliability of the current
    TBI Clinical Reminder Screen.
        4. Identify approaches to improve the TBI Clinical Reminder
    screening protocol, including modifications of the screening instrument
    and process.

        Research Design: This is both a retrospective analysis of existing
    VA patient care data (TBI Clinical Reminder and TBI Comprehensive
    Evaluation) and a prospective study completing ``gold standard''
    interviews of both positive and negative TBI Screens.

        Methodology:
        1. Using a panel of national experts develop a ``gold standard''
    semi-structured interview to identify and confirm TBI history.
        2. Statistically analyze the TBI Clinical Reminder database from
    Patient Care Services to identify provider, patient, and system
    characteristics associated with delays in or failure to successfully
    complete the TBI screening process.
        3. Use the ``gold standard'' semi-structured interview to complete
    a prospective study on a sample of veterans at 8 VA sites (2 PRC, 3
    PNS, 3 PSCT) to assess the psychometric characteristics of the TBI
    screen (reliability, sensitivity, and specificity).
        4. Improve the current TBI Clinical reminder through examination of
    each of the questions and response options within the TBI screen to
    determine which are most related to gold standard identification versus
    false positive responses.

        Current Status: Local Tampa IRB approval, National data requested
    (not yet received), Expert panel meeting convened, Working on
    finalizing the ``gold standard'' semi-structured interview, Recruiting
    local PIs for the other 7 VA sites to assist with local IRB approval
    and subject recruitment.

        Senator Murray. Are we doing anything in the interim to
    address the concerns about the screening tool that is currently
    being used? Or are we just waiting for a study?
        Ms. Beck. No, Senator Murray, what we are doing is we are
    recognizing that the screen is a screen, that it probably
    overrefers, and we are conducting a full and complete
    evaluation of everyone who screens positive, and providing care
    and treatment for the symptoms and the disorders that we
    evaluate during the assessment.
        Senator Murray. I am out of time, but I do have additional
    questions, so I will wait until the next round.
        Chairman Akaka. Thank you very much, Senator Murray.
        Senator Isakson?

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

        Senator Isakson. Thank you, Mr. Chairman.
        Dr. Guice, Laurie Ott at Uptown VA--you are probably
    already ready for this; I can tell by that smile--sings the
    praises of your Recovery Coordinator Program and says that it
    is most particularly beneficial for those that suffer from
    Traumatic Brain Injury. I understand there are three recovery
    coordinators at the Uptown VA in Augusta, but I understand
    there are less than 30 nationwide. What are your plans to
    expand that program?
        Dr. Guice. Thank you, sir. Laurie is a great supporter of
    the program, and we appreciate her interest and time in helping
    us do what we need to do.
        We currently have three FRCs at Eisenhower Army Medical
    Center. We currently have 20 nationwide and are in the process
    of hiring an additional 5. What we do is we constantly project
    based on the number of referrals we are getting to the program
    and the number of individuals who enroll in the program as to
    the need. So we sort of do a just-in-time staffing. Of course,
    just-in-time does not mean we can hire them tomorrow. It means
    we have to have a little bit of lead time. So, I am constantly
    doing projections to see when those points of hiring need to
    happen, and we are currently in the process of hiring five
    additional FRCs.
        Senator Isakson. When did you originally implement the
    program?
        Dr. Guice. The program was implemented in--it first started
    taking clients, which is the best time point, in February 2008.
        Senator Isakson. And they coordinate the transition from
    DOD to VA Health Care, too, do they not? Aren't they more like
    a caseworker that follows in that transition?
        Dr. Guice. It is a very unique program in that we
    coordinate the care and benefits that these individuals need
    across the transition. So if you think about any time we have
    some individual moving from hospital to hospital or hospital to
    another facility and finally moving from active duty to veteran
    status, those are all transitions. Sometimes we have difficulty
    managing transitions.
        What the FRCs do is once they have a client assigned to
    them, they stay with that client throughout all of the
    transitions, which is relatively unique given the way we have
    our system structured where most case managers are facility
    based. So they really do stay with that individual and with
    that family and really try to mitigate any problems almost
    before they happen, and coordinate the benefits and care that
    they need using all the case managers and all the providers
    that we have.
        Senator Isakson. Well, I apologize for missing Dr. Beck's
    testimony, but I note that she is the chief consultant to the
    VA. So I would just say this: In my experience with veterans
    returning from Afghanistan and Iraq, particularly those with
    Traumatic Brain Injury, the single biggest problem we had,
    which is now lessening, was they fell between the cracks
    between DOD and VA. These recovery coordinators are a bridge in
    that transition, which for TBI, probably more than any other
    injury, is tremendously important. They are doing wonderful
    work down there--I am prejudiced because I am a hometown guy--
    at Augusta VA. They have returned some soldiers who have come
    home from Iraq or Afghanistan with TBI, have rehabilitated
    them, and some have actually volunteered to go back, which is
    an amazing testimony to what Eisenhower has done and what the
    Uptown VA has done.
        Thank you very much, Dr. Guice.
        Chairman Akaka. Thank you very much, Senator Isakson.
        Senator Tester?
        Senator Tester. Yes, thank you, Mr. Chairman.
        I have a couple different ways to go here. I think I am
    going to put forward a couple of examples, and then I have got
    a question for you, Dr. Beck, in relation to these.
        One, there is a New York Times article that described a
    scenario of a wife of a soldier who happened to be recovering
    from TBI at Fort Carson's warrior transition unit. She was
    reprimanded when she sought additional therapy for her husband,
    told by an NCO that he does not deserve his uniform, he should
    give it to her.
        Two, about 3 years ago, I visited with a young lieutenant
    from Shelby, MT, who was at Walter Reed dealing with a very
    serious leg injury. He and his wife were very frank with me.
    They told me they had an impossible time handling the
    bureaucracy, getting appointments scheduled, and trying to get
    through the discharge process.
        I recall thinking at that point in time you have got a
    bright, young officer whose wife is in law school. These folks
    are having a tough time getting through the process. How does
    anybody ever get anything done here if they do not have an
    advocate?
        The question I have is: Have things improved in the last 3
    years? How have they improved in the last 3 years? And do you
    see this as a problem? I am talking about making sure the needs
    of the soldier are met without having to have a mother, a
    father, a wife, a sibling quit their job to advocate for them?
        Ms. Beck. Thank you, Senator Tester. We have placed VA
    military liaisons, social workers, at the military treatment
    facilities. We currently have 33 of those VA military liaisons
    at 18 of our military treatment facilities. We are in
    discussions with the Army currently to expand those numbers.
        We have found that the liaison capability of VA social
    workers working with the military care coordinators and social
    workers has improved the transition.
        Senator Tester. OK. And just so I get your numbers right,
    you have got 33 transition workers at 18 facilities?
        Ms. Beck. That is correct, sir, social work liaisons.
        Senator Tester. So a little less than two per facility, is
    that fair to say?
        Ms. Beck. They are distributed----
        Senator Tester. OK, based on numbers? And what is that
    ratio? What are those numbers? I mean, how many soldiers does
    it take to say we need another one?
        Ms. Beck. Well, I think we do it based on size and scope of
    medical services at the military treatment facilities, and we
    work collaboratively with the commanders at those facilities to
    determine----
        Senator Tester. OK. So give me--what I am looking for is an
    idea of how many people these folks could be responsible for,
    helping them through the maze. And I do not mean that in a bad
    way, but it kind of represents it. Are we talking one worker
    per five soldiers, 10 soldiers, 20 soldiers, 100 soldiers? And
    you can answer, Colonel, if you would like. However you want to
    do it. I am just trying to get an idea if we are even close to
    meeting the demand that is out there. Are we? I mean, I think
    they are probably effective. I mean, I do not doubt that a bit.
        Ms. Beck. They are--Senator----
        Senator Tester. But if we are understaffed, that is another
    issue that this Committee probably will want to address.
        Ms. Beck. The positions and the roles are effective. We
    recognize that we can always do more, and that is the reason
    that we are continually working with the military service and
    the commanders to identify opportunities.
        For example, because so many of the seriously injured and
    the wounded are returning to Walter Reed and Bethesda, we have
    a higher number of social workers there than we do----
        Senator Tester. That makes sense. Could you get back to us
    with some numbers so we can get some sort of scope?
        Ms. Beck. Yes.
        Senator Tester. And I am sure it is going to vary from soup
    to nuts, but if you could give us the number of social workers
    at each of those 18 facilities and how many soldiers--that is
    really the key.
        Ms. Beck. Yes.
        Senator Tester. How many soldiers they are working with----
        Ms. Beck. Yes, sir.
        Senator Tester. That would be great.
        Ms. Beck. We have those numbers, and we have the number of
    referrals, and I would----
        Senator Tester. That would be great.
        Ms. Beck [continuing]. Provide it for the record.
        Senator Tester. Thank you very much.

        [The information requested during the hearing follows:]
     Response to Request Arising During the Hearing by Hon. Jon Tester to
     Lucille Beck, Ph.D., Chief Consultant, Rehabilitation Services, U.S.
                         Department of Veterans Affairs
        Response. The Department of Veterans Affairs (VA) has a robust
    system in place to transition severely ill and injured Servicemembers
    from the Department of Defense (DOD) to VA's system of care, as well as
    transitions to their home or the most appropriate facility capable of
    providing the specialized services their medical condition requires.
    The VA Liaisons for Health Care represent a key component for this
    process. The VA Liaisons for Health Care, either social workers or
    nurses, are placed strategically in Military Treatment Facilities (MTF)
    with concentrations of recovering Servicemembers returning from
    Operation Enduring Freedom or Operation Iraqi Freedom (OEF/OIF). This
    program has grown in size from a single Liaison supporting both Walter
    Reed Army Medical Center and the National Naval Medical Center at
    Bethesda to now supporting 33 VA Liaisons for Health Care at 18 MTFs.
        VA Liaisons are co-located with DOD Case Managers at MTFs where
    possible and provide onsite consultation and collaboration regarding VA
    resources and treatment options. The Liaisons work closely with the
    military case managers who are providing case management for these
    Servicemembers, as well as the receiving VA case managers who will be
    providing ongoing case management through the transition and once they
    arrive at the VA medical center. VA Liaisons educate Servicemembers and
    their families about the VA system of care, coordinate the
    Servicemember's initial registration with VA, and secure outpatient
    appointments or inpatient transfer to a VA health care facility as
    appropriate. VA Liaisons make early connections with Servicemembers and
    families to begin building a positive relationship with VA. VA Liaisons
    coordinated 4,567 referrals for health care and provided over 24,000
    professional consultations in fiscal year 2009. In the first two
    quarters of fiscal year 2010, VA Liaisons have coordinated 3,201
    referrals for health care and provided over 14,191 professional
    consultations.
    ------------------------------------------------------------------------
                                                                Number of VA
                             Locations                            Liaisons
    ------------------------------------------------------------------------
     Walter Reed Army Medical Center, Washington, DC..            5
     National Naval Medical Center, Bethesda, Maryland            1
     Brooke Army Medical Center, Ft. Sam Houston,                 4
     Texas....................................................
     Eisenhower Army Medical Center, Ft. Gordon,                  2
     Georgia..................................................
     Madigan Army Medical Center, Ft. Lewis,                      3
     Washington...............................................
     Darnall Army Medical Center, Ft. Hood, Texas.....            2
     Evans Army Community Hospital, Ft. Carson,                   2
     Colorado.................................................
     Womack Army Medical Center, Ft. Bragg, North                 2
     Carolina.................................................
     Naval Hospital Camp Pendleton, Camp Pendleton,               2
     California...............................................
     Naval Medical Center San Diego, California                   2
     (Balboa).................................................
     Martin Army Community Hospital, Fort Benning,                1
     Georgia..................................................
     Winn Army Community Hospital, Fort Stewart,                  1
     Georgia..................................................
     William Beaumont Army Medical Center, Fort Bliss,            1
     Texas....................................................
     Irwin Army Community Hospital, Fort Riley, Kansas            1
     Medical Activity, Fort Drum, New York............            1
     McDonald Army Health Center, Fort Eustis,                    1
     Virginia.................................................
     Ireland Army Medical Center, Fort Knox, Tennessee            1
     Blanchfield Army Community Hospital, Fort                    1
     Campbell, Kentucky.......................................
    ------------------------------------------------------------------------

        Senator Tester. With the exception of my friend Senator
    Begich here to my left, we have got the highest per capita
    percentage of veterans in the United States. Alaska beats us
    out. But we have got a bunch. The polytrauma network
    rehabilitation within--I mean, our nearest center--let me get
    right to it--is in Seattle or Denver. Senator Baucus and I
    introduced legislation that would task the VA with a study to
    establish a new polytrauma center in the area that Montana is
    in. I think it is a good idea. My question is: Would you commit
    to doing that study?
        Ms. Beck. We are aware of the introduction of that
    legislation to do that study, and we are preparing views and
    costs. The Department is preparing views now.
        Senator Tester. It would be good. I mean, I think the issue
    is--and I am going to give up the microphone here because I am
    out of time. But I think the issue is when you are dealing
    with--and I know you talked about distance, condition, and
    specialty care--but when you are dealing with a 12-hour drive--
    and, actually, that is not the longest. That is from where I
    live to a place like Seattle or Denver. I live in the center
    part of the State of Montana. It becomes a real issue even if
    it is a minor injury to make that kind of travel.
        So thank you very much. I appreciate the panel for being
    here. Thank you very much. A panel of five docs. That is pretty
    impressive. Thanks.
        [Laughter.]
        Chairman Akaka. Thank you very much, Senator Tester.
        Senator Begich?

                    STATEMENT OF HON. MARK BEGICH,
                        U.S. SENATOR FROM ALASKA

        Senator Begich. Thank you very much, Mr. Chairman.
        If I can just tag on to one of the questions that Senator
    Tester had, Dr. Beck, you have--and I will use my phrases--33
    social workers that are distributed around. When you decided to
    implement that program, I am assuming you did some analysis of
    the need and, therefore, you had to have some understanding of
    how many you would need to do the job which you estimated
    before you started that program. Am I assuming that right?
        Ms. Beck. Yes, sir.
        Senator Begich. So there is nothing wrong with saying we do
    not have enough, and I want you to kind of be okay with that.
        Ms. Beck. Yes.
        Senator Begich. If we need more, we need to know that. So I
    know you had to do an analysis. A program--anything with the VA
    or the military does not get implemented unless there is a huge
    analysis behind it. So my assumption is you did an analysis
    based on what you saw the growth would be in this area with the
    folks coming back, as well as people who are here that needed
    services of social workers from the VA connected with the DOD.
    So in doing that, you must have had some ratio, some analysis
    of where you needed to be to be at optimum delivery level.
        Can you share that with us at some point? I know you do not
    have it now. That will tell me what your thinking was rather
    than what you think you need right now, because that was the
    basis for moving forward on this, which I think is a great idea
    to have those social workers there. My staff to this Committee
    is a social worker, so she is probably very excited about it. I
    cannot see her facial expression.
        Ms. Beck. She is.
        Senator Begich [continuing]. But I am sure she is.
        Ms. Beck. She is, sir.
        Senator Begich. So that analysis to me is a document that
    makes a difference.
        Ms. Beck. Absolutely.
        Senator Begich. So I can only assume you have that, so I
    will leave it at that. I do not want to speak for Senator
    Tester, but I think we want to help you in this area because we
    think the social workers are an important component.

        [The information requested during the hearing follows:]
     Response to Request Arising During the Hearing by Hon. Mark Begich to
     Lucille Beck, Ph.D., Chief Consultant, Rehabilitation Services, U.S.
                         Department of Veterans Affairs
        Response. The VA Liaison Program was established in October 2003.
    VA recognized the need to establish a seamless transition process to
    ensure all Servicemembers transitioning from DOD to VA receive world-
    class service and transition assistance. The first VA Liaison served at
    both Walter Reed Army Medical Center and National Naval Medical Center
    in Bethesda to transition severely ill and injured Servicemembers
    transitioning from MTFs to VA. Since that time, the program has
    continued to grow, and VA has placed additional VA Liaisons at MTFs
    with concentrations of recovering Servicemembers returning from Iraq
    and Afghanistan. DOD requests assistance for VA Liaisons and recommends
    locations based on the following criteria.

         Numbers of wounded, ill and injured Servicemembers at a
    given MTF
         Severity of conditions at a given MTF
         Likelihood that wounded, ill and injured will need to
    access VA health care
         Number of population that will return to duty

        Senator Begich. Along with that, in the health care piece
    of legislation we passed, there was a provision there called
    the Alaska Federal Interagency Task Force to look at improved
    services throughout Alaska on health care. It actually started
    with us looking at VA, as well as certain services to our
    active military, but now it is a little broader.
        One, are you aware of it? If not, we want to make sure you
    are engaged in this, because the idea is to look at the
    delivery of services in a very rural State. As Senator Tester
    said, we both have a very high percentage per capita of
    veterans that are not necessarily in urban areas, and we need
    to look at how we integrate TBI services in remote areas.
        So, one, are you aware of that? If not, we will get you
    information on it. We want to engage you to make sure we are
    not disconnected from this. I do not know if anyone can answer
    that, but I will just start with you.
        Ms. Beck. We are aware of that initiative related to
    providing services in Alaska, and we will make sure that our
    rehab services group, our Federal Recovery Coordinator Program,
    and our Social Work Case Management Program is engaged in that
    initiative.
        Senator Begich. Fantastic.
        The other is, again, in rural areas, telemedicine is--you
    know, a lot of pioneering has been done in Alaska. I know the
    VA has done some especially around physical therapy and speech
    therapy.
        Ms. Beck. Yes.
        Senator Begich. How do you see TBI, if at all, used in
    telemedicine? And are you using it now? And what is your kind
    of analysis of that? Whoever wants to answer that.
        Ms. Beck. I will start and others can add. We are very
    committed to and looking carefully at the technologies in
    telehealth and how they can help us. Currently, we have two
    projects under way with Traumatic Brain Injury.
        One was referred to earlier, and that is the screening,
    conducting our screening and our evaluations. Denver actually
    pioneered that TBI screening and evaluation tool, and we have
    three other sites that are currently using it. We are
    evaluating the accuracy, the consistency, and the effectiveness
    of using that tool.
        The second initiative that we are evaluating is a case
    management tool, and it allows us to use what we call a
    telebuddy system, which looks a lot like a personal assistant
    or a telephone or an iPhone, and we are establishing capability
    to dialog. So every morning the patient can say good morning,
    work with the case manager: ``Have you done this today? Have
    you done that today?'' And then the dialog exists so that we
    can call the case manager.
        There has been some very good work done in Seattle in the
    rural environments, which may have involved Alaska as well, by
    a rehab group there that has shown that it is an effective
    mechanism. Actually Dr. Bell, Kathy Bell, who is the chief of
    physical medicine and rehab at the University of Washington,
    was a consultant and worked with us on the development of the
    dialog.
        Senator Begich. Very good.
        Ms. Beck. So we are working to implement that this year and
    see that as a way to do good remote case management in
    telehealth.
        Senator Begich. Very good. Thank you for that.
        I will just end on this last question. Should the mental
    health professionals--you know, lots of times it is the VA kind
    of going this way with DOD, but DOD has a lot of additional
    mental health professionals working on the ground in the field
    all the way through the process. As a member of the Armed
    Services Committee, we hear a lot about it.
        Is there enough of activity from the DOD mental health
    professional who is following, say, an individual soldier who
    is starting to show signs of issues that that carries forward
    into the VA? In other words, that DOD mental health
    professional starts their service and then VA picks it up on it
    next? Is there enough transition, and do they do enough coming
    in your direction? VA does a lot going this direction. I know
    that. You have a much smaller budget. DOD has a huge budget.
    But do they do enough coming this way? And if you do not want
    to counter that--I do not want you to have DOD calling you in a
    few minutes and saying, ``Why did you say that?'' But I want
    you to, if you could, just quickly respond, and then my time is
    up.
        Ms. Beck. I have Dr. Batten at the table with us today, and
    she is VA's representative and is the Deputy Director of the
    Defense Center of Excellence. We have had an ongoing project
    and integrated work through the Defense Center of Excellence,
    and Dr. Batten, I think, can comment on that.
        Ms. Batten. Thank you, sir. It is a great question and one
    that both Departments have identified as an important area of
    emphasis. In fact, a new program was implemented about 6 months
    ago, maybe closer to 9 months ago, called the In Transition
    Program that is focused on exactly the need you are
    identifying, where coaches are assigned to individuals who are
    in mental health treatment and are transitioning from one care
    setting to another. That actually works both for individuals
    who may be transferring from one MTF to another as well as from
    an MTF to a VA, to make sure that that transition is kept up.
    So it is a great point, and it is one that we are addressing.
        Senator Begich. Thank you very much.
        Thank you, Mr. Chairman.
        Chairman Akaka. Thank you very much, Senator Begich.
        Let me ask two fast questions here of Dr. Beck and Dr.
    Jaffee. We have talked about screening and about coordination,
    but proper diagnosis is one of the major challenges in treating
    TBI. The question is: What state-of-the-art imaging techniques,
    if any, are being used and how? Dr. Beck?
        Ms. Beck. Next to me is Colonel Jaffee who has a great
    amount of expertise in this area. I am going to ask him to
    respond.
        Chairman Akaka. Colonel Jaffee.
        Colonel Jaffee. In our research, Investment Resources has
    been very committed to exploring the latest advances in
    neurodiagnostics to include neuroimaging and other forms of
    biomarkers. To summarize a couple of the neuroimaging
    initiatives, we have done a lot of work with the technology
    known as diffusion tensor imaging. It allows us to look at some
    of the subcortical white matter tracks in the brain. We
    actually were able to complete the first study comparing the
    patterns on DTI in patients who had blasts as a component of
    their injury compared to more traditional forms of injury. This
    research was actually recognized by the American Academy of
    Neurology as one of the six most important late-breaking
    research findings of the year and was featured at their annual
    meeting last year.
        We have had DVBIC researchers coordinate with those at the
    University of California at San Diego evaluating the use of
    MEG, magnetoencephalography, an advanced imaging technique
    looking at some of the gray matter in the brain.
        We have had investigators and surgeons at the National
    Naval Medical Center use near-infrared spectroscopy to help in
    their angiography, getting better pictures and better
    understanding of the vasculature and the vascular damage that
    may occur in significant injuries.
        There has been a bit of work done on PET scans;
    specifically, Walter Reed has done a great deal of work on
    that. The SPECT scans, another form of functional imaging that
    has been utilized with soldiers at Fort Carson, and there is a
    protocol about to further evaluate that in San Antonio.
        The CDMRP process, the Congressionally Directed Medical
    Research Process funded some initiatives looking at functional
    MRI. We have been working with industry as industry is working
    to modify some of their imaging equipment to make CT and MRI
    scanners smaller, more portable, utilizing head-only. These
    would possibly lead to being able to place such devices farther
    forward in the field to be closer to the points of injury. We
    have been looking at other technologies in addition to imaging
    such as: quantitative EEG in neurophysiology; electrical
    signals from the skull known as piezoelectricity; and looking
    at ultrasound technologies.
        One of the things that I am proud of is that at end of this
    month, May 24 through 27, USU, the Uniformed Services
    University, is hosting the 7th Annual World Congress of the
    International Brain Mapping and Intraoperative Surgical
    Planning Society. This conference features academic
    presentations featuring the latest technologies in neuroimaging
    and other translational technologies. DOD, DVBIC, and the NIH
    are sponsors. Last year's keynote speaker included our Chairman
    of the Joint Chiefs, Admiral Mullen, and currently slated this
    year as our keynote speaker is President Obama.
        Chairman Akaka. Thank you very much.
        Dr. Beck, please update us on the status of the TBI
    registry that was mandated in 2008, NDAA. How are DOD and VA
    working together to keep the registry up to date?
        Ms. Beck. The TBI Veterans Health Registry is functional,
    and it is currently providing reports on a monthly basis. We
    are in a data validation mode now--identifying the data
    sources, assuring that all of the data feeds that we need are
    available and assuring that the data coming from the registry
    is valid.
        We received a roster from DOD of veterans who have
    separated and become--or of active-duty servicemembers who have
    been deployed in support of OEF/OIF and have become veterans.
    We also are receiving pre-deployment health assessments and
    post-deployment health risk assessments. We have those
    available for integration into the record.
        We are also receiving and have added--all of the veterans
    who have any service connection for Traumatic Brain Injury are
    in the record. That is approximately 24,000 veterans to date.
        Chairman Akaka. Thank you.
        Senator Burr?
        [No response.]
        Chairman Akaka. Senator Murray?
        Senator Murray. Thank you. I just had one quick question. I
    wanted to know, maybe Colonel Jaffee or Dr. Batten, how the DOD
    is working to distinguish between TBI and PTSD.
        Colonel Jaffee. That is an excellent question which has
    been a major focus of emphasis for both of us in the DOD and VA
    over the past several years. There has been an ongoing amount
    of research dedicated to that process, to that end. DVBIC
    cosponsored with the Congressional Brain Injury Task Force an
    international symposium on behavioral health and Traumatic
    Brain Injury, bringing together a lot of the best researchers
    in the country throughout the VA and DOD systems and around the
    world to evaluate the state of the science and develop
    appropriate ways to manage this.
        There have been consensus conferences hosted by the VA,
    including the DOD, looking at ways to handle what we call these
    dual diagnoses or comorbidities. Our current guidelines, as we
    have them, is that if you are identified with symptoms that
    have either one of them, then you need to undergo screening and
    evaluation, because our whole philosophy in our current
    treatment plan and guidelines is that we want to make sure that
    we are aware of all the conditions an individual may have and
    incorporate that into their management plan.
        We have found from experience that if we focus only on one
    and not the other, the ultimate outcomes are not as favorable
    as if we can integrated both together. So, what we have found
    is when we--looking at a lot of data and research, which is
    actually from our VA colleagues who have been very excellent in
    quantifying this--we have found that not everyone who has a TBI
    has PTSD; not everyone who has PTSD has a TBI; but there is a
    robust overlap, and that overlap tends to cluster at
    approximately 45 percent, which makes that holistic evaluation
    and incorporation into the treatment plan a very important
    aspect of that process.
        So through these combined efforts, I think we have been
    able to, through our educational efforts, get people away from
    the paradigm of a few years ago, which was looking at this as
    an either/or phenomenon and looking at this as a comorbidity
    that requires a comprehensive management plan.
        Senator Murray. OK. I appreciate that. I assume the
    treatment is different depending on whether you have TBI or
    PTSD or both.
        Colonel Jaffee. There are considerations that need to be
    taken into account if one has both. As one example, if someone
    has residual cognitive deficits from their Traumatic Brain
    Injury, they may not be as capable of participating in the
    types of psychotherapies that one might choose in certain cases
    of Post Traumatic Stress Disorder. So being able to quantify
    and identify these aspects allows us to target the most
    appropriate treatments for all the symptoms that the individual
    may have.
        Senator Murray. OK. I appreciate that.
        Thank you, Mr. Chairman.
        Chairman Akaka. Thank you very much, Senator Murray.
        Senator Isakson, any questions?
        Senator Isakson. No.
        Chairman Akaka. Senator Tester?
        Senator Tester. Yes, very quickly. Thank you, Mr. Chairman.
        Dr. Beck, are you familiar with VA's Office of Rural
    Health?
        Ms. Beck. I am sorry. Can you repeat the question?
        Senator Tester. Are you familiar with the VA's Office of
    Rural Health?
        Ms. Beck. Oh, yes, sir. I am sorry. I did not----
        Senator Tester. How closely do you work with them?
        Ms. Beck. We work closely with the office. We have
    participated with the ORH in the development of requests for
    proposals and reviews of the projects that Rural Health is
    undertaking.
        Senator Tester. And what kind of projects--are you using--
    let me just cut right to it. I mean, do you use them for
    devising plans for outreach to veterans in rural America and
    treatment efforts? Is that something that is within their
    purview and that you would utilize them for?
        Ms. Beck. I would like to take that for the record, sir,
    because the scope of services that our Office of Rural Health
    is providing right now, I think we would like to give you a
    full listing of those.
        Senator Tester. That is fine. I was just wondering how you
    are utilizing them, if they are effective, if there is
    something that we can do to make them more effective.

        [The information requested during the hearing follows:]
     Response to Request Arising During the Hearing by Hon. Jon Tester to
     Lucille Beck, Ph.D., Chief Consultant, Rehabilitation Services, U.S.
                         Department of Veterans Affairs
        Response: VA has no specific outreach efforts or initiatives
    directly related to Veterans with Traumatic Brain Injury (TBI) residing
    in rural areas. However, VHA Rural Health has two TBI telehealth
    initiatives that will be useful in rural settings. They are the TBI
    telehealth screening and the TBI case management home buddy dialog.
    Both were mentioned at the hearing.

        Senator Tester. My last question is--Senator Begich asked a
    little bit about this. How effective is telemed in dealing with
    TBI or PTSD?
        Ms. Beck. We are in the early stages of evaluating
    telemedicine and telehealth technologies for TBI, and----
        Senator Tester. How long is this evaluation going to take?
    The reason I ask is because we are dealing with something that
    is pretty time sensitive here. I mean, there are all sorts of
    issues. Senator Begich has told me about a soldier who came
    back----
        Ms. Beck. Yes, we are fast-tracked to look at these
    technologies.
        Senator Tester. So what kind of timeframe are we looking
    at?
        Ms. Beck. I expect that we will have our TBI screening up
    and running this year and be able to give you some feedback on
    the way the implementation of that program is working.
        Senator Tester. As far as the effectiveness of the telemed.
        Ms. Beck. Effectiveness and usefulness of that program.
        Senator Tester. OK. Thank you very much.
        Thank you, Mr. Chairman.

        [The information requested during the hearing follows:]
     Response to Request Arising During the Hearing by Hon. Jon Tester to
     Lucille Beck, Ph.D., Chief Consultant, Rehabilitation Services, U.S.
                         Department of Veterans Affairs
        Response: See our response to Sen. Murray about the status of TBI
    screening. Findings of these programs are not yet available, and are
    expected in fiscal year 2011.

        Ms. Batten. There are actually several PTSD studies that
    have been completed. They are with smaller groups because they
    were pilot studies, but they have shown that telemedicine for
    PTSD is--at this point, it looks like it is approximately as
    effective as treatment in person. So those are pilot studies.
    They are smaller. We cannot draw large generalizations. But so
    far the pilot data are good.
        Senator Tester. Well, I think that is a good sign. The
    margin for error here is we want to make it as close to zero as
    possible, and that is why I think it is critically important in
    rural areas because it is one of the ways that are being
    utilized to reach out to veterans. I think it makes sense if it
    is effective. If it is not effective, we should not be wasting
    our time on it.
        Chairman Akaka. Thank you very much, Senator Tester.
        Senator Begich?
        Senator Begich. I do not have anything further right now.
        Chairman Akaka. Thank you. Thank you very much.
        Let me thank this panel for your statements. It is valuable
    for what we are trying to do together. And I want to stress
    that word ``together'' between DOD and VA as well as the
    Congress. We would certainly like to do all we can to give the
    best service possible to the servicemembers and veterans of our
    country.
        Thank you very much.
        Ms. Beck. Thank you.
        Chairman Akaka. Now I would like to welcome the witnesses
    on our second panel.
        They are: Mrs. Karen Bohlinger, the Second Lady of Montana;
    Mr. Jonathan Barrs, an Operation Iraqi Freedom Veteran; Dr.
    Bruce Gans, who is the Executive Vice President and Chief
    Medical Officer at the Kessler Institute for Rehabilitation;
    Mr. Michael Dabbs, President of the Brain Injury Association of
    Michigan; and joining him today is the veterans program
    manager, Retired Air Force Major Richard Briggs, Jr., who is
    seated in the front row.
        Senator Isakson would like to welcome our next panelist.
        Senator Isakson. Thank you, first of all, Mr. Chairman, for
    allowing Dr. LaPlaca to testify today. I am very proud as a
    Georgian, even though I graduated from the University of
    Georgia, to introduce a distinguished professor at the Georgia
    Institute of Technology in Atlanta, and Emory University in
    biomedical engineering. Dr. LaPlaca received her doctorate
    degree from the University of Pennsylvania, is trained in
    neurosurgery, and is funded by both the National Institute of
    Health and the National Science Foundation in her research on
    brain injury, spinal cord injury, and cognitive disabilities
    from both injury as well as aging. We are delighted to welcome
    her today to testify.
        Thank you, Mr. Chairman.
        Chairman Akaka. Thank you very much.
        I thank all of you for being here. Your full testimony will
    appear in the record.
        Ms. Bohlinger, would you please proceed with your
    statement?

             STATEMENT OF KAREN L. BOHLINGER, SECOND LADY,
                            STATE OF MONTANA

        Ms. Bohlinger. Thank you, Mr. Chairman and Members of the
    Committee. I appreciate the opportunity to speak with you today
    about TBI from a very personal view. My son, a former Special
    Forces officer with nearly 12 years of experience, has one
    severe and one moderate head injury. He is now classified as
    100 percent disabled.
        We are over 4 years into active and ongoing treatment with
    moderate results. However, this is primarily due to my personal
    commitment of time and money invested in my son's care, as
    opposed to the services he has received through the Veteran
    Administration Health Care System, and he had the unfortunate
    experience of being one of the early TBIs, so I just need to
    make that clear, because there have been some incredible
    improvements since the early years.
        I continue to fly to Seattle every 10 days and stay as long
    as necessary to monitor and assist in his care. I think it was
    2008 when I was home 22 days out of 365. He is determined to
    live independently and has surpassed all predictions for
    functional independence. I cannot bring him home to Montana as
    Montana does not have appropriate follow-up care for him, and,
    again, that rural issue is huge. These are individuals whose
    culture is rural. They are not used to being in a city
    environment, and as we all know, additional stress is not good
    for a TBI.
        Since 2007, I have tried to be an advocate for other
    veterans and their families, with the hope of their receiving
    more timely, effective, and state-of-the-art care. I have
    personally visited several VA medical centers throughout the
    United States to observe and learn. And I will tell you this
    very forthrightly, that the guided tour as the Second Lady of
    Montana and my going in just as an individual are two entirely
    different experiences.
        Our Montana congressional delegation, especially our
    Senator Tester, and Secretary Shinseki of the Veteran's
    Administration have been very accessible and responsive. I feel
    they have shown extraordinary leadership for our veterans and
    their families.
        Changes in the delivery of care since 2008 are
    unprecedented from my perspective as an organizational
    psychologist in an institutional setting. Inclusion of family
    members in case management, caregiver status for reimbursement,
    care coordination, and outreach efforts are absolutely
    necessary components of treatment, and while they are mandated
    by what you all have passed into law, they are not being
    implemented across all the VA centers at all. And while we are
    grateful for the many devoted and competent VA employees--and I
    would say Dr. Jay Umamoto at the Seattle VA is an extraordinary
    asset to the VA--what we know is that consistent standards of
    care should be available to all veterans.
        I cannot stress enough the importance of family
    involvement, as TBI self-assessment is often very different
    from the family member's assessment. These guys do not want
    anything wrong with them. It takes a long time to break through
    that denial.
        The VA Medical System in Baltimore, MD, for TBI/PTSD is one
    shining example of what your legislation did, and so I would
    just like to let you know that they have a model that preserves
    the dignity and respect for the veteran. They include the
    family members. They bring them into a room, and from the very
    first point, it is total family, open involvement that builds
    trust rather than separate groups that undermine trust. They
    really have worked at how to best transition the new life
    together.
        I have met and worked with, on a volunteer basis, literally
    hundreds of soldiers, veterans, and family members. There is
    not a day that goes by that I do not have a phone call or an
    interaction, especially with young wives, who have not the life
    experience to deal with what is now going on in their family.
        I have learned some important insights to pass on to you.
    Number 1 is this: neuroimaging is a critical component in a TBI
    assessment, treatment planning, and, most importantly, the
    disability rating. There have been so many cases where the
    opinion said this soldier is 10 percent disabled, yet their
    life disintegrates. Then, after they get a scan, it is set at
    100 percent. Scans are available in the private sector. Our
    soldiers deserve no less.
        Technology is available that demonstrates brain function.
    We have already heard about that today. My message is this is
    not a guessing game. These are people's lives. My son was given
    many medications which ultimately caused more damage than his
    original injury. We have been through hell literally, which was
    not necessary.
        I private-paid for a brain scan to determine what course of
    care was scientifically needed. Latest and best technology must
    be available to all. News correspondent Bob Woodruff--and you
    all know him--was given the best medical treatment money could
    buy. His family was with him every step of the way. They were
    not separated into separate groups. He had a spirit that would
    not quit, and his recovery has been remarkable, and he is still
    advocating for veterans, most recently on suicide prevention
    and including family members. Our wounded warriors have the
    spirit, no doubt about it, but lack the same level of medical
    care.
        When neuroimaging is integrated with neuropsychological and
    neurocognitive evaluations, biometrics and social functioning,
    you can get an effective treatment plan and really make a
    difference in the soldier's recovery.
        Number 2, Pre/Post Assessments for cognitive and neural
    functioning. Current technology allows for biomarker testing. I
    do not know what the components are of the screening that the
    gentleman referred to before, but I would be interested to know
    if that is included. What I do know is that this is a
    scientific baseline. It is a statement that cannot be changed.
    A lot of us know that the self- and counselor assessments are
    not always accurate. People tell us that they lie on them,
    period. So that much we know.
        We also know that we do not need more money for this. It is
    already covered under TRICARE. It is a $450 test. We already
    give a blood test to all the soldiers.
        Number 3, follow-up treatment. Functional independence is a
    realistic goal for many. Relearning their own abilities and
    developing strategies to make up for injury-related
    deficiencies and losses--it works. We just know that it works.
        Treatment must be personal, bring about patient engagement,
    positive response, and include performance-based outcomes.
        I was employed one time as a caseworker early in my career
    at a hospital, and if we did not have measurable outcomes, we
    did not have a job. That is not the current state of situation
    that you have going on right now.
        Services should be veteran driven and not for the staff's
    convenience. Scheduling a TBI group during peak traffic hours
    is a disincentive for participation because it creates more
    stress than benefits. As Mrs. Murray knows, eight lanes of
    traffic in Seattle getting to the hospital on Columbia Way
    between 3 and 5 o'clock----
        Senator Murray. It is stressful for me.
        [Laughter.]
        Ms. Bohlinger. Me, too, as the mom driving. It is not good
    for them, and so this last group was canceled. So when you all
    get the paperwork, it is going to say, ``Gee, there were not
    enough soldiers who wanted to participate.'' That is not the
    case. They just cannot do it at that time of day.
        Also, their TBI group was canceled a couple of days before
    Thanksgiving until the end of January. When do these people
    need care the most? When do they need a contact? Because they
    have lost their wives. My son lost his high school sweetheart
    wife. That is when they need the care. So when I say it should
    not be staff convenience, I mean it should be veteran-centered.
        And this one I feel very passionate about.
        There are many active-duty soldiers and marines who would
    ask for help if they could without consequences to their
    career. Last fall, I was part of a meeting on a military base
    with over 400 soldiers in attendance, and family members in
    addition to that. Many had served at least three tours in Iraq.
    When asked through a confidential questionnaire how many felt
    they had symptoms of either TBI or PTSD, over 40 percent
    responded yes and that they would ask for help if there were
    not negative consequences attached.
        One example I would like to give you is a soldier with 19
    years--19 years--in the Army. He has been to Iraq four times.
    And he was ordered to go again. He told his commanding officer,
    ``Sir, I cannot do that. I am not OK.'' He has a wife and four
    children. His commanding officer said, ``Well, sir, then you
    are going to get a dishonorable discharge.'' So the wife called
    me, and I got a doctor to donate a scan for him, and he is a
    mess. He has a severe TBI along with PTSD, and now he is on a
    medical stay. So those are the things that we are talking
    about. Their family did not have the money for a scan.
        Additional treatment is not always about more money,
    however. Effective use of current dollars, with measurable
    outcomes that would include feedback from veterans and family
    members--I listened to all of what is going on in this
    testimony, and I find it really interesting because my personal
    experience has been so different with no mechanism by which for
    me to give feedback--good, objective, accurate feedback. I
    think that that is a critical component in any care, especially
    of this magnitude.
        Also, create incentives that benefit the veteran. Are they
    in healthy social networks? You know, what are they involved
    in? Instead, we have created a system where the community
    mental health providers for the VA are reimbursed for the
    number of DSM-IV diagnoses. So they may come in with TBI and
    PTSD, and now they are diagnosed with depression, sleep
    disorder, ``Oh, you might be bipolar,'' and, ``You know, I
    think you have a borderline personality as well.''
        I was in a training session with over 250 VA providers. I
    overheard them discussing how to ``tag'' the veteran with
    multiple diagnoses so they could make more money. Clearly, that
    does not benefit the veteran, and it does not benefit the
    taxpayer.
        Chairman Akaka. Ms. Bohlinger, will you please summarize
    your statement?
        Ms. Bohlinger. Yes, OK. I just admire that you continue to
    do this. They fought for us, protected our freedom. We need to
    protect them.
        I would just say to you: What does my son miss most? Just
    working. He is a Montanan. He wants to work.
        Thanks.
        [The prepared statement of Ms. Bohlinger follows:]
            Prepared Statement of Karen L. Bohlinger, Second Lady,
                                State of Montana
        Dear Mr. Chairman and Members of the Committee: I appreciate the
    opportunity to speak with you today about TBI from a very personal
    view. My son, a former Special Forces officer with nearly 12 years of
    service, has one severe and one moderate head injury. He is classified
    as 100% disabled.
        We are 4\1/2\ years into active and ongoing treatment with moderate
    results. However, this is primarily due to my personal commitment of
    time and money invested in my son's care, as opposed to the services he
    has received through the Veteran Administration Healthcare System.
        I continue to fly to Seattle every 10 days and stay as long as
    necessary to assist in and monitor his care. He is determined to live
    independently and has surpassed all predictions for functional
    independence. I cannot bring him home as Montana does not provide the
    follow up TBI care he needs.
        Since 2007, I have tried to be an advocate for other veterans and
    their families, with the hope of their receiving more timely, effective
    and state-of-the-art care. I have personally visited several VA medical
    centers throughout the United States to observe and learn.
        Our Montana Congressional Delegation and Secretary Shinseki, of the
    Veteran's Administration, have been accessible and responsive. They
    have shown extraordinary leadership for our veterans and their
    families.
        Changes in the delivery of care since 2008 are unprecedented in an
    institutional setting. Inclusion of family members in case management,
    caregiver status for reimbursement, care coordination and outreach
    efforts are necessary components of treatment, and while mandated are
    not implemented in all VA Centers. While we are grateful for the many
    devoted and competent VA employees, consistent standards of care should
    be available to all veterans.
        I cannot stress enough the importance of family involvement, as TBI
    self assessment can often be very different than the family member
    assessment. It requires a team effort for best outcomes.
        The VA Medical System in Baltimore, Maryland for TBI/PTSD is a
    model that preserves the dignity, and respect for the veteran, while
    including and training family members in how to best transition to
    their new life together.
        I have met and worked with, on a volunteer basis, hundreds of
    soldiers, veterans and their family members, especially young wives,
    who have not the life experience or training to understand their new
    reality.
        I feel I have learned some important insights to pass on to you:

        1. Neuroimaging is a critical component in TBI assessment,
    treatment planning and disability rating.
        Technology is available which demonstrates brain function and
    activity. It is not a guessing game. My son was given many medications,
    which ultimately caused more damage than his original injuries. We have
    been through hell, unnecessarily.
        I had to private pay for a brain scan to determine what course of
    care was scientifically needed. Latest and best technology must be made
    available for all TBI veterans. News correspondent Bob Woodruff was
    given the best medical treatment money can buy. His family was with him
    every step of the way and he had a spirit that would not quit, and look
    at his remarkable recovery. Our wounded warriors also have the spirit,
    but lack the same level of medical care.
        When neuroimagaging is integrated with neuropsychological and
    neurocognitive evaluations, biometrics and social functioning, a more
    effective treatment plan can be developed.
        2. Pre/Post Assessments for cognitive and neural functioning.
    Current technology allows for bio-marker testing. This would provide a
    scientific baseline. This is a statement that cannot be changed. It
    ensures accuracy. Self and counselor assessments are not always
    accurate.
        3. Follow-up treatment:
              A. Functional independence is a realistic goal for many. Re-
            learning their own abilities and developing strategies to make
            up for injury related deficiencies/losses works.
              B. Treatment must be personal, bring about patient
            engagement, positive response and include performance based
            outcome measures.
              C. Services should be veteran driven not for the staff's
            convenience. Scheduling a TBI group during peak traffic hours
            is a disincentive for participation, because it creates more
            stress than benefits.

        4. There are many active duty soldiers and Marines who would ask
    for help if they could do so, without consequences to their career.
    Last fall, I was part of a meeting on a military base with over 400
    soldiers in attendance; many had served over 3 tours of duty in Iraq.
    When asked through a confidential questionnaire how many felt they had
    symptoms of either TBI or PTSD, over 40% responded yes and would like
    help, but did not feel they could ask for it, without negative
    consequences.

        Additional treatment is not always about more money. Effective use
    of current dollars, with measurable outcomes that includes feedback
    from the veterans and family members, would provide accurate
    information about what is working and what is not.
        Create incentives that benefit the veteran. For example, current
    community mental health providers for the VA are reimbursed per the
    number of DSM III diagnosis. In a training session of over 250 VA
    providers, I overheard providers discussing how to ``tag'' the veteran
    with multiple diagnoses so they could make more money. Clearly this
    does not benefit the veteran, or the tax paying public.
        I admire the continuing commitment and the bi-partisan effort to
    make the necessary changes that will provide the best possible services
    for our veterans. They have fought for and protected our freedom; it is
    our duty to protect them. They deserve respect, dignity and self worth.
        What does my son miss most? Working! He is after all a Montanan and
    we work! He loves his country and would go active military if he could.
    Thank you for listening!

        Senator Murray [presiding]. Thank you very much for that
    testimony. It is extremely helpful. We will accommodate you in
    Seattle any time, although I know the heart of Montana wants to
    be back home.
        Mr. Barrs?

                    STATEMENT OF JONATHAN W. BARRS,
                    OPERATION IRAQI FREEDOM VETERAN

        Mr. Barrs. Well, good morning, Mr. Chairman, Ranking Member
    Burr, and other Members of the Committee. As you know, my name
    is Jonathan Barrs, and I live in Cameron, NC. I just want to
    thank you for inviting me to testify today before this
    Committee.
        I am 24 years old, and I served in the Marine Corps in Iraq
    in 2005-06 and also in 2007-08. During my first deployment in
    2005-2006, I was a turret gunner in a Humvee. During combat
    operations, I experienced two improvised explosive device (IED)
    blasts in a period of a week. The first IED detonated
    approximately 30 to 50 feet from my vehicle. When it exploded,
    the concussion from the blast slammed me into the turret. Glass
    from the vehicle became embedded in my head, but I did not
    think much of it at the time and I did not seek medical care.
    The second IED blast occurred about the same distance away as
    the first. After the second blast, the corpsman checked me out.
    It was never really documented. He just shined a light in my
    eyes to see if I could stay with him, and he asked me what day
    of the week it was. Of course, I never knew what day of the
    week it was, but shortly afterwards, I was kept off of mission
    due to stomach problems. I was eventually taken to another
    Forward Operating Base, also known as a FOB, because of
    excessive weight loss and was given steroids to fix the
    problem.
        I was screened by the DOD for TBI, and was diagnosed with
    it in November 2008. At that time, I never looked to see
    exactly how it would impact me in the future. Basically, all I
    knew was I still wanted to be in the Marine Corps, and I did
    not know exactly what was going on.
        I was medically retired in May 2009. The hand-off from DOD
    to the VA was very slow. I have been out of the Marine Corps
    for almost a year now, and I am just now getting care for the
    TBI. I have also been screened by VA for PTSD, and I have been
    diagnosed with PTSD and depression.
        So far, the VA care has been good, but this whole time of
    waiting was very hard. I had to keep asking my primary care
    doctor for a consult, which took a very long time. I have a
    case manager at VA in Fayetteville. Her name is Robin. She is a
    great woman. She really does do everything she can in her power
    to help me, mostly by just checking up on me. I get random
    phone calls from her asking me how I am doing, and she
    reschedules my appointments when I miss them. She is currently
    helping me change my primary care doctor. The reason behind
    that is because the doctor seems like he is not really
    concerned about me, just more concerned about what the books
    tell him to do.
        The honest truth is dealing with TBI is like a living
    horror film over and over again. Daily things you are supposed
    to do, you forget. I have missed at least five important VA
    appointments, also others not so important. I missed a job
    interview because I forgot about it. When you forget, the PTSD
    side of you rolls around because you knew you were never like
    this before, and it makes it very hard for people to deal with
    you. For example, the relationship I have with my girlfriend.
    It has been over a year now, and things are not really right
    due to the injuries, just mostly because I forget things and I
    get to the point where I just kind of snap. So dealing with all
    that is pretty hard.
        I went to junior college and tried to get through the
    course work to get a degree, but I was trying and still failing
    tests. The teachers found out I was in a special populations
    group and felt sorry for me, and they started giving me all
    this leeway and saying they will do whatever it takes for me to
    get a passing grade. I knew that getting passing grades I had
    not earned would not be the way I wanted to do things. I was
    only trying to better myself, and they were making it hard to
    do that because they were willing to make excuses for me.
        In conclusion, of all these things that have been
    addressed, life for me as of now is hard because I look for
    jobs and the documentation of my Marine Corps--excuse me. I am
    sorry. I look for jobs, and when the documentation of my Marine
    Corps career is shown to the interviewer, just the look on
    their face will say it all; basically, judging off of what my
    DD-214 is telling them, and when all is said and done, I am
    denied a job just because they see the words ``temporarily
    disabled.''
        For the time being I am focused on getting my VA and Social
    Security squared away and still looking for another career
    path.
        Thank you, ladies and gentlemen, for your time and efforts
    to help me and also hopefully other veterans down the road. I
    will be happy to answer any questions that you have for me.
        [The prepared statement of Mr. Barrs follows:]
        Prepared Statement of Jonathan W. Barrs, Operation Iraqi Freedom
        Good morning Chairman Akaka and Ranking Member Burr. My name is
    Jonathan Barrs and I live in Cameron, North Carolina. Thank you for
    inviting me to testify today before this Committee.
        I am twenty-four and served as a Marine in Iraq in 2005-2006 and
    2007-2008. During my first deployment in 2005-2006, I was in a turret
    gunner in a Humvee. During combat operations, I experienced two
    Improvised Explosive Device (IED) blasts in a period of a week. The
    first IED detonated approximately thirty to fifty feet from my vehicle.
    When it exploded, the concussion from the blast slammed me into the
    turret. Glass from the vehicle became embedded in my head, but I did
    not think much of it at the time and did not seek any medical care. The
    second IED blast occurred about the same distance away as the first.
    After the second blast, the corpsman checked me out. He shined a light
    in my eyes and asked me what day it was just to see if I was able to
    stay with him.
        Documentation was never given for the IED explosions, but shortly
    afterwards I was kept off of mission due to stomach problems and
    eventually taken to another Forward Operating Base because of excessive
    weight loss and was given steroids to fix the problem.
        I was screened by the DOD for TBI and it was diagnosed in
    November 2008. At the time, I never looked to see exactly how this
    would impact me in the future.
        I was medically retired in May 2009. The hand-off from DOD to VA
    was very slow. I have been out of the Marine Corps for almost a year
    now and I am just now getting care for the TBI. I have also been
    screened by VA for PTSD and I have been diagnosed with PTSD and
    depression.
        So far, the VA care has been good, but this whole time of waiting
    was very hard and I had to keep asking my primary care doctor for a
    consult, which took a very long time. I have a case manager at VA in
    Fayetteville. Her name is Robin she is a great woman who does
    everything in her power to help me help myself by checking up on me and
    rescheduling my appointments when missed and currently helping me
    change my primary care doctor, because the doctor seems like he isn't
    really concerned about me, just more concerned about what the book
    tells him to do.
        The honest truth is dealing with TBI is like a living horror film
    over and over again. Daily things that you know you're supposed to do,
    you forget. I have missed at least five important VA appointments also
    others not so important and I missed a job interview because I forgot
    about it. When you forget, the PTSD side of you rolls around because
    you knew you were never like this and it makes it very hard for people
    to deal with you. For example, the relationship I have with my
    girlfriend. It's been over a year now, but things aren't really right
    due to injuries that occurred while I was in the Marine Corps and I am
    still dealing with now I am out of the Marine Corps.
        I went to junior college and tried to get through the coursework to
    get a degree, but I tried so hard and I was still failing tests. The
    teachers found out because I was in a special populations group and
    felt sorry for me and they started giving me all this leeway and saying
    they will do whatever it took to get me a passing grade. I knew that
    getting passing grades I hadn't earned wouldn't be the way I wanted to
    do things. I was only trying to better myself and they were making it
    hard to do that because they were willing to make excuses for me.
        In conclusion, of all things that have been addressed, life for me
    as of now is very hard because I look for jobs and when the
    documentation of my Marine Corps career is shown to the interviewer,
    just the look on there face says it all, basically judging off of what
    my DD-214 is telling them and when all is said and done I am denied a
    job just because they see the words ``temporarily disabled'' on my DD-
    214. For the time being I am focusing on getting my VA and Social
    Security squared away and still looking for another career path.
        Thank you, ladies and gentlemen, for your time and efforts to help
    me and also other veterans. I will be happy to answer any questions
    that you have for me.

        Senator Murray. Mr. Barrs, thank you so much for your
    courage in coming forward and telling your story to help us
    understand others. I appreciate your being here.
        Mr. Barrs. You are welcome, ma'am.
        Senator Murray. Dr. Gans?

    STATEMENT OF BRUCE M. GANS, M.D., EXECUTIVE VICE PRESIDENT AND
      CHIEF MEDICAL OFFICER, KESSLER INSTITUTE FOR REHABILITATION

        Dr. Gans. Thank you very much, Ranking Member Burr and
    Members of the Committee. I am Dr. Bruce Gans. I had the
    pleasure to be here in 2007 and to provide some input, and I am
    very pleased to be able to be back here and try to give you
    some sense of, at least from my view, what has changed, where
    the advances are, and where we still have opportunities for
    improvement.
        In 2007 I made a few recommendations, and I would just like
    to give you a sense of what those were and my view of what
    happened since then.
        The big theme was trying to find coordination between the
    private sector and the VA and DOD, to find a way for the
    organizations to work together, not just on a day-to-day
    operational basis but strategically, to plan together, to
    create seamless systems of care that could take advantage of
    all the collective resources that would be available. We
    suggested the creation of a Coordinating Council as a mechanism
    to do that. I am not aware of that type of enterprise having
    been conducted, and I am not aware of an organized strategic
    plan between the field, the private providers as a community,
    and VA and DOD as systems of care to try to make a seamless
    system of care available to veterans and active servicemembers.
        We also talked about the case management and care
    coordination services and how they needed to be improved. There
    has been very significant improvement, as we have heard today.
    There are still some deficiencies that I will tell you about
    when I tell you some stories of family members that I have
    interviewed recently in anticipation of coming here before you.
        In 2007 I also talked about research that was ongoing and
    urged that there be some collaboration and cooperation between
    the existing network of Traumatic Brain Injury research
    systems, the model systems, and the VA and DOD. I am happy to
    tell you that there has been some increasing collaboration.
    There are some data collection efforts with the model systems
    and the VA Polytrauma Rehab Centers. We heard about a number of
    research projects that are also being funded, but I will also
    tell you there are still opportunities in that regard as well.
        In terms of the current state of treatment of individuals
    with especially severe, the most severe Traumatic Brain
    Injuries, there are diagnostic tools that Dr. Jaffee, Col.
    Jaffee mentioned to you. I will mention a few others. In
    addition to the functional magnetic resonance imaging and the
    magnetoencephalography, there is magnetic resonance
    spectroscopy, there is quantitative electroencephalography, and
    near infrared spectroscopy. These are tools that are existing
    but, frankly, not commonly used and not readily available. And
    more than just diagnostic tools, we are now starting to see
    that they can even be used as tools to guide treatment, to
    suggest interventions, to monitor the effect of medications, to
    determine what is going on, and to guide changes in treatment
    management.
        On the treatment front, there really have been some
    dramatic new technologies made available for patients. Many of
    them are not yet proven scientifically. We have growing
    clinical experience. We have anecdotes. We do have some
    examples of specific studies. I want to mention just a couple
    of them.
        In the use of medications to treat brain injuries,
    conventional medicine would have you use one drug at a time and
    be careful in its administration to figure out what it does.
    Now the notion is going to be using many drugs all at the same
    time by expert clinicians who understand the interaction of
    these drugs and the fact that in combination they may work
    differently than individual effect. These so-called drug
    cocktails, which are actually quite a common strategy in cancer
    care, have not traditionally been part of the care of patients
    in rehabilitation from serious brain injuries.
        Adding nutraceuticals--these are materials that are
    available that are not classified as drugs but are drug-like in
    their effect. They have many interesting properties. Some come
    from Eastern medicine. There are centers experimenting with and
    trying to use these additional stimulating drugs in ways that
    influence the brain neurochemistry.
        And there are a whole host of very intriguing
    interventional strategies available: peripheral nerve
    stimulation to help arouse the most severely unconscious
    individuals; and direct brain stimulation using either direct
    current or magnetic stimulation. These are available
    technologies. They are non-invasive, they are not harmful. They
    have very low risks, and they have very, very rapidly expanding
    scope of potential impact. But they are not being widely used
    in the world of brain injury rehabilitation, partly because
    they are so new that the full body of research is not totally
    available.
        The strategies in our clinical experiences at Kessler and a
    few other centers really suggest that the combination of using
    neuroimaging technologies and multi-drug and multi-physical
    modality interventions, along with the traditional
    rehabilitation strategies that we use, seem to have the best
    potential for making very significant differences in the lives
    of the most severely involved individuals.
        We have had these kinds of experiences at Kessler with
    patients. We recently submitted an article that has been
    approved for publication describing our clinical experiences
    and are about to launch a very significant research project
    trying to understand these multi-modality approaches and what
    beneficial effect they really have to offer.
        Another problem that you need to be aware of--it was
    actually mentioned--is there is a very significant shortage of
    professionals who know how to take care of people with brain
    injuries. Whether it is physicians, therapists, psychologists,
    or neuropsychologists, there just are not a lot of people who
    are highly skilled and dedicated to this population. These
    patients are extremely difficult to take care of; they are
    stressful for providers to take care of. And there is not that
    great a capacity to train people in this country. I am going to
    make a recommendation or two specifically in that regard as
    well.
        In terms of the coordination opportunities, there have been
    significant advances in the VA system, and I would like to
    recognize and applaud the work that has gone on. I personally
    had the opportunity to visit the Richmond VA Polytrauma Center
    and I have had a chance to visit the Center for the Intrepid in
    San Antonio, just as a couple of examples of where the DOD and
    the private sector and the VA have really made significant
    improvements in capacity in general to provide for care.
        But to find out what it seems to be like in the real world
    that I live in, I interviewed about two dozen providers of
    rehabilitation--executives, physicians, people in research,
    people who run large companies of rehab, people that provide or
    are part of advocacy organizations--to just ask them 3 years
    later, how is it going, what is your view, what are you seeing
    in the real world about how the private community is able to
    work with veterans, active military? What is going on? And that
    is, sadly, where I have to tell you that from the views of
    those that I talked to, there just does not seem to be a lot
    that is different. There definitely are some centers that have
    had a slow trickle of individuals. Most places have become
    capable of working with TRICARE to provide services under that
    financing mechanism. Yet, the single most common word I heard
    from the people I talked to is ``frustrating.'' These are folks
    who have the capacity to provide high-quality brain injury care
    and services, want to do it, want to be able to work within the
    system, but just have not consistently had a flow of
    individuals.
        In late 2008, some folks experienced a slight increase in
    referrals. Many of those seemed to disappear with time. It
    seemed to be coordinated with when the VA became--was able to
    staff up and build capacity. That may be just fine, but it is
    an observation that we made.
        I would like to just contrast that experience with what is
    going on with the VA and the DOD in another area, and that is
    with amputations. We see a number of patients who have
    traumatic amputations and injuries, and in that case we have
    seen dramatic advances in the technology of prosthetics by
    collaboration between the DOD, VA, and private providers. There
    are new exciting limbs being developed by DARPA for upper
    extremity amputees. We have seen significant improvement in the
    capacity to care for the amputees and their prosthetic needs. I
    would point out that it was said to me that about 97 percent of
    the amputee care that is provided by the VA is done through
    private contractors. So in that particular case, the VA does
    use a network of community-based prosthetists to actually
    deliver the care and services, and it is high quality and has
    all the characteristics I think people would want to see.
        Another comment that I would like to share with you is the
    significant improvement in case management services. But what
    is interesting is that--what I was told is that--well, they are
    managing the people, but they are still not able to help them
    get access to the care, because although they are case managing
    and coordinating, there are still very significant limitations
    of who is available to be seen, to be referred to, to provide
    expert services. So the coordination is good, but the
    consequence of that coordination, the actual impact by having
    services delivered seems to still be deficient per the
    experience of the folks whom I talked to and to some degree the
    experience----
        Chairman Akaka [presiding]. Dr. Gans, please summarize your
    statement.
        Dr. Gans. I will.
        The last thing I would just like to say is I did talk with
    three active-duty servicemembers and their families Monday
    afternoon who are currently at Kessler, and they wanted me to
    share just a few of their experiences with you. They found that
    they would like to see easier ways of working with the system,
    the bureaucracy and the difficulty of having their choice to be
    expressed, to want to move to another provider outside of the
    VA Polytrauma System. One wife told me it took her a year from
    the time she started requesting until she was finally able to
    get a referral to--it happened to be Kessler in this case, and
    that was a lot of work and energy. That led to a sense of
    guilt. If they had only been able to start sooner, might things
    have been different? They felt that it just all took too long,
    and they also felt that there was a significant problem with
    access to services if they were to move into or accept medical
    discharge. They felt their resource access would be
    substantially reduced in terms of their flexibility to actually
    receive care and services.
        I guess I would like to close by thanking you for giving me
    the time to speak to you again, appreciating all the work the
    VA has done, but saying there are still things left unfinished.
        [The prepared statement of Dr. Gans follows:]
    Prepared Statement of Bruce M. Gans, M.D., Executive Vice President and
          Chief Medical Officer, Kessler Institute for Rehabilitation
        Good morning, Senator Akaka and Members of the Committee. Thank you
    for inviting me back to testify before this Committee regarding
    progress that has been made in the diagnosis and treatment of Traumatic
    Brain Injuries (TBI) and our experiences working with the VA to provide
    treatment and rehabilitation to servicemembers and veterans.
        I am Dr. Bruce Gans, a physician specializing in Physical Medicine
    and Rehabilitation (PM&R). I hold the positions of Executive Vice
    President and Chief Medical Officer for the Kessler Institute for
    Rehabilitation in New Jersey. I am a past-president of the Association
    of Academic Physiatrists (the society that serves medical school
    faculty members and departments), and the American Academy of PM&R,
    which represents approximately 8,000 physicians who specialize in PM&R.
    Currently, I serve as Chair of the Board of the American Medical
    Rehabilitation Providers Association (AMRPA), the national association
    that represents our Nation's rehabilitation hospitals and units. At the
    UMDNJ-New Jersey Medical School I am a Professor of Physical Medicine
    and Rehabilitation. In the past, I have practiced in academic medical
    centers as a faculty member at the University of Washington in Seattle,
    Tufts University in Boston, Massachusetts, Wayne State University in
    Detroit, Michigan, and the Albert Einstein College of Medicine in New
    York. In Detroit I also served as President and CEO of the
    Rehabilitation Institute of Michigan for 10 years.
        Kessler Institute for Rehabilitation is the largest medical
    rehabilitation hospital in the Nation. We operate specialized Centers
    of Excellence to treat adults with Traumatic Brain Injuries, spinal
    cord injuries, amputations, strokes and many other neurological and
    musculoskeletal diseases and injuries. We also operate more than 70
    sites for outpatient rehabilitation services in New Jersey that provide
    medical care, physical therapy, prosthetic fabrication and fitting,
    cognitive rehabilitation treatment, high technology wheelchairs and
    electronic assistive device fittings, and many other services.
        We are also a major medical rehabilitation education and research
    facility. In cooperation with the Kessler Foundation and the UMDNJ-New
    Jersey Medical School, we train physicians, therapists, psychologists,
    and many other disciplines to provide rehabilitation services and run
    rehabilitation programs. We also conduct many research programs and
    projects to advance the knowledge and science of medical
    rehabilitation. Much of this research is funded under Federal grants
    from the National Institutes of Health (NIH), the National Institute
    for Disability and Rehabilitation Research (NIDRR), other Federal and
    state organizations and private foundations.
                               previous testimony
        When I testified before this Committee in 2007, I expressed concern
    that the civilian rehabilitation providers in this country were
    capable, available and interested in providing high quality
    rehabilitation care and treatment to servicemembers and veterans but
    they were not being utilized. In particular, providers wanted to make
    themselves available to patients from their own communities so that
    long stays in far distant care centers could be prevented. I noted that
    there was little evidence of cooperative planning among the DOD, VA,
    and civilian sectors to make the best services available in a timely
    way in home communities.
        At that time I recommended the creation of a Coordinating Council
    on which leaders from all three stakeholders would participate in order
    to work together to strike a balance between building up care delivery
    capacity in Military Treatment Facilities (MTF) or VA health centers,
    and utilizing private partnerships when they were more cost effective
    and more appropriate for the needs of servicemembers and veterans. I
    also urged targeting case management and care coordination services so
    that individual patients and families could be helped to navigate among
    the military, VA, and private sectors to help make their care seamless
    and effective with a view to long-term needs once they returned to
    their home communities.
        In addition, I recommended that there be close collaboration and
    cooperation among the DOD, VA and the private TBI research community
    (especially the TBI Model Systems programs of NIDRR) to study the
    effectiveness of current treatment approaches, and to develop new
    breakthroughs in how to care for all levels of TBI, from mild, to
    moderate or severe. The allocation of research funds that could be used
    to sponsor research partnerships among the DOD, VA and private research
    community was also proposed.
                    the current state of tbi rehabilitation
        Happily there have been some advances in the state-of-the-art for
    treating individuals with serious brain injuries. Many of the most
    advanced and innovative approaches have not yet found their ways into
    common practice. The newest innovations have not been fully researched
    to prove their efficacy, but clinical experience and some retrospective
    studies are showing much promise.
    Diagnosis
        New diagnostic tools such as Functional Magnetic Resonance Imaging
    (FMRI), Magnetoencephalography (MEG), Magnetic Resonance Spectroscopy
    (MRS), quantitative Electroencephalographic brain mapping (QEEG) and
    Near Infrared Spectroscopy (NIRS) are all non-invasive methods of
    observing brain activity and responses to treatments. These evaluative
    tools are allowing clinicians to be aware of patient responses when
    behaviors cannot be observed, and serving as guides to how treatments
    should be modified.
    Treatment
        Innovative treatments are also being utilized. Pharmaceuticals are
    being much more aggressively used to help patients be aroused from
    coma, better organize their thinking, and control difficult behaviors.
    Multiple drug ``cocktails'' used by expert clinicians appear to have
    beneficial effects. Supplemental uses of nutraceuticals are also being
    pursued, and intriguing clinical experience being accumulated. Physical
    modalities are being applied with much more intensity to attempt to
    help patients. They include peripheral nerve stimulation, brain
    stimulation by direct or magnetically induced currents, and
    neurofeedback.
        More interestingly, the use of these diagnostic and therapeutic
    modalities together, with multi-modal interventions, may be more
    effective than the conventional ``one at a time'' approach used
    previously. Clinical experience gained at Kessler Institute and other
    centers in this regard has prompted the development of significant
    research projects to test these findings. A large study of this type is
    expected to begin shortly at Kessler Institute in partnership with the
    International Brain Research Foundation and the Kessler Foundation.
    Workforce Shortages
        There is a shortage of trained and experienced clinicians with
    experience in the treatment of TBI patients. Physicians in PM&R or
    Neurology, neuropsychologists, physical therapists and other
    rehabilitation disciplines are all highly sought after because of the
    demands of treating these patients and the shortage of available
    talent. For this reason, in part, patients have waited for prolonged
    periods to access treatment centers, and been shunted to regional or
    national centers of excellence, both the VA Polytrauma Rehabilitation
    Centers, and occasionally at institutions like Kessler.
        care delivery and coordination among the dod, va, and civilian
                                   providers
        The proposed Coordinating Council was never pursued and, at least
    to my knowledge, the VA did not develop any organized method of
    identifying high quality providers in communities to supplement or
    obviate the need for them to hire scarce staff to treat patients
    internally.
        It is not my place to detail the changes in care delivery capacity
    of the VA or their relationship with the military. It is clear that the
    VA has strengthened the care delivered through its Polytrauma
    Rehabilitation Centers and Polytrauma Network, and their coordination
    with the MTFs. I have personally had the opportunity to visit the
    Polytrauma Rehabilitation Center in Richmond, Virginia, and the Center
    for the Intrepid in San Antonio, Texas, and was impressed by both of
    these facilities.
        In an effort to gauge the current status of the relationship
    between private providers and the VA and DOD and to share with this
    Committee, I communicated with more than 16 medical and administrative
    leaders in the field. These individuals ranged from rural providers to
    large national companies, and included community hospitals and large
    academic health systems. I asked these leaders to share with me their
    views on how care is being provided to patients in their communities,
    and what their facility experiences have been in working with the VA or
    the DOD.
        It appears that little has changed since 2007 regarding the use of
    local care providers for TBI care. Some private sector rehabilitation
    hospitals experienced a transient increase in referrals for evaluative
    services. Most if not all, had established relationships with TRICARE
    so that they could see patients and get reimbursed for the care they
    hoped to provide. The most common word used to describe the situation
    was ``frustrating''. Repeatedly, I heard comments such as, ``we have
    high quality services available, but patients and their families are
    being uprooted to distant care settings for long periods of time. When
    they finally come back to their home community, there is little
    available to them for their long term needs.''
        One interviewee contrasted the TBI situation to that of Amputees.
    He pointed out the significant research partnerships among the DOD
    (DARPA in particular), VA, private centers and commercial interests to
    develop new advanced prostheses. He also pointed out that the vast
    majority of prosthetic care delivered by the VA is done through private
    contractors.
        Another individual commented that there has been a substantial
    increase in the availability of case management services. While
    individuals who work with specific patients are now more available,
    families have expressed great frustration that they don't have contact
    with physicians and direct care providers; so the availability of case
    managers is not sufficiently helpful since they haven't got access to
    the care itself.
        I can speak most readily about the experience of my own hospital,
    Kessler Institute for Rehabilitation. Since March 2007, Kessler
    Institute has cared for 10 servicemembers. Two patients currently are
    receiving inpatient care at our hospital. All were Active Duty at the
    time of admission. All 10 had serious TBI. Three also had Spinal Cord
    Injuries. One had multiple amputations as well as the TBI. Six of these
    patients were injured in theater, five from IEDs. The other four
    patients were injured in motor vehicle accidents. VA funds supported
    two of the patients while TRICARE sponsored 9 (one patient transitioned
    from VA to TRICARE while at Kessler).
        Ironically, one of the first patients in this group was the son of
    Denise Mettie, the parent who testified to this Committee just before I
    did in 2007. Our chance meeting on that day led to her pressing for
    Evan to be referred to Kessler for ongoing care. Her experience of
    needing to be a strong and uncompromising advocate for her loved one
    has been a common thread for many of the families of the patients we
    have seen. Only with sustained pressure were many of these patients
    allowed to be referred to us. This observation is similar to the
    experience described by other leaders in the field whom I interviewed.
                            tbi research cooperation
        There have been some advances in the collaboration among the DOD,
    VA and private sector in rehabilitation research. The Polytrauma
    Rehabilitation Centers have initiated work with the TBI Model Systems
    for data contribution and other purposes. Also, research centers around
    the country have been applying for funding from DOD solicitations in
    this area, and a number of active projects are underway at centers such
    as our own, Spaulding Rehabilitation Hospital and Harvard University,
    and Rehabilitation Institute of Chicago. The research being conducted
    ranges from retrospective reviews of secondary data to assess outcomes
    and long-term effects, to clinical trials of innovative treatment
    approaches in the hope of finding breakthroughs in care.
           overall assessment of the relationship between the va and
                               civilian providers
        The VA has clearly improved its capacity to care for patients with
    TBI. It has not done so with an eye to the long term needs of patients
    who return to more remote communities, however, and has, instead,
    chosen to strengthen its internal capacity.
        While I may have a limited sample, it appears that family members
    are dissatisfied with their inability to access providers of choice
    outside of the VA system, and that the case management system is not
    consistently resulting in better access to care. These observations may
    not be generally applicable, but seem to be on target for the most
    severely injured patients and their families.
        The research collaborations are encouraging, but not pushing the
    envelope far enough or fast enough. The truly innovative
    neurodiagnostic and therapeutic work appears to be being conducted
    outside of the VA, not within it. In fact, the conventional research
    establishment is showing some resistance to the most innovative
    approaches (multi-modal treatment protocols, for example).
                                recommendations
        It is important to commend the VA and the DOD for their hard work
    and the progress they have made in the acute and early-phase care of
    patients with TBI. My concerns remain for the breadth and depth of that
    capacity and the anticipated life-long needs of a new generation of
    brain injured veterans.
        I still contend that collaboration with the private sector and
    enhanced efforts in this regard are the right thing to do. As large as
    the TBI problem in the military sector is, it is dwarfed by the
    magnitude of the problem in the civilian population. Over a million
    brain injuries occur in the US every year. Admittedly, not many are
    blast injuries, but when it comes to rehabilitation care, that is not a
    major distinguishing feature. Hence, the capacity in the civilian
    sector will not only be great, it will be available for the long term.
    The VA and DOD should work for strategic alliances with civilian
    providers so that a sustainable infrastructure of care delivery
    capacity for servicemembers and civilians is available now and for the
    foreseeable future. This could be accomplished beginning with creating
    the Coordinating Council I recommended previously.
        Congress could create incentives for the VA and DOD to improve
    collaboration by establishing a budget item for each to support this
    activity, and structuring the budgets so that rather than being
    penalized at the local level, a VA facility could access special
    supplemental funds if it found a way to utilize local resources to
    create a sustainable care delivery capacity.
        In particular, the VA and DOD should develop a method of early
    identification of individuals who are clearly going to be destined for
    medical discharge because of their injury. This ``pre-discharge''
    determination should be a guiding condition that triggers care planning
    based not on regionalized care delivery within the VA, but prioritizes
    accessing closer to home providers that will be life-long resources to
    the patients and their families.
        Congress could prioritize the research budgets for both the VA and
    DOD to promote searching for breakthrough research to dramatically
    advance the state of treatment and rehabilitation of TBI. Whether it
    supports stem-cell techniques to develop brain grafting possibilities,
    multi-modal rehabilitation interventions, or tele-rehabilitation, it
    should place a premium on dramatically improving our care capacity, not
    just incrementally advancing it.
        Further emphasis on funding training for TBI-related health
    professionals in more innovative ways is also an important possibility.
    For example, while the VA does currently support medical residency
    training and some fellowship training, there are administrative
    barriers for some of these positions to utilize advanced training
    settings outside of the VA. Rules should be changed as needed to allow
    trainees to learn in the most appropriate settings, regardless of
    whether they are within a VA or a civilian facility.
        The VA should explore how the innovative health care delivery ideas
    contained in the recently passed Health Care Reform legislation may be
    relevant to this population. In particular, demonstrations of an
    Accountable Care Organization focused on the TBI population could be
    implemented. Being charged with managing the best outcomes for the best
    value, regardless of provider setting, might stimulate new levels of
    collaboration. Similarly, establishing a demonstration Medical Home for
    TBI patients could show another way in which the care coordination
    resources and medical management obligations could be integrated to the
    benefit of patients and their families.
                                  conclusions
        In closing, I would like to express my gratitude to the men and
    women of our armed services and the agencies themselves for their
    dedication and sacrifices to defend and protect our country. I hope
    that these observations and suggestions can help to provide more and
    better care for those who have given so much for our Nation.
                                     ______

    Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to
        Bruce M. Gans, M.D., Executive Vice President and Chief Medical
                 Officer, Kessler Institute for Rehabilitation
        Question 1. In her testimony, Mrs. Bohlinger discussed the
    importance of brain imaging to improve the accuracy of TBI screening.
    From your perspectives, what new imaging technologies are being
    developed or can be made available to VA?
        Response. There are many emerging imaging techniques that can both
    improve the diagnostic accuracy of identifying brain injury, and help
    to guide therapeutic interventions. One receiving the most attention
    right now is Functional Magnetic Resonance Imaging (fMRI) because it is
    capable of showing areas of metabolic activity in relationship to brain
    functions, such as motor, sensory, and even thought processes.
    Diffusion Tensor Imaging (DTI) can be very helpful in detecting subtle
    brain injuries. Magnetic Resonance Spectroscopy (MRS) is becoming
    useful for observing metabolic activity within the brain and using that
    information for diagnostic purposes.
        Electrical ``imaging'' of the brain through studies of the wave
    patterns and analysis with quantitative electroencephalography (qEEG)
    allows useful diagnostic information to be accumulated. In addition,
    magnetic electroencephalography (MEG) detects the magnetic fields
    generated by the electrical activity of the brain, and is potentially
    useful as a diagnostic tool.
        Near Infrared Spectroscopy (NIRS) is a non-invasive method of
    studying the metabolic activity of the brain by observing blood flow
    patterns. It may serve to partially substitute for fMRI studies but is
    limited to allowing observation of only the activity at the surface
    levels of the brain (fMRI allows observation of deeper structures).
        Each of these methods has its strengths and limitations for
    contributing to the diagnosis and treatment of TBI. Their use depends
    on what information is needed or what treatment goals are being
    pursued. Many of these techniques are still being studied to better
    understand their value and ultimate role in the care of patients with
    TBI. As the research and clinical experience mature, it will become
    clearer as to which should become routinely available, which should be
    used just for research purposes, and which should be discarded because
    they do not contribute to helping in the care of patients.
        Today, the imaging methods that should be readily available to
    patients are fMRI (especially for patients with severe brain injury)
    and DTI (to help diagnose patients who have experienced a mild TBI).

        Question 2. Cooperation with the private sector is important to
    expand access to care. However, veterans are a unique population. What
    steps has your organization, or other private entities with which you
    may be familiar, taken to become more ``culturally literate'' with
    respect to servicemembers and veterans?
        Response. Familiarity with the VA (more so than the military)
    health system is quite pervasive for physicians, since most of us have
    had at least part of our medical training in VA hospitals. As an
    organization, Kessler Institute has taken many steps to enhance its
    understanding and ability to work with both VA and military medicine.
    We have visited a number of military and VA health care facilities,
    interacted extensively with professionals from both settings, and
    encouraged close interactions between our case managers and other
    clinicians with military or VA care givers, coordinators, and
    administrators around the planning and delivery of care to patients,
    both active military and veterans.
        In addition, many senior officers have visited Kessler Institute to
    observe the care we have been providing to the servicemembers whom we
    have been allowed to treat. We have also received visitations by a
    number of VA professionals.
        Nationally, the field has reached out to both military and VA
    professionals to conduct training sessions, provide lectures,
    encouraged them to interact with their civilian colleagues, and
    promoted their participation in meetings of the American Academy of
    Physical Medicine and Rehabilitation (AAPM&R), the professional society
    of physicians who practice physiatry, and the American Medical
    Rehabilitation Providers Association (AMRPA), the national organization
    that represents rehabilitation hospitals and units. Both the AMRPA and
    the AAPM&R have reached out to the VA to attempt to systematically
    build mutual understanding and establish a relationship.
        It is common for civilian health care facilities to treat a diverse
    patient population, and at Kessler Institute, we train our staff
    formally in the concepts of cultural diversity. Our experience with the
    military and VA is not that different from other patients who identify
    with a specific culture, and I believe we have demonstrated sensitivity
    to each individual's background, needs and concerns. The military and
    VA have done a great job of staying actively involved with the patients
    we have cared for, and helped us on a day-to-day basis to deal with the
    unique issues associated with their culture and systems. Family members
    also help to provide us with important insight and guidance on a
    regular basis.

        Question 3. Does your organization, or ones you are familiar with,
    use telehealth technologies to provide care and services to individuals
    with TBI?
        Response. Kessler Institute has limited experience with
    telemedicine. We do use remote radiology services to review all imaging
    studies; the images are transmitted digitally to offsite radiologists
    who read the films and transmit their reports electronically. There are
    institutions that do have experience in a variety of tele-
    rehabilitation activities. For example, the University of Pittsburgh
    operates a Rehabilitation Engineering Research Center (RERC) dedicated
    to tele-rehabilitation. It is funded by the National Institute on
    Disability and Rehabilitation Research (NIDRR) within the Department of
    Education.

        Question 4. Your testimony discussed that Kessler Institute will
    begin a study regarding the effectiveness of combining diagnostic and
    therapeutic modalities for treating TBI. Do you anticipate this new
    form of treatment would have a significant impact on cost?
        Response. If our research demonstrates the clinical effectiveness
    and value of these interventions, it is likely that they would become
    the standard of care. There are certainly short-term incremental costs
    associated with the use of these drugs, nutraceuticals, imaging
    studies, and electrical stimulation modalities. But, if these therapies
    help a patient to become more conscious (``wake up'') and able to walk,
    communicate, function, and return home instead of being a permanent
    resident of an institution, then the ultimate total costs of care will
    be substantially reduced and the cost benefit will be enormous.

        Question 5. Is there a benefit to continuing rehabilitation
    therapy, with the goal of maintaining a current level of functioning,
    for those with severe TBI for whom no further gains in functioning are
    expected?
        Response. The question of maintenance therapy is frequently
    addressed in medical rehabilitation. In many cases, formal therapy can
    be replaced with self-care programs performed by patients on their own
    or with family caregiver assistance. There are situations, however,
    where patients and families cannot sustain these activities on their
    own. The need for continuing formal therapy then depends on what the
    risks of deterioration are. Each case is unique, of course, so
    generalizations are difficult. The risks of disengaging from even
    seemingly simple therapies such as range of motion exercises can be
    profound. I have seen patients develop severe contractures, serious
    skin ulcers, and even die from the lack of what was described as ``only
    maintenance'' therapy. So, in the end, there needs to be reasoned
    clinical judgment applied to the individual patient.
        The other question is whether more improvement can be achieved with
    additional therapies or if the patient has ``plateaued'' and will not
    benefit any further. Recovery from serious brain injury can be likened
    to athletic training. For an athlete to obtain peak performance,
    sustained, intensive and consistent training is required. For a
    seriously impaired patient with a brain injury, it may take similar
    sustained, intensive and consistent therapy to make any improvements.
    For certain patients, even modest incremental gains can be very
    meaningful. How much further improvement is ``enough'' will depend on
    the individual, their goals and needs. In the case of our wounded
    warriors, I would give them the benefit of the doubt, and support
    longer term access to therapies, even if only ``modest'' benefits were
    expected. Once again, it is a matter of individual situations and
    expert clinical judgment.

        Chairman Akaka. Thank you very much, Dr. Gans.
        Mr. Dabbs?

        STATEMENT OF MICHAEL F. DABBS, PRESIDENT, BRAIN INJURY
                        ASSOCIATION OF MICHIGAN

        Mr. Dabbs. Good morning, and thank you, Senator Akaka,
    Senator Brown, and members of the staff of the Senate Committee
    on Veterans' Affairs, for the opportunity to address you about
    how effective State, local, and private entities have been
    engaged by the Veterans Administration to provide the best
    access to care and services for veterans with TBI.
        The Brain Injury Association of Michigan was incorporated
    in 1981 as a 501(c)(3) nonprofit organization and is one of 44
    chartered State affiliates of the Brain Injury Association of
    America. We are one of the leading State affiliates due to
    Michigan having more brain injury rehabilitation providers than
    any other State in the country. This extensive provider network
    has been developed over the past 37 years as a result of
    Michigan's auto no-fault insurance system. It provides a
    lifetime continuum of care with a singular focus: to assist the
    injured victim recover to their fullest potential. My written
    testimony provides a comprehensive overview of our association:
    its veterans program under the guidance of Major Richard
    Briggs, Jr., U.S. Air Force (Retired), who is with me today;
    and the collaboration with the Michigan Department of Military
    and Veterans Affairs, the members of the Joint Veterans
    Council, the Veterans Service Organizations, the Michigan
    Association of County Veterans Counselors, and the Veterans
    Integrated Service Network 11 director and staff. As a result
    of this collaboration, I will share my observations, possible
    approaches, and potential solutions in response to the
    Committee's inquiry. My comments only reflect my experiences
    within the Michigan region of VISN-11, which is the lower
    peninsula of Michigan.
        In Secretary Shinseki's report, he indicated a number of
    ``landmark programs and initiatives that VA has implemented to
    provide world-class rehabilitation services for veterans and
    active-duty servicemembers with TBI.'' These are important
    developments, but let me express a few concerns.
        One, Enclosure A of his report, page 2, states that ``VA
    directed medical facilities are to identify public and private
    entities within their catchment area that have expertise in
    neurobehavioral rehabilitation and recovery programs for TBI.''
    To date, in Michigan there have been only three such referrals
    according to the VISN-11 Cooperative TBI Agreements Patient
    Tracking fiscal year 2009 report. One of these was due to a
    mother's insistence that such care be provided to her son.
        This is a critical part of my testimony. I have provided a
    chart based on the information shown on the Commission on
    Accreditation of Rehabilitation Facilities, better known as
    CARF, Web site that indicates all accredited brain injury
    providers in the United States. This report indicates that in
    military commission alone, there are nine brain injury
    residential rehabilitation providers with 78 facilities; that
    is 24 percent of the U.S. total. Eight brain injury home and
    community-based rehabilitation providers with 16 facilities;
    that is 33 percent. There are similar percentages for
    outpatient rehabilitation providers and vocational
    rehabilitation services.
        There are even more non-CARF-accredited providers in
    Michigan, but, unfortunately, none of these providers or the
    CARF-accredited providers are being utilized to the extent they
    should be by the VA. I am going to provide the Committee with
    this book, which is our Directory of Facilities and Services in
    Michigan as a future reference.

        [The aforementioned Directory was received and is being
    held in Committee files.]

        Point 2, Enclosure A, page 2, of Secretary Shinseki's
    report, the second paragraph states the numbers and cost of
    veterans with TBI receiving inpatient and outpatient hospital
    care through public and private entities for fiscal year 2009.
    The average cost indicated is approximately $5,800 per veteran.
    Let me give you a comparison.
        As part of the Michigan Department of Community Health's
    TBI Grant from HRSA, Michigan's Medicaid data during the past 4
    years indicates an annual average cost of $28,500 just for
    services with a TBI diagnosis; and an annual average cost of
    $41,200 for services with TBI and non-TBI diagnosis. I believe
    these numbers may be further indication of less than optimal
    use of outside contractors or, at the very least, not fully
    using these contractors and should be reviewed in greater
    depth.
        Point 3, Enclosure A, page 4, number 4 discusses ``Programs
    to maximize Veterans' independence, quality-of-life, and
    community integration, and establish an assisted living
    pilot.'' I would recommend to the VA that they immediately
    explore and/or expand such a pilot using the Michigan CARF-
    accredited providers. In fact, the solider whose mother was
    insistent on the care outside of the VA system might be one to
    include in such a pilot.
        There are other concerns of equal importance that have been
    stated to us by the Michigan Department of Military and
    Veterans Affairs. I urge the Committee to review these as part
    of my report to you in terms of your future actions.
        Again, let me thank the Committee for allowing me to
    testify. Brain injury is an unique injury that has by some been
    called a ``life sentence'' to veterans and to their families
    who do not receive timely--and I want to emphasize that word,
    ``timely''--comprehensive, and sufficient cognitive
    rehabilitative care.
        In wrapping up, let me personally testify to this fact. My
    father, who served with the U.S. Marines during the assault on
    Guadalcanal, sustained a brain injury that we learned about
    near the end of his life. His undiagnosed brain injury was
    diagnosed in the late 1970s, early 1980s as PTSD. The VA's
    treatment at that time was to overprescribe (my opinion)
    medication. It was not until there was a determination that
    there was a brain injury and the medication protocol was
    greatly changed did he ever have the quality-of-life he should
    have had while raising his family.
        On behalf of today's veterans, let me plead that we
    collectively do everything in our wisdom and power to prevent
    their lives having the same fate. Thank you.
        [The prepared statement of Mr. Dabbs follows:]
              Prepared Statement of Michael F. Dabbs, President,
                      Brain Injury Association of Michigan
        Let me begin by expressing my sincere appreciation to Senator Akaka
    and all senators of the U.S. Senate Committee on Veteran Affairs for
    the opportunity to address you on the issue of our Association's
    experience in working with the VA to provide brain injury treatment and
    rehabilitation to veterans. As part of my testimony I will address how
    effectively state, local and private entities have been engaged by the
    VA to provide the best access to care and services for veterans with
    TBI.
        Before discussing this matter, allow me to provide you with some
    basic information about the Brain Injury Association of Michigan and in
    particular, its Veterans Program. The Brain Injury Association of
    Michigan was incorporated in 1981 as a 501(c)(3) nonprofit organization
    by individuals with a brain injury, their families and professionals in
    the field of brain injury to provide support and education to one
    another, as well as to advocate on behalf of persons with a brain
    injury and their families. Additionally, research and prevention
    programs were primary goals. Our Association is one of 44 chartered
    state affiliates of the Brain Injury Association of America.
        In 2007, with funding provided by the Health Resources Services
    Administration to the State of Michigan Department of Community Health
    (MDCH) as part of the Federal Government Traumatic Brain Injury State
    Grant program, a portion of these funds were sub-contracted to our
    Association to serve the needs of Michigan veterans. Through the
    guidance of the MDCH's TBI Grant Services and Prevention Council the
    following goals were established:

         Goal 1--Create a comprehensive and coordinated state-wide
    Traumatic Brain Injury (TBI) awareness and resource program for
    veterans, their families and friends/co-workers through implementation
    of a Veteran TBI Awareness Campaign.
         Goal 2--Create a working relationship with the Michigan
    based VA VISN 11, VA medical centers and subordinate VA health care
    providers.
         Goal 3--Survey all TBI health care providers to ascertain
    their interest in and capabilities of providing care for military
    personnel.

        In order to accomplish these goals, Major Richard Briggs, Jr., USAF
    (Retired) was hired to manage this program and accompanies me today.
    Though I would be pleased to share a more comprehensive report about
    our Veterans Program accomplishments, I will limit my comments to
    addressing our activities as it relates to Goal 2 and its relevancy to
    the stated purpose of this hearing.
        Major Briggs developed a working relationship with the Michigan
    Department of Military Affairs and with their assistance was able to
    create partnerships with the Veterans Service Organizations' Council
    and the VA County Counselors. Also, because of this relationship with
    the Department of Military Affairs, he and I were invited to meet with
    the Veterans Integrated Service Network (VISN) 11 director and staff.
    As a result of these meetings, Major Briggs was able to meet with the
    four VA Medical Center Directors in Michigan, as well as their
    respective OEF/OIF Coordinators. These meetings afforded Major Briggs
    the opportunity to share with them the unique capabilities for brain
    injury rehabilitation available in Michigan. These capabilities will be
    explained at further length below as it pertains to the Committee's
    inquiry.
        Finally, let me share with the Committee that the Brain Injury
    Association of Michigan's Veterans Program was just recently ranked
    21st out of 128 nonprofits providing support and service to our
    veterans in a recently-conducted 2010 Veterans Choice Campaign special
    survey done by Great Nonprofits.
        The information above is provided to serve as credible evidence of
    our ability to address the Committee's meeting purpose and to
    demonstrate our efforts to reach out and work with the VA and the main
    organizations that already exist that work with the VA, or collaborate
    closely with it.
        It is my intention with the comments that follow to suggest to the
    Committee possible approaches or potential solutions to consider as it
    attempts to ensure that the intent of the Federal legislation is in-
    fact carried forward at the local level. Let me be clear that my
    comments only reflect the experiences of our Association with VISN-11
    and in particular, the Michigan region of VISN-11, which is the lower
    peninsula of Michigan.
        In my nearly 18 years as president of the Brain Injury Association
    of Michigan, I have rarely seen as comprehensive a piece of legislation
    regarding brain injury and best practices as what was included in Title
    XVI, Wounded Warriors Matters of the ``National Defense Authorization
    Act for Fiscal Year 2008.'' In addition, the Veterans Omnibus Health
    Services Act of 2010 (S. 1963) also is an excellent piece of
    legislation as it pertains to soldiers who have sustained a Traumatic
    Brain Injury (TBI). In fact, some of the proposed approaches that I
    will mention address some of the provisions (sections 506, 507, 509,
    and 515) of this bill.
        In Secretary Shinseki's report to the Committee dated March 23,
    2010 indicated a number of ``* * * landmark programs and initiatives
    that VA has implemented to provide world class rehabilitation services
    for Veterans and active duty Servicemembers with TBI * * *'' It is my
    opinion that these are valuable and important developments; but here
    are a few concerns I have regarding this.

        1. The first point mentions ``* * * 108 specialized rehabilitation
    sites across the VA medical centers that offer treatment by
    interdisciplinary teams of rehabilitation specialists * * *''--
        I agree that the VA medical centers do offer such rehabilitation;
    however the VA appears to be limited in providing brain injury
    rehabilitation. Our experience in Michigan however, is that these
    hospitals are over-burdened and given their patient load simply are
    unable to provide timely care and frequency of care that is required
    for a person who has suffered a TBI.
        Furthermore, as we have witnessed with one of the four VA medical
    centers in Michigan that is located in close proximity to a major
    hospital medical school, this VA medical center only has one doctor who
    is qualified to administer Neuro-psychological testing. Neuro-
    psychological testing is critical to the proper and thorough screening
    of soldiers who have a suspected TBI.
        As further evidence of the significance of this problem, let me
    provide you with one of the recommendations given to me by the State of
    Michigan Department of Military Affairs in preparation for this
    testimony:

            ``Access problems and long waits continue to be problematic
            despite the best attempts of the VA.''

        One additional point to consider regarding this issue of adequacy
    of resources--it is my understanding that Michigan has over 725,000
    Veterans, and only 207,000 are registered with the VA. Yet as stated
    above, the current VA medical centers are seriously over-whelmed with
    trying to provide care to those they are servicing. Assuming the
    Michigan numbers of Veterans and the Veterans who are registered with
    the VA are reflective of other states, this would dictate that the VA
    absolutely must aggressively seek outside contractors to assist them
    with providing care to our Veterans. Simply put, the VA must use its
    financial resources to contract with public and private partners to
    provide care and not spend these funds trying to build facilities and
    staff them. I implore this Committee and the VA to immediately take
    action on this issue. Veterans who have a TBI need treatment now--not
    in a few years when a few more facilities might be operational. Does it
    even seem reasonable to think that there are sufficient funds to build
    enough facilities in Michigan to meet the long-term care needs of
    Veterans with TBI, if the numbers above are correct; much less the rest
    of U.S.?
        2. The second point indicates that ``TBI screening and evaluation
    program to ensure that Veterans with TBI are identified and receive
    appropriate treatment for their conditions''--though this has been
    implemented, the current assessment that I believe is being referred
    to--a four question survey--is not adequate. Another one of the State
    of Michigan Department of Military Affairs recommendations states:

            ``TBI continues to be missed when it co-occurs with other
            disorders. Soldiers who are being diagnosed with disorders such
            as Bipolar Disorder and PTSD should be universally screened for
            TBI because of the similarities in their presentation. Likewise
            all soldier receiving VA disability for hearing loss or
            Tinnitus (ear ringing) should have mandated TBI screen.''

        3. Enclosure A, Page 2 notes that ``* * * VA directed medical
    facilities to identify public and private entities within their
    catchment area that have expertise in neurobehavioral rehabilitation
    and recovery programs for TBI, and to ensure that referrals for
    services are made seamlessly when necessary.'' A similar point is made
    in S. 1963, Section 507. To date in Michigan, there have been only
    three such referrals according to the VISN-11 Cooperative TBI
    Agreements Patient Tracking FY 2009. One of these was due to a mother's
    insistence that such care be provided to her son.
        This is a critical point of my testimony. For over 37 years,
    Michigan, due to its unique automobile no-fault insurance system,
    provides comprehensive lifetime care for those sustaining injuries in
    an automobile crash in Michigan. The care provided is unique to each
    person and provides cognitive rehabilitation care. As a result, there
    are more brain injury rehabilitation providers than any other state in
    the U.S. I have provided a chart that we created as an attachment to
    this testimony. This information was taken directly from the Commission
    on Accreditation of Rehabilitation Facilities (CARF) Web site that
    indicates all certified brain injury providers in the United States.
    Let me give you just a couple of the more salient points. There are 9
    brain injury residential rehabilitation providers with 78 facilities in
    Michigan--this is 24% of the total in the U.S. Michigan has 8 brain
    injury home and community-based rehabilitation providers with 16
    facilities in Michigan--this is 33% of the total in the U.S. Brain
    Injury outpatient rehabilitation providers in Michigan number 12 with
    22 facilities, which represent 15% of similar providers in the Nation.
    And finally, there are six providers with 12 facilities, which is 24%
    of the total in the U.S.
        Again, these are CARF accredited providers and represent only a
    fraction of similar program providers within Michigan who are not
    certified. A copy of the Brain Injury Association of Michigan's
    Directory of Facilities and Services will be provided to the
    Committee's staff to provide you with an idea of just how extensive
    these resources are throughout Michigan. All of these providers are
    spread across Michigan, though the preponderance are located in or near
    the larger urban areas of the state. Attached is a Michigan map with
    just the CARF accredited facilities.
        4. Enclosure A, page 2, second paragraph also states the numbers of
    Veterans with TBI receiving inpatient and outpatient hospital care
    through public and private entities for FY 2009. The average cost per
    Veteran would be $5,800.
        By way of comparison, as part of the MDCH TBI Grant from HRSA,
    Michigan has done an extensive analysis of its Medicaid Data for the
    past 10 years. During the past four years, our analysis of a subset of
    TBI cases who receive Medicaid provide us a the cleanest estimate of
    cost (that is, Medicaid cases who had no other insurance, were not in
    Medicaid prior to their TBI hospitalization, had Medicaid eligibility
    for at least a year after the TBI hospitalization and had Fee For
    Service cost data) showed the following:

        > Annual average cost of $28,539 just for services with a TBI
    diagnosis.
        > Annual average cost of $41,243 for services with TBI and non-TBI
    diagnosis.

        An issue to consider regarding this data is that I believe that
    Medicaid is more restrictive of services than would be available
    through the VA.
        5. Enclosure A, page 4, #4 discusses ``Programs to maximize
    Veterans' independence, quality of life, and community integration, and
    establish an assisted living pilot.'' I believe this program could have
    been expedited had the VA utilized the resources available in Michigan.
    I would encourage the Committee to recommend to the VA that they
    immediately explore and/or expand such a pilot utilizing the CARF
    accredited providers that I have mentioned above. In fact, the solider
    mentioned above whose mother was insistent on the care outside of the
    VA system might be one to include in such a pilot.
                                recommendations
        The Brain Injury Association of Michigan would readily welcome the
    opportunity to partner with the Veterans Administration to work
    expeditiously to implement the policy directives and guidance that
    Congress and the VA have directed. With the collaboration of the
    partners that I indicated in the beginning of this testimony, I believe
    that we can effectively assist with demonstrating how the ``new'' VA
    can operate in the 21st Century to meet its congressionally mandated
    responsibility of providing care to our Nation's Veterans.

        1. Create a pilot study in Michigan that utilizes the extensive
    continuum of care of CARF accredited brain injury rehabilitation
    providers. The goal of such a pilot would be to validate Secretary
    Shinseki's desire for a seamless system of care between VA and private
    or public partners. Additionally, its greatest value would be to ensure
    the Veteran is receiving the most comprehensive program of brain injury
    rehabilitation that would give them the greatest opportunity to
    reintegrate into the community.
        2. Review current legislation and possibly creating additional
    legislation as required creating a program that would address some of
    the following concerns (this is not comprehensive, simply a starting
    point):

              - Automatically enroll a soldier into the VA upon discharge
            from active duty;
              - Improved TBI screening;
              - Comprehensive case-management;
              - Increased educational offerings and support regarding their
            loved-ones who have a TBI pertaining to their challenges and
            limitations;
              - Realization of ``seamless transitions'' and an
            interdisciplinary approach between health care providers across
            disciplines to assure that the Veterans challenges is not
            navigation through bureaucracy or red tape.

        3. The VA should undertake a study of medical specialties that they
    have shortages of and what opportunities exist in their region to
    ensure that more timely care is rendered to Veterans who have sustained
    a TBI.
                                   conclusion
        In conclusion, let me again express my sincere thanks to the
    Committee for allowing me to testify. Brain injury is an unique injury
    that can be a ``life-sentence'' as one radio personality once called
    it. It can be a needless life-sentence to the Veteran who does not
    receive timely, comprehensive and sufficient rehabilitative care. I
    would also suggest that it is a life-sentence for their loved ones. It
    impacts the family and the community. I can personally testify to this
    fact as my father who served with the U.S. Marines during the assault
    on Guadalcanal sustained a brain injury that we learned about near the
    end of his life. His undiagnosed brain injury was diagnosed in the late
    1970's, early 1980's as PTSD. The VA's treatment at the time was to
    over-prescribe (my opinion) medication. It wasn't until there was a
    determination that there was brain injury and the medication protocol
    was greatly changed did he ever have the quality of life; he should
    have had while raising his family. On behalf of today's Veterans let me
    plead that we collectively do everything in our wisdom and power to
    prevent their lives having the same fate.

    Attachments:
        1. CARF Statistics Table for Michigan
        2. State of Michigan map identifying CARF accredited providers
                Attachment 1--CARF Statistics Table for Michigan

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

       Attachment 2--State of Michigan maps identifying CARF accredited
                                   providers

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     ______

    Response to Post-Hearing Questions Submitted by Senator Daniel K. Akaka
      to Michael F. Dabbs, President, Brain Injury Association of Michigan
        Question 1. You stated that you have concerns with the current TBI
    screening tool. Concerns have also been expressed about the clinical
    validity of this tool. Please specifically identify your reservations
    in addition to possible ways to improve the tool.
        Response. I do not have expert knowledge or training regarding TBI
    screening tools for me to be able to provide specific concerns or more
    importantly about how it can be improved. However, let me share these
    observations regarding the current tool (I am referring to the VA's TBI
    Pre-screening Tool--four questions evaluation tool). First, it does not
    require much experience or knowledge to recognize that these limited
    and broad questions are inadequate at best. These questions would
    appear to disproportionately identify the number of soldiers, which may
    lead to unnecessarily overloading the medical systems of the DOD and
    VA.
        Second, though it may not be intended by the military command, we
    have heard many anecdotal comments from soldiers who believed
    responding affirmatively to any of the questions on this tool would
    jeopardize their career. I have no potential solutions regarding this;
    however, this may be one of the most difficult and pressing issues
    requiring attention.
        Third, it is puzzling as to why this tool was developed when there
    has been a great deal of research into various concussion tools. I
    certainly do not know all of the details in the development of this
    tool and at this point it is meaningless to discuss; other than to
    realize that in the future, greater effort should be made to seek out
    and use the state-of-the-art resources available and expend the effort
    to improve them.
        Fourth, as directed by the 2008 National Defense Authorization Act
    for pre and post-deployment testing, as well as in the combat theater
    testing, this directive does not appear to have been applied, or at
    least not fully to National Guard soldiers--as indicated by experiences
    in Michigan. This would create problems for soldiers, whose brain
    injury is not addressed as quickly as possible that could lead to
    problems with their family, holding a job, substance abuse and others.
    Additionally, it further exacerbates issues with the soldier that the
    VA must contend with.

        Question 2. Cooperation with the private sector is important to
    expand access to care. However, veterans are a unique population. What
    steps has your organization, or other private entities with which you
    may be familiar, taken to become more ``culturally literate'' with
    respect to servicemembers and veterans?
        Response. In the first sentence, it is stated that ``Cooperation
    with the private sector is important * * *'' with which I totally
    agree. Unfortunately, as I indicated in my testimony this has not been
    borne out by execution of this policy. Michigan's wealth of TBI
    rehabilitation continuum of care services has not been effectively used
    despite the relationships we have established with VISN-11 and the four
    VA medical centers. Furthermore, I believe in the testimony that I
    witnessed at the hearing that indicated that the VA was going to have a
    pilot of less than 12 veterans using services is an embarrassment. Such
    a limited number when compared to the thousands requiring services
    should be seen as unacceptable. In my judgment, if there were 12 sent
    to Michigan rehab facilities, I would see it as unacceptable.
    Furthermore, why is it that a pilot is only now being done--nearly 10
    years since the start of the conflict?
        The poly-trauma system that was created, I believe was an
    excellent, well-conceived approach to dealing with brain injuries and
    other trauma. What has not been dealt with effectively is the long-term
    rehabilitative care necessary. Appointments at a VA Medical Center
    every couple of months (or even longer) is woefully inadequate to
    providing cognitive rehabilitation. Again, let me urge that the over 35
    year history of brain injury rehabilitation and expansive network of
    care in Michigan be utilized, to demonstrate what can be done in
    assisting a soldier recover.
        In regards to our Association's being ``cultural literate'' it is
    for this very reason why Richard Briggs, Major, USAF (Retired) was
    hired. As a former U.S. Army Captain, I was keenly aware of the need to
    hire an individual with a military background to work on this issue. It
    was clear to me that the individual managing the Association's efforts
    with veterans must understand the chain of command, military
    terminology, and be able to relate to those in the military.
        Unfortunately as mentioned above, there has been nearly no
    interaction with other private facilities by the VA in the State of
    Michigan; thus, the military literacy issue has not been an issue to
    date. However, we completely agree that this will be a key component in
    the development of any relationships. We pledge our efforts to ensure
    that any such facility receives training about the military culture to
    ensure they can provide effective rehabilitation.
        Finally, Major Briggs has worked with numerous public and private
    entities on recreational activities for soldiers. As part of those
    efforts, Major Briggs has ensured that there is an understanding and
    respect for the military culture, which has won him many words of
    praise from participants. Most notable was a comment following a recent
    fishing event from a Viet Nam era veteran who commented that seeing all
    of the American and Service flags flying along the pier, as well as
    people cheering and waving made him feel that for the first time since
    he returned from Viet Nam, he was finally welcomed home!

        Question 3. Does your organization, or others with which you are
    familiar, use tele-health technologies to provide care and services to
    individuals with TBI?
        Response. Our Association has not utilized nor has there been a
    need for tele-health technologies. However, because of comments we have
    received from many of the soldiers who desire support but do not wish
    that support to be in a typical support group environment, we will be
    introducing in the third quarter of the calendar year a telephonic
    support group. This will enable a veteran to remain in their home
    (without the need to travel) and know that at a prescribed time they
    can meet with other veterans via phone (possibly video in the future)
    to receive support and provide support.
        Included with my response, I am including an outline of the TBI
    Resource Optimization Center's Brain Injury Navigator, which is being
    piloted at the current time. As shown, the purpose is to assist a
    soldier or their family with identifying needed services in or near
    where they live.
                                   conclusion
        Once again, I deeply appreciate the opportunity to address the U.S.
    Senate Committee on Veterans Affairs and to respond to these questions.
    Senator Akaka asked a very significant question during the Question and
    Answer period at the Hearing, which I did not feel I responded to in an
    adequate manner. In essence, the question was, is the VA doing a more
    effective job treating brain injury today than they were two or three
    years ago. In considering this question during the past few weeks, I
    would respond that Congress has enacted cutting edge laws and guidance
    to address the needs of veterans with a Traumatic Brain Injury. Thus,
    there has been an effort made to improve care--or, said another way,
    when there was effectively nothing to begin with, anything is better.
        However, the execution of these laws and policies remains less than
    adequate and therein is the problem that is creating the distrust,
    mistrust and futility being experienced by many veterans. The VA so
    jealously guards its Congressional mandated responsibility to care for
    our veterans; however, the sheer numbers of veterans and the limited
    number of VA medical facilities simply prohibit the VA from being able
    to carry out this responsibility properly or fully. I do not believe
    that adequate funds can be appropriated to the VA to build the needed
    facilities, staff them and operate them. Furthermore, it is highly
    unlikely there can ever be sufficient facilities so as to make them
    convenient to where veterans live. Thus, a new paradigm must be used--
    namely contracting with private providers and the VA effectively
    monitoring the delivery of care.
        Finally, allow me to reiterate my comment pertaining to TRICARE and
    its rules, which effectively sets up the VA to not be as effective as
    it could be in treating a veteran with a brain injury. It is my
    understanding that TRICARE currently operates using Medicare rules.
    Medicare rules do not address cognitive rehabilitation or long-term
    rehabilitative care and yet this is the essence to the continuum of
    care needs of the veteran. Because cognitive rehabilitation is not
    provided immediately following the time of injury, once the soldier
    leaves the active military and must use the VA system, significant time
    has elapsed. This dramatically decreases the opportunity for the
    soldier to recover skills both cognitively and emotionally that may
    have been impaired by their Traumatic Brain Injury.
        Changing the Medicare Rules to expand coverage to cognitive
    rehabilitation could be one of the quickest and most effective changes
    to providing comprehensive brain injury rehabilitation to soldiers,
    which would give them a greater opportunity to return to the quality of
    life they enjoyed prior to their military duty. I believe it would also
    lessen the demands for brain injury rehabilitation on the VA system.

    Enclosure: TBI-ROC Brain Injury Navigator
                   Enclosure--TBI-ROC Brain Injury Navigator

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman Akaka. Thank you very much, Mr. Dabbs.
        And now we will receive the statement of Dr. LaPlaca.

     STATEMENT OF MICHELLE C. LAPLACA, PH.D., ASSOCIATE PROFESSOR,
       WALLACE H. COULTER DEPARTMENT OF BIOMEDICAL ENGINEERING,
    GEORGIA INSTITUTE OF TECHNOLOGY AND EMORY UNIVERSITY, INSTITUTE
            OF BIOENGINEERING AND BIOSCIENCE, LABORATORY OF
                     NEUROENGINEERING, ATLANTA, GA

        Ms. LaPlaca. Good morning, and thank you, Mr. Chairman and
    the Committee, for the opportunity to share my thoughts and
    experience from a professor and a researcher's point of view on
    the current state of Traumatic Brain Injury research,
    diagnosis, and treatment.
        We have heard a lot about transitioning between DOD and
    Veterans Affiars. What I am going to be discussing is a
    transition that occurs before then in terms of getting the
    latest research into the clinic and to our warfighters and our
    veterans in a timely manner.
        My primary research interests, as Senator Isakson pointed
    out, are in Traumatic Brain Injury. I studied biomechanics as
    well as acute mechanisms and different treatments.
        I first became interested in the brain when I took a
    research assistant position at Walter Reed Army Institute of
    Research as a sophomore in college. The complexity of the brain
    is what intrigued me then and what still drives my enthusiasm
    today over 20 years later. Since that time, we have passed what
    NIH termed the ``Decade of the Brain,'' entered a new century
    and several military conflicts which have exposed new war-
    related health care issues.
        The advent of new protective materials, as has been noted,
    has improved survivability, and that is a wonderful thing. I
    commend the biomaterials and the engineer folks who developed
    those protective mechanisms. But they have left us with more
    injured warfighters and more disabled veterans than ever before
    to care for. So I will highlight some of the advances, some of
    which have already been noted. I will be brief.
        Collectively, TBI researchers--and that is in military labs
    as well as academic labs--have uncovered numerous cell pathways
    over the past few decades that lead to cell damage. Cells can
    be compromised in different ways. They can be injured from both
    what we are calling a traditional brain injury--a contusion--
    and from a blast. In both cases, the brain tissue itself
    undergoes deformation, although blasts produce that deformation
    at a much higher frequency. We need to learn what we can from
    existing models of brain injury because they do tell us things
    that blast injury models have yet to uncover.
        We have refocused attention on damaged receptors,
    membranes, and white matter, all of which affect cell
    communication and lead to ultimate disabled function.
        Inflammation, vascular damage, and edema are all events
    that have multiple components to them and are being revisited
    by scientists. How exactly these are related to each other and
    how they can be targeted for therapeutic intervention, however,
    is still not well understood.
        Genomics and proteomics--techniques where large numbers of
    genes and proteins can be screened--offer an enormous
    opportunity, also an enormous amount of information that must
    be analyzed using very sophisticated models. A repository of
    both experimental and clinical data would provide data sets to
    researchers to drive validation studies and generate new
    directions of research and potential treatments.
        As of today, we have no FDA-approved treatments for TBI
    itself. Most clinical interventions will stabilize symptoms,
    such as reducing intracranial pressure, and then the
    warfighter, the TBI patient goes on to rehabilitation and post-
    care. Some of the reasons for that are divided into four broad
    categories.
        One, the heterogeneity. No two Traumatic Brain Injuries are
    alike. We heard about polytrauma that is now being appreciated.
    We do not model polytrauma in the lab. This is a huge gap in
    research.
        Variables like age, underlying health, genetic make-up, and
    environment factors all affect injury outcome. One size does
    not fit all in terms of treatment or rehabilitation, and
    personalized care must be sought.
        Complexity is the number 2 reason for no treatments. Injury
    mechanisms are poorly understood and leave the question as when
    to intervene and how to intervene. Combination therapies are
    likely.
        Diagnosis is different and crude due to the heterogeneity
    and the complexity I just discussed, as well as the clinical
    classification systems. New diagnostic tools such as biomarkers
    and imaging must be worked into this classification system.
    There are poor clinical translation avenues. Most of the
    clinical trials are funded by industry; most researchers do not
    know how to translate their successful results. Clinical trials
    must be done on sound science, yet many of the successful
    experimental results are never tested in the pre-clinical
    setting.
        Last, some of the challenges that were faced as a result of
    this: continued and increased collaboration between academic,
    medical, and military training facilities in terms of medical
    care, TBI awareness and treatment strategies; programs that
    fund pre-clinical experiments; better diagnostic and uniform
    registries across the country. These need to be developed in
    parallel with point-of-care technologies and diagnostics.
        More coordination is needed between basic and clinical
    research. One of the most underutilized laboratories is the
    clinic itself. Systems engineering and informatics approach to
    handle the vast amounts of data will be needed to implement and
    decipher all of these complex data sets. And continued
    dissemination of findings and dialog among educators and the
    clinic and the VA is required.
        Clinical trials must be fast-tracked and have uniform
    injury management guidelines, as well as deal with HIPAA and
    IRB compliance. These are major hurdles in the current system.
        So, in closing, the fields of neurotrauma and trauma
    medicine are at a very exciting crossroads, and I thank the
    Committee for providing me the opportunity to share my thoughts
    on this.
        [The prepared statement of Ms. LaPlaca follows:]
    Prepared Statement of Michelle C. LaPlaca, Ph.D., Associate Professor,
       Wallace H. Coulter Department of Biomedical Engineering, Georgia
          Institute of Technology and Emory University, Institute of
         Bioengineering and Bioscience, Laboratory of Neuroengineering
        Mr. Chairman, Mr. Ranking Member, and Members of the Committee: I
    appreciate the opportunity to appear today to discuss the Department of
    Veterans' Affairs (VA) efforts to address the progress in Traumatic
    Brain Injury research, diagnosis, and treatment as it relates to
    academia-VA collaborations and ultimate clinical implementation.
    progress that has been made in understanding, diagnosing, and treating
                          traumatic brain injury (tbi)
        The annual incidence of TBI in the US is estimated at 1.5 million,
    and brain injury remains a major cause of long-term disability or
    death. Additionally, the yearly economic burden exceeds $60 billion,
    which does not include the social and emotional toll on patients,
    families, and the community. The understanding of TBI mechanisms has
    increased tremendously over the past 30 years, although this progress
    in scientific findings has not paralleled improvements in diagnosing
    and treatments for brain injured patients. Scientists have better tools
    to investigate cellular mechanisms of injury (i.e. what happens to the
    cells of the brain when they are injured) due to general advancements
    in genetics, molecular biology and biochemistry. Engineers use
    computers with much more computing power than previous generations.
    Working at the micro- and nano-levels, while unimaginable 20 years ago,
    is becoming commonplace at top research universities. Imaging
    techniques and processing capabilities has advanced quite rapidly,
    however, most hospitals do not have access to trained personnel, even
    IF they can afford the imaging equipment. These are just a few examples
    underlying improvements in TBI research and treatment.
    Understanding TBI
        The devastating events that surround a TBI are associated not only
    with the physical deformation of the brain, but also with secondary
    complications (such as inflammation, altered cellular signaling, and
    changes in gene expression--all of which affect cell function, organ
    function, and overall functional ability of the wounded). It is worthy
    to note that the high incidence of blast-related brain injuries in
    recent and ongoing US military operations has caused engineers and
    scientists to reconsider some of the animal models being used to study
    blast injury versus injury types that commonly occur in the US civilian
    population. Specifically, blast injuries occur at a much higher
    frequency than even motor vehicle accidents. The questions remain as to
    whether we can treat the basic mechanisms, learned over the past
    several decades, as the same in both populations. In addition, the
    competition among researchers--academic and military alike--in
    developing these models has been overwhelming and very unlike the
    advent of animal models developed in the 1980's and 1990's for
    concussive and diffuse brain injury.
        In both humans and animal models, complications that result from
    the primary insult (blast, head acceleration, or impact) can lead to
    cell death and progressive neurodegeneration, accompanied by prolonged
    or permanent loss of sensory, motor, and/or cognitive function. In
    order to understand the physical tolerance of neurons to traumatic
    insults, engineers and neuroscientists have attempted to reproduce the
    biomechanical environment during a traumatic event using cell, animal,
    and computer modeling. This approach allows one to begin to unravel the
    underlying injury mechanisms that lead to cell dysfunction and death as
    a function of input physics. To date, several cellular events have been
    identified that contribute to damage, such as cell membrane damage,
    imbalance of ions, abnormal release and deployment of normally
    controlled molecules, neurotransmitters, hormones, and enzymes.
    However, how these events relate to each other and how they can be
    targeted for therapeutic intervention are not well understood.
    Diagnosing TBI
        In October, 2007, the National Institute of NeurologicalDisorders
    and Stroke, with support from the Brain Injury Association of America,
    the Defense and Veterans Brain Injury Center, and the National
    Institute of Disability and Rehabilitation Research, convened a
    workshop to outline the steps needed to develop a reliable, efficient
    and valid classification system for TBI that could be used to link
    specific patterns of brain and neurovascular injury with appropriate
    therapeutic interventions. The primary system is the Glascow coma
    scale, as well as injury type, injury severity, pathoanatomy, and
    pathophysiology. It was agreed that compliant data sharing, uniform
    diagnostic criteria, and sophisticated modeling (prognostic modeling,
    informatics-based analyses, and more personalized diagnostics) are
    reasonable approaches to better stratifying patients. Success of the
    proposed changes, however, will require large center trials,
    integration of systems informatics to the neurotrauma field, and
    cooperation between academic and VA researchers.
        On the advent of diagnostic techniques are biomarkers. Biomarkers
    are substances released in to the blood stream at high levels that may
    be associated with a particular type of lesion/region affected. The
    process is analogous to the blood tests given to help diagnosis heart
    attack severity.
    Treating TBI--Current Clinical Therapies
        Unfortunately, the current clinical treatments for TBI are very
    limited. Emergency care primarily addresses the acute physiological
    responses (e.g., controlling elevations in intracranial pressure and
    cerebral perfusion pressure) and long-term therapies are largely
    palliative measures. A large number of pharmacological therapies have
    gone to clinical trials for TBI; however, such treatments either focus
    on a single signaling cascade or the target spectrum has collateral
    detrimental effects systemically and have failed in clinical trials. As
    there are currently no FDA-approved therapeutic interventions for the
    treatment of TBI, developing efficacious treatment strategies remains
    an important research priority. TBI initiates an abundant number of
    highly complex molecular signaling pathways; thus, a multifaceted
    therapy is required to attenuate the degenerating injury environment.
    Other current clinical trials include therapies aimed at hindering the
    inflammatory response and provide neuroprotective effects, such as
    acute hypothermia (Adelson et al. 2005; Davies 2005), and early
    administration of erythropoietin (Grasso et al. 2007), progesterone
    (Wright et al. 2005), and citicoline (Calatayud Maldonado et al. 1991).
    Moreover, clinical trials are also evaluating pharmaceutical therapies
    for post-TBI behavioral issues, such as depression, irritation, and
    aggression. Sertraline, a selective serotonin reuptake inhibitor, is
    one example of this treatment that addresses behavioral disorders that
    persist after a TBI (Fann et al. 2001; Zafonte et al. 2002). Each of
    these treatment modalities target specific events that occur after
    injury. Indeed, recent clinical advances using combination therapy,
    such as Highly Active Antiretroviral Therapy (HAART) to treat AIDS or
    in metastatic breast cancer, lend credence to this approach.
    Combination therapies for TBI is a relatively new approach only
    recently gaining acceptance. Their discovery may significantly shift
    clinical practice to target the underlying pathology rather than
    relying on surgical or symptomatic (i.e. intracranial pressure)
    management.
        Given the complex and dynamic injury environment and interactions
    among secondary injury mechanisms, it is likely, if not required, that
    multiple agents will be needed to provide neuroprotection after TBI.
    Neuroprotection refers to the ability to SAVE cells. Repair and
    regeneration cannot provide their maximal benefit if the environment of
    the injured brain is not stabilized and receptive to regeneration.
    However, testing drug combinations is challenging given the
    combinatorial explosion of formulations. A traditional study may choose
    to test only two drugs, but such a strategy could easily miss more
    effective combinations and is essentially a fishing-expedition in a
    very tiny bucket. As an alternative, we have proposes a highly
    systematic, rigorous statistical approach to sample from a larger pool
    of literature-based candidates, whereby providing predictive capability
    for evaluation in vivo, streamlining the route to pre-clinical and
    clinical trials. The following categories of secondary damage have been
    selected, based on a wide literature search: 1) acute damage and
    excitotoxicity, 2) free radical damage and compromised energetics, and
    3) inflammation. This is an example of a research approach that will
    operate out of the box and will hopefully be an example for others to
    follow on the path to translational discovery in neurotrauma. For
    example, novel combinations of FDA-approved drugs may be discovered,
    which could be fast-tracked into the clinic. These results will require
    non-biased dissemination, as well as a robust analysis platform.
        Summarizing some of the top reasons why we don't have more options
    to treat TBI highlights the complexity faced and underlines the need
    for more cooperation and collaboration:

        1) Heterogeneity of injuries between patients and within the brain
    means that one size will not fit all patients in terms of treatment or
    rehabilitation;
        2) Injury mechanisms are poorly understood, due to the complexity
    of the brain microenvironment;
        3) TBI changes over time (primary versus secondary mechanisms;
    propensity to sudden onset neurodegenerative disease; complication with
    aging and other health issues), leaving the question as to when to
    intervene and how often;
        4) Polytrauma, or trauma to many bodily systems (physiological and
    psychological), is commonplace, but not well studied, complicating
    research findings, diagnosis and treatment
        5) The classification system (GCS and experimental) and the
    diagnosis systems are variable and crude;
        6) No effective treatments exist clinically and we (all researchers
    and clinicians) need better avenues for collaboration and clinical
    translation;
        7) It is unclear what are the right treatment target(s) to focus
    on? For example, is it neuroprotection versus repair versus
    regeneration versus replacement?
            experience in collaborating with va on tbi research and
                      implementation of research findings
        I have limited experience collaborating with the VA in Atlanta. The
    Atlanta VAMC Rehabilitation R&D Center of Excellence has recently
    undergone some restructuring and this will prompt reorganization and/or
    priorities shifting. The investigator and clinical staff have been
    extremely supportive and encouraging in navigating the system in order
    to find the right collaborators and passing along funding
    opportunities. I plan to submit to the fall cycle and in parallel seek
    a partial appointment at the VA. In addition to these plans, the
    Veterans' Innovation Center (VIC) (www.hinri.com) is an excellent
    example of local enthusiasm and timeliness. I commend Senator Isakson
    for his support of this initiative.
        My impression is that the VA scientists are eager to collaborate
    with academic institutions and vis versa. There are several issues that
    hinder this process. The VA has a highly specialized and secured
    computer network. Virtual, secure data rooms may be a solution to the
    difficulty in communication and data sharing. There are different types
    of bureaucracy, but each is poorly understood by the other party.
        Federal money for TBI research seems to be in silos, making cross-
    institutional and cross-agency collaboration difficult. It is my
    perception that TBI research finding within the Department of Defense
    is not shared with non-military institutions and vis versa, unless
    published in the public domain. The notion that upper-level review
    committees will match qualified grant applicants to appropriate
    researchers within military research institutions is nice in theory,
    but the most successful collaborations come from the ground up, not
    top-down. Conferences and other venues for data sharing need to include
    both civilian and military research sharing. Without this, the
    relationships will not develop and the collaboration success will move
    at a snail's pace.
                            challenges of the future
        Below are a summary of challenges that face researchers and
    clinicians, together with suggestions for improvement:

        1) Cooperation between academic, medical, and military training
    facilities in terms of TBI awareness and care;
        2) Better diagnostics--biomarkers--imaging--uniform registries
    across Level 1 Trauma Centers;
        3) Platforms for deploying small, inexpensive diagnostic ``kits''
    to smaller hospitals and portable/temporary medical units--i.e. no
    large equipment, easy steps, stable at a range of environment
    conditions;
        4) Many more and uniformed programs to filter research findings in
    an unbiased manner. In other words, beyond open access journals, the
    mere volume of scientific papers published limits investigators.
    Government databases with secure access that are professional designed
    to maximize dissemination and interpretation of published work;
        5) Programs that encourage and fund pre-clinical experiments with
    large numbers of interventions (pharmaceuticals, biologics) and in
    combinations that provide widespread screening, rather that narrow
    investigations that don't take into consideration the complexity of
    TBI;
        6) Cross-agency collaborative funding mechanisms designed for data
    sharing, uniform financial and administrative responsibility, and
    shared resources;
        7) Proactive involvement of informatics and information science to
    consolidate and analyze large and diverse data sets from basic lab
    studies to pre-clinical studies to clinical trials. The advent of
    traumanomics--to follow along with the ``--omic'' nomenclature adopted
    in the 21st Century--is relatively new, but yet few investigators
    understand or appreciate the necessity to use unbiased statistical and
    multilevel modeling. Freely providing data to such ``number crunching''
    efforts goes against the culture of publications;
        8) Open dissemination of findings, including unpublished data and
    protocols;
        9) Open dialog among educators, policymakers, clinical leadership,
    and research directors.

        In closing, the fields of neurotrauma and trauma medicine are at a
    very exciting crossroads. We have learned so much about injury
    mechanisms and are beginning to appreciate the complexity and wide
    variety of pathologies associated with TBI. Successful implementation
    of the findings is possible, providing cooperation is focused on the
    patient or warfighter/veteran. I thank the Committee for providing me
    the opportunity to share my experience and recommendations on TBI with
    respect to veteran's healthcare.
                                     ______

    Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to
      Michelle C. LaPlaca, Ph.D., Associate Professor, Wallace H. Coulter
     Department of Biomedical Engineering, Georgia Institute of Technology
        Question 1. Please elaborate on the long-term effects of adopting
    combination therapies, in terms of improving treatment and management
    of TBI.
        Response. The long-term effects of adopting combination therapies
    is unknown, however, this is true of many treatment in clinical
    practice today. The FDA has a responsibility to enforce regulations for
    any therapy in which the risks are minimal compared to the potential
    benefits. Furthermore, even if more than one drug is given (the
    definition of a combination therapy in the context of the hearing
    discussion), the effects rely on the target(s), the duration of action,
    and the interaction with other physiological systems. For example, one
    drug may act on many targets and may be beneficial, while two drugs--
    each with a narrow function--may affect two specific targets, and not
    have the ``magnitude'' of effects that the single drug has. Therefore,
    the challenge is similar that that of translating a single drug to
    market, with the additional burden of dosing for each individual drug
    and the potential drug interactions at each dose that may affect
    ultimate function (in other words, a more complex pharmacokinetics
    analysis).
        In the best case, the long-term effects of combination therapies
    are that overall function is improved and therefore, fewer
    complications arise, such as continued memory loss. The potential
    danger is that an acute therapy--whether a single agent or
    combination--may result in side effects that are detrimental, such as
    saving cells that are dysfunctional. The reality is somewhere in
    between these extremes. Many of the drugs that are being considered
    pre-clinically and clinically are aimed at protecting cells and halting
    the progression of tissue damage. The premise here is that saving cells
    in the early period will preserve nerve function within the brain and
    reduce aberrant nervous system control of systems such as motor,
    sensory, cardiovascular, renal, etc. The benefit of most drugs under
    consideration for early intervention is that they are ``short-acting'',
    meaning that long-term side effects are unlikely. The ``window'' of
    delivery is very important, however, since we want to have available
    interventions that will be effective past the acute period. It is
    generally thought that the more delayed a neuroprotective agent is
    given the less effect it will have (presumably since more cells are
    dead by then and there are less that need to be ``rescued''), but this
    is a subject that deserves further study. A potential benefit of the
    ``combination approach'' is that different drugs or drug combinations
    could be given at different times, depending on variables such as time
    since injury, age, other health issues, responsiveness to a particular
    therapy, and other individual factors. In the case of delayed treatment
    (days, weeks, months post-injury), a neuroprotective approach may be
    mute, as cell death, although ongoing, has slowed. Here combinations of
    drugs that augment residual function and/or encourage regeneration are
    possible, as is the combination of drug therapy with occupational and
    other rehabilitative interventions.
        In summary, combination therapy is an avenue worthy of
    investigation, given that TBI is a complex disorder, and it is unlikely
    that there will be a ``magic bullet'' that corresponds to a single
    treatment. Given the complexity of TBI and of the pharmacology involved
    in combining drugs with different (or overlapping) mechanisms of
    action, it is necessary to approach the study of such approaches with
    rational studies and analyses.
        See attached article summarizing the combination therapy approach
    for TBI. Marguiles et al. Combination Therapies for Traumatic Brain
    Injury: Prospective Considerations Journal of Neurotrauma; Vol 26: 925-
    939, June 2009. (Attachment 1)

        Question 2. Is there a benefit to continuing rehabilitation
    therapy, with the goal of maintaining a current level of functioning,
    for those with severe TBI for whom no further gains in functioning are
    expected?
        Response. Yes, there may be benefit for continued rehabilitation
    therapy even is no further gains are expected. As an individual ages,
    loss of function may become more pronounced, and therefore a cessation
    of therapy could cause rapid decline. Even if no gains in functioning
    are expected, the maintenance of function is crucial for day-to-day
    living, and will reduce caregiver burden and additional long-term
    health decline. If those with severe TBI are not mobile and cannot
    carryout routine hygiene care, however, then continued rehabilitation
    in a VA hospital or nursing home setting may not benefit the
    individual. The quality of life should be considered for those who are
    not on life support, but are still bed- or home-bound. In addition to
    routine care to avoid infections (e.g., weight shifting, turning to
    avoid bed ulcers, etc.) and blood clots (e.g., passive leg and trunk
    movement), other types of therapy should be considered. Sensory stimuli
    such as touch (e.g., massage, grooming), sound and visual therapy, and
    companionship can have beneficial effects on psychological states as
    well as physiological wellness. Home therapies that are simplified
    version of in-patient rehabilitation warrant study, as there is cost
    savings for the VA system in both short term patient satisfaction and
    long-term health costs and needs. And, while the chance for recovery of
    function declines with age and with time from the original injury, it
    is not impossible. Intensive early therapy (according to clinical
    guidelines for appropriate delay from time of injury and rest) should
    be considered for motor, sensory, and cognitive rehabilitation. An
    effort to treat the entire TBI patient and not just the symptom(s),
    throughout a person's life, will be the most beneficial approach.
        See attached article for opinion about therapies for TBI. There is
    a section about the use of rehabilitation as a treatment (p. 15,
    section 7.7). Xiong et al. Emerging treatments for Traumatic Brain
    Injury. Expert Opin Emerg Drugs.; Vol 14 (issue 1): 67-84, March 2009.
    (Attachment 2)

        Question 3. In her testimony, Mrs. Bohlinger discussed the
    importance of brain imaging to improve the accuracy of TBI screening.
    From your perspective, what new imaging technologies are being
    developed or should be adopted by VA?
        Response. Brain imaging advances have been made in the past decade
    that can contribute to TBI screening, diagnosis, and outcome
    monitoring. Although brain imaging is beyond my area of expertise, I am
    aware that diffusion tensor imaging (or DTI) is an improvement over
    other methods in detecting edema as well as some structural defects. I
    believe that in the current form, DTI (or other imaging techniques)
    will be best used for diagnosis and outcome monitoring, not screening
    per se. It is currently too expensive for screening and the
    availability is limited. Following further evaluation and validation of
    imaging as an effective diagnostic tool, portable versions should be
    further developed and deployed in the military and to facilities that
    do not have the space or money to install large imaging equipment. The
    rationale is that something is better than nothing, but that the
    utility of imaging, either alone or with other diagnostic tools, has to
    be systemically and rigorously tested. It is my understanding that many
    facilities have expensive imaging equipment, but do not have trained
    personnel. There is a danger in non-experts interpreting clinical
    imaging scans. Therefore, a large need exists for more training, as
    well as standardized protocols before imaging can be routinely used on
    a widespread basis. There are several centers across the country that
    have the expertise in TBI imaging (for example, UCLA, Univ.
    Pennsylvania, among others). Standard of care in Level 1 Trauma Centers
    should be established, followed by training in other Centers with
    existing equipment. See the attached article for further comments on
    the classification of TBI, which include imaging as a potential future
    tool.
        See the attached review article for more about the future of
    imaging (and other issues) for TBI. Saatman et al., Classification of
    Traumatic Brain Injury for Targeted Therapies. Journal of Neurotrauma
    Vol 25, p. 719-738, July 2008. (Attachment 3)
                                  Attachment 1

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman Akaka. Thank you very much, Dr. LaPlaca.
        This question is for all the witnesses. You can answer it
    in one word or a brief comment. It is my view that VA care for
    TBI has dramatically improved since the start of the war in
    Iraq. My simple question to you is: Do you share that view?
        [Ms. Bohlinger nodding affirmatively.]
        Chairman Akaka. Ms. Bohlinger says yes.
        Mr. Barrs?
        Mr. Barrs. Yes, sir.
        Chairman Akaka. Dr. Gans?
        Dr. Gans. Yes, it has.
        Mr. Dabbs. I would tend to agree.
        Ms. LaPlaca. I would agree.
        Chairman Akaka. Now, Ms. Bohlinger, you mentioned the
    importance of family, family involvement in treatment, and I
    certainly agree with you. As the mother of a veteran with TBI,
    and as a family caregiver, what services and support have been
    most important to you in helping to care for your son?
        Ms. Bohlinger. I would say, Mr. Chairman, the most
    important has been the TBI group on an ongoing basis, because
    what it does is give him real people to be around. His life is
    very isolated now, and even the telemedicine, while that is
    going to be really important, for some of these individuals
    their worlds have become so small that they do not get much
    person-to-person contact.
        So I would say that group setting has been helpful. They
    just need to schedule it at a time that is convenient for the
    veteran.
        Chairman Akaka. What services did you not receive that
    would have been helpful?
        Ms. Bohlinger. Services that I did not receive would
    include the scan when that was requested, because I knew the
    other assessments were not correct. Services for me, you know,
    it is wearing. I am emotionally, physically, financially
    exhausted after 5 years. When we talked about integrating
    family members in our situation, that is not going on yet. They
    set up separate groups. Then they used information, very candid
    information that we gave, and then went to our loved one and
    told him, which undermined trust. So you can imagine then
    having to create another bridge to get back with your loved one
    and have him trust you.
        Really, it just all needs to be together. It needs to all
    be together.
        Chairman Akaka. Thank you.
        Mr. Dabbs, you mentioned that in VISN-11 only three
    veterans have been referred to private care by VA. Do you have
    any sense of why this is the case or how many other veterans
    could benefit by increasing referrals?
        Mr. Dabbs. Yes, sir. I think as it pertains to your
    question and in answer to this one as well, the VA has made
    significant strides of improving care, but I believe, at least
    what we are seeing in Michigan, that there is total inadequate
    resources available within the VA to be able to execute that
    care for the numbers of people involved. Therein lies the
    problem. I think it speaks a bit to Dr. Gans' point a moment
    ago where he indicated that there is a very finite number of
    people who work in the field of brain injury and brain injury
    rehabilitation. The VA does not have them. The private sector
    does not have them. It means that it is more critical than ever
    that the two work together closely to be able to provide this
    care that is needed.
        Chairman Akaka. Thank you.
        Dr. LaPlaca, while I am a strong supporter of VA research,
    your testimony about the difficulty you have had in cooperating
    with VA is unfortunate. What benefits would you expect to see
    if you were able to work more closely with VA?
        Ms. LaPlaca. Thank you for the question. It is a very
    important issue. There are many successful research
    collaborations between academic professors and VA researchers,
    and there is a lot of encouragement to do so. So although I
    have had some frustration at the level between myself and other
    researchers, there is a lot of enthusiasm to share ideas, share
    research resources.
        I think an added benefit for me is to have more exposure to
    the patient. The VA researchers have a more realistic idea of
    the needs and how that can trickle down and what needs to drive
    our research.
        I think the main problem is that there is bureaucracy.
    There are a lot of IT issues. You know, computers cannot come
    out of the VA, so data sharing has to be done pretty much
    offsite, which requires approval. There are hurdles like that
    which are just--that part of it is frustrating, but it is
    possible. The VA system has made it possible for academic
    researchers to have appointments within the system and compete
    for VA merit grants. But it is not widespread, and it can be
    difficult.
        Chairman Akaka. Thank you very much.
        Senator Tester?
        Senator Tester. Thank you, Mr. Chairman.
        I think it is important to point out before I get into my
    questions that the previous panel stuck around--and I want to
    thank them for that--to listen to the comments of this panel. I
    very much appreciate that, and I appreciate your commitment.
        I want to start with Ms. Bohlinger. You talked about the
    fact that your son is a rural kid living in Seattle in an urban
    area, and it is just impossible to get them back to the State.
    What would the VA have to do to be able to allow you to bring
    your son back to a State like Montana?
        Ms. Bohlinger. Well, I would like to see a polytrauma
    center, because he goes in twice a week still for services, and
    we do not have those services available. His medical team is
    important.
        Senator Tester. So if a polytrauma center was set up, that
    would take care of it.
        Ms. Bohlinger. Yes.
        Senator Tester. OK. One of the things that I think is very
    important is everybody has equal access, and you talked about
    in your opening remarks that you got different treatment as--I
    will just say ``as a regular person'' than as the Second Lady
    of Montana. Could you tell me what the difference was? Can you
    give me an example of how it was different? Because it should
    not have been. It should not have been different for you or me
    or anybody in the audience. The level of respect and treatment
    should be the same.
        Ms. Bohlinger. An example would be when I was led through a
    particular center, I was able to talk with certain veterans
    only. I went back on my own time to talk to whoever I wanted
    to, and the other veterans that they steered me away from, they
    said, ``Oh, no, you cannot go in that door; that gentleman is
    having issues,'' I went back and talked to people and found out
    what they were really experiencing.
        Senator Tester. OK. Dr. LaPlaca, you talked about--and I am
    not a researcher. I am not an M.D. I majored in music, not in
    science, so this is out of my area. You talked about how you
    could not duplicate polytrauma in the law. I do not want to put
    words in your mouth, but that is what I heard you say.
        Is that because we have not tried, or is that because it
    just cannot be done?
        Ms. LaPlaca. No, let me rephrase that. Perhaps I misspoke.
    I said it is not studied in the laboratory.
        Senator Tester. OK.
        Ms. LaPlaca. It is not a common--our injuries that we study
    are very homogeneous, not heterogeneous like the real
    population.
        Senator Tester. Would it be your advocacy then that we head
    in that direction?
        Ms. LaPlaca. I think it is going to be very important. I
    think there will be some hesitation to do that because even
    studying an isolated brain injury alone is so complex that I
    think it scares most researchers to think, OK, well, let us
    add, you know, a leg injury or a lung injury to that.
        However, I think we have to bite the bullet, and we have to
    move forward in that direction in order to--I mean, a drug that
    works on a brain injury may not work or may be adverse to give
    to a patient who has multiple thoracic injuries.
        Senator Tester. OK. Thank you very much.
        I want to thank everybody on the panel today for being here
    and sharing your time and your stories and your vision with us.
    Thank you very much.
        Thank you, Mr. Chairman.
        Chairman Akaka. Thank you very much, Senator Tester.
        Senator Brown?

                   STATEMENT OF HON. SCOTT P. BROWN,
                    U.S. SENATOR FROM MASSACHUSETTS

        Senator Brown of Massachusetts. Thank you, Mr. Chairman. I
    appreciate your patience with me running around today. I have a
    bunch of different hearings, so thank you. And thank you to the
    panel.
        Jonathan, in dealing with your situation--first of all,
    thank you for your service and your sacrifice. I know you are
    dealing with trying to get your life back on track. What can
    you tell me that would help other soldiers who are in similar
    situations? Because in reading about you and having my team
    brief me, it seems to me the biggest problem was time and the
    fact that it moved like molasses. You always felt like you were
    in quicksand trying to get the answers, trying, you know, to
    get help, trying to get services. I was hoping you could tell
    us what would be something that we could do and make
    recommendations to the appropriate agencies?
        Mr. Barrs. Thank you, sir. I would say when I first got out
    I was still--I guess as you can say, I can meet a new person,
    it is OK, because, you know, you got new guys coming in the
    Marine Corps all the time. And like I said in one of my
    statements, I just started getting treatment for my TBI. That
    was last month. I think if they were to be faster with it, it
    would be--I cannot think of the word.
        Senator Brown of Massachusetts. Better results? Quicker
    results?
        Mr. Barrs. Along that track, and also you would be able to,
    I guess, talk to somebody and let them know, because hearing
    Mrs. Bohlinger talk about her son, I actually know what she is
    talking about. I am not very good at meeting new people, and I
    am isolated. I do not just speak for myself. I think it is for
    everybody else out there that also has this injury.
        So I think waiting on, for instance, Winston-Salem to give
    me a letter, I mean, I can wait all day for that. But when you
    got a primary care doctor, as I stated, he is more going by the
    book, what the book is telling him to do. I am asking for
    certain things. I am not asking it--well, as they say, ``I am
    not asking for my health.'' Actually, I am.
        [Laughter.]
        Ms. Bohlinger. That is OK.
        Mr. Barrs. It is just the doctors--it seems like the
    doctors I have met--I guess that is where the problem starts.
    It is like they are 9 to 5 people. You know, I am over here
    struggling wondering how I am going to get the next meal on the
    table because I have not received my VA rating yet. This guy is
    making $100,000 a year and he is just basically pushing me off.
        Senator Brown of Massachusetts. So let me ask you a
    question. When you came off of active duty, traditionally you
    get, you know, the--you get evaluated, you get determined if
    there is any type of disabilities, any injuries. Did you go
    through that exit process with your unit?
        Mr. Barrs. What happened, see, as you guys said, yes, there
    is a pre-deployment and post-deployment exam, but I can say--
    and I do not mean to sound rude--you have to realize that yes,
    I have seen combat. I know I am going to be different. And I am
    not going to write on some piece of paper, yes, I have seen
    this, yes, I have seen this, because, yes, there are
    consequences. I never wanted to get out. But--I just totally
    lost my point. I am sorry.
        Senator Brown of Massachusetts. No, that is OK, because
    what I am trying to just figure out is in my experience as a
    JAG in the military, one of the biggest problems that I
    recognize, Mr. Chairman and members of the panel, is that as a
    lawyer I look at, OK, this is the problem, how do we solve it,
    how do we make it better, how do we streamline and how do we
    get the services and access better. And not to put Jonathan on
    the spot, but what I found--and I am hoping that you all can
    address, whoever is in the room dealing with these things--is
    when the people are doing their post-deployment process and
    they are being evaluated, we need to make sure that we have--
    that every State has--the tools and resources to quickly,
    effectively, and compassionately evaluate our soldiers, because
    you are taught in the military to be macho and to be tough and
    to, you know, bite the bullet, pull up your pants, you know,
    the whole--it is the same with postpartum depression with
    women. I am hopeful that each State--and Massachusetts is a
    little bit different. We have identified it a little bit
    better. Montana is different, it seems.
        So how do we make sure that each soldier that is getting
    through with their duty is quickly and effectively evaluated?
    And is there anyone on the panel that can address that? Sir?
        Mr. Dabbs. Senator, what we have done in Michigan, Major
    Briggs has developed a great working relationship, and every
    single unit that comes back Major Briggs briefs regarding brain
    injury. Also as part of that, he briefs their families. And it
    is really--as Mrs. Bohlinger indicated earlier, it is often the
    family that is really the key person, the key group to help
    identify.
        That does not solve the screening issue or any of that, I
    realize, but I think it is the easiest step that could be
    executed immediately in almost every State of this country if
    we were to choose to do so.
        Senator Brown of Massachusetts. Well, is there a national
    plan that is, in fact, being instituted or is it being left up
    to individual States to do this? Is there a national model
    where we are saying to the States and/or the individual units,
    whether Guard, Reserve, active, ``Hey, this is what you guys
    need to do. When somebody gets home, this is going to happen.
    We are going to brief the families and let them know''--is
    there a plan like that?
        Mr. Dabbs. Sir, I am not aware of one. And let me as part
    of that thought, throw out one other point that I think the
    Committee needs to recognize. We talk about the VA, or at least
    what we have seen in Michigan, being overburdened. I got some
    figures yesterday from the Department of Military and Veterans
    Affairs of Michigan that indicate that there are over 725,000
    veterans in Michigan, and yet only 230,000 are enrolled in the
    VA. So not everyone is even taking advantage of that system,
    yet the system is already overburdened. Just overburdened.
        Senator Brown of Massachusetts. Right. Mr. Chairman, do I
    have a chance to continue on for a little bit?
        Chairman Akaka. Surely.
        Senator Brown of Massachusetts. Thank you.
        And that is one of those reasons because, you know, not
    everybody stays in the military system. They get better primary
    care coverages, obviously. And one of the biggest complaints
    that I have heard in my many, many years of serving and just
    being alive is that people do not feel that they are getting
    the best service or the most quality services from the VA as
    evidenced by what happened a few years ago.
        I know we are trying to tackle those very sensitive
    problems, but, ma'am, if I could direct my question to you.
    Thank you for your sacrifice, your family's sacrifice, and your
    son's service. You mentioned briefly the respite care that you
    have, and you have made the resources a little better for you
    to travel and go see your son and the like. And being who you
    are, you get that little extra help, which is--whatever it is,
    if it was my son, I would not care. I would go through the
    wall. It does not matter.
        What suggestions or improvements can you give to us that we
    can convey to the appropriate authorities as to how to help
    people in your situation who are affected by, you know, the
    change in their kids' lives.
        Ms. Bohlinger. Thank you for that question. I would just
    refer back quickly to what Jonathan said because I think this
    is at the core of it. It is that length of time delay. While I
    did have resources, I have spent over $180,000 of my retirement
    funds on his care.
        Senator Brown of Massachusetts. Right.
        Ms. Bohlinger. Now, that is going to be difficult at my age
    to try to make up. Frankly, I will spend it all if I need to.
    But when he said, ``I do not know where the next meal is coming
    from''--because there are no resources in between. If you do
    not have a family member who is going to pay your rent, buy
    your groceries, pay your bills, get everything taken care of
    for you, a couple of years go by, and that is a lot of money.
    And it is very stressful, if I may say this, for the individual
    because these guys are taught to be macho. Failure is not an
    option. They take the warrior creed. So then, to not only be
    dependent and know that your life has changed, but now you have
    to ask someone to, you know, buy your groceries and help you
    put food on the table because you served your country and in a
    year or two they cannot get that determination done?
        Senator Brown of Massachusetts. Right. You know, Mr.
    Chairman, one of the things I would hope that with your
    leadership we could direct and insist that we speed up the
    process, because when somebody is hurt like this and they need
    our help and resources, I feel the delay is the biggest
    obstacle. We should be able to process these soldiers quickly
    and effectively and give them the funds and care and love and
    attention that they need right away. To think that somebody is
    going a couple of years before they even get, you know,
    screened properly and properly identified in this day and age
    just blows my mind. I do not know if offline we can talk, the
    three of us, to kind of come up with a plan and get some
    guidance; try to push the buttons and put the fire under
    somebody, because it is unacceptable to me, Mr. Chairman. And I
    thank you for your allowing me to inquire.
        Ms. LaPlaca. Excuse me. May I add to that? I think there is
    another reason to speed up the time, not just in terms of these
    very important issues, but also because the injury is getting
    worse over time.
        Senator Brown of Massachusetts. The recovery time.
        Ms. LaPlaca. The window for recovery is----
        Senator Brown of Massachusetts. It gets smaller and
    smaller.
        Ms. LaPlaca. It is small. Things are ongoing. You can do
    delayed treatment, but the longer you wait, the less beneficial
    it is going to be for most veterans.
        Senator Brown of Massachusetts. That makes sense with any
    injury, and since you spoke up, how do you think the VA can
    better partner with nongovernmental health care providers to
    help in that effort?
        Ms. LaPlaca. I think more of what we are already doing in
    terms of collaboration, I think multi-agency funding mechanisms
    that require and encourage basic findings to get to the right
    level, and----
        Senator Brown of Massachusetts. But none of that is in
    place now, right, really? In reality, none of that----
        Ms. LaPlaca. No, the previous panel spoke about many
    granting programs that are in place, and the 2007
    appropriations for Traumatic Brain Injury research included
    both clinical and basic research. But I think, you know, that
    was a good boost for the community, but it needs to continue.
    We need more of it. We need more cooperation among the
    agencies.
        Senator Brown of Massachusetts. Thank you.
        Mr. Chairman, I have to get back to the other hearing now.
    Thank you.
        Chairman Akaka. Senator Brown, thank you so much for your
    questions and the responses that you received. I agree with
    you. This is why we are holding these hearings, to bring the
    different parts of our Government, including Congress and the
    Administration, together so that we can move more quickly. I
    would tell you also that we are so fortunate we have brought
    into play advanced funding to deal with this because without
    resources we cannot do it. So now it is a little easier to do
    it because we now have the possibility for better resources.
        So all of these are coming in quickly, and I expect to see
    movements faster than there has ever been before. And so with
    your experience and your recommendations, we can move more
    quickly in a concerted way.
        Mr. Dabbs, do you have a comment to make?
        Mr. Dabbs. Senator, if I may--and it may go out of the
    purview of this Committee, but I would like to at least toss
    out the idea that one of the hindrances that we have seen with
    TRICARE is that they operate under the Medicare guidelines. The
    Medicare guidelines do not provide for cognitive rehabilitation
    for long-term care, and therein lies one of the major stumbling
    points that is affecting the VA as well as DOD. So I would
    urge, if there is a way which that could be addressed, I would
    certainly be willing to share our thoughts with the Committee
    at a later date.
        Chairman Akaka. Well, with that, I ask any member of the
    panel if you want to make a closing statement as to what you
    think about what we can do. Dr. Gans?
        Dr. Gans. I would like to just add that the notion that I
    have heard from family members and those patients who are able
    to advocate for themselves is very similar to what Ms.
    Bohlinger and Jonathan Barrs have said: It is timely access and
    it is choice. Whether it is choice of staying within the VA
    Polytrauma System, which many people are very happy with and
    that is their choice, that is great, but if it is choice for
    using a facility that has certain other resources available in
    a different location or if it is choice to be closer to home
    and community--it is timeliness. The stories that I heard from
    the family members I talked about, waiting a year and fighting
    for a year to provide services, getting Members of Congress to
    help advocate on their behalf to get services provided; it is
    just not the right way to treat these folks.
        Chairman Akaka. Thank you.
        Dr. LaPlaca?
        Ms. LaPlaca. Chairman, as an engineer and as a scientist,
    we are constantly looking for innovative solutions to these
    very problems. However, I do think we need to take a look at
    home health care and simple solutions. I mean, cognitive rehab
    over a long period of time can be done in a simple manner, in
    an inexpensive manner, if it is organized and if it is part of
    these programs.
        So while people are waiting for the doctor--I mean, there
    are a lot of problems here that need to be addressed. But
    organizing these case managers and some of these transitional
    programs, it is worthwhile, in my opinion, to look for simple
    solutions that can be implemented and taken home, and that I
    think partially addresses some of the rural area problems as
    well as some of the cognitive rehabilitation that is so
    critical.
        Chairman Akaka. Let me ask a final question to Mr. Barrs
    because I think your answer and what you have been through will
    help us. I am very concerned about your testimony that you were
    twice exposed to IED blasts in your first tour, but were not
    screened for TBI until late 2008. In the interim, you were sent
    back for a second tour without proper treatment. Were you ever
    told why it took so long for you to be screened and treated?
        Mr. Barrs. Mr. Chairman, when I was in Iraq for my first
    tour, we were at this train station that we were building up,
    so we did not really have that much to work with. And I had in
    my statement that I had to go to another FOB, also known as the
    Forward Operating Base, because of excessive weight loss. I was
    puking every day. I could not hold anything down. I lost
    approximately 40 pounds in 2 weeks. That was my biggest issue
    then, I guess. And because we had really nobody--I never really
    noticed that I had glass in my head until I got back to the
    FOB. I took off my Kevlar, and then when I ran my fingers
    through my hair, that is when I noticed it. So I did not really
    say anything before then. I am still walking. You know, the
    good Lord kept me alive, so I was just, like, OK.
        And the second blast, it was noted though it was never put
    into my medical record. The corpsman just checked me out and I
    never said anything on my, you know, post-deployment/pre-
    deployment stuff because I am a U.S. Marine. I am not going to
    argue. The only thing that really got it started was I had
    these horrible migraines, and finally it took several BAS
    appointments just to get looked at for migraines; and as soon
    as that hit, I really did not have time to think. It was
    appointment, appointment, OK, you are out of the Marine Corps
    now.
        So it could have been, you know, it could be my fault, too,
    that it was not done quickly. But like I said, I am a U.S.
    Marine, and I am not going to argue about what I do.
        Chairman Akaka. Thank you very much, Mr. Barrs. I asked
    that because we need to deal with some of these delays that
    have occurred and improve our system.
        I believe that together we have made important strides in
    caring for veterans with TBI. VA has dramatically improved
    services for these veterans. We are learning more each day
    about how to screen, diagnose, and treat this signature wound
    of the current wars. I thank the VA employees and providers
    throughout the entire VA system for making this possible.
    However, as long as we have any veterans with undiagnosed TBI,
    partnerships with community providers left untapped, or
    research left unused, there is still work to do.
        I will conclude by thanking all of our witnesses for your
    testimony today. Your insights, without question, have been
    helpful in better understanding the state of TBI care. I
    especially thank Mr. Barrs for his service and his sacrifice.
    Also, Mrs. Bohlinger, I thank you and thank your son for his
    service, as well.
        Finally, I again acknowledge and commend the roughly
    280,000 VA employees who choose to work for veterans and their
    families. As many of you know, this is Public Service
    Recognition Week, an ideal opportunity to recognize and thank
    those who serve our former servicemembers with such dedication
    and commitment. I offer you our gratitude.
        Thank you very much, and thank you for this great hearing.
    This hearing is now adjourned.
        [Whereupon, at 12:06 p.m., the Committee was adjourned.]
                                A P P E N D I X

                                  ----------

           Prepared Statement of Sarah Wade, Wounded Warrior Project
        Chairman Akaka, Ranking Member Burr and Members of the Committee,
    Thank you for inviting Wounded Warrior Project (WWP) to provide a
    perspective on the Department of Veterans Affairs (VA) efforts to
    respond to the rehabilitation needs of veterans with Traumatic Brain
    Injury.
        Through our extensive work both with servicemembers and veterans
    who have sustained severe Traumatic Brain Injuries, and with their
    family caregivers, Wounded Warrior Project brings a keen appreciation
    of VA's critically important role in the care and rehabilitation of
    these warriors. I've had the opportunity to work with many of these
    families, and will attempt to include their experiences as well as my
    own into our testimony.
        My husband Ted sustained a severe Traumatic Brain Injury in
    February 2004 as a result of an IED while serving in Operation Iraqi
    Freedom. Given the gravity of his injuries, we were told it was
    doubtful Ted would survive, and were approached with the option to
    withdraw care. Ted did pull through, but remained in a coma for two
    more months. Ted is alive today because of the extraordinary
    neurosurgical care he received. No one ever questioned doing the costly
    surgeries that saved Ted's life. In fact, because Ted's case was so
    complicated, the Army arranged for the surgeries to be performed by
    experts at a German university hospital, and later Walter Reed brought
    in an outside neurologist to provide care.
        We had been told that it was highly unlikely that Ted would ever
    function at a higher level. In fact, he is living far more
    independently and functioning at a far higher level than many would
    have imagined because of the outstanding rehabilitative care he got
    later. But, in contrast to the Army's ``exhaust-all-possibilities''
    approach, I've had to fight over the years to get VA to authorize many
    of the rehabilitative services that have truly made a difference,
    enabling Ted to live in the community and to continue to progress.
        VA has certainly made very substantial strides in responding to the
    treatment and rehabilitative needs of veterans with severe TBI. Among
    its very important achievements are the build-out of a polytrauma
    network, the establishment of OEF/OIF coordinators and Federal Recovery
    Coordinators, and more frequent use of fee-basis and contracting
    authority. But notwithstanding very real and tangible institutional
    changes and compassionate care provided by many, many dedicated
    clinical staff, there remain troubling gaps. We deeply appreciate the
    Committee's concern with closing those gaps, and ensuring these
    veterans the opportunity to realize the highest level of independence
    and functioning they can attain.
     gaps in va rehabilitative services for veterans with traumatic brain
                                     injury
        As you know, Mr. Chairman, our troops have sustained relatively few
    casualties in Operation Enduring Freedom (OEF) and Operation Iraqi
    Freedom (OIF), and servicemembers who would likely not have survived in
    previous conflicts are returning home with unprecedented complex,
    severe injuries. Some 1,500 have sustained a severe TBI since
    October 2001.\1\ Many of these young men and women will require
    assistance for life, ranging from total care for the most basic needs,
    to supports for semi-independent living.
    ---------------------------------------------------------------------------
        \1\ Defense and Veterans Brain Injury Center, http://www.dvbic.org/
    TBI-Numbers.aspx
    ---------------------------------------------------------------------------
        Veteran-centered care: Each case of Traumatic Brain Injury is
    unique. Depending on the site of the injury and other factors, patients
    may experience a wide range of medical and related physical effects--
    from profound neurological deficits, to problems with speaking, vision,
    eating, incontinence, etc.--as well as dramatic behavioral symptoms and
    cognitive deficits. As VA clinicians themselves recognize, it is
    difficult to predict a person's ultimate level of recovery.\2\ But to
    be effective in helping an individual recover from a brain injury and
    return to a life as independent and productive as possible,
    rehabilitation must be targeted to the specific needs of the individual
    patient. In VA parlance, rehabilitation must be ``veteran-centered.''
    This simple principle is a critical touchstone by which to gauge VA's
    progress in TBI care. Is VA providing ``veteran-centered TBI care?'' We
    see progress; but the system does not live up to the VA's claim of
    ``world class'' service,\3\ in our view. Let me highlight some of the
    critical gaps.
    ---------------------------------------------------------------------------
        \2\ Sharon M. Benedict, Ph.D., ``Polytrauma Rehabilitation Family
    Education Manual,'' Department of Veterans Affairs Polytrauma
    Rehabilitation Center, McGuire VA Medical Center, Richmond, Virginia;
    http://saa.dva.state.wi.us/Docs/TBI/Family_Ed_Manual112007.pdf
    (accessed April 27, 2010).
        \3\ Eric K. Shinseki, Secretary of Veterans Affairs to the
    Honorable Daniel Akaka, Chairman, Committee on Veterans' Affairs, U.S.
    Senate, 23 March 2010.
    ---------------------------------------------------------------------------
    Access to the right services:
        Given that every case of TBI is unique and each patient's care and
    rehabilitative needs differ, it is unrealistic to believe that every VA
    medical center, or even most, can have the needed range of expertise
    ``in-house'' to meet the wide-ranging, often complex needs of all TBI
    patients. WWP's experience is that even the over 100 VA facilities that
    have received additional staffing, equipment and training and
    constitute its TBI/Polytrauma System of Care are not fully equipped to
    provide the wide range of services TBI patients need.
        Even a facility with the most well equipped, well-staffed
    rehabilitation service may not be the right setting for some TBI
    patients. A young veteran who needs help with community reintegration
    and relearning basic life skills cannot be expected to make meaningful
    gains in a geriatric facility. Too often, VA TBI care for OEF/OIF
    veterans is not age-appropriate.
        Unlike the Army's willingness to bring in outside experts when it
    was not fully prepared to meet Ted's clinical needs, my own experience
    and that of other families is that VA facilities have been much less
    open to acknowledge limitations in expertise or lack of options when
    they exist and to offer alternatives that might produce better
    outcomes. We have noted that with greater congressional focus on the
    issue, VA has demonstrated greater openness to authorizing non-VA
    sources to provide rehab services that are not available at, or cannot
    feasibly be provided, through VA facilities. But surely in a veteran-
    centered system of care a patient's spouse would not have to take the
    lead on researching how best to meet her husband's rehabilitative needs
    and have to press to get those services approved. And as the examples
    cited below reflect, a more veteran-centered system would not so
    routinely reject such requests.
    Individualized Rehabilitation Plans:
        VA has advised this Committee that ``[a]n individualized
    rehabilitation and community reintegration plan is developed for every
    Veteran and active duty Servicemember who requires ongoing
    rehabilitation care for TBI;'' VA has also reported to you that ``[t]he
    patient and family participate in development of the treatment plan and
    receive a copy of the plan from the care coordinator.'' \4\ Of course,
    VA is required by law to develop such plans, engage family and veteran
    in the plan's development, and provide copies of the plan to the
    veteran and family.\5\ But caregivers with whom I've worked closely
    have never seen a rehabilitation plan, and--while they acknowledge that
    VA clinicians may develop a plan--they report that they have not been
    afforded an opportunity to play a role in its development. I have seen
    a VA document that was described to me as a veteran's TBI rehab plan
    but was little more than a list of the services VA would be providing
    or had authorized. In contrast, the law makes it clear that these plans
    are to include rehabilitative objectives for improving the physical,
    cognitive, and vocational functioning of the individual with the goal
    of maximizing the independence and reintegration of such individual
    into the community.\6\ It is critical, in our view, that those rehab
    objectives are clearly identified, and that the veteran and family are
    active participants in setting those objectives and in identifying the
    specific treatments and services to be provided to achieve those
    objectives. Effective rehabilitation requires that providers, patients
    and their families work together to achieve the best possible outcomes.
    That must start with rehabilitation planning. Veteran-centered
    rehabilitation demands no less.
    ---------------------------------------------------------------------------
        \4\ Id.
        \5\ 38 U.S.C. sec. 1710C.
        \6\ 38 U.S.C. sec. 1710C(b)(1).
    ---------------------------------------------------------------------------
    Effectiveness of case-management and care-coordination:
        The Federal Recovery Coordination Program has proven an exceptional
    initiative in assisting many who were severely injured in Iraq and
    Afghanistan, and their families, to access needed care, services, and
    benefits. It has been especially important for veterans with multiple
    complex needs, such as those with severe TBI. But as the program was
    not established until 2007, many who were severely wounded earlier in
    the war and who are still struggling years after their injuries, lack
    this singular support. In all, only about 460 warriors have Federal
    Recovery Coordinators (FRC's). There is a clear need to augment the
    number of FRC's assigned to help wounded warriors, particularly those
    with the complex needs associated with a severe brain injury.
        But as helpful as FRCs have been in removing barriers to services,
    having an FRC does not solve all problems. Not all case-managers and
    care-coordinators necessarily have experience with brain injury. And as
    FRC's are for the most part located at a handful of key DOD acute-care
    facilities, these individuals are generally not familiar with the
    resources in the veteran's community. Given deep resistance at many VA
    facilities to draw on community expertise, the FRC's limited ability to
    navigate locally is concerning. But an even more fundamental, troubling
    issue is the deeply engrained culture of ``no'' that too often
    confronts veterans and their advocates, whether parents, spouses, or
    care-coordinators attempting to meet the veteran's needs. Too often, VA
    facilities do not seem hesitant to say ``no'' to FRCs.
        In short, the individual case-management assistance afforded by an
    FRC is no substitute for more thorough-going system changes.
    Scope and duration of rehabilitative services:
        While many VA facilities have dedicated rehabilitation physicians,
    therapists and other specialists, the scope of services actually
    provided these veterans is often limited, both in duration and in the
    range of services VA will provide or authorize. Such barriers
    needlessly constrain rehabilitative and long-term care options, and as
    a result, prevent too many veterans with severe TBI from attaining
    their goal of continued recovery and maximum quality of life.
        The literature indicates that some people make a good recovery
    after suffering a severe TBI. But many have considerable difficulty
    with community integration even after undergoing rehabilitative care,
    and may need further services and supports.\7\ But it is all too common
    for families--reliant on VA to help a loved one recover after
    sustaining a severe Traumatic Brain Injury--to be told that VA can no
    longer provide a particular service because the veteran is no longer
    making significant progress. Imagine the frustration and feeling of
    abandonment when a Department whose mission is to ``care for him who
    has borne the battle'' says, ``no more therapy!''
    ---------------------------------------------------------------------------
        \7\ Nathan D. Cope, M.D., and William E. Reynolds, DDS, MPH;
    ``Systems of Care,'' in Textbook of Traumatic Brain Injury (4th ed.),
    American Psychiatric Publishing (2005), 533-568.
    ---------------------------------------------------------------------------
        It is not clear whether VA's failure to provide veterans who
    sustained severe TBI with ongoing maintenance rehabilitation is based
    on a perception that VA's statutory authority is limited to therapy to
    ``regain function,'' on cost concerns, or on other considerations. But
    it is clear that ongoing rehabilitation is often needed to maintain
    function.\8\ Whatever the explanation for limiting the duration of a
    veteran's therapy, there is profound reason for concern that many
    veterans denied maintenance therapy will regress, losing cognitive,
    physical and other gains made during earlier rehabilitation.
    ---------------------------------------------------------------------------
        \8\ Id.
    ---------------------------------------------------------------------------
        Significantly, VA facilities are also denying requests to provide
    TBI patients with what might be deemed ``non-medical'' supports. Yet
    supports like community-reintegration therapy, life-skills coaching, or
    supported employment, for example, afford the veteran the opportunity
    to gain greater independence and improved quality of life. Given TBI
    sequellae that cause individuals considerable difficulty re-integrating
    into the community, VA's rigid adherence to a medical model of
    rehabilitation--and foreclosing social supports--is a formula for
    denying a veteran the promise of full recovery.
                          veteran and family profiles
        In attempting to emphasize the importance of making TBI-care truly
    veteran-centered, let me give you some context by sharing the
    perspectives of a few of family members with whom I've worked who have
    a son or spouse who suffered a TBI.
        Houston VAMC: After her son sustained a severe TBI and was
    medically retired in 2006, one mother-turned-caregiver encountered a VA
    system she has experienced as inflexible and quick to say ``no.''
    Despite ``spots of brilliance'' in the care her son has received, the
    process of gaining access to needed services has often been ``dogged
    and exhausting.'' After long acting as her son's full-time at-home
    caretaker, she encountered repeated VA refusals to provide a few hours/
    day of home-attendant services on the basis that the services ``weren't
    medically necessary.'' Ultimately, she pursued congressional help to
    win the Houston VAMC's agreement to provide assistance she discovered
    was routinely furnished by other VA facilities. But the medical center
    would authorize that help only one-hour per day, three times weekly--
    insufficient to give her the respite she so badly needed. The home
    attendant assistance also lacked the structure and routine that young
    TBI patients so desperately need, with attendants coming at varying and
    unpredictable hours each day. Frustrated with a system that was much
    more attuned to the needs of geriatric patients rather than young
    wounded warriors like her son, she canceled the VA-arranged home-
    attendant care in favor of more age-appropriate help that the family
    covered out of pocket.
        As the veteran has slowly regained cognition, his needs and those
    of his family have changed. When his mother requested counseling (as
    provided for by law) for the veteran's two younger siblings to help
    them cope with the trauma and profound adjustments associated with
    their brother's injuries, VA rejected the request. The medical center's
    unwillingness to recognize the direct relationship between the mental
    health of the caretaking family and the veteran's continuing therapy
    continues to trouble her. A Federal Recovery Coordinator has made a
    difference in winning approval of some needed services. But when she
    recently sought approval to get a mode of therapy to help her son learn
    to progress toward vocational and other personal goals, her VA social
    worker questioned ``when is enough enough'' in terms of further
    therapy. The subliminal message was clear: ``the clock is running out
    on providing more therapy for your son.'' I think we can all agree that
    this is not the message of a ``veteran centered'' system.
        Tampa VAMC: After making dramatic progress in recovering from an
    open head wound incurred in March 2006, this OIF veteran had a setback
    while undergoing rehab at VA's Tampa polytrauma center. His mother, a
    nurse herself, had found the clinical staff agonizingly slow in
    responding to her plea to compare her slowly-dying son's CT scans with
    those last taken at Walter Reed. At last discovering a massive buildup
    of brain fluid, Tampa returned the veteran to Walter Reed for emergency
    brain surgery. After re-entering therapy from ground zero, the veteran
    progressed well for about a year. In the first of what became a series
    of problems, the Tampa VA was unwilling to provide physical therapy to
    help him restore left-arm movement. In frustration, his mother turned
    to a Member of Congress; VA did then arrange for the needed therapy to
    be provided at the University of Alabama-Birmingham. When Tampa later
    refused her requests for further therapy to prevent reversal in the
    gains he had made, she turned to Medicare. That apparently prompted
    Tampa to discharge the veteran altogether, with no follow-up plan
    whatsoever. He moved into his own apartment, but--without structure and
    supervision, and with a condition marked by impulsivity and lack of
    insight--he spun out of control, and has struggled since then with
    PTSD, depression, and substance-use complicating his TBI problems. In
    describing just one chapter of the family's long ordeal with his self-
    destructive behaviors, his mom reports having begged Tampa for help
    with his complex problems, and being told they didn't feel it was their
    responsibility as this veteran wasn't asking for help. Despite Tampa's
    lack of cooperation, she ultimately succeeded in having him admitted to
    Bethesda Naval Hospital for neuropsychiatric care. While his
    neuropsychiatrist at Bethesda, after a four-month hospitalization,
    recommended that he be provided a full-time life-skills coach to
    furnish constant supervision and structure, Tampa ultimately agreed
    instead to provide a home health aide and regular VA outpatient
    treatment. The veteran's mother observed that ``while Tampa has stepped
    up'' since the neuropsychiatrist's involvement, they seem to ``have
    only one care plan, and if you don't fit into it, you're out of luck.''
        Iowa City VAMC: Caregiver; accountant; occupational therapist;
    physical therapist; driver; mental health counselor; life coach. These
    are all roles an Iowa wife has taken on since her husband was injured
    in a mortar attack in 2005 in Iraq. He sustained a penetrating injury
    to the right side of his brain, leaving him hemiplegic, and without a
    right eye. After two trips to Walter Reed and a seven month stay at the
    Minneapolis VA, the veteran returned home, becoming Iowa City VA's
    first polytrauma patient. But despite its classification as one of the
    VA's 108 specialized rehabilitation centers, Iowa City VAMC has proven
    ill-equipped to provide the range of services the veteran needed,
    particularly, physical, occupational, and cognitive therapy. While the
    facility arranged for the veteran to receive rehab services from a
    better-equipped private facility, it discontinued the services after a
    year based apparently on the view that he wasn't improving quickly
    enough. It intermittently provided brief periods of fee-basis physical
    therapy in response to the wife's concerns that the veteran fell
    frequently, but discontinued that therapy, citing funding constraints
    and a policy of limiting patients to no more than 24 such sessions. She
    was advised that it was time for the family to pay for further physical
    therapy. The decision left the veteran's wife to become her husband's
    physical and occupational therapist, using the techniques she
    videotaped at the independent facility. She later taught a nursing
    assistant, who VA furnishes twice-weekly through a home-health agency,
    to administer physical therapy. While she has requested VA to allow the
    agency to send a physical therapist to their home, the medical center
    refused. She expressed reluctance to push any harder for the needed
    therapy for fear of ``burning bridges'' with the VA--her husband's only
    source of health care.
                                closing the gaps
        VA leaders have taken important steps toward establishing both a
    TBI system of care and policies aimed at fostering optimal recoveries
    for veterans and servicemembers with severe TBI. But deep, troubling
    gaps in that system are compromising realization of too many veterans'
    potential for full rehabilitation. This must change--and the needed
    change must be in a single direction--toward truly veteran-centered
    care.
        The principle of veteran-centered care must be more than a slogan.
    It must be a core value at the heart of VA's TBI program. If
    rehabilitation and care is to be veteran-centered, VA facilities must
    develop truly individualized rehabilitation plans built around goals
    developed in concert with the veteran and his/her family. Those plans
    must also provide for access to all ``appropriate rehabilitative
    components,'' \9\ a requirement that encompasses ``age-appropriate''
    services. Providing veteran-centered care also requires a fundamental
    change aimed at meeting each veteran's rehabilitation needs--whether
    through services VA provides or procures. If VA TBI care is to be
    veteran-centered and ``world class,'' it can no longer reflect an
    approach that says, in effect, ``we don't provide that service; you'll
    have to accept our service or pay for the care you want out of
    pocket.'' Successful rehabilitation must build on the strengths and
    needs of the injured individual; requiring the injured veteran to adapt
    to arbitrary VA requirements or limitations is a sure path to
    rehabilitative failure. To put it another way, VA must become a system
    that looks for ways to say ``yes,'' rather than ``no.''
    ---------------------------------------------------------------------------
        \9\ 38 U.S.C. sec. 1710C(b)(2).
    ---------------------------------------------------------------------------
        But achieving veteran-centered care will also require statutory
    change. Under current law, the Veterans Health Administration (VHA) is
    to provide a comprehensive program of long-term care for post-acute
    Traumatic Brain Injury rehabilitation that includes residential,
    community, and home-based components using interdisciplinary treatment
    teams.\10\ Rehabilitative services, however, are defined in law to mean
    ``such professional, counseling, and guidance services and treatment
    programs as are necessary to restore, to the maximum extent possible,
    the physical, mental, and psychological functioning of an ill or
    disabled person.'' \11\ Our experience, however, is that while VA
    furnishes services to restore function, wounded warriors are not
    necessarily assured under this statutory framework--or under current
    practice--of continued therapy to sustain function and to prevent loss
    of the gains achieved. The distinction is critically important to the
    well-being of a warrior with severe Traumatic Brain Injury. In
    addition, VA's authority to provide rehabilitative services (as defined
    above) suggests the provision of services under a medical model. But a
    traditional medical model may not best meet the range of rehabilitative
    needs of a profoundly injured young warrior. Rehabilitation after a
    moderate to severe TBI requires more than just addressing physical
    deficits; it is also about improving and sustaining to the greatest
    extent possible that injured individual's quality of life.\12\ It is
    vital that rehabilitative care and services for very severely injured
    warriors be individualized and holistic in nature, and that these
    warriors have reasonable access to, and a choice of options geared to
    their age and injury, whether through government facilities, private,
    or a combination.
    ---------------------------------------------------------------------------
        \10\ 38 U.S.C. sec. 1710D(a).
        \11\ 38 U.S.C. sec. 1701(8).
        \12\ James F. Malec, ``Ethical and evidence-based practice in brain
    injury rehabilitation,'' Neuropsychological Rehabilitation 19, no. 6
    (2009), 800.
    ---------------------------------------------------------------------------
        Mr. Chairman, we urge you, accordingly, to take up legislation to
    clarify VA's authority to provide maintenance-rehabilitation to those
    with Traumatic Brain Injury as well as to enable VA to provide
    individualized rehabilitative services (not limited to a restrictive
    medical model) and patient-centered supports to permit the severely
    wounded warrior to live as normal a life as possible in whatever
    setting is most appropriate, to include in-home or in home-like
    residential options. Such legislation would be a step toward moving VA
    to pioneer new approaches to rehabilitation and community living for
    young veterans learning to live with Traumatic Brain Injury, and to
    educating and training a new generation of specialists in Traumatic
    Brain Injury rehabilitation.

        We would welcome the opportunity to work with the Committee to
    shape such legislation.
                                     ______

      Prepared Statement of The National Association of State Head Injury
                                 Administrators
        Dear Chairman Akaka and Members of the Senate Veterans' Affairs
    Committee: The National Association of State Head Injury Administrators
    (NASHIA) appreciates this opportunity to submit testimony about how the
    Veterans Administration (VA) can best meet the needs of veterans with
    Traumatic Brain Injury (TBI). The National Defense Authorization Act
    for Fiscal Year 2008 directs the VA to collaborate with local, State,
    and private entities to improve services for veterans with TBI. It is
    NASHIA's experience that the collaboration to date has largely been as
    the result of State and local initiatives. Greater efforts on the part
    of the VA and Department of Defense to coordinate with State resources
    and services could help fill the gaps in information and referral and
    service delivery.
           nashia and the role of states in serving persons with tbi
        NASHIA was established in 1990 as a non-profit organization
    representing State governmental officials who administer an array of
    short-term and long-term rehabilitation and community services and
    supports for individuals with TBI and their families. NASHIA members
    include State officials administering public TBI programs and services,
    and associate members who are professionals, provider agencies, state
    affiliates of the Brain Injury Association of America (BIAA), family
    members and individuals with brain injury. NASHIA holds annual State-
    of-the-States conferences throughout the United States and public
    policy seminars with Federal officials and Congressional staff, serves
    as a resource to the Congressional Brain Injury Task Force and provides
    technical assistance and advice to State TBI program managers.
        Most long-term care services and supports for persons with TBI are
    administered by the States, and funded mainly through the shared
    Federal/State Medicaid Home and Community-based Services Waivers
    (HCBS), nursing homes, Medicaid State Plan services, such as personal
    assistance and in-home care; State funds; and designated trust funds,
    derived primarily through traffic fines. Medicaid HCBS Waivers for
    Individuals with TBI have grown significantly in recent years, doubling
    from 5,400 individuals served in 2002 to 11,214 in 2006, at a cost of
    $155 million in 2002 to $327 million in 2006 (Kaiser Commission on
    Medicaid and the Uninsured (2007, December); Medicaid Home and
    Community-Based Service Programs: Data Update, The Henry J. Kaiser
    Family Foundation, Washington DC). Individuals with TBI are also served
    in other State waiver programs designed for physical disabilities,
    developmental disabilities, elderly and other populations. Individuals
    with TBI who are not Medicaid eligible receive similar services through
    programs funded by State general revenue and trust funds, and may also
    receive services through other disability programs such as Vocational
    Rehabilitation. Almost half of the States have enacted TBI trust
    legislation generating approximately $70 million a year for services
    and supports.
        Individuals with TBI seek State services often as the last resort.
    Private insurance generally has not provided for extended
    rehabilitation and long-term care, supports and services. And, in some
    instances, States have developed HCBS Waiver programs to end costly out
    of State placements. Families and individuals with TBI seek services in
    crisis situations, when families are in turmoil due to job loss, out of
    control behaviors or substance abuse that may result in family violence
    or dangerous situations to self and others.
        Without appropriate services and supports, individuals with TBI
    often are inappropriately placed in institutional settings or end up in
    State Correctional facilities due to their cognitive and behavioral
    disabilities. A recent report issued by the Centers for Disease Control
    and Prevention (CDC) cited other jail and prison studies indicating
    that 25-87% of inmates report having experienced a TBI as compared to
    8.5% in a general population reporting a history of TBI.
        Often States provide the first contact for persons with TBI and
    their families, and provide referral to appropriate rehabilitative
    resources or advocacy services such as are provided by BIAA affiliates.
    Especially in cases where TBI has been undiagnosed, it is often when a
    person is homeless, the police are involved, that State services are
    called upon and appropriate services are coordinated. A critical
    service that States provide is service coordination to help coordinate
    and maximize resources and supports for individuals with TBI and their
    families.
               the incidence and prevalence of tbi is on the rise
        CDC recently released new data showing that the incidence and
    prevalence of TBI in the United States is on the rise. CDC reported
    that ``each year, and estimated 1.7 million people sustain a TBI. Of
    them: 52,000 die; 275,000 are hospitalized; and 1.365 million (nearly
    80%) are treated and released from an emergency department. TBI is a
    contributing factor to a third (30.5%) of all injury-related deaths in
    the United States. About 75% of TBIs that occur each year are
    concussions or other forms of mild TBI. The number of people with TBI
    who are not seen in an emergency department or who receive no care is
    unknown.'' (www.cdc.gov/Traumatic BrainInjury/statistics.hml)
        The data collected by CDC relies heavily on State data, gathered
    through State Registries and hospital discharge data.
        These numbers do not include the veterans who sustained TBIs in
    Iraq or Afghanistan and now use private or State funded resources for
    care, or undiagnosed TBIs.
                          state resources and services
        Over the past 25 years, States have developed service delivery
    systems that generally offer information and referral, service
    coordination, rehabilitation, in-home support, personal care,
    counseling, transportation, housing, vocational and other support
    services for persons with TBI and their families. These services are
    funded by State appropriations, designated funding (trust funds),
    Medicaid and Rehabilitation Act programs and administered by programs
    located in the State public health, vocational rehabilitation, mental
    health, Medicaid, developmental disabilities or social services
    agencies.
        Approximately half of all States have a dedicated funding
    mechanism, mainly through traffic related fines, that fund services and
    about half of all States also administer a Medicaid Home and Community-
    Based Services Waiver for individuals with brain injury who are
    Medicaid eligible. Some States have the advantage of both of these
    funding mechanisms in addition to other State and Federal resources.
    Most States have identified a lead agency responsible for providing and
    or coordinating services and most States have an advisory board or
    council to plan and coordinate public policies to better serve
    individuals who frequently needs assistance from multiple agencies and
    funding streams in order to address the complexity of their needs.
        Under the TBI Act of 1996, the US Department of Health and Human
    Services, Health Resources and Services Administration (HRSA) provides
    grants to States to expand services and resources particularly to
    underserved populations. Since the program began, almost every State
    has received TBI Act funding, but there are currently less than 20
    States participating in the program due to a lack of sufficient Federal
    funding.
          state collaborative efforts to address the needs of veterans
        Since servicemembers and veterans first began to return from Iraq
    and Afghanistan, NASHIA and some individual States have reached out to
    VA staff to participate in educational forums and national TBI
    conferences. Some States have reached out to work with the VA,
    particularly staff from individual Polytrauma Centers, to promote
    collaboration in order to better understand VA benefits for veterans
    that may be seeking State services, and for VA to understand what is
    available in the communities. In addition, some States have added
    representatives from VA, National Guard and Reserves, State Veterans
    Affairs, and/or veterans organizations to serve on their State advisory
    board in order to improve communications and policies across these
    programs.
        Some States have used the HRSA grant funding to address the needs
    of returning servicemembers and veterans with TBI.
        With the knowledge that veterans could fall through the cracks
    between discharge from the military or veteran care and community
    reentry, States have responded in a variety of ways. Here are a few
    examples:

         Alaska convened an informal group of representatives from
    the State TBI Program, 3rd Medical Group (Elmendorf Air Force base),
    Alaska VA, Vet Centers, Alaska Federal Health Care Partnership, Alaska
    Native Tribal Health Consortium, hospital providers, behavioral health
    providers, workforce development agencies, and disability advocacy
    organizations. The purpose of this group is to assess the services and
    resources available in Alaska and partner in the planning of a
    comprehensive system of care; emergency medical services, acute/trauma
    care, post-acute rehabilitation, community re-entry, and long-term
    supports.
         The Nebraska Veterans Brain Injury Task Force, which
    includes representatives from the civilian and military sector, and key
    State and Federal Government agencies, addresses the increasing needs
    for brain injury awareness and education among returning servicemembers
    from Iraq and Afghanistan.
         The Vermont TBI program and the State Division of
    Vocational Rehabilitation share the cost of a neuro-resource
    facilitation (NRF) Job Developer to educate and coordinate training for
    the Vermont business community to increase awareness of the issue
    facing returning veterans with TBI. Similarly, the State TBI Program
    shares the cost of a NR Facilitator with the Department of Mental
    Health as a liaison to the mental health court, specifically serving
    veterans involved with the Department of Corrections.
         Using funds from the American Recovery and Reinvestment
    Act of 2009, the California Department of Rehabilitation, the lead
    agency for TBI, awarded a grant ($486,923) to the Central Coast Center
    for Independent Living to increase independent living service capacity
    and coordinate existing services and programs for veterans with TBI and
    other TBI survivors.
         The New York TBI Program and the Brain Injury Association
    of New York partner to promote awareness, training, outreach and
    support to Iraq and Afghanistan military with TBI and their families.
         Similarly, the Massachusetts Brain Injury & Statewide
    Specialized Community Services Department, known as SHIP, is partnering
    with the Veterans Administration, Veterans Organizations, TBI providers
    and the Brain Injury Association of Massachusetts to conducting
    outreach, information and referral services.
                         recommendations for the future
        Given State history with providing rehabilitation and community
    short-term and long-term services and supports for 25 years, NASHIA
    recommends the following:

        1) Linkages to services are critical at the time of hospital or
    rehabilitation discharge. Some States, such as Missouri and Florida,
    found that individuals were often 7-9 years post injury before
    accessing community services and resources. After implementing an early
    referral program linking families and individuals with service
    coordination at the time of hospital discharge, Missouri found that
    individuals had better outcomes than those who were not linked early in
    the reintegration process.
        2) Systems need to be flexible and responsive. State systems strive
    to provide the right services at the right time. Such services are
    provided on a short-term, long-term and episodic basis. Individuals
    with TBI may receive services for a period of time, then later, they
    may require similar or different services. Therefore, systems need to
    have policies that do not impose caps or timelines on services, and
    they must be able to respond to crisis or changes that may occur within
    the individual's environment, such as a job change or a caretaker
    change; or changes that may occur as the result of the TBI, such as
    behavior or personality changes. A good system will have the capability
    of providing on-going supports to help prevent crisis from occurring.
        3) Veterans with TBI need to be empowered to choose services and
    supports that best suit their needs and enable them to live in their
    own homes and communities. As a result of the US Supreme Court Olmstead
    Decision affirming the rights of individuals with disabilities to live
    in the community, States have expanded community options, and the
    Federal Government has provided funds over the years to help States
    balance institutional and community services for individuals with
    disabilities. While directed at civilians with disabilities, these
    rights no doubt apply to veterans with disabilities as well.
        4) State and Federal systems are complex and difficult to
    negotiate. Individuals with TBI frequently request services from
    different systems, such as Vocational Rehabilitation, behavioral
    health, substance abuse, and TBI programs. They may also need help with
    housing, utilities, food, day care for their children, transportation
    to jobs and other financial assistance. Service coordination or case
    management is critical to facilitating the coordination and
    maximization of these resources.
        5) Workforce that has training and understanding of TBI. Most
    States that provide an array of services provide opportunities for on-
    going training and education through web training, conferences or on-
    site training. A few have developed core competencies for in-home
    support staff. Not all community providers that offer similar services
    to individuals with disabilities understand the behavioral and
    cognitive problems associated with brain injury.
        6) In 2008, the VA began collaboration with the Administration on
    Aging (AoA) to provide an additional opportunity to State Units on
    Aging (SUAs) and Area Agencies on Aging (AAAs) to serve veterans at
    risk of nursing home placement. This initiative demonstrates the
    willingness to coordinate with State and local agencies to support
    veterans living in the community. However, the AAAs serve primarily
    seniors within the States, not necessarily young adults with TBI at
    risk of being referred to nursing home for long-term care and supports.
    We believe that expanding this initiative to collaborate with NASHIA
    and State agencies that serve TBI would help families and veterans to
    locate and receive coordinated community services and supports.
        7) The Institute of Medicine's (IOM) Preliminary Assessment on the
    Readjustment Needs of Veterans, Servicemembers and their families notes
    that there is a paucity of information on the lifetime needs of persons
    with TBI in the military and civilian sectors and recommends additional
    research into protocols to manage the lifetime effects of TBI. NASHIA
    supports such research efforts and recommends that it be conducted in
    coordination with State data and resources. States have experience in
    this area.
        8) The IOM notes the critical shortage of health care specialists
    and that veterans having to wait for appropriate care remains a
    problem. In the meantime, families and veterans with TBI are calling
    State TBI programs for assistance. In some cases, when military
    discharge status is unsettled, veterans turn to State resources first.
    State TBI programs are often the point of contact for information and
    referral for families and returning soldiers and veterans seeking local
    services, especially with regard to the National Guard and Reserves.
    NASHIA supports greater collaboration with the civilian sector with the
    recruitment and training of TBI specialists.
        9) NASHIA strongly agrees with the IOM's recommendation that DOD
    and VA improve coordination and communication among the multitude of
    programs that have been created to meet the needs of returning
    servicemembers and veterans.
        10) The VA Secretary stated in the March 23, 2010, report to your
    Committee that ``collaborations with private sector facilities are
    regularly used to successfully meet the individualized needs of
    Veterans and complement VA care.`` This has been limited to medical
    care and treatment. The next step is to extend similar policies to
    community providers that offer home, community and family supports and
    services.

        In closing, NASHIA offers its expertise, experience and assistance
    to further improve the connection between community services and
    supports to enable veterans with TBI to live in their communities after
    receiving acute and post acute care, rehabilitation and other services
    through the VA. Given these difficult budget times, NASHIA recommends
    greater coordination among all Federal, State and local resources in
    order to improve the lives of veterans with TBI and to enable them to
    live as independently as possible.
        We applaud your leadership and efforts to address the needs of our
    veterans with TBI and their families. The Department of Defense and
    VA's TBI initiatives for servicemembers and veterans will no doubt help
    civilians with TBI as well, so that all Americans with TBI, regardless
    of cause, will benefit from the research, education, care, treatment,
    rehabilitation and community supports carried out by these departments.
        For additional information or assistance, please contact Lorraine
    Wargo, Executive Director at awarg@madriver.com or Susan Vaughn,
    Director of Public Policy, at susanvaughn@mchsi.com, phone: 573-636-
    6946.
                                     ______

        Prepared Statement of Charles M. ``Mason'' Poe, SSGT USMC (Ret.)
        Mr. Chairman, Ranking Member Senator Burr, and Members of the
    Committee: My name is Mason Poe, SSGT USMC (ret), and I come from a
    strong military minded family. I am a medically retired SSGT after
    serving one week shy of a nine year service in our beloved United
    States Marine Corps.
        First and foremost, I would like to thank the veterans in which
    have been wounded in our previous wars and/or conflicts. They have set
    the high standards of care provided by today's Department of Defense
    and our Veterans Affairs which provided the necessary healthcare that I
    needed in 2004 and still need today.
        On April 20, 2004, after being informed of the safety of a squad of
    Marines, my Marines and I were returning back to the Forward Operating
    Base in Haditah, Iraq, where I was severely wounded after our Humvee
    was directly hit by an Improvised Explosive Device.
        After being in a medically induced coma for approximately one month
    and bed-ridden for 3\1/2\ months, I was wheeled out of the hospital and
    my recovery started in August 2004. Due to my significant injuries I
    was told I would never walk again and the chances of being a father
    were limited. For the record, no doctor should ever tell a Marine he
    will never walk again, as I walked into this building to speak to our
    Nation's elected officials on May 5, 2010. Furthermore, my wife and I
    are proud parents of a beautiful 10\1/2\-month-old daughter. I
    personally find it hard to understand people who do not believe in a
    higher power. My faith is stronger now more than ever.
        After six years of recovery and 30-plus surgeries, doctors and I
    have come to the decision that on June 7, 2010, I will undergo yet
    another surgery at Duke University Medical Center by having a below-
    the-knee amputation of my right leg.
        I have undergone mostly all physical injuries. Please note; I am
    not a ``disabled'' Marine whereas I am a Marine with limitations. The
    doctors and non-profit organizations such as Wounded Warrior Project
    and Military Missions in Action from North Carolina can help, assist,
    and offer ideas and solutions to my physical limitations. However, in
    my particular case there is one limitation in which only the Lord and I
    can overcome.
        When I was wounded, I was thrown 40-plus feet, my flak jacket was
    separated and Kevlar helmet was displaced, which did not allow
    protection when I impacted the ground. After a field tracheotomy was
    performed in order to clear my airway I was resuscitated and was flown
    to Baghdad to begin my critical care. As I suffered from a skull
    fracture, a stint was placed in my brain to reduce the swelling. This
    leads to why I am here.
        Traumatic Brain Injury or TBI, is an injury known as the ``unseen
    injury'' for many reasons. The average person will never be able to
    tell without speaking to you for a period of time that you may have
    problems accomplishing everyday tasks. Please note, Doctors can fix a
    broken bone but there is no known cure from TBI. I was screened by the
    DOD for TBI prior to discharge but the issues regarding TBI have been
    addressed by the VA.
        Every day I struggle with this injury. I have trouble remembering
    things such as: meetings, phone calls, grocery lists, times to pick up
    my daughter, and remembering people's names.
        Fortunately, Marines are taught from day one to adapt and overcome,
    therefore I have learned ways to accomplish my tasks successfully.
        Transitioning to civilian life has been trying because I am no
    longer physically able to do the things I used to. The reason I am
    speaking before this congressional committee today and testifying
    before you is to inform you of my particular case and care that I have
    received. I am satisfied with how I have been treated at my local
    Veterans Affairs hospital.
        My case manager, Ms. Collette Wallace, keeps me informed by calling
    and reminding me of my appointments on a regular basis. I also receive
    letters of verification of my appointments. I have even attended
    classes at the VA regarding ways to accommodate my memory issues and
    have successfully completed a college course in Introduction to
    Business Administration at my local community college. I have
    considered returning to the school atmosphere, however that one course
    I took was more time consuming than I expected as I struggled to recall
    information required in order to pass each test. As the number of
    veterans needing medical care from Operation Iraqi Freedom and Enduring
    Freedom increase the number of case managers at our VA facilities needs
    to as well.
        The VA has provided me with a PDA and recorder to assist me in
    overcoming some of these memory issues. Whereas these devices have
    assisted me I cannot rely on them 100% of the time. Luckily, I have a
    wonderful wife to help me remember names as well as help me around the
    house with any other limitations I may suffer from.
        My local VA hospital in Durham, North Carolina has seen to it that
    my medical treatments have been and continue to be satisfactorily met
    and a supportive reassurance for me. I know that I am not traveling
    this road to recovery on my own. However, I have been informed by other
    veterans throughout the Nation that all veterans do not receive the
    same satisfactory care such as mine.
        Other organizations that have made it possible for me to heal are
    Wounded Warrior Project and Military Missions in Action. Wounded
    Warrior Project has called once a month to check in with my health.
    They are always asking ways to help with my transition and recovery. My
    case is difficult as I am 100% permanent and total ``disabled'' and
    have loss use of my lower right limb and suffer from double vision but
    have not actually lost my limb. Military Missions in Action realized
    the physical help I needed and has made it possible to assist my wife
    more in the care of our daughter. Military Missions in Action from
    North Carolina has made a huge impact on my quality of life. I would
    not be able to undergo this upcoming surgery if they had not added a
    master bedroom downstairs.
        In the future I hope to have a successful service contracting
    business where I can still honorably serve our country. I look forward
    to actively being involved with my daughter and wife with a prosthetic
    leg. I hope to have started a cycling team for Military Missions in
    Action in order to successfully recover and improve the quality of life
    of other wounded servicemembers.
        I would like to thank those elected officials in which are striving
    to improve the lives of my fellow Marines and servicemen and women that
    suffer from wounds in our current conflicts abroad. I hope that our
    current administration will show the priority of healthcare needed to
    all our veterans which ultimately allows all Americans to live free.

        My final thought to the Committee is regardless of the amount of
    cutbacks this country is facing on a day-to-day basis, can we really
    afford cutting back the healthcare provided to these veterans. Who is
    going to take long term care of them after they have taken care of us
    and given this country its freedoms?
                                     ______

                                            Mrs. Kristin M. Poe
                                           Washington, DC, May 5, 2010.
    Hon. Daniel K. Akaka,
    Chairman,
    Hon. Richard Burr,
    Ranking Member,
    Committee on Veterans' Affairs
    U.S. Senate, Washington, DC.
        Dear Chairman Akaka and Ranking Member Burr: ``I am ten feet tall
    and bullet proof.'' This is what Mason said to me as he told me he had
    been recalled and volunteered to deploy to Iraq. On April 20, 2004, I
    found out his angels were ten feet tall and bullet proof. This day has
    changed our lives forever.
        Mason and I met here in DC at a Carolina vs. Capitals hockey game.
    Although warned not to date Marines because they would break your
    heart, Mason managed to steal mine. If I had to choose one word to
    describe Mason it would be ``active.'' There was not one moment where
    he would sit still; we could hardly get through a movie. Mason
    volunteered at a fire department in Maryland while stationed at Marine
    Barracks under Presidential security. I always knew to bring homework
    while spending time with him because consequently there was going to be
    time where he was either running a fire call or dealing with Marines.
    Mason got honorably discharged June 2003 and was voluntarily recalled
    December 2003.
        As Mason's best friend insisted upon picking me up and driving to
    Dunn, NC, just to hang out with a group of friends, I briefly thought
    Mason had come home early from his deployment. As we drove up to his
    parent's house, my stomach sank when I saw the amount of cars outside
    the house. His mother walked up to me and murmured those words no one
    wants to hear, ``Mason has been wounded. He is in critical condition.''
    As the days went by we learned more of his injuries and the list of
    them just kept growing. Sandstorms kept his aircraft from leaving
    Baghdad Hospital and it seemed nothing was in our favor.
        Finally, Mason arrived at Landstuhl Army Hospital in Germany a few
    days later. However due to the severity of the case and the only
    neurosurgeon at the other base hospital in Ramstein, Mason had to be
    transferred to Homburg, a private German hospital. Things were looking
    better until we got a call saying Mason had taken a turn for the worse
    and the military was flying his parents to Germany to say their ``Good-
    Byes.'' Since we were not married at the time I was not a priority to
    go. Luckily Mason's brother, Gunner Poe, was able to get it worked out
    so that, although I had to take a civilian flight, I was able to
    accompany his parents to Germany.
        Mason stayed at Homburg hospital for a month. We were only allowed
    to visit him for two hours a day. As you can imagine the 22 hours
    between visits seemed like a lifetime. The Fischer House was an
    enormous help while we were in Germany. We had an affordable room, free
    use of the kitchen, drivers to the grocery store and I even finished my
    finals using their computer.
        As Mason began to heal plans were made to get him back to the
    states and although our prayers were being answered we knew he still
    had a long way to go. Mason was just coming out of the medically
    induced coma at the end of the May.
        Mason spent the next month in Bethesda Naval Hospital in Maryland
    surrounded by friends and family. There he made enough progress to be
    sent to an inpatient rehabilitation facility in North Carolina. Mason
    still had fixators in both legs and could not move by himself but the
    doctors felt he was ready to start therapy.
        While at Southeastern Medical Center, Mason continued making great
    improvements. He surpassed all of the doctors' expectations. By the end
    of the June he was walking about 100 feet on a walker. From the day he
    left the hospital until today he has never stopped fighting. He is one
    of the most determined people I know.
        Mason was not medically discharged until May 2008 when most of his
    healing had come to a standpoint. I firmly believe that one of the main
    reasons mason had such good care was the military allowed him to stay
    active duty until he was thoroughly healed. This gave him options to
    find the best therapy to fit his needs.
        Although the transition from the military to civilian life has been
    tough, Mason continues to find ways to stay active. He is involved with
    many civic organizations like the Rotary, Scottish Rites, Masonic
    Lodge, and the Shriners. Mason just recently cofounded a Marine Corps
    League in Dunn, North Carolina which also helps with fundraisers like
    Toys for Tots.
        As Mason mentioned the organization Military Missions in Action has
    been a God send for us. They have made it possible for us to adapt our
    house to fit Mason's needs. This allows him to be able to take care of
    his daughter, move comfortably around the house, and have a peace of
    mind for his recovery in June.
        Many people may ask me if Mason is the same person as before he
    left for Iraq. Ironically, the answer lies within the Marine Corps
    saying. Although he has had to adapt and overcome a lot of physical and
    emotional limitations Mason still continues to be just as active and
    determined as he has always been.
                Sincerely,
                                                Kristin M. Poe.