[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


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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 [email protected] or Susan Vaughn, 
Director of Public Policy, at [email protected], 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.

      

                                  
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