[Senate Hearing 112-]
[From the U.S. Government Publishing Office]



 
       DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2013

                              ----------                              


                       WEDNESDAY, MARCH 28, 2012

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Daniel K. Inouye (chairman) 
presiding.
    Present: Senators Inouye, Mikulski, Murray, Cochran, and 
Murkowski.

                         DEPARTMENT OF DEFENSE

                        Medical Health Programs

STATEMENT OF LIEUTENANT GENERAL CHARLES B. GREEN, 
            SURGEON GENERAL OF THE AIR FORCE


             OPENING STATEMENT OF CHAIRMAN DANIEL K. INOUYE


    Chairman Inouye. I'd like to welcome all of you, as we 
review the Department of Defense (DOD) medical programs this 
morning. There will be two panels. First, we'll hear from the 
Service Surgeons General, and then from the Chiefs of the Nurse 
Corps. Although she has appeared before the subcommittee in her 
previous assignment as Chief of the Army Nurse Corps, I'd like 
to welcome back Lieutenant General Patricia Horoho for her 
first testimony before this subcommittee as a Surgeon General 
of the Army, and commend her for becoming the first female as 
well as first Nurse Corps officer to serve in this capacity.
    And I'd like to also welcome Vice Admiral Matthew Nathan 
and Lieutenant General Charles Green. General Green, I 
understand you're retiring later this year, and I thank you for 
your many years of service to the Air Force, and I look forward 
to working with all of you to ensure that the medical programs 
and personnel under your command are in good shape.
    Every year, the subcommittee holds this hearing to discuss 
the critically important issues related to the care and well-
being of our servicemembers and their families, as healthcare 
is one of the most basic benefits we can provide to the men and 
women of our Nation. The advancements military medicine has 
made over the last several decades have not only dramatically 
improved medical care on the battlefield, but it also enhanced 
the healthcare delivery and scientific advancements throughout 
the medical field. The results benefit millions of Americans 
who likely are unaware that these improvements were developed 
by the military.
    There is still much more to be done. Despite the great 
progress the military medical community has achieved, more and 
more of our troops are suffering from medical conditions that 
are much harder to identify and treat, such as traumatic brain 
injury (TBI), post-traumatic stress, and depression. We must 
continue our efforts to heal these unseen wounds of the 
military that have been at war for more than 10 years.
    In addition, DOD has recommended changes to Military Health 
System (MHS) governance and proposed TRICARE fee increases. And 
I hope to address some of these issues today, and I look 
forward to your testimony and note that your full statements 
will be made part of the record.
    And now I'd like to call upon our Vice Chairman, Senator 
Cochran.


               OPENING STATEMENT OF SENATOR THAD COCHRAN


    Senator Cochran. Mr. Chairman, I'm pleased to join you in 
welcoming our panel of witnesses today. We appreciate the 
leadership you are providing in the various services--the Air 
Force, Army, and Navy. Our men and women in uniform deserve 
opportunities for high-quality medical care, and I think your 
leadership is proving that we do have the best in the world for 
our military men and women, and we appreciate that service, and 
that leadership, and your success. We want to find out if there 
are things that can be done through the Congress's efforts to 
help shore up weak spots or identify things that need to be 
changed, funding levels that may not be appropriate, because of 
changing circumstances. And that's what this hearing is 
designed to do. Thank you for helping us do our job, and we 
hope we help you do your job better.
    Thank you.
    Chairman Inouye. Senator Mikulski.


            OPENING STATEMENT OF SENATOR BARBARA A. MIKULSKI


    Senator Mikulski. Well, thank you very much, Mr. Chairman. 
We, in Maryland, feel so proud of military medicine, because we 
are the home to the new Naval Bethesda Walter Reed. That's a 
new facility. It's the old-fashioned values of taking care of 
those who fought for us. And we're very proud of that. We're 
very proud of the fact that Uniformed Services University of 
the Health Sciences (USUHS) is in Maryland, and also the 
fantastic TRICARE network, where our men and women on Active 
Duty, Reserves have access to the great academic medical 
institutions of Maryland and Hopkins, particularly if they need 
specialized care.
    So, if you have a little child with pediatric neurological 
problems, you have access to Dr. Ben Carson. If you have a 
neonatal child, you have access to Maryland and to Hopkins. If 
you have, like one of the men I met at Walter Reed, who had 
dystonia, a very rare and unusual disease, again, access to 
Maryland there through this.
    So, we're very proud of you, and we look forward to working 
with you, hearing from you, and how we can not only respond to 
the acute care needs, but really go to the new innovative ways 
of delivery of healthcare that manage chronic illness, prevent 
chronic illness, and deal with the stresses of battle, whether 
you're endured it in the battlefield or at home, supporting the 
warrior at the front. And today's a big day for healthcare, 
Senator Harkins having a hearing on National Institutes of 
Health (NIH), so after I finish my questions, I'm going to be 
dashing over there, your neighbor across the street.
    If I could, Mr. Chairman, one point of personal Maryland 
privilege. One of the worst traffic jams in American history is 
at the convergence of Walter Reed Naval Bethesda. It's across 
the street from NIH. On the corner is the Institute of 
Medicine. It is the largest convergence of intellectual 
brainpower to serve the healthcare needs, and they're all at 
the same traffic light, at the same time. And if you want to 
see geniuses throwing Petri dishes at people, just come to 
that.
    So, we want to thank you for your help in cracking that 
transportation bottleneck. Am I right? Yes.
    Chairman Inouye. That's right.
    Senator Mikulski. That's got the biggest applause going 
yet.


        SUMMARY STATEMENT OF LIEUTENANT GENERAL CHARLES B. GREEN


    Chairman Inouye. General Green, if I may begin with you, 
Sir. Would you care to make a statement before we proceed?
    General Green. Yes, Sir. Thank you. Good morning.
    Chairman Inouye, Vice Chairman Cochran, distinguished 
members of the subcommittee, thank you for inviting me here 
today. The Air Force Medical Service cannot achieve our goals 
of readiness, better health, better care, and best value 
without your support. We thank you for this.
    To meet these goals, the Air Force Medical Service is 
transforming deployable capability, building patient-centered 
care, and investing in education training and research to 
sustain worldwide and world-class healthcare. This year, we 
established 10 new expeditionary medical support health 
response teams. These 10-bed deployable hospitals enable us to 
provide emergency care within 30 minutes of arriving on scene, 
and do surgery within 5 hours. And this will happen in any 
contingency. Light and lean, it's transportable in a single C-
17, with full-base operating support requiring only one 
additional aircraft.
    The health response team was successfully used in Trinidad 
for a humanitarian mission last May, and is our new standard 
package for rapid battlefield care and humanitarian assistance.
    Critical care air transport teams and air evacuation 
continue to be a dominant factor in our unprecedented high-
survival rates. To close the gap in en route critical care 
continuum, we applied the Critical Care Air Transportation Team 
(CCATT) concept to tactical patient movement and delivered the 
same level of care during inter-theater transport on rotary 
platforms this year.
    The tactical critical care evacuation team was fielded in 
2011. We've trained five teams. Two teams are currently 
deployed to Afghanistan. Each team has an emergency physician 
and two nurse anesthetists, and we're now able to move critical 
patients between level two and level three facilities much more 
safely.
    At home, we enrolled 941,705 beneficiaries in the team-
based patient-centered care at all of our Air Force medical 
facilities worldwide. This care model is reducing emergency 
room visits, improving health indicators, and it has achieved 
an unprecedented continuity of care for our military 
beneficiaries. The Air Force remains vigilant in safeguarding 
the well-being and mental health of our people. Postappointment 
health reassessment completion rates are consistently above 80 
percent for our Active Duty, Guard, and Reserve personnel.
    The new deployment transition center at Ramstein Air Base, 
Germany, provides effective reintegration programs for 
deploying troops. More than 3,000 have been through to date, 
and a study of these airmen who attended showed significantly 
fewer symptoms of post-traumatic stress and lower levels of 
both alcohol use and conflict with family or coworkers upon 
return home.
    By this summer, behavioral health providers will be 
embedded in every primary care clinic in the Air Force. We 
reach Guard and Reserve members through tele-mental health and 
embedded psychological health directors, and are furthering 
increasing mental health provider manning over the next 5 
years.
    New training to support air evacuation and expeditionary 
medical capability is now in place. Our training curriculums 
are continuously updated to capture lessons from 10 years of 
war. Our partnerships with civilian trauma institutions prove 
so successful in maintaining wartime skills that we've expanded 
training sites to establish new programs with the University of 
Nevada--Las Vegas, and Tampa General Hospital. We also shifted 
our initial nursing training for new Air Force nurses to three 
civilian medical centers. The nurse transition program is now 
at the University of Cincinnati, Scottsdale, and Tampa Medical 
Centers, has broadened our resuscitative skills, and the 
experience that they receive early in their careers.
    Air Force graduate medical education programs continue to 
be the bedrock for recruiting top physicians. Our graduate 
programs are affiliated with Uniform Services University and 
civilian universities. These partnerships build credibility in 
the United States and in the international medical communities.
    One of our most significant partners is the Department of 
Veterans Affairs (VA), and we are very proud of our 6 joint 
ventures, 59 sharing agreements, and 63 joint incentive fund 
projects, which are improving services to all of our 
beneficiaries. We've also made significant progress to the 
integrated electronic health record to be shared by DOD and the 
VA.
    In the coming year, we will work shoulder-to-shoulder with 
our Army, Navy, and DOD counterparts to be ready to provide 
even better health, better care, and best value to America's 
heroes. Together, we'll implement the right governance of our 
MHS, we'll find efficiencies, and provide even higher quality 
care with the resources we are given.


                           PREPARED STATEMENT


    I thank this subcommittee for your tremendous support to 
military medics. Our success both at home and on the 
battlefield would not be possible without your persistence and 
generous support.
    On a personal note, I thank you for your tolerance and for 
having me here, now the third time, to talk to you about Air 
Force medicine. I look forward to answering your questions.
    [The statement follows:]

    Prepared Statement of Lieutenant General (Dr.) Charles B. Green

                              INTRODUCTION

    Mr. Chairman, Vice Chairman, and distinguished members of the 
subcommittee: Thank you for inviting me to appear before you today. The 
men and women of the Air Force Medical Service (AFMS) have answered our 
Nation's call and maintained a standard of excellence second to none 
for more than a decade of sustained combat operations. We provide 
servicemembers, retirees, and families the best care America has to 
offer. We take tremendous pride in providing ``Trusted Care Anywhere'' 
for the Nation.
    We support the President's budget request and the proposed changes 
to the military health benefit. I am confident that the recommendations 
included in the budget reflect the proper balance and the right 
priorities necessary to sustain the benefit over the long term. 
National healthcare costs continue to rise at rates above general 
inflation, and the Department of Defense (DOD) is not insulated from 
this growth as we purchase more than 60 percent of our care from 
private sector. DOD beneficiaries' out-of-pocket costs with the 
proposed changes remain far below the cost-sharing percentage they 
experienced in 1995. We understand we cannot ask our beneficiaries to 
share more of the cost for healthcare without seeking significant 
internal efficiencies. We are increasing efficiency by reducing 
administrative costs, improving access, recapturing care, and 
introducing cutting-edge technology to better connect our providers and 
patients.
    Ready, better health, better care, and best value are the 
components of the quadruple aim for the Military Health Services. To 
meet these goals, the AFMS set priorities to transform deployable 
capability, build patient-centered care, and invest in education, 
training, and research to sustain world-class healthcare. We have made 
significant inroads in each of these areas over the past year.

                    TRANSFORM DEPLOYABLE CAPABILITY

    In times of war there are always significant advances in the field 
of medicine. Today we are applying these lessons to shape future 
readiness and care. We have found new ways to manage blood loss and 
improve blood replacement. Significant improvements in the blood 
program improved transfusion capability and changed the way we use 
fluids to resuscitate patients. Air Force trauma surgeons in deployed 
hospitals better control hemorrhage and treat vascular injury by 
designing and using new arterial shunts that have been adopted by 
civilian trauma surgeons. These innovations contribute to a very low-
case fatality rate and allow earlier transport of casualties.
    Through innovative training and quick thinking, Air Force, Army, 
and Navy medics continue to perform miracles in field hospitals. Last 
spring in Balad, Iraq, our Critical Care Air Transport Teams (CCATT) 
saved the life of a soldier who had suffered blunt force trauma to his 
chest, causing his heart to stop. After an unknown period without a 
pulse, there was significant risk of brain injury. Using coolers of 
ice, the team undertook a rare therapeutic hypothermia procedure to 
lower body temperature, decreasing tissue swelling, and damage to the 
brain. The soldier was transported to Landstuhl Medical Center in 
Germany where his temperature was slowly raised, bringing him back to 
consciousness. Within 4 days of injury, the soldier arrived at Brooke 
Army Medical Center, San Antonio, Texas, and walked out of the hospital 
with thankful family members. Incredible ingenuity, dedication, and 
teamwork continue to save lives every day.
    We have an impressive legacy of building highly capable deployable 
hospitals over the past decade. This year we have established 10 new 
Expeditionary Medical Support (EMEDS) Health Response Teams (HRT). 
These newly tested and proven 10-bed packages enable us to arrive in a 
chaotic situation, provide emergency care within 30 minutes, and 
perform surgery within 5 hours of arrival. The entire package is 
transportable in a single C-17, and full-base operating support for the 
hospital requires only one additional C-17. The HRT was used 
successfully in a Trinidad humanitarian mission in April and will be 
our standard package to provide rapid battlefield medicine and 
humanitarian assistance. This year we will establish intensive training 
with the HRT and will expand its capability with additional modular 
sets to respond to specialized missions such as obstetrics, pediatrics, 
or geriatrics required for humanitarian response.
    We are also pursuing initiatives to improve air evacuation 
capability. New advances in ventilators allow us to move patients 
sooner and over longer distances with less oxygen. We pursued new 
capabilities for heart-lung bypass support by reducing the size of 
extracorporeal membrane oxygenation (ECMO) equipment. ECMO has been in 
use for many years transporting neonatal patients, and we now have 
critical care teams using this advanced technology for adult patient 
transportation. We moved the first patient on full heart-lung bypass 
out of Afghanistan in 2011. We are working to miniaturize and 
standardize ECMO equipment so it can be operated by less specialized 
teams. David Grant Medical Center at Travis Air Force Base (AFB), 
California, recently became the first DOD recipient of the smallest 
ECMO device. Known as CARDIOHELP, the device is light enough to be 
carried by one person and compact enough for transport in a helicopter 
or ambulance. Researchers will utilize CARDIOHELP to evaluate the 
effects of tactical, high-altitude, and long-haul flights on patients 
who require the most advanced life support. We continue to advance the 
science of patient transport moving the sickest of the sick, as we 
decrease the amount of time from point-of-injury to definitive care in 
the United States.
    The insertion and integration of CCATTs into the air evacuation 
(AE) system continues to be a dominant factor in our unprecedented 
high-survival rates. These teams speed up the patient movement process, 
bring advanced care closer to the point-of-injury, free up hospital 
beds for new causalities, allow us to use smaller hospitals in-theater, 
and move patients to definitive care sooner. We have improved CCATT 
equipment with more wireless capability aboard aircraft to simplify 
connection of medical equipment to critical care patients. We are 
continuously finding better technologies for more accurate patient 
assessment in flight and working to standardize equipment and supplies 
used by coalition teams.
    We developed and fielded the Tactical Critical Care Evacuation Team 
(TCCET) in 2011. This team was built to deliver the same level of care 
during intra-theater transport on non-AE platforms as that provided by 
our CCATT teams. Our first deployed team safely transported 130 
critical patients on rotary aircraft. The team is composed of an 
emergency physician and two nurse anesthetists that separate and fly 
individually with a pararescue airman to move the sickest patients. We 
are now able to move critical patients between Level II and Level III 
facilities in theater even more expeditiously, using either rotary or 
fixed wing aircraft.
    The Theater Medical Information Program Air Force (TMIP-AF) 
continues to make tremendous progress supporting the war-fighting 
community both on the ground and in the air. We leveraged existing 
information management and technology services to integrate with Line 
of the Air Force communication groups at all deployed Air Force ground-
based units. This decreased end user devices, numbers of personnel at 
risk, and contractor-support requirements in theater. This integration 
allowed us to remotely support deployed units from State-side locations 
for the first time and with improved timeliness. Today, AFMS units are 
documenting all theater-based patient care electronically, including 
health records within the AE system, and securely moving information 
throughout the DOD healthcare system.

                      BUILD PATIENT-CENTERED CARE

    At home, we continue to advance patient-centered medical home 
(PCMH) to improve delivery of peacetime healthcare. The foundation of 
patient-centered care is trust, and we have enrolled 920,000 
beneficiaries into team-based, patient-centered care. Continuity of 
care has more than doubled with patients now seeing their assigned 
physician 80 percent of the time and allowing patients to become more 
active participants in their healthcare. PCMH will be in place at all 
Air Force medical treatment facilities (MTFs) by June of this year. The 
implementation of PCMH is decreasing emergency room visits and 
improving health indicators.
    We have also implemented pediatric PCMH, focused on improving well 
child care, immunizations, reducing childhood obesity, and better 
serving special needs patients. A recent American Academy of Pediatrics 
study analyzed the impact of medical home on children. Their report 
concluded, ``Medical home is associated with improved healthcare 
utilization patterns, better parental assessment of child health, and 
increased adherence with health-promoting behavior.'' We anticipate 
completing Air Force pediatric PCMH implementation this summer through 
simple realignment of existing resources.
    Our PCMH teams are being certified by the National Committee for 
Quality Assurance (NCQA). NCQA recognition of PCMH is considered the 
current gold standard in the medical community, with recognition levels 
ranging from 1-3, 3 being the highest. To date, all MTFs who completed 
evaluation were officially recognized by NCQA as a PCMH, with 10 sites 
recognized as a level 3. This level of excellence far exceeds that seen 
in the Nation overall. An additional 15 Air Force sites will 
participate in the NCQA survey in 2012.
    We are enabling our family healthcare teams to care for more 
complex patients through Project Extension for Community Healthcare 
Outcomes (ECHO). This program started at the University of New Mexico 
to centralize designated specialists for consultation by local primary 
care providers. ECHO allows us to keep patients in the direct care 
system by having primary care providers ``reach back'' to designated 
specialists for consultation. For example, rather than send a diabetic 
patient downtown on a referral to a TRICARE network endocrinologist, 
the primary care team can refer the case to our diabetes expert at the 
59th Medical Wing, Lackland AFB, Texas, without the patient ever 
departing the clinic. ECHO now includes multiple specialties, and has 
been so successful, the concept has been adopted by the Mayo Clinic, 
Johns Hopkins, Harvard, DOD, and the Veterans Administration (VA).
    Our personalized medicine project, patient-centered precision care 
(PC2), which builds on technological and evidence-based genomic 
association, received final Institutional Review Board approval. We 
enrolled the first 80 patients this year with a goal of enrolling 2,000 
patients in this research. PC2 will allow us to deliver state-of-the-
art, evidence-based, personalized healthcare incorporating all 
available patient information. A significant aspect of PC2 is genomic 
medicine research, the advancement of genome-informed personalized 
medicine. With a patient's permission, we analyze DNA to identify 
health risks and then ensure follow up with the healthcare team. De-
identified databases will allow us to advance research efforts. 
Research groups can determine associations or a specific area where 
they think there may be merit in terms of how we can change clinical 
practice. This research will likely change the way we view disease and 
lead to much earlier integration of new treatment options.
    MiCare is currently deployed to our family practice training 
programs and will be available at 26 facilities before the end of 2012. 
This secure messaging technology allows our patients to communicate 
securely with their providers via email. It also allows our patients to 
access their personal health record. Access to a personal health record 
will provide the ability to view lab test results at home, renew 
medications, and seek advice about nonurgent symptoms. Healthcare teams 
will be able to reach patients via MiCare to provide appointment 
reminders, follow up on a condition without requiring the patient to 
come to the MTF, provide medical test and referral results, and forward 
notifications on various issues of interest to the patient. We 
anticipate full implementation by the end of 2013.
    We are also testing incorporation of smart-phones into our clinics 
to link case managers directly to patients. Linking wireless and 
medical devices into smart phones allows the patient to transmit 
weight, blood pressure, or glucometer readings that are in high-risk 
parameters directly to their health team for advice and consultation. 
Patients with diabetes or congestive heart failure can see significant 
reductions in hospitalizations when interventions with the healthcare 
team are easily accessible on a regular basis. This improves quality of 
life for the diabetic or cardiology patient, reduces healthcare costs, 
and increases access for other patients. We have a pilot effort 
underway with George Washington University Hospital to use this tool in 
diabetes management.
    Safeguarding the well-being and mental health of our people while 
improving resilience is a critical Air Force priority. We remain 
vigilant with our mental health assessments and consistently have 
postdeployment health reassessment (PDHRA) completion rates at 80 
percent or higher for Active Duty, Guard, and Reserve personnel. In 
January 2011, we implemented section 708 of the 2010 National Defense 
Authorization Act (NDAA) for Active-Duty airmen, and in April 2011, for 
the Reserve component. The two-phased approach requires members to 
complete an automated questionnaire, followed by a person-to-person 
dialogue with a trained privileged provider. Whenever possible, these 
are combined with other health assessments to maximize access and 
minimize inconvenience for deployers. Each deployer is screened for 
post-traumatic stress disorder (PTSD) four times per deployment 
including a person-to-person meeting with a provider.
    Although Air Force PTSD rates are rising, the current rate remains 
low at 0.8 percent across the Air Force. Our highest risk group is 
explosive ordnance disposal (EOD) at about 7 percent, with medical 
personnel, security forces, and transportation at less risk, but higher 
than the Air Force baseline. Our mental health providers, including 
those in internships and residencies, are trained in evidence-based 
PTSD treatments to include prolonged exposure, cognitive processing 
therapy, and cognitive behavioral couples therapy for PTSD. Virtual 
Iraq/Afghanistan uses computer-based virtual reality to supplement 
prolonged exposure therapy at 10 Air Force sites. Diagnosis is still 
done through an interview, supported by screening tools such as the 
PTSD checklist (PCL) and other psychological testing as clinically 
indicated.
    We are working closely with Air Force leadership to inculcate 
healthy behaviors. Comprehensive airmen fitness focuses on building 
strength across physical, mental, and social domains. Airman resiliency 
training (ART) provides a standardized approach to pre-exposure 
preparation training for redeploying airmen, including tiered training 
that recognizes different risk groups. Traumatic stress response teams 
at each base foster resiliency through preparatory education and 
psychological first-aid for those exposed to potentially traumatic 
events.
    The Deployment Transition Center (DTC) at Ramstein Air Base, 
Germany, soon to be 2 years old, provides an effective reintegration 
program for our redeploying troops. More than 3,000 deployers have now 
processed through the DTC. A study of the first 800 airmen to go 
through the DTC, compared with 13,000 airmen matched to demographics, 
mission set, and level of combat exposure, demonstrated clear benefit 
from the DTC. Analyzing their PDHRA, airmen who attended the DTC showed 
positive results--significantly fewer symptoms of post-traumatic 
stress, lower levels of alcohol use, and lower levels of conflict with 
family/coworkers. This study provided solid evidence that the DTC helps 
airmen with reintegration back to their home environment. We are now 
partnering with the RAND Corporation in two other studies, looking at 
the overall Air Force resilience program and studying the effectiveness 
of the current ART program.
    While we experienced a drop in the Active-Duty suicide rate in 
2011, we remain concerned. Guard and Reserve suicide levels have 
remained steady and low. The major risk factors continue to be 
relationship, financial, and legal problems, and no deployment or 
history of deployment associations have been found. We strive to find 
new and better ways to improve suicide prevention efforts across the 
total force. By summer of this year, we will embed behavioral health 
providers in primary care clinics at every MTF. The Behavioral Health 
Optimization program (BHOP) reduces stigma by providing limited 
behavioral health interventions outside the context of the mental 
health clinic, offering a first stop for those who may need counseling 
or treatment. The Air Reserve Components instituted on-line training 
tools and products that support Ask, Care, Escort (ACE), our peer-to-
peer suicide prevention training. The Air Force Reserve Command also 
added a new requirement for four deployment resilience assessments 
beginning last April.
    We are increasing our mental health provider manning over the next 
5 years with more psychiatrists, psychologists, social workers, 
psychiatric nurse practitioners, and technicians. We increased Health 
Professions Scholarship Program (HPSP) scholarships for psychologists, 
as well as psychiatry residency training billets and the psychology 
Active-Duty Ph.D. program and internship billets. To enhance social 
worker skills, we placed social workers in four internship programs and 
dedicated HPSP scholarships and Health Professions Loan Repayment 
Program slots for fully qualified accessions. Accession bonuses for 
fully qualified social workers were approved for fiscal year 2012 for 
3- and 4-year obligations. These actions will help us to meet mental 
health manning requirements for both joint deployment requirements and 
at home station in compliance with section 714 in the 2010 National 
Defense Authorization Act. Air Force tele-mental health is now in place 
at 40 sites across the Air Force, and is planned for a total of 84 
sites.
    Like our sister Services, the Air Force continues to be concerned 
about, and focused on, the consequences of traumatic brain injury 
(TBI). We fully implemented TBI testing across the Air Force, and 
collected more than 90,000 Automated Neurological Assessment Metric 
(ANAM) assessments in the data repository. The Air Force accounts for 
10-15 percent of total TBI in the military with approximately 4 percent 
of deployment-associated TBI. Most Air Force cases, more than 80 
percent, are mild in severity. Of all our completed postdeployment 
health assessments and reassessments, less than 1 percent screened 
positive for TBI with persistent symptoms.
    Despite our relatively lower incidence, the Air Force continues to 
work with DOD partners to better understand and mitigate the effects of 
TBI. In collaboration with Defense and Veterans Brain Injury Center, 
Air Force, and Army radiologists at the San Antonio Military Medical 
Center are working jointly to study promising neuroimaging techniques 
including volumetric magnetic resonance imaging (MRI) using the Federal 
Drug Administration-approved software NeuroQuant, functional MRI, 
spectroscopy, and diffusion tensor imaging to identify structural 
changes that may result from TBI. Ongoing studies will find more 
definitive answers to this complex diagnostic and treatment problem.
    As co-chairman of the Recovering Warrior Task Force, I have come to 
understand all Services Wounded Warrior Programs. I have been on site 
visits with our committee as we seek to discern best practices to help 
our wounded, ill, and injured members recover. The joint efforts of DOD 
and the Department of Veterans Affairs to streamline the integrated 
delivery evaluation system (IDES) are paying dividends. In the Air 
Force, we are augmenting pre-Medical Evaluation Board (MEB) screening 
personnel to streamline IDES processing. Our electronic profile system 
gives us full visibility of those in the process and close coordination 
with the VA is reducing the time to complete the IDES processing.

              INVEST IN EDUCATION, TRAINING, AND RESEARCH

    Providing ``Trusted Care Anywhere'' requires our people to have the 
best education and training available to succeed in our mission. We 
strive to find new and better ways to ensure our Airmen not only 
survive but thrive.
    This is the goal of the Medical Education and Training Campus 
(METC), and it truly is a joint success story. METC has already 
matriculated 10,000 graduates from the Army, Navy, and Air Force, and 
now has numerous international students enrolled. The majority of the 
services' education and training programs have transferred to METC, and 
the remainder will transfer during the course of this year. The 
Institute for Credentialing Excellence (ICE) awarded METC the ICE 
Presidential Commendation for the pharmacy technician program and 
praised it as being the best program in the United States.
    Air Force graduate medical education (GME) programs continue to be 
the bedrock for recruiting top-notch medics. Since the 1970s, many of 
our GME programs have been affiliated with renowned civilian 
universities. These partnerships are critical to broad-based training 
and build credibility in the U.S. and international medical 
communities. GME residencies in Air Force medical centers develop 
graduates who are trained in humanitarian assistance, disaster 
management, and deployment medicine. National recognition for top 
quality Air Force GME programs improves our ability to recruit and 
retain the best. First-time pass rates on specialty board exams 
exceeded national rates in 26 of 31 specialty areas, and stand at 92 
percent overall for the past 4 years.
    Over the next few years, we will transform training to support new 
assets in air evacuation and expeditionary medical support. Flight 
nurse and technician training and AE contingency operations training 
curriculums have been entirely rewritten to capture lessons from 10 
years of war. The Centers for Sustainment of Trauma and Readiness 
Skills (C-STARS) in Baltimore, St. Louis, and Cincinnati, have been 
extraordinarily successful in maintaining wartime skills. We have 
expanded training sites to establish sustainment of traumas skills--
Sustainment of Trauma and Resuscitation Skills Programs (STARS-P)--to 
University of California Davis, Scottsdale, University of Nevada-Las 
Vegas, and Tampa General Hospitals. This will include greater use of 
simulation at C-STARS, STARS-P, and other Air Force medical sites. We 
have many testimonials from deployed graduates who credit their 
competence and confidence in theater to C-STARS and STARS-P training. 
We will continue efforts to expand this training so we will have full-
up trauma teams and CCATT that are always ready to go to war.
    One of our most significant partners in GME and resource-sharing is 
the Department of Veterans Affairs. We are proud of our 6 joint 
ventures, 59 sharing agreements, and 63 Joint Incentive Fund (JIF) 
projects, all win-wins for the military member, veteran, and American 
taxpayer. All four Air Force JIF proposals submitted for fiscal year 
2012 were selected. These include a new CT Scan at Tyndall AFB, 
Florida, that will also benefit the Gulf Coast VA Health Care System 
(HCS); establishment of an orthopedic surgery service for Mountain Home 
AFB, Idaho, and the Boise VAMC; funding for an additional cardiologist 
at Joint Base Elmendorf-Richardson and the Alaska VA HCS--critical to 
reducing the number of patients leaving our system of care; and an 
ophthalmology clinic at Charleston with the Naval Health Clinic 
Charleston and the Charleston VA Medical Center. The JIF program is 
extremely helpful in supporting efficiencies that make sense in the 
Federal Government, while improving access to care for our 
beneficiaries.
    Collaboration with the VA in the Hearing Center of Excellence (HCE) 
continues as we pursue our goals of outreach, prevention, enhanced 
care, information management, and research to preserve and restore 
hearing. Compounding hearing loss related to noise, the effect of 
improvised explosive devices (IEDs) that military personnel experience 
in Iraq and Afghanistan expands the threat and damage to the 
audiovestibular system. Traumatic brain injury may damage the hearing 
senses and the ability to process sound efficiently and effectively. 
Dizziness is common, and almost one-half of servicemembers with TBI 
complain of vertigo following blast exposure.
    We are coordinating and integrating efforts with the other 
congressionally mandated centers of excellence to ensure the clinical 
care and rehabilitation of the Nation's wounded, ill, and injured have 
the highest priority. Partnering with the Defense and Veterans Eye 
Injury Registry has resulted in the Joint Theater Trauma Registry 
adding ocular and auditory injury modules to look at the effect and 
relation eye and ear injury has on TBI and psychological health 
rehabilitation. And the Vision Center of Excellence under Navy lead and 
HCE have contributed to the planning, patient management, and clinical 
guidelines with the National Intrepid Center of Excellence, the Center 
for the Intrepid, and within the Institute of Surgical Research.
    We have expanded our research with the opening of the new School of 
Aerospace Medicine at Wright Patterson and our collaborative efforts 
with the Army in the San Antonio Military Medical Center. The 59th 
Medical Wing at Lackland AFB, Texas, is using laser treatment to 
improve range of motion and aesthetics in patients with burn scars. In 
the 10 subjects enrolled to date in the research, the laser treatments 
have resulted in an immediate reduction in scar bulk, smoothing of 
irregularities, and the production of scar collagen. The scars have 
also shown improved pliability, softness, and pigmentation. This is 
encouraging for our wounded warriors and servicemembers who have 
received thermal or chemical burns.
    Another promising laser initiative is the Tricorder Program, a 
collaboration effort with the University of Illinois, Chicago, designed 
to detect/characterize laser exposure in ``real time,'' assisting in 
the development of force health protection measures, such as laser eye 
protection. Air Force and Navy testers evaluated the prototype laser 
sensors in simulated air and ground field environments. An upcoming 
exercise with the FBI Operational Technology Division will assess the 
laser sensor for forensic capability in a domestic aircraft 
illumination scenario.
    Another collaborative effort, with the Department of Homeland 
Security, is the development of an environmental/medical sensor 
integration platform that provides real-time data collection and 
decision support capability for medical operators and commanders, 
integrating environmental and medical sensor data from the field into a 
hand-held platform. The sensor integration platform was demonstrated 
successfully several times, including its deployment for environmental 
monitoring capability with the Hawaii National Guard, where the 
platform quadrupled Hawaii's radiation monitoring capability after the 
tsunami in Japan. It is now the backbone of Hawaii's State civil 
defense system real-time environmental monitoring capability.
    The U.S. Air Force School of Aerospace Medicine (USAFSAM), Wright-
Patterson AFB, Ohio, developed the cone contrast test (CCT) for 
detection of color vision deficiency. The CCT was selected as a winner 
of the 2012 Award for Excellence in Technology Transfer, presented 
annually by the Federal Laboratory Consortium to recognize laboratory 
employees who accomplished outstanding work in the process of 
transferring a technology developed by a Federal laboratory to the 
commercial marketplace. The technology was developed by vision 
scientists in USAFSAM's Aerospace Medicine Department and uses computer 
technology to replace the colored dot Ishihara Plates developed in the 
early 1900s. The CCT indicates vision deficiency type and severity, and 
can distinguish hereditary color vision loss from that caused by 
disease, trauma, medications, and environmental conditions--ensuring 
pilot safety while facilitating the detection and monitoring of 
disease.

                             THE WAY AHEAD

    I look back 10 years to 9/11 and marvel at how far we have come in 
a decade. While sustaining the best battlefield survival rate in the 
history of war, we have simultaneously completed complex base 
realignment and closure projects, and enhanced our peacetime care 
worldwide. We changed wartime medicine by moving the sickest of the 
sick home to the United States within 3 days, while shifting 1 million 
enrolled patients into team based, patient-centered care that improved 
continuity of care 100 percent. One thing has not changed . . . the 
talent, courage, and dedication of Air Force medics still inspires me 
every day. As I retire later this year, I know that I leave our Air 
Force family in exceptional hands. Air Force medics will always deliver 
``Trusted Care, Anywhere'' for this great Nation.
    The AFMS will work shoulder-to-shoulder with our Army, Navy, and 
DOD counterparts to be ready, and provide better health, better care, 
and best value to America's heroes. Together we will implement the 
right governance of our Military Health System. We will find 
efficiencies and provide even higher quality care with the resources we 
are given. I thank this subcommittee for your tremendous support to 
military medics. Our success, both at home and on the battlefield, 
would not be possible without your persistent and generous support. 
Thank you.

    Chairman Inouye. Thank you, Sir.
    Admiral Nathan.

STATEMENT OF VICE ADMIRAL MATTHEW L. NATHAN, SURGEON 
            GENERAL OF THE NAVY
    Admiral Nathan. Good morning, Chairman Inouye, Vice 
Chairman Cochran, and Senator Mikulski, distinguished members 
of the subcommittee. Thank you for the opportunity to provide 
this update on Navy Medicine, including some of our strategic 
priorities, accomplishments, and opportunities.
    I report to you that Navy Medicine remains strong, capable, 
and mission-ready to deliver world-class care anywhere, 
anytime, as is our motto. We're meeting our operational wartime 
commitments, including humanitarian assistance and disaster 
response, and concurrently delivering outstanding patient- and 
family-centered care to our beneficiaries.
    Force health protection is what we do, and is at the very 
foundation of our continuum of care in support of the 
warfighter, and optimizes our ability to promote, protect, and 
restore their health. One of my top priorities since becoming 
the Navy Surgeon General in November has been to ensure that 
Navy Medicine is strategically aligned with the imperatives and 
priorities of the Secretary of the Navy, the Chief of Naval 
Operations, and the Commandant of the Marine Corps--all of my 
bosses.
    Each day, we are fully focused on executing the operational 
missions and core capabilities of the Navy and Marine Corps, 
and we do this by maintaining warfighter health readiness, 
delivering the continuum of care from the battlefield, to the 
bedside, from the bedside, to the unit, to the family, or to 
transition.
    Earlier this month, Secretary Mabus launched the 21st 
Century Sailor and Marine program, a new initiative focused on 
maximizing each sailor's and marine's personal readiness. This 
program includes comprehensive efforts in areas that are key, 
such as reducing suicides, and suicide attempts, curbing 
alcohol abuse, and reinforcing zero tolerance on the use of 
designer drugs or the newly arising synthetic chemical 
compounds. It also recognizes the vital role of safety and 
physical fitness in sustaining force readiness. Navy Medicine 
is synchronized with these priorities and stands ready to move 
forward at this pivotal time in our service's history. We 
appreciate the subcommittee's strong support of our resource 
requirements.
    The President's budget for fiscal year 2013 adequately 
funds Navy Medicine to meet its medical mission for the Navy 
and the Marine Corps. We recognize the significant investments 
made in supporting military medicine, and providing a strong, 
equitable, and affordable healthcare benefit for our 
beneficiaries. Moving forward, we must operate more jointly, we 
must position our direct care system to recapture private 
sector care, and deliver best value to our patients.
    A few specific areas of our attention. Combat casualty 
care, Navy Medicine, along with our Army and Air Force 
colleagues, are delivering outstanding combat casualty care. 
There is occasionally discussion about what constitutes world-
class care, and I can assure you that the remarkable skills and 
capabilities in a place like the Role 3 facility, at the 
multinational medical unit in Kandahar, Afghanistan, is 
delivering truly world-class trauma care.
    Traumatic brain injury (TBI), post-traumatic stress, and 
post-traumatic stress disorder (PTSD): Caring for our sailors 
and marines suffering with TBI and PTSD remains a top priority. 
We must continue active and expansive partnerships with other 
services, our Centers of Excellence, the VA, and leading 
academic medical and research centers to make the best care 
available to our warriors afflicted with TBI. I have been 
encouraged by our progress, but I'm not yet satisfied.
    Warrior recovery: Our wounded, ill, and injured 
servicemembers need to heal in mind, body, as well as spirit, 
and they deserve a seamless and comprehensive approach to their 
recovery. We must continue to connect our heroes to a proved 
emerging and advanced diagnostic and therapeutic options, but 
within our medical treatment facilities and outside of military 
medicine, through the collaborations with major medical centers 
of reconstructive and regenerative medicine. This commitment 
can never waiver.
    And finally, Medical Home Port: We've completed our initial 
deployment of Medical Home Port, which is basically patient-
centered medical homes, as utilized in some of the larger 
organizations in the civilian sector, and the preliminary 
reports from the first sites of Navy Medicine show better 
health, better value, and less cost utilization of those 
enrolled.
    Our innovative research and outstanding medical education 
are truly force multipliers. Our critical overseas laboratories 
provide not only world-class research but invaluable engagement 
with host and surrounding nations to strengthen the theater 
security cooperation in longstanding research facilities that 
reside in places like Egypt, South America, Southeast Asia.
    We continue to welcome and leverage our joint relationships 
with the Army, the Air Force, the VA, as well as other Federal 
and civilian partners in these important areas. I believe this 
interoperability helps us create system-wide synergies and 
allows us to invest wisely in education and training, research, 
and information technology.
    None of these things would be possible without our 
professional and dedicated workforce. More than 60,000 men and 
women, Active Duty, Reserve personnel, civilians and 
contractors, all working the world to provide outstanding 
healthcare and support services to our beneficiaries.

                           PREPARED STATEMENT

    In closing, let me briefly address the MHS governance. The 
Deputy Secretary of Defense has submitted his report to the 
Congress, required by section 716 of fiscal year 2012 National 
Defense Authorization Act (NDAA). It addresses the Department's 
plans, subject to review, and concurrence by the Government 
Accountability Office (GAO), to move forward with governance 
changes. Throughout my remarks this morning, and in my 
statement for the record, I have referred to our commitment to 
jointness in theater, in our classrooms, in our training, in 
our laboratories, and in our common pursuit of solutions like 
challenges like TBI. We all recognize the need for 
interoperability and cost-effective joint solutions, in terms 
of overall governance. We must, however, proceed in a 
deliberate and measured manner to ensure that our readiness to 
support our services missions and core war fighting 
capabilities will be maintained, and our excellence in 
healthcare delivery will be sustained.
    On behalf of the men and women in Navy Medicine, I want to 
thank this subcommittee for your tremendous support, your 
confidence, and your leadership, and I look forward to your 
questions.
    Thank you.
    [The statement follows:]

          Prepared Statement of Vice Admiral Matthew L. Nathan

                              INTRODUCTION

    Chairman Inouye, Vice Chairman Cochran, and distinguished members 
of the subcommittee: I am pleased to be with you today to provide an 
update on Navy Medicine, including some of our collective strategic 
priorities, accomplishments, and opportunities. I want to thank the 
subcommittee members for the tremendous confidence and support of Navy 
Medicine.
    I can report to you that Navy Medicine remains strong, capable, and 
mission-ready to deliver world-class care, anytime, anywhere. We are 
operating forward and globally engaged, no matter what the environment 
and regardless of the challenge. The men and women of Navy Medicine 
remain flexible, agile, and resilient in order to effectively meet 
their operational and wartime commitments, including humanitarian 
assistance; and concurrently, delivering outstanding patient and 
family-centered care to our beneficiaries. It is a challenge, but one 
that we are privileged to undertake.
    One of my top priorities since becoming the Navy Surgeon General in 
November 2011 is to ensure that Navy Medicine is strategically aligned 
with the imperatives and priorities of the Secretary of the Navy, Chief 
of Naval Operations, and Commandant of the Marine Corps. We are fully 
engaged in executing the operational missions and core capabilities of 
the Navy and Marine Corps--and we do this by maintaining warfighter 
health readiness, delivering the continuum of care from the battlefield 
to the bedside and protecting the health of all those entrusted to our 
care. Our focus remains in alignment with our Navy and Marine Corps 
leadership as we support the defense strategic guidance, ``Sustaining 
U.S. Global Leadership: Priorities for the 21st Century'' issued by the 
President and Secretary of Defense earlier this year. The Chief of 
Naval Operations in his ``Sailing Directions'' has articulated the 
Navy's core responsibilities and Navy Medicine stands ready as we move 
forward at this pivotal time in our history.
    Navy Medicine appreciates the subcommittee's strong support of our 
resource requirements. The President's budget for fiscal year 2013 
adequately funds Navy Medicine to meet its medical mission for the Navy 
and Marine Corps. We recognize the significant investments made in 
supporting military medicine and remain committed to providing 
outstanding care to all our beneficiaries. Moving forward, we must 
innovate, position our direct care system to recapture private sector 
care, and deliver best value to our patients. Driving these changes is 
critical and necessary but not sufficient. The Secretary of Defense has 
articulated that the current upward trajectory of healthcare spending 
within the Department is not sustainable. Accordingly, the President's 
budget includes important healthcare proposals designed to address this 
situation, including adjustments in TRICARE fees. The Department of 
Navy supports these proposals and believes they are important for 
ensuring a sustainable and equitable benefit for all our beneficiaries. 
We deliver one of the most comprehensive health benefits available and 
these changes will help us better manage costs, provide quality, 
accessible care, and keep faith with our beneficiaries. As the Navy 
Surgeon General, I appreciate the tremendous commitment of our senior 
leaders in this critical area and share the imperative of controlling 
costs and maintaining an affordable and sustainable benefit.
    Value--a key analytic in our decisionmaking--must inherently 
address cost and quality as we implement efficiencies and streamline 
operations. All of us in the Military Health System (MHS) recognize the 
challenges ahead are significant, including rising healthcare costs, 
increased number of beneficiaries, and maintaining long-term care 
responsibilities for our medically retired warriors.
    Additionally, we are very focused on improving internal controls 
and financial procedures in response to congressional priorities to 
obtain a clean financial audit. We have mandated the use of standard 
operating procedures at all our activities for those business processes 
which impact financial transactions. I have also emphasized the 
responsibility of every commanding officer in setting and maintaining 
appropriate internal controls. We are regularly evaluating our progress 
through financial transactions and process reviews which help us 
identify if any changes need to be made. We are making progress and our 
leadership is fully engaged and leaning forward to ensure the best 
possible stewardship of our resources.
    Alignment is also critical as we focus on more joint solutions 
within the MHS and in conjunction with the Army and Air Force. We see 
tremendous progress in joint medical operations, from battlefield 
medicine to education and training to research and development. As we 
continue to synchronize our collective efforts through deliberative 
planning and rigorous analyses, I believe we will have more 
opportunities to create synergies, reduce redundancies, and enhance 
value across the MHS.
    Our continuing joint efforts in the integration of the Quadruple 
Aim initiative is helping to develop better outcomes and implement 
balanced incentives across the MHS. The Quadruple Aim applies the 
framework from the Institute for Healthcare Improvement (IHI) and 
customizes it for the unique demands of military medicine. It targets 
the MHS and services' efforts on integral outcomes in the areas of 
readiness, population health and quality, patient experience, and cost. 
Our planning process within Navy Medicine is complementary to these 
efforts and targets goals that measure our progress and drive change 
through constructive self-assessment. I have challenged Navy Medicine 
leaders at headquarters, operational and regional commands, and 
treatment facilities to maintain strategic focus on these key metrics.

                 OUR MISSION IS FORCE HEALTH PROTECTION

    Force Health Protection is at the epicenter of everything we do. It 
is an expression of our Core Values of Honor, Courage, and Commitment 
and the imperative for our worldwide engagement in support of 
expeditionary medical operations and combat casualty care. It is at the 
very foundation of our continuum of care in support of the warfighter 
and optimizes our ability to promote, protect, and restore their 
health. It is both an honor and obligation.
    Our Force Health Protection mission is clearly evident in our 
continued combat casualty care mission in Operation Enduring Freedom 
(OEF). Navy Medicine personnel are providing direct medical support to 
the operating forces throughout the area of responsibility (AOR). We 
continue to see remarkable advances in all aspects of life-saving 
trauma care. These changes have been dramatic over the last decade and 
enabled us to save lives at an unprecedented rate. We are continuously 
implementing lessons learned and best clinical practices, ensuring our 
providers have the most effective equipment available, and focusing on 
providing realistic and meaningful training. Mission readiness means 
providing better, faster combat casualty care to our warfighters.
    The North Atlantic Treaty Organization (NATO) Role 3 Multinational 
Medical Unit (MMU), operating at Kandahar Airfield, Afghanistan is a 
world-class combat trauma hospital that serves a unique population of 
United States and coalition forces, as well as Afghan National Army, 
National Police, and civilians wounded in Afghanistan. Led by Navy 
Medicine, the Role 3 MMU is an impressive 70,000 square foot state-of-
the-art facility that is the primary trauma receiving and referral 
center for all combat casualties in Southern Afghanistan. It has 12 
trauma bays, 4 operating rooms, 12 intensive care beds, and 35 
intermediate care beds. The approximately 250 staff of Active component 
(AC) and Reserve component (RC) personnel includes 30 physicians with 
multiple surgical specialties as well as anesthesia, emergency 
medicine, and internal medicine. RC personnel currently make up 27 
percent of overall manning and provide us unique and invaluable skill 
sets. With trauma admissions averaging 175 patients per month, the unit 
achieved unprecedented survival rates in 2011. In addition, MMU has two 
forward surgical teams deployed in the region to provide frontline 
surgical trauma care demonstrating agility to meet changing operational 
requirements.
    Training is critical for our personnel deploying to the MMU Role 3. 
This year, we established a targeted training program at the Naval 
Expeditionary Medical Training Institute (NEMTI) onboard Marine Corps 
Base Camp Pendleton for our personnel deploying to the MMU. The 
training is part of an effort designed to foster teamwork, and build 
medical skills specific to what personnel require while on a 6-month 
deployment. Navy Medicine and U.S. Fleet Forces Command (FFC) 
recognized the need to integrate medical training scenarios to expand 
upon the knowledge and skills required to fill positions at the 
Kandahar Role 3 facility. In January, I had the opportunity to see this 
impressive training in action during the course's final exercise and 
saw our personnel implement the clinical skills they honed during the 
2-week course. They participated in a scenario-driven series of 
exercises, including staffing a fully equipped hospital receiving 
patients with traumatic injuries, simulated air strike, and a mass 
casualty drill. This training, as well as the program at the Navy 
Trauma Training Center (NTTC) at Los Angeles County/University of 
Southern California Medical Center where our personnel train as teams 
in a busy civilian trauma center, help ensure our deployers have the 
skills and confidence to succeed in their combat casualty care mission.
    Recognizing the importance of ensuring our deployed clinicians have 
access to state-of-the-art capabilities, Navy Medicine, in conjunction 
with the Army, Air Force, and our contracted partners worked 
successfully to deliver the first ever magnetic resonance imaging (MRI) 
technology in a combat theatre to aid the comprehensive diagnosis and 
treatment of concussive injuries. Efforts included the planning, 
design, and execution of this new capability as well as ensuring that 
clinical, logistical, transportation, environmental, and sustainment 
considerations for the MRIs were fully addressed prior to the 
deployment of the units to the battlefield. The fact that we were able 
to design, acquire, and deliver this new capability to the battlefield 
in approximately 6 months from contract award is a testament to the 
commitment of the joint medical and logistics teams. MRIs are now in 
place Role 3 MMU in Kandahar, Role 3 Trauma Hospital in Camp Bastion 
and the Joint Theatre Hospital located on Bagram Airfield.
    Navy Medicine also supports stability operations through multiple 
types of engagements including enduring, ship-centric humanitarian 
assistance (HA) missions such as Pacific Partnership and Continuing 
Promise, which foster relationships with partner countries. During 2011 
Pacific Partnership 2011, 86 Navy Medicine personnel augmented with 
nongovernmental organization, interagency, and other Service personnel 
conducted activities in Tonga, Vanuatu, Papua New Guinea, Timor Leste, 
and the Federated States of Micronesia. Engagements included 
engineering projects, veterinary services, preventive medicine/public 
health, and biomedical equipment repair. Continuing Promise 2011 
involved 480 Navy Medicine personnel conducting activities in Jamaica, 
Peru, Ecuador, Colombia, Nicaragua, Guatemala, El Salvador, Costa Rica, 
and Haiti. More than 67,000 patients were treated and 1,130 surgeries 
were performed during this important mission. In addition to our 
efforts at sea, Navy Medicine also supports land-based HA engagements 
including Marine Corps exercises such as Africa Partnership Station and 
Southern Partnership Station as well as multiple Joint exercises such 
as Balikatan in the Philippines.

          MEDICAL HOME PORT: PATIENT- AND FAMILY-CENTERED CARE

    We completed our initial deployment of Medical Home Port (MHP) 
throughout the Navy Medicine enterprise. MHP is Navy Medicine's 
adaptation of the successful civilian patient-centered medical home 
(PCMH) concept of care which transforms the delivery of primary care to 
an integrated and comprehensive suite of services. MHP is founded in 
ensuring that patients see their assigned provider as often as 
possible, and that they can access primary care easily rather than 
seeking primary care in the emergency room. Strategically, MHP is a 
commitment to total health and, operationally, it is foundational to 
revitalizing our primary care system and achieving high-quality, 
accessible, cost-efficient healthcare for our beneficiaries.
    We are also working with the Marine Corps to implement the Marine-
centered medical home (MCMH) as a complementary analogue to the MHP. 
Likewise, we are working with U.S. Fleet Forces Command to establish a 
fleet-based model of the PCMH using the same principles. The first 
prototype carrier-based PCMH concept will be developed for USS Abraham 
Lincoln (CVN-72).
    Initial results are encouraging. MHP performance pilots at the 
Walter Reed National Military Medical Center (WRNMMC) and Naval 
Hospital Pensacola have shown improvement in key healthcare outcomes 
such as:
  --increased patient satisfaction;
  --improved access to care; and
  --improved quality of care associated with decreased use of the 
        emergency room (an important cost driver).
    Data show similar results enterprise-wide through October 2011, and 
also indicate improved continuity with assigned provider, decreased 
emergency room utilization, and better cost containment when compared 
with fiscal year 2010.

                   HEALING IN BODY, MIND, AND SPIRIT

    Health is not simply the absence of infirmity or disease--it is the 
complete state of physical, mental, spiritual, and social well-being. 
As our wounded warriors return from combat and begin the healing 
process, they deserve a seamless and comprehensive approach to their 
recovery. Our focus is integrative, complementary, and 
multidisciplinary-based care, bringing together clinical specialists, 
behavioral health providers, case managers, and chaplains. There are 
approximately 170 medical case managers who work closely with their 
line counterparts in the Marine Corps' Wounded Warrior Regiment and the 
Navy's Safe Harbor program to support the full-spectrum recovery 
process for sailors, marines, and their families.
    We have made remarkable progress in ensuring our wounded 
servicemembers get the care they need--from medical evacuation through 
inpatient care, outpatient rehabilitation to eventual return to duty or 
transition from the military. With our historically unprecedented 
battlefield survival rate, we witness our heroes returning with the 
life-altering wounds of war which require recovery and long-term care. 
We must continue to adapt our capabilities to best treat these 
conditions and leverage our systems to best support recovery.
    To that end, we are committed to connecting our wounded warriors to 
approved emerging and advanced diagnostic and therapeutic options 
within our military treatment facilities (MTFs) and outside of military 
medicine. We do this through collaborations with major centers of 
reconstructive and regenerative medicine while ensuring full compliance 
with applicable patient safety policies and practices. The Naval 
Medical Research and Development Center in Frederick, Maryland, is 
aggressively engaged in furthering support for cooperative medical 
research between multiple centers of regenerative and reconstructive 
medicine. Their collaborative efforts, in conjunction with the Armed 
Forces Institute of Regenerative Medicine (AFIRM), are essential in 
developing new regenerative and transplant capabilities, both at the 
civilian and the military institutions with ultimate sharing of 
knowledge, expertise, and technical skills in support of restoration of 
our wounded warriors.
    Navy Medicine continues a robust translation research program in 
wound healing and wound care, moving technologies developed at the 
bench to deployment in the clinic to enhance the care of the wounded 
warfighter. Concurrently, we are focused on improving the capability 
and capacity to provide comprehensive and interdisciplinary pain 
management from the operational setting to the MTF to home. This 
priority includes pain management education and training to providers, 
patients, and families to prevent over-prescribing, misuse of 
medications, and promoting alternative therapies.
    Preserving the psychological health of servicemembers and their 
families is one of the greatest challenges we face today. The Navy 
continues to foster a culture of support for psychological health as an 
essential component to total force fitness and readiness. Navy and 
Marine Corps combat operational stress control (COSC) programs provide 
sailors, marines, leaders, and families the skills and resources to 
build resiliency. We also continue to address stigma by encouraging 
prevention, early intervention, and help-seeking behaviors. Training is 
designed to build teams of leaders, marines, sailors, medical, and 
religious ministry personnel to act as sensors for leadership by 
noticing small changes in behavior and taking action early. These 
efforts support in fostering unit strength, resilience, and readiness.
    Navy Medicine has continued to adapt psychological health support 
across traditional and nontraditional healthcare systems. Access to 
psychological health services have increased in venues designed to 
reduce the effects associated with mental health stigma. These efforts 
are also focused on suicide prevention and are designed to improve 
education, outreach, and intervention. In 2011, more than 1,000 health 
providers received targeted training in assessing and managing suicide 
risk. We are also integrating behavioral health providers in our MHP 
program to help address the needs of our patients in the primary care 
setting.
    Post-traumatic stress disorder (PTSD) is one of many psychological 
health conditions that adversely impacts operational readiness and 
quality of life. Navy Medicine has an umbrella of psychological health 
programs that target multiple, often co-occurring, mental health 
conditions including PTSD. These programs support prevention, 
diagnosis, mitigation, treatment, and rehabilitation of PTSD. Our 
efforts are also focused on appropriate staffing, meeting access 
standards, implementing recommended and standardized evidence-based 
practices, as well as reducing stigma and barriers to care.
    We recently deployed our fifth Navy Mobile Mental Health Care Team 
(MCT) in Afghanistan. Consisting of two mental health clinicians, a 
research psychologist and an enlisted behavioral health technician, 
their primary mission is to administer the Behavioral Health Needs 
Assessment Survey (BHNAS). The results give an overall assessment and 
actionable intelligence of real-time mental health and well-being data 
for our deployed forces. It can also identify potential areas or 
subgroups of concern for leaders on the ground and those back in 
garrison. The survey assesses mental health outcomes, as well as the 
risk and protective factors for those outcomes such as combat 
exposures, deployment-related stressors, positive effects of 
deployment, leadership perceptions, and morale and unit cohesion. The 
MCT also has a preventive mental health and psycho-education role and 
provides training in COSC and combat and operational stress first aid 
(COSFA) to sailors in groups and individually to give them a framework 
to mitigate acute stressors and promote resilience in one another.
    Data from previous MCT deployments and BHNAS analyses indicate 
continued need for implementation of COSC doctrine and command support 
in OEF. In addition, the Joint Mental Health Assessment Team (J-MHAT 7) 
surveillance efforts conducted in Afghanistan during 2010 indicate an 
increase in the rate of marines screening at-risk for PTSD relative to 
similar surveys conducted in marine samples serving in Iraq during 2006 
and 2007. This assessment also shows increases in training 
effectiveness regarding managing combat deployment stress, as well as a 
significant reduction in stigma associated with seeking behavioral 
health treatment.
    In collaboration with the Marine Corps, the operational stress 
control and readiness (OSCAR) program represents an approach to mental 
healthcare in the operational setting by taking mental health providers 
out of the clinic and embedding them with operational forces to 
emphasize prevention, early detection, and brief intervention. OSCAR-
trained primary care providers recognize and treat psychological health 
issues at points where interventions are often most effective. In 
addition, OSCAR includes chaplains and religious personnel (OSCAR 
Extenders) who are trained to recognize stress illness and injuries and 
make appropriate referral. More than 3,000 marine leaders and 
individual marines have been trained in prevention, early detection, 
and intervention in combat stress through OSCAR Team Training and will 
operate in OSCAR teams within individual units.
    Through the caregiver occupational stress control (CgOSC) program, 
Navy Medicine is also working to enhance the resilience of caregivers 
to the psychological demands of exposure to trauma, wear and tear, 
loss, and inner conflict associated with providing clinical care and 
counseling. The core objectives include:
  --early recognition of distress;
  --breaking the code of silence related to stress reactions and 
        injuries; and
  --engaging caregivers in early help as needed to maintain both 
        mission and personal readiness.
    Our emphasis remains ensuring that we have the proper size and mix 
of mental health providers to care for the growing need of 
servicemembers and their families who need care. Within Navy Medicine, 
mental health professional recruiting and retention remains a top 
priority. Although shortfalls remain, we have made progress recruiting 
military, civilian, and contractor providers, including psychiatrists, 
clinical psychologists, social workers, and mental health nurse 
practitioners. We have increased the size of the mental health 
workforce in these specialties from 505 in fiscal year 2006 to 829 in 
fiscal year 2012. Notwithstanding the military is not immune to the 
nationwide shortage of qualified mental health professionals. 
Throughout the country, the demand for behavioral health services 
remains significant and continues to grow.
    Caring for our sailors and marines suffering with traumatic brain 
injury (TBI) remains a top priority. While we are making progress, we 
have much work ahead of us as we determine both the acute and long-term 
impact of TBI on our servicemembers. Our strategy must be both 
collaborative and inclusive by actively partnering with the other 
Services, our Centers of Excellence, the Department of Veterans Affairs 
(VA), and leading academic medical and research centers to make the 
best care available to our warriors afflicted with TBI.
    Navy Medicine is committed to ensuring thorough screening for all 
sailors and marines prior to deployment, while in theatre, and upon 
return from deployment. Pre-deployment neurocognitive testing is 
mandated using the Automated Neuropsychological Assessment Metrics 
(ANAM). The ANAM provides a measure of cognitive performance, that when 
used with a patient with confirmed concussion, can help a provider 
determine functional level as compared to the servicemember's baseline. 
In-theatre screening, using clinical algorithms and the Military Acute 
Concussion Evaluation (MACE), occurs for those who have been exposed to 
a potentially concussive event, as specified by the event driven 
protocols of the TBI Directive-type Memorandum (DTM) 09-033 released in 
June 2010.
    DTM-09-033 has changed the way we treat TBI in theatre. It requires 
pre-deployment on point-of-injury care, improved documentation, and 
tracking of concussion by line and medical leaders, as well as a move 
toward standardization of system-wide care.
    In-theatre, the Concussion Restoration Care Center (CRCC) at Camp 
Leatherneck Afghanistan, became operational in August 2010. CRCC 
represents a ground-breaking, interdisciplinary approach to 
comprehensive musculoskeletal and concussion care in the deployed 
setting. As of December 1, 2011, the CRCC has seen more than 2,500 
patients (more than 750 with concussion) with a greater than 95 percent 
return to duty rate. I am encouraged by the impact the CRCC is having 
in theatre by providing treatment to our servicemembers close to the 
point-of-injury and returning them to duty upon recovery. We will 
continue to focus our attention on positioning our personnel and 
resources where they are most needed.
    Postdeployment surveillance is accomplished through the 
postdeployment health assessment (PDHA) and postdeployment health 
reassessment (PDHRA), required for returning deployers. Navy Medicine 
has conducted additional postdeployment TBI surveillance on high-risk 
units and those marines with confirmed concussions in theatre, with a 
goal of improving patient outcomes and better informing leaders.
    Access and quality of care for treating TBIs are being addressed 
through standardization of Navy Medicine's current six clinical TBI 
specialty programs at Naval Medical Center Portsmouth, Naval Medical 
Center San Diego, Naval Hospital Camp Lejeune, Naval Hospital Camp 
Pendleton, Naval Health Clinic New England--Branch Health Clinics 
Groton and Portsmouth. Additionally, we have an inpatient program at 
WRNMMC which focuses on moderate and severe TBI while also conducting 
screening for TBI on all polytrauma patients within the medical center.
    The National Intrepid Center of Excellence (NICoE) is dedicated to 
providing cutting-edge evaluation, treatment planning, research, and 
education for servicemembers and their families dealing with the 
complex interactions of mild TBI and psychological health conditions. 
Their approach is interdisciplinary, holistic, patient-, and family-
centered. The NICoE's primary patient population is comprised of Active 
Duty servicemembers with TBI and PH conditions who are not responding 
to current therapy. The NICoE has spearheaded partnerships with many 
military, Federal, academic, and private industry partners in research 
and education initiatives to further the science and understanding of 
these invisible wounds of war. The Department of Defense (DOD) has 
recently accepted an offer from the Intrepid Fallen Heroes Fund to 
construct several NICoE Satellite centers to treat our military 
personnel suffering from PTSD or TBI locally. The first installations 
to receive these centers will be Fort Belvoir, Camp Lejeune, and Fort 
Campbell. The Services are actively working together to determine the 
details regarding project timelines, building sizes, staffing, funding, 
and sustainability.
    We need to continue to leverage the work being done by the Defense 
Centers of Excellence for Psychological Health and Traumatic Brain 
Injury, including the Defense and Veterans Brain Injury Center, given 
their key roles in the expanding our knowledge of PH and TBI within the 
MHS, the VA and research institutions. This collaboration is also 
evident in the work being conducted by the Vision Center of Excellence 
(VCE), established by the National Defense Authorization Act of 2008. 
VCE, for which Navy Medicine currently provides operational support, 
exemplifies this important symmetry with military medicine, the VA and 
research partners. They are developing a distributed and integrated 
organization with regional locations that link together a network of 
clinical, research, and teaching centers around the world. The VCE 
encompasses an array of national and international strategic partners, 
including institutions of higher learning, and public and private 
entities.
    Family readiness supports force readiness so we must have programs 
of support in place for our families. We continue to see solid results 
from FOCUS (Families Over Coming Under Stress), our evidence-based, 
family-centered resilience training program that enhances understanding 
of combat and operational stress, psychological health and 
developmental outcomes for highly stressed children and families. 
Services are offered at 23 CONUS/OCONUS locations. As of December 2011, 
270,000 families, servicemembers, and community support members have 
been trained on FOCUS. Based on the program's annual report released in 
July 2011, we can see there has been a statistically significant 
decrease in issues such as depression and anxiety in servicemembers, 
spouses, and children who have completed the program as well as a 
statistically significant increase in positive family functioning for 
families.
    For our Marine Corps and Navy Reserve populations, we have 
developed the Reserve Psychological Health Outreach Program (PHOP). 
PHOP provides psychological health outreach, education/training, and 
resources a 24/7 information line for unit leaders or reservists and 
their families to obtain information about local resources for issues 
related to employment, finances, psychological health, family support, 
and child care. PHOP now includes 55 licensed mental health providers 
dispersed throughout the country serving on 11 teams located centrally 
to Navy and Marine Force Reserve commands.
    Returning warrior workshops (RWWs) began with the Navy Reserve more 
than 5 years ago and are conducted quarterly in each Navy Reserve 
Region across the country. As of September 2011, more than 10,000 
servicemembers and their families have participated in RWWs. RWWs 
assist demobilized servicemembers and their loved ones in identifying 
immediate and potential issues that often arise during postdeployment 
reintegration.
    Navy Medicine maintains a steadfast commitment to our substance 
abuse rehabilitation programs (SARPs). SARPs offer a broad range of 
services to include alcohol education, outpatient and intensive 
outpatient treatment, residential treatment, and medically managed care 
for withdrawal and/or other medical complications. We have expanded our 
existing care continuum to include cutting-edge residential and 
intensive outpatient programs that address both substance abuse and 
other co-occurring mental disorders directed at the complex needs of 
returning warriors who may suffer from substance abuse disorders and 
depression or PTSD. In addition, Navy Medicine has developed a new 
program known as My Online Recovery Experience (MORE). In conjunction 
with Hazelden, a civilian leader in substance abuse treatment and 
education, MORE is a ground-breaking Web-based recovery management 
program available to servicemembers 24/7 from anywhere in the world. 
Navy Medicine has also invested in important training opportunities on 
short-term interventions and dual diagnosis treatment for providers and 
drug and alcohol counselors, markedly improving quality and access to 
care.
    Our Naval Center for Combat & Operational Stress Control (NCCOSC)--
now in its fourth year--continues to improve the psychological health 
of marines and sailors through comprehensive programs that educate 
servicemembers, build psychological resilience and promote best 
practices in the treatment of stress injuries. The overarching goal is 
to show sailors and marines how to recognize signs of stress before 
anyone is in crisis and to get help when it is needed. NCCOSC continues 
to make progress in advancing research for the prevention, diagnosis, 
and treatment of combat and operational stress injuries, including 
PTSD. They have 50 on-going scientific projects and have doubled the 
number of enrolled participants from a year ago to more than 7,100. 
Similarly, they have expanded the enrollment in their psychological 
health pathways (PHP) pilot project to 2,248 patients--a 38-percent 
increase over last year.

   FORCE MULTIPLIERS: RESEARCH AND DEVELOPMENT AND GRADUATE MEDICAL 
                               EDUCATION

    Innovative research and development and vibrant medical education 
help ensure that we have the capabilities to deliver world-class care 
now and in the future. They are sound investments in sustaining our 
excellence to Navy Medicine to our mission of Force Health Protection.
    The continuing mission of our Medical Research and Development 
program is to conduct health and medical research in the full spectrum 
of development, testing, clinical evaluation (RDT&E), and health threat 
detection in support of the operational readiness and performance of 
DOD personnel worldwide. In parallel with this primary operational 
research activity, our clinical investigation program (CIP) continues 
to expand at our teaching MTFs with direct funding being provided to 
support the enrichment of knowledge and capability of our trainees. 
Where consistent with this goal, these programs are participating in 
the translation of knowledge and tangible products from our RDT&E 
activity into proof of concept and cutting edge interventions that are 
directly applied in benefit of our wounded warriors and our 
beneficiaries.
    Navy Medicine's five strategic research priorities are set to meet 
the war-fighting requirements of the Chief of Naval Operations and the 
Commandant of the Marine Corps. These pursuits continue with 
appropriate review and the application of best practices in meeting our 
goals. These five areas of priority include:
  --TBI and psychological health treatment and fitness;
  --medical systems support for maritime and expeditionary operations;
  --wound management throughout the continuum of care;
  --hearing restoration and protection for operational maritime surface 
        and air support personnel; and
  --undersea medicine, diving, and submarine medicine.
    We continue to strengthen our medical partnerships in Southeast 
Asia, Africa, and South America through the cooperation and support 
provided by our Naval Medical Research Units and medical research 
operations in those geographical regions. We find that the application 
of medical and healthcare diplomacy is a firm cornerstone of successful 
pursuit of overarching bilateral relations between allies. These 
engagements are mutually beneficial--not only for the relationships 
with Armed Forces of engaged countries but for generalization of 
healthcare advances to the benefit of peoples around the globe.
    Graduate Medical Education (GME) is vital to the Navy's ability to 
train board-certified physicians and meet the requirement to maintain a 
tactically proficient, combat-credible medical force. Robust, 
innovative GME programs continue to be the hallmark of Navy Medicine. 
We are pleased to report that despite the challenges presented by 10 
years of war, GME remains strong.
    Our institutions and training programs continue to perform well on 
periodic site visits by the Accreditation Council for Graduate Medical 
Education (ACGME) and most are at or near the maximum accreditation 
cycle length. The performance of our three major teaching hospitals, in 
particular, has been outstanding with all three earning the maximum 5-
year accreditation cycle length. Board certification is another 
hallmark of strong GME. The overall pass rate for Navy trainees in 2011 
was 96 percent, well-above the national average in most specialties. 
Our Navy-trained physicians continue to prove themselves exceptionally 
well-prepared to provide care to all members of the military family, 
and in all operational settings ranging from the field hospitals of the 
battlefield to the platforms that support disaster and humanitarian 
relief missions.
    Overall, I am pleased with the progress we are making with our 
joint enlisted training efforts at the Medical Education and Training 
Campus (METC) in San Antonio, Texas. I had an opportunity to visit the 
training center earlier this year and meet with the leadership and 
students. We have a tremendous opportunity to train our sailors with 
their Army and Air Force counterparts in a joint environment, and I am 
working with my fellow Surgeons General to ensure we optimize our 
efforts, improve interoperability and create synergies.

             INTEROPERABILITY AND COLLABORATIVE ENGAGEMENT

    Navy Medicine continues to leverage its unique relationships with 
the Army, Air Force, the VA, as well as other Federal and civilian 
partners. This interoperability helps create system-wide synergies and 
foster best practices in care, education and training, research and 
technology.
    Our sharing and collaboration efforts with the VA continue 
throughout our enterprise and Navy Medicine's most recent joint venture 
is a unique partnership between the Naval Health Clinic Charleston, 
Ralph H. Johnson Veterans Affairs Medical Center, Naval Hospital 
Beaufort and the Air Force's 628th Medical Group. This partnership will 
manage joint healthcare services and explore local joint opportunities 
for collaboration. In addition, our new replacement facility at Naval 
Hospital Guam, currently under construction, will continue to provide 
ancillary and specialty service to VA beneficiaries.
    Operations continue at the Captain James A. Lovell Federal Health 
Care Center (FHCC) in Great Lakes, Illinois--a first-of-its-kind fully 
integrated partnership that links Naval Health Clinic Great Lakes and 
the North Chicago VA Medical Center into one healthcare system. This 
joint facility, activated in October 2010, is a 5-year demonstration 
project as mandated by the National Defense Authorization Act of Fiscal 
Year 2010. During its first year, FHCC successfully completed the 
Civilian Personnel Transfer of Function which realigned staff from 
1,500 to more than 3,000. The USS Red Rover Recruit Clinic processed 
more than 38,000 U.S. Navy recruits and delivered more than 178,000 
immunizations to the Navy recruits. We continue to work with DOD and 
the VA to leverage the full suites of information technology 
capabilities to support the mission and patient population.
    In addition, our collaborative efforts are critical in continuing 
to streamline the integrated disability evaluation system (IDES) in 
support of our transitioning wounded, ill, and injured servicemembers. 
Within the Department of Navy (DON), we have completed IDES expansion 
to all 21 CONUS MTFs and we are working to implement improvements and 
best practices in order to streamline the IDES process to allow for 
timely and thorough evaluation and disposition. Further collaboration 
between DOD, the Services, and the VA regarding information technology 
improvements, ability for field-level reports for case management and 
capability for electronic case file transfer is ongoing.
    In support of DOD and VA interagency efforts, we are leveraging our 
information technology capabilities and building on joint priorities to 
support a seamless transition of medical information for our 
servicemembers and veterans. This ongoing work includes the development 
of an integrated electronic health record and the virtual lifetime 
electronic record (VLER), including the Naval Medical Centers San Diego 
and Portsmouth participation in VLER pilot projects.
    We completed the requirements associated with the base realignment 
and closure (BRAC) in the National Capital Region (NCR) with the 
opening of the Walter Reed National Military Medical Center and Fort 
Belvoir Community Hospital. The scope of this realignment was 
significant, and we are continuing to devote attention to ensuring that 
our integration efforts reduce overhead, maintain mission readiness, 
and establish efficient systems for those providing care to our 
patients. We have outstanding staff members comprised of Navy, Army, 
Air Force and civilians, who are executing their mission with skill, 
compassion, and professionalism. The opening of these impressive 
facilities represented several years of hard work by the men and women 
of military medicine, as well as generous support from Members of 
Congress. I am proud of what we accomplished and, moving forward, 
encouraged about the opportunities for developing a sustainable, 
efficient integrated healthcare delivery model in the NCR. I, along 
with my fellow Surgeons General, am committed to this goal and 
recognize the hard work ahead of us.

                    PEOPLE--OUR MOST IMPORTANT ASSET

    The hallmark of Navy Medicine is our professional and dedicated 
workforce. Our team consists of more than 63,000 Active component (AC) 
and Reserve component (RC) personnel, government civilians as well as 
contract personnel--all working around the world to provide outstanding 
healthcare and support services to our beneficiaries. I am continually 
inspired by their selfless service and sharp focus on protecting the 
health of sailors, marines, and their families.
    Healthcare accessions and recruiting remain a top priority, and, 
overall, Navy Medicine continues to see solid results from these 
efforts. Attainment of our recruiting and retention goals has allowed 
Navy Medicine to meet all operational missions despite some critical 
wartime specialty shortages. In fiscal year 2011, Navy Recruiting 
attained 101 percent of Active Medical Department officer goals, and 85 
percent of Reserve Medical Department officer goals. In a collaborative 
effort with the Chief of Navy Reserve and Commander, Navy Recruiting 
Command, we are working to overcome challenges in the RC medical 
recruiting missions. We recently held a recruiting medical stakeholders 
conference during which we discussed the challenges and courses of 
action to address them. Using a variety of initiatives such as the 
Health Professions Scholarship Program (HPSP), special incentive pays 
and selective re-enlistment bonuses, Navy Medicine is able to support 
and sustain accessions and retention across the Corps. We are grateful 
to the Congress for the authorities provided to us in support of these 
programs.
    As a whole, AC Medical Corps manning at the end of fiscal year 2011 
was 100 percent of requirements; however, some specialty shortfalls 
persist including general surgery, family medicine, and psychiatry. 
Aggressive plans to improve specialty shortfalls include continuation 
of retention incentives via special pays, and an increase in psychiatry 
training billets. Overall AC Dental Corps manning was at 96 percent of 
requirements, despite oral and maxillofacial surgeons manning at 77 
percent. A recent increase in incentive special pays was approved to 
address this shortfall. General dentist incentive pay and retention 
bonuses have helped increase general dentist manning to 99 percent, up 
from 88 percent manning a year ago. At the end of fiscal year 2011, AC 
Medical Service Corps manning was 94 percent of requirements. A 
staffing shortage does exist for the social work specialty, manned at 
45 percent. This shortage is due to increased requirements and billet 
growth during the past 3 years. We anticipate that this specialty will 
be fully manned by the end fiscal year 2014 through increased 
accessions and incentive programs. Our AC Nurse Corps manning at the 
end of fiscal year 2011 was 94 percent of requirements. Undermanned 
low-density/high-demand specialties including peri-operative nurses, 
certified registered nurse anesthetists and critical care nurses are 
being addressed via incentive special pays.
    Our AC Hospital Corps remains strong with manning at 96 percent. 
Critical manning shortfalls exist in several skill sets such as 
behavioral health technicians, surface force independent duty corpsmen, 
dive independent duty corpsmen, submarine independent duty corpsmen, 
and reconnaissance corpsmen. Program accession and retention issues are 
being addressed through increased special duty assignment pay, 
selective re-enlistment bonuses and new force shaping policies.
    Reserve component Medical Corps recruiting continues to be our 
greatest challenge. Higher AC retention rates have resulted in a 
smaller pool of medical professionals leaving Active Duty, and 
consequently, greater reliance on highly competitive Direct Commission 
Officer (DCO) market. RC Medical Corps manning at the end of fiscal 
year 2011 manning was at 71 percent of requirements while our Nurse 
Corps RC manning was 88 percent. To help mitigate this situation, there 
is an affiliation bonus of $10,000 or special pay of up to $25,000 per 
year based on specialty, and activated reserves are also authorized 
annual special incentive pays as applicable. Due to robust recruiting 
efforts and initiatives, the Reserve component Nurse Corps exceeded 
recruiting goals for the second consecutive year. Dental Corps and 
Medical Service Corps RC manning is 100 and 99 percent, respectively.
    Overall RC Hospital Corps manning is at 99 percent; however, we do 
have some shortfalls in surgical, xray, and biomedical repair 
technicians. Affiliation bonuses are specifically targeted toward those 
undermanned specialties.
    We are encouraged by our improving overall recruiting and retention 
rates. Improvements in special pays have mitigated manning shortfalls; 
however, it will take several years until Navy Medicine is fully manned 
in several critical areas. To ensure the future success of accession 
and retention for Medical Department officers continued funding is 
needed for our programs and special incentive pays. We are grateful for 
your support in this key area.
    For our Federal civilian personnel within Navy Medicine, we have 
successfully transitioned out of the National Security Personnel System 
(NSPS) and, in conjunction with the Assistant Secretary of Defense for 
Health Affairs and the other Services, we have begun a phased 
transition to introduce pay flexibilities in 32 healthcare occupations 
to ensure pay parity among healthcare providers in Federal service. The 
initial phase occurred in fiscal year 2011 when more than 400 Federal 
civilian physicians and dentists were converted to the new Defense 
Physician and Dentist Pay Plan. Modeled on the current VA pay system, 
the Defense Physician and Dentist Pay Plan provides us with the 
flexibility to respond to local conditions in the healthcare markets. 
We continue to successfully hire required civilians to support our 
sailors and marines and their families--many of whom directly support 
our wounded warriors. Our success is largely attributed to the hiring 
and compensation flexibilities granted by the Congress to the DOD's 
civilian healthcare community over the past several years.
    The Navy Medicine Reintegrate, Educate and Advance Combatants in 
Healthcare (REACH) program is an initiative that provides wounded 
warriors with career and educational guidance from career coaches, as 
well as hands-on training and mentoring from our hospital staff. To 
date, Navy Medicine has launched the REACH program at WRNMMC, Naval 
Medical Centers Portsmouth and San Diego, as well as Naval Hospital 
Camp LeJeune. The ultimate goal of the REACH program is to provide a 
career development and succession pipeline of trained disabled veterans 
for Federal Civil Service positions in Navy Medicine.
    I am committed to building and sustaining diversity within the Navy 
Medicine workforce. Our focus remains creating an environment where our 
diversity reflects that of our patients and our Nation and where our 
members see themselves represented in all levels of leadership. We 
embrace what we learn from our unique differences with the goal of a 
work-life in balance with mind, body, and spirit. I believe we are more 
mission-ready, stronger, and better shipmates because of our diversity. 
Navy Medicine will continue to harness the teamwork, talent, and 
innovation of our diverse force as we move forward into our future.

                               CONCLUSION

    In summary, Navy Medicine is an agile and vibrant healthcare team. 
I am grateful to those came before us for their vision and foresight; I 
am inspired by those who serve with us now for commitment and bravery; 
and I am confident in those who will follow us because they will surely 
build on the strength and tradition of Navy Medicine. I have never been 
more proud of the men and women of Navy Medicine.
    On behalf of the men and women of Navy Medicine, I want to thank 
the subcommittee for your tremendous support, confidence, and 
leadership. It has been my pleasure to testify before you today and I 
look forward to your questions.

    Chairman Inouye. Thank you very much, Admiral.
    General Horoho.

STATEMENT OF LIEUTENANT GENERAL PATRICIA HOROHO, 
            SURGEON GENERAL OF THE ARMY
    General Horoho. Good morning, Chairman Inouye, Ranking 
Member Cochran, and distinguished members of the subcommittee. 
Thank you for providing me with this opportunity to share with 
you today my thoughts on the future of Army Medicine and 
highlight some of the incredible work that is being performed 
by the dedicated men and women with whom I'm honored to serve 
alongside.
    We are America's most trusted premiere medical team, and 
our successful mission accomplishment over these past 10 years 
is testimony to the phenomenal resilience, dedication, and 
innovative spirit of the soldier medics, civilians, and family 
members throughout the world. Since 1775, Army Medicine has 
been there. In every conflict, the United States has fought 
with the Army, Army Medicine has stood shoulder-to-shoulder 
with our fighting forces in the deployed environment, and 
receive them here at home when they returned.
    It cannot be overstated that the best trauma care in the 
world resides with the United States military in Afghanistan, 
prosecuted by a joint healthcare team. Yet, we cannot have gone 
through 10 years of war for the length of time and not been 
aware of these experiences and how they've changed us as 
individuals, as an organization, and as a Nation.
    The Army, at its core, is its people, not equipment or 
weapon systems. I'd like to thank the subcommittee for ensuring 
these brave men and women, who have endured so much over the 
past decade, have received a variety of programs, policies, and 
facilities to cope with the cumulative stress, the injuries, 
and the family separations caused by 10 years of war.
    The warfighter does not stand alone. We must never forget 
that our success in Iraq and Afghanistan comes at a heavy price 
for our Army family. In supporting a nation in persistent 
conflict, with the stressors resulting from 10 years of war, 
Army Medicine has a responsibility to all those who serve, to 
include family members, our retirees, who have already answered 
the call to our Nation.
    We hold sacred the enduring mission of providing support to 
the wounded warriors and their families. I would like to take a 
moment to acknowledge the warm embrace from communities across 
America, as our veterans transition back to civilian life.
    While proudly acknowledging our many healthcare 
accomplishments at home and in theater, I want to turn to the 
future. The scope of Army Medicine extends beyond the 
outstanding in-theater combat care, and our mission is larger 
than the wartime medicine. We are an organization that has 
endured and excelled in global healthcare delivery, medical 
research and training programs, and collaborative partnerships. 
We are at our best when we operate as part of the joint team, 
and we need to proactively develop synergy with our partners as 
military medicine moves towards a joint operating environment. 
Continuity of care, continuity of information, and unity of 
effort are key not only to the current delivery of care as a 
DOD and VA team but also as we move forward in military 
medicine.
    The current conflicts have shown the Nation and the world 
the incredible care that is provided by the joint team, and 
this unity of effort will continue to be key in facing future 
challenges. For example, we have partnered with the VA, the 
Defense and Veterans Brain Injury Center, and the Defense 
Center of Excellence for TBI and psychological health and 
academia, as well as the National Football League, to improve 
our ability to diagnose, treat, and care for those that are 
affected by TBI.

                             NEW CHALLENGES

    Army Medicine has a history of changing to meet new 
challenges. We are looking at our culture and practices that 
focus on systems of care and transforming our enterprise from a 
healthcare system to a system for health. This transformation 
requires that we expand our focus beyond the treatment of 
illness and injury, and emphasize the importance of health, 
wellness, and prevention. In order for us to influence the 
health and wellness of our military members and families, we 
must engage with those entrusted to our care, so that we can 
influence their behaviors and impact their life space, where 
the daily decisions are made that ultimately have the greatest 
effect on health and wellness.
    The Army Medicine team is committed to ensuring the right 
capabilities are available to promote health and wellness, 
support and sustain a medically ready force, and leverage 
innovation in order to remain a premiere healthcare 
organization. We are focused on decreasing variance, while 
increasing standards and furthering standardization across our 
organization.
    The comprehensive behavioral health system is restoring the 
resiliency, resetting the formation, and re-establishing family 
and community bonds. We are strengthening our soldiers and 
family's behavior health and emotional resiliency through 
multiple touch points across a spectrum of time, from pre-
deployment to redeployment, and into garrison life. We are 
committed to providing the continuity and standardized approach 
across the care continuum.
    It is truly an honor to care for our military members and 
their families. We are advocates for those that are entrusted 
to our care, and Army Medicine team proudly serves our Nation's 
heroes with the respect and dignity that they have earned. In 
an increasingly uncertain world, we can state with certainty 
that Army Medicine is committed to providing the patient and 
family centric care. Every warfighter has a unique story, and 
we are dedicated to caring for each patient with compassion, 
respect, and dignity. This approach to medicine enhances the 
care, and we believe our patients deserve a care experience 
that embraces their desire to heal and have an optimal life.
    I would like to close today by discussing the Army Medicine 
promise. The promise, a written covenant that will be in the 
hands of everyone entrusted to our care over the next year, 
tells those that we care for, the Army Medicine team believe 
they deserve from us. It articulates what we believe about the 
respect and dignity surrounding the patient care experience. 
The promise speaks to what we believe about the value of care 
we deliver, about the compassion contained in the care we 
deliver, and how we want to morally and ethically provide care 
for those that we serve.
    I'll share two items with you of the promise. ``We believe 
our patients deserve a voice in how Army Medicine cares for 
them, and all those entrusted to our care''. Our patients want 
to harness innovation to improve and change their health, and 
we are empowering their efforts via the wellness centers. At 
our premiere wellness clinics, we collaborate with patients to 
not only give them the tools that they need to change their 
health but also a life-space partner to help them change their 
life.
    Our wellness clinics are new and still evolving, but I'm 
committed to increasing their numbers and expanding their 
capabilities in order to dramatically impact those more than 
500,000 minutes out of the year when our patients are living 
life outside the walls of our hospitals. The wellness clinics 
allow us to reach out to those we care for rather than having 
them reach in.
    ``We believe our patients deserve an enhanced care 
experience that includes our belief and their desire to heal, 
be well, and have an optimal life''. We are committed to 
ensuring that we in Army Medicine live up to this promise.

                           PREPARED STATEMENT

    In conclusion, I'm incredibly honored and proud to serve as 
the 43rd Surgeon General of the Army and Commander of the U.S. 
Medical Command. There are miracles happening every day in 
military medicine because of the dedicated soldiers and 
civilians that make up the Army Medical Department.
    With the continued support of the Congress, we will lead 
the Nation in healthcare, and our men and women in uniform will 
be ready when the Nation calls them to action. Army Medicine 
stands ready to accomplish any task in support of our 
warfighters and military families. Army Medicine is serving to 
heal and truly honored to serve.
    Thank you. And I look forward to entertaining your 
questions.
    [The statement follows:]

      Prepared Statement of Lieutenant General Patricia D. Horoho

                              INTRODUCTION

    Chairman Inouye, Vice Chairman Cochran, and distinguished members 
of the subcommittee: Thank you for providing me this opportunity to 
share with you today my thoughts on the future of the U.S. Army Medical 
Department (AMEDD) and highlight some of the incredible work being 
performed by the dedicated men and women with whom I am honored to 
serve alongside. We are America's most trusted premier medical team, 
and our successful mission accomplishment over these past 10 years is 
testimony to the phenomenal resilience, dedication, and innovative 
spirit of soldier medics, civilians, and military families throughout 
the world.
    Since 1775, Army Medicine has been there. In every conflict the 
U.S. Army has fought, Army Medicine stood shoulder-to-shoulder with our 
fighting forces in the deployed environment and received them here at 
home when they returned. The past 10 years have presented the AMEDD 
with a myriad of challenges, encompassing support of a two-front war 
while simultaneously delivering healthcare to beneficiaries across the 
continuum. Our experiences in Iraq and Afghanistan have strengthened 
our capacity and our resolve as a healthcare organization. Army 
Medicine, both deployed and at home, civilian, and military, has worked 
countless hours to ensure the wellness of our fighting force and its 
families. Army Medicine continues to support in an era of persistent 
conflicts, and it is our top priority to provide comprehensive 
healthcare to support war-fighters and their families. The soldier is 
America's most sacred determinant of the Nation's force projection and 
the Army's most important resource; it is our duty to provide full-
spectrum healthcare for our Nation's best. Committed to the health, 
wellness, and resilience of our force and its families, we will stand 
alongside and inspire confidence in our warriors when our Nation calls. 
Through the development of adaptive, innovative, and decisive leaders, 
we stand poised to support the foundation of our Nation's strength.
    Over the past decade, Army Medicine has led the joint healthcare 
effort in the most austere environments. As part of the most decisive 
and capable land force in the world, we stand ready to adapt to the 
Army's reframing effort. Ten years of contingency operations have 
provided numerous lessons learned. We will use these as the foundations 
from which we deliver the Army's vision. The following focus areas are 
the pillars upon which we deliver on that effort.

                           SUPPORT THE FORCE

    I was privileged to serve as the International Security Assistance 
Force Joint Command (COMIJC) Special Assistant for Health Affairs (SA-
HA) from July-October 2011. My multidisciplinary team of 14 military 
health professionals conducted an extensive evaluation of theater 
health services support (HSS) to critically assess how well we were 
providing healthcare from point of injury to evacuation from theater. 
It cannot be overstated that the best trauma care in the world resides 
with the U.S. military in Afghanistan and Iraq. From the most forward 
combat outposts to the modern Role 3 facilities on the mature forward 
operating bases, the performance and effectiveness of the U.S. military 
health system (MHS) is remarkable. The medical community holds the 
trust of the American servicemember sacred. The fact that 
servicemembers are willing to go out day-to-day and place themselves in 
harm's way in support of our freedom is strongly dependent on the 
notion that, if they become injured, we will be there providing the 
best medical care in the world. This has been proven time and time 
again with MEDEVAC remaining an enduring marker of excellence in the 
CJOA-A. The average mission time of 44 minutes is substantially below 
the 60-minute mission standard established by the Secretary of Defense 
in 2009. The survival rate for the conflict in Afghanistan is 90.1 
percent. This ability to rapidly transport our wounded servicemembers 
coupled with the world-class trauma care delivered on the battlefield 
has resulted in achievement of the highest survival rate of all 
previous conflicts. The survival rate in World War II (WWII) was about 
70 percent; in Korea and Vietnam, it rose to slightly more than 75 
percent. In WWII, only 7 of 10 wounded troops survived; today more than 
9 out of 10 do. Not only do 9 in 10 survive, but most are able to 
continue serving in the Army.
    Enhanced combat medic training has without question, contributed to 
the increased survival rates on the battlefield by putting the best 
possible care far forward. The need for aerial evacuation of critical, 
often postsurgical patients, presented itself in Afghanistan based on 
the terrain, wide area dispersement of groundbased forces, as well as 
increased use of forward surgical teams. En route management of these 
patients required critical care experience not found organic to 
MEDEVAC. In response to these needs, our flight medic program (AD, NG, 
AR) is raising the standard to the EMT-Paramedic level to include 
critical care nursing once paramedic certified for all components. This 
will enhance our capabilities to match the civilian sector and make our 
flight medics even more combat ready for emergencies while on mission. 
We've just begun the first course that will pave the way with 28 flight 
medics coming from all components. By 2017, we will have all flight 
medics paramedic certified. In the area of standardization of enlisted 
medical competencies, we are ensuring that our medics are being 
utilized as force multipliers to ensure world-class healthcare in our 
facilities. We are working with our sister services to ensure that all 
medics, corpsmen, and medical technicians are working side-by-side in 
our joint facilities and training to the highest joint standard.
    We have an enduring responsibility, alongside our sister services 
and the Department of Veterans Affairs (VA), to provide care and 
rehabilitation of wounded, ill, and injured servicemembers for many 
years to come. We will stand alongside the soldier from point of injury 
through rehabilitation and recovery, fostering a spirit of resiliency. 
The Warrior Care and Transition Program is the Army's enduring 
commitment to providing all wounded, ill, and injured soldiers and 
their families a patient-centered approach to care. Its goal is to 
empower them with dignity, respect, and the self-determination to 
successfully reintegrate either back into the force or into the 
community. Since the inception of warrior transition units in June 
2007, more than 51,000 wounded, ill, or injured soldiers and their 
families have either progressed through or are being cared for by these 
dedicated caregivers and support personnel. Twenty-one thousand of 
these soldiers, the equivalent of two divisions, have been returned to 
the force, while another 20,000 have received the support, planning, 
and preparation necessary to successfully and confidently transition to 
civilian status. Today, we have 29 warrior transition units (WTUs) and 
9 community-based warrior transition units (CBWTU). More than 9,600 
soldiers are currently recovering in WTUs and CBWTU with more than 
4,300 professional cadre supporting them. Standing behind these 
soldiers each stage of their recovery and transition is the triad of 
care (primary care manager, nurse case manager, and squad leader) and 
the interdisciplinary team of medical and nonmedical professionals who 
work with soldiers and their families to ensure that they receive the 
support they deserve.
    The Army remains committed to supporting wounded, ill, or injured 
soldiers in their efforts to either return to the force or transition 
to Veteran status. To help soldiers set their personal goals for the 
future, the Army created a systematic approach called the Comprehensive 
Transition Plan, a multidisciplinary and automated process which 
enables every warrior-in-transition to develop an individualized plan, 
which will enable them to reach their personal goals. These end goals 
shape the warrior-in-transition's day-to-day work plan while healing.
    For those soldiers who decide to transition to veteran status the 
Warrior Transition Command's (WTC) mission is to assist them to 
successfully reintegrate back into the community with dignity, respect, 
and self-determination. One example of how the WTC is working to better 
assist this group of soldiers is the WTC-sponsored, joint service 
Wounded Warrior Employment Conference (WWEC) held in February. This is 
the second year the WWEC has brought together key stakeholders in the 
Federal Government and private industry. The goal is improved alliance 
and collaboration between military, civilian, Federal entities, and 
employers to encourage them to cooperatively support employment related 
objectives and share best practices in hiring, retaining, and promoting 
wounded warriors, recently separated disabled veterans, their spouses, 
and caregivers.

                          THE CARE EXPERIENCE

    The warfighter does not stand alone. Army Medicine has a 
responsibility to all those who serve, to include family members and 
our retirees who have already answered the call to our Nation. We 
continue to fully engage our patients in all aspects of their 
healthcare experience. At each touch point, starting with the initial 
contact, each team member plays an important role in enhancing patient 
care. We will make the right care available at the right time, while 
demonstrating compassion to those we serve and value to our 
stakeholders. Beneficiaries will choose hospitals who give them not 
only outstanding outcomes but the best-possible experience. And we aim 
to elevate the patient care experience across the enterprise to make 
the direct care system the preferred location to receive care. I am 
proud to share today that our patient satisfaction rate is currently 
above 92 percent, and we are in the top 10 percent of health plans in 
the United States according to Healthcare Effectiveness and Data 
Information Set (HEDIS), a tool used by more than 90 percent of 
America's health plans to measure performance on important dimensions 
of care. This said, my challenge--and my personal belief is that we can 
get better--we must be better. I'd like to outline a few areas where we 
continue to better ourselves in order to better the care experience for 
our patients.
    Army Medicine is committed to accountable care--where our clinical 
processes facilitate best practice patterns and support our healthcare 
team in delivering competent, compassionate care. In everything we do, 
there is a need for accountability--to our patients, our team members, 
and ourselves. Accountability is not just providing competent delivery 
of healthcare; our warfighters deserve more than that. Accountability 
is about taking ownership of the product we create and how it is 
delivered, considering it a reflection of ourselves and the 
organization. At the end of the workday, accountability is not measured 
by relative value units, but by impact on patients. It is not about the 
final outcome, but about the process and upholding our commitment to 
soldiers and their families. Soldier well-being and health are 
absolutely our top priorities. The Army Medicine team will continue 
advocating for patients and their well-being. As an Army at war for 
more than a decade, we stand shoulder-to-shoulder with the warfighter, 
both on the battlefield and at home. This means never losing sight of 
the importance of caring for our Nation's heroes and their families. 
Realizing that this Army Medicine team is working around the clock and 
around the world to ensure soldiers and their families are cared for 
with compassion and dignity, I have asked our leaders to focus on 
caring for those who are giving care. The Army Medicine team is not 
immune to the stress of deployments, workload demands, and challenging 
circumstances. We provide the best care for our patients when we take 
care of each other. By doing that, we give our best to all those 
entrusted to our care.
    Army Medicine has consciously committed to building a ``culture of 
trust''. Trust in patient care, trust within Army Medicine and the Army 
family. In healthcare, trust plays a critical and important role. This 
strategic initiative is focused on an organizational culture change 
within Army Medicine and creating a lifestyle of trust. A culture of 
trust in Army Medicine is a shared set of relationship skills, beliefs, 
and behaviors that distinguish our commitment to our beneficiaries to 
provide the highest quality and access to health services. Every 
initiative aimed at reducing variance and standardizing and improving 
patients' healthcare experiences, outcomes, and readiness will be 
founded on a culture of trust. Last fall the culture of trust task 
force began piloting the initial culture of trust training. This 
foundational training provides information on trust behaviors, tenets, 
and fundamentals creating a baseline upon which we will grow and 
expand.
    We constantly seek to establish stronger, more positive 
relationships with all that we serve in Army Medicine, to produce the 
very best-possible individual care experience. To that end, Army 
Medicine has implemented a training program titled, ``Begin with the 
Basics''. The central theme of this training is individual personalized 
engagement practiced by each and every member of Army Medicine. Through 
these relationships we increase understanding and in understanding our 
patients better, we are able to provide better solutions. The goal is 
full deployment of the basics of this model across Army Medicine in the 
next 18 months. We are using this model for care and service training 
as we deploy our medical home care model across Army Medicine.
    In February 2011, Army Nursing began implementing a patient-
centered outcomes focused care delivery system encompassing all care 
delivery environments; inpatient, outpatient, and deployed. The Patient 
Caring Touch System (PCTS) was designed to reduce clinical quality 
variance by adopting a set of internally and externally validated best 
practices. PCTS swept across Army Medicine, and the last facility 
completed implementation in January 2012. PCTS is a key enabler of Army 
Medicine's Culture of Trust and nests in all of Army Medicine's 
initiatives. PCTS is enhancing the quality of care delivery for 
America's sons and daughters. PCTS has improved communication and 
multidisciplinary collaboration and has created an increased demand and 
expanded use of multidisciplinary rounds. Several facilities have 
reported that bedside report, hourly rounding, and multidisciplinary 
rounding are so much a part of the routine that they cannot recall a 
time when it was not part of their communication process.
    The collective healthcare experience is driven by a team of 
professionals, partnering with the patient, focused on health 
promotion, and disease prevention to enhance wellness. Essential to 
integrated healthcare delivery is a high-performing primary care 
provider/team that can effectively manage the delivery of seamless, 
well-coordinated care and serve as the patient's medical home. Much of 
the future of military medicine will be practiced at the patient-
centered medical home (PCMH). We have made PCMHs and community-based 
medical homes a priority. The Army's 2011 investment in patient-
centered care is $50 million. PCMH is a primary care model that is 
being adopted throughout the MHS and in many civilian practices 
throughout the Nation. Army PCMH is the foundation for the Army's 
transition from a ``healthcare system to a system for health'' that 
improves soldier readiness, family wellness and overall patient 
satisfaction through a collaborative team-based system of comprehensive 
care that is ultimately more efficient and cost effective. The PCMH 
will strengthen the provider-patient relationship by replacing episodic 
care with readily available care with one's personal clinician and care 
team emphasizing the continuous relationship while providing proactive, 
fully integrated and coordinated care focusing on the patient, his or 
her family, and their long-term health needs. The Army is transforming 
all of its 157 primary care practices to PCMH practices. A key 
component of transformation to the Army PCMH requires each practice to 
meet the rigorous standards established by the National Committee for 
Quality Assurance (NCQA). In December 2011, 17 Army practices received 
NCQA recognition as PCMHs, and I anticipate we will have 50 additional 
practices that will obtain NCQA recognition by the end of this calendar 
year. It is expected that all Army primary care clinics will be 
transformed to Army Medical Homes by fiscal year 2015. Transformation 
to the PCMH model should result in an increased capacity within Army 
military treatment facilities (MTFs) of more than 200,000 beneficiaries 
by fiscal year 2016. The Army has established Community Based Medical 
Homes to bring Army Medicine closer to our patients. These Army-
operated clinics in leased facilities are in off-post communities 
closer to our beneficiaries and aim to improve access to healthcare 
services, including behavioral health, for Active-Duty family members 
by expanding capacity and extending the MTF services off post. 
Currently we are approved to open 21 clinics and are actively enrolling 
beneficiaries at 13 facilities.

                            UNITY OF EFFORT

    The ability to form mixed organizations at home and on the 
battlefield with all service and coalition partners contributing to a 
single mission of preserving life is proof of the flexibility and 
adaptability of America's medical warfighters. It is our collective 
effort--Army, Air Force, and Navy--that saves lives on the battlefield. 
It is an Army MEDEVAC crew who moves a wounded servicemember from the 
point-of-injury to a jointly staffed Role III field hospital. It's the 
Air Force provided aeromedical evacuation to Landstuhl Regional Medical 
Center where a triservice medical care team provides further definitive 
care. And then finally it's a joint team's capabilities at locations 
such as Walter Reed National Military Medical Center and the San 
Antonio Military Medical Center that provide the critical care and 
rehabilitative medicine for this servicemember, regardless if they are 
a soldier, sailor, airman, or marine. The AMEDD is focused on building 
upon these successes on the battlefield as we perform our mission at 
home and is further cementing our commitment to working as a combined 
team, anywhere, anytime.
    We are at our best when we operate as part of a Joint Team, and we 
need to proactively develop synergy with our partners as military 
medicine moves toward a joint operating environment. The wars in 
Afghanistan and Iraq have led to increased collaboration and 
interoperability with allied medical services, and have highlighted 
differences and gaps in our respective combat health service support 
systems. While the combatant commands have a responsibility to harvest 
and publicize lessons learned and implement new best practices 
operationally, the MHS has the opportunity to address and apply, at the 
strategic, operational and tactical levels, the lessons learned 
regarding combat casualty care and medical coalition operations.
    MHS governance changes will change the way we currently operate for 
everyone. These recommended changes will strengthen our system. In the 
delivery of military medicine, the military departments have more 
activities in common than not--together we will drive toward greater 
common approaches in all areas, except where legitimate uniqueness 
requires a service-specific approach. Our commitment is to achieve 
greater unity of effort, improve service to our members and 
beneficiaries, and achieve greater efficiency through a more rapid 
implementation of common services and joint purchasing, as well as 
other opportunities for more streamlined service delivery.
    Our MHS is not simply a health plan for the military; it is a 
military health system. A system that has proven itself in war and 
peace time. Our focus continues to be on supporting soldiers, other 
warriors and their families--past, present, and future--and on the most 
effective and efficient health improvement and healthcare organization 
to add value in the defense of the Nation. The best way to do that is 
through a unified and collaborative approach to care, both on the 
battlefield and in garrison. We must have outcome and economic metrics 
to measure and accountability assigned. And we must develop standard 
and unified performance measures across a wide-range of health and care 
indicators e.g., population health, clinical outcomes, access, 
continuity, administrative efficiency, agile operational support, 
warrior care, and transition programs, patient satisfaction, cost, and 
others, to ensure we are effective, efficient, and timely.

           INNOVATE ARMY MEDICINE AND HEALTH SERVICE SUPPORT

    Many innovations in healthcare have their origins on the 
battlefield. Army Medicine's medical innovations borne from lessons 
learned in combat have become the world-class standard of care for 
soldiers on the battlefield and civilians around the world. As our 
presence in the current war begins to change, we must remain vigilant 
in developing and assessing strategies to protect, enhance, and 
optimize soldier wellness, prevention, and collective health. Through 
leverage of information technology and militarily relevant research 
strategies, we will continue to develop new doctrine and education 
programs to reflect best practice healthcare on and off the 
battlefield, while ensuring that Army Medicine remains responsive and 
ready. Our speed of execution, combined with the ability to leverage 
knowledge and actionable ideas quickly, is paramount to optimize the 
constancy of improvement. Our biggest competitive edge is our knowledge 
and our people.
    In 2004, the Assistant Secretary of Defense for Health Affairs 
directed to the formation of the Joint Theater Trauma System (JTTS) and 
the Joint Theater Trauma Registry (JTTR). The JTTS coordinates trauma 
care for our wounded warriors. Since that time the services, working 
together, have created a systematic and integrated approach to 
battlefield care which has minimized morbidity and mortality and 
optimized the ability to provide essential care required for the battle 
injuries our soldiers are facing. The vision of the JTTS is for every 
soldier, marine, sailor, or airman wounded or injured in the theater of 
operations to have the optimal chance for survival and maximal 
potential for functional recovery and they are. Our 8,000-mile 
operating room stretches from Kandahar to Landstuhl to Walter Reed 
National Military Medical Center at Bethesda, to San Antonio Military 
Medical Center to the Veteran's Administration and other facilities 
throughout the United States. It's collaborative, it's integrated, and 
it knows no boundaries. JTTS changed how the world infuses blood 
products for trauma patients. In fact we just had a patient receive 400 
units of blood. He coded three times on the battle field. And today he 
is recovering in Walter Reed National Medical Center at Bethesda. The 
JTTS also led to materiel changes in helmets, body armor, and vehicle 
design. This is not a success of technology or policy. This is a 
success of a trauma community that expects and values active 
collaboration across its 8,000-mile operating room.
    The JTTR, is the largest combat injury data repository and is an 
integral and integrated part of the JTTS. It provides the information 
necessary to advance the improvement of battlefield and military trauma 
care and drive joint doctrine and policy, while enabling process 
improvement and quality assurance. Additionally, it enables more 
efficient and effective medical research in a resource-constrained 
environment. The improvements in trauma care driven by both the JTTS 
and JTTR are increasing the survival rate on today's battlefield and 
saving lives in our Nation's civilian trauma centers through shared 
lessons learned. We must maintain this critical capability to ensure 
that we continue to drive innovation and are able to respond to our 
next threat.
    An area in which the Army and our sister services have innovated to 
address a growing problem is in concussion care. The establishment of a 
mild traumatic brain injury (mTBI)/concussive system of care and 
implementation of treatment protocols has transformed our management of 
all battlefield head trauma. Traumatic brain injury (TBI) is one of the 
invisible injuries resulting from not only the signature weapons of 
this war, improvised explosive devices, and rocket propelled grenades 
but also from blows to the head during training activities or contact 
sports. Since 2000, 220,430 servicemembers have been diagnosed with TBI 
worldwide (Armed Forces Health Surveillance Center, 2011). In 2010, 
military medicine implemented a new mTBI management strategy to 
disseminate information that our healthcare workers needed and outlined 
the unit's responsibilities, creating a partnership between the medical 
community and the line units. This policy directed that any soldier who 
sustained a mandatory reportable event must undergo a medical 
evaluation including a mandatory 24-hour down time followed by medical 
clearance before returning to duty. The mandatory events are a command-
directed evaluation for any soldier who sustains a direct blow to the 
head or is in a vehicle or building associated with a blast event, 
collision, or rollover, or is within 50 meters of a blast. Since the 
Department of Defense (DOD) implemented Policy Guidance for Management 
of Concussion/mTBI in the Deployed Setting in June 2010, deployed 
Commanders screened more than 10,000 servicemembers for concussion/
mTBI, temporarily removed them from the battlefield to facilitate 
recovery, and ensured that each of them received a mandatory medical 
evaluation. Codification of this concussive care system into AMEDD 
doctrine is ongoing. To further support the TBI care strategy over the 
past 21 months the services have stood up 11 facilities devoted to 
concussive care far forward on the battlefield, staffed with concussion 
care physicians and other medical providers, in order to care for those 
with TBI at the point-of-injury. The Army has medical staff at nine of 
these facilities. These centers provide around-the-clock medical 
oversight, foster concussion recovery, and administer appropriate 
testing to ensure a safe return to duty. The current return to duty 
rate for soldiers who have received care at theater concussion centers 
is more than 90 percent.
    To further the science of brain injury recovery, the Army relies on 
the U.S. Army Medical Research and Materiel Command's (MRMC) TBI 
Research Program. The overwhelming generosity of the Congress and the 
DOD's commitment to brain injury research has significantly improved 
our knowledge of TBI in a rigorous scientific fashion. Currently, there 
are almost 350 studies funded by DOD to look at all aspects of TBI. The 
purpose of this program is to coordinate and manage relevant DOD 
research efforts and programs for the prevention, detection, 
mitigation, and treatment of TBI. In the absence of objective 
diagnostic tools, MRMC is expediting research on diagnostic biomarkers 
and other definitive assessment tools that will advance both military 
and civilian TBI care. By identifying and managing these injuries on 
the battlefield, we have eliminated many unnecessary medical evacuation 
flights and facilitated unprecedented return to duty rates. The Army 
realizes that there is much to gain from collaboration with external 
partners and key organizations. We have partnered with the Department 
of Veterans Affairs, the Defense and Veterans Brain Injury Center, the 
Defense Centers of Excellence for Psychological Health and Traumatic 
Brain Injury, academia, civilian hospitals, and the National Football 
League, to improve our ability to diagnose, treat, and care for those 
affected by TBI.
    There are significant health related consequences of more than 10 
years of war, including behavioral health needs, post-traumatic stress, 
burn or disfiguring injuries, chronic pain, or loss of limb. Our 
soldiers and their families need to trust we will be there to partner 
with them in their healing journey, a journey focused on ability vice 
disability.
    A decade of war in Afghanistan and Iraq has led to tremendous 
advances in the knowledge and care of combat-related physical and 
psychological problems. Ongoing research has guided health policy, and 
multiple programs have been implemented in theater and postdeployment 
to enhance resiliency, address combat operational stress reactions, and 
behavioral health concerns. Similar to our approach to concussive 
injuries, Army Medicine harvested the lessons of almost a decade of war 
and has approached the strengthening of our soldiers and families' 
behavioral health and emotional resiliency through a campaign plan to 
align the various behavioral health programs with the human dimension 
of the Army Force Generation (ARFORGEN) cycle, a process we call the 
Comprehensive Behavioral Health System of Care (CBHSOC). This program 
is based on outcome studies that demonstrate the profound value of 
using the system of multiple touch points in assessing and coordinating 
health and behavioral health for a soldier and family. The CBHSOC 
creates an integrated, coordinated, and synchronized behavioral health 
service delivery system that will support the total force through all 
ARFORGEN phases by providing full-spectrum behavioral healthcare. We 
leveraged experiences and outcome studies on deploying, caring for 
soldiers in combat, and redeploying these soldiers in large unit 
movements to build the CBHSOC. The CBHSOC is a system of systems built 
around the need to support an Army engaged in repeated deployments--
often into intense combat--which then returns to home station to 
restore, reset the formation, and re-establish family and community 
bonds. The intent is to optimize care and maximize limited behavioral 
health resources to ensure the highest quality of care to soldiers and 
families, through a multiyear campaign plan.
    The CBHSOC campaign plan has five lines of effort:
  --Standardize Behavioral Health Support Requirements;
  --Synchronize Behavioral Health Programs;
  --Standardize & Resource AMEDD Behavioral Health Support;
  --Access the Effectiveness of the CBHSOC; and
  --Strategic Communications.
    The CBHSOC campaign plan was published in September 2010, marking 
the official beginning of incremental expansion across Army 
installations and the Medical Command. Expansion will be phased, based 
on the redeployment of Army units, evaluation of programs, and 
determining the most appropriate programs for our soldiers and their 
families.
    Near-term goals of the CBHSOC are implementation of routine 
behavioral health screening points across ARFORGEN and standardization 
of screening instruments. Goals also include increased coordination 
with both internal Army programs like Comprehensive Soldier Fitness, 
Army Substance Abuse Program, and Military Family Life Consultants. 
External resources include VA, local, and State agencies, and the 
Defense Centers of Excellence for Psychological Health.
    Long-term goals of the CBHSOC are the protection and restoration of 
the psychological health of our soldiers and families and the 
prevention of adverse psychological and social outcomes like family 
violence, driving under intoxication violations, drug and alcohol 
addiction, and suicide. This is through the development of a common 
behavioral health data system; development and implementation of 
surveillance and data tracking capabilities to coordinate behavioral 
health clinical efforts; full synchronization of tele-behavioral health 
activities; complete integration of the Reserve components; and the 
inclusion of other Army Medicine efforts including TBI, patient-
centered medical home, and pain management. We are leveraging 
predictive modeling tools to improve our insight into data, research 
advances, and electronic medical record systems in order to provide 
``genius case management'' for our patients with behavioral health 
disease, that is, care that is tailored for each patient, and a care 
plan aimed at better understanding the patient, and not just their 
disease. Integral to the success of the CBHSOC is the continuous 
evaluation of programs, to be conducted by the Public Health Command 
(PHC).
    For those who do suffer from PTSD, Army Medicine has made 
significant gains in the treatment and management of PTSD as well. The 
DOD and VA jointly developed the three evidenced-based Clinical 
Practice Guidelines for the treatment of PTSD, on which nearly 2,000 
behavioral health providers have received training. This training is 
synchronized with the re-deployment cycles of U.S. Army brigade combat 
teams, ensuring that providers operating from MTFs that support the 
brigade combat teams are trained and certified to deliver quality 
behavioral healthcare to soldiers exposed to the most intense combat 
levels. In addition, the U.S. Army Medical Department Center and School 
collaborates closely with civilian experts in PTSD treatment to 
validate the content of these training products to ensure the 
information incorporates emerging scientific discoveries about PTSD and 
the most effective treatments.
    Work by the AMEDD and the MHS over the past 8 years has taught us 
to link information gathering and care coordination for any one soldier 
or family across the continuum of this cycle. Our behavioral health 
specialists tell us that the best predictor of future behavior is past 
behavior, and through the CBHSOC we strive to link the management of 
issues which soldiers carry into their deployment with care providers 
and a plan down-range and the same in reverse. We have embedded 
behavioral health personnel within operational units circulate across 
the battlefield to facilitate this ongoing assessment.
    The management of combat trauma pain with medications and the 
introduction of battlefield anesthesia was a tremendous medical 
breakthrough for military medicine. The first American use of 
battlefield anesthesia is thought to have been in 1847 during the 
Mexican-American War, and the use of opioid medication during the Civil 
War was not uncommon. Military medicine has worked very hard to manage 
our servicemembers' pain from the point-of-injury through the 
evacuation process and continuum of care. The management of pain--both 
acute and chronic or longstanding pain--remains a major challenge for 
military healthcare providers and for the Nation at large. We have 
launched a major initiative through a multidisciplinary, multiservice 
and DOD-VA pain management task force to improve our care of pain. The 
use of medications is appropriate, if required, and often an effective 
way to treat pain. However, the possible overreliance on medication-
only pain treatment has other unintended consequences, such as 
prescription medication use. The goal is to achieve a comprehensive 
pain management strategy that is holistic, multidisciplinary, and 
multimodal in its approach, uses state-of-the-art modalities and 
technologies, and provides optimal quality of life for soldiers and 
other patients with acute and chronic pain. The military is developing 
regional pain consortiums that combine the pain expertise from DOD with 
local Veterans Health Administration (VHA) and civilian academic 
medical centers. The first of many of these relationships has been 
established in Washington State between Madigan Army Medical Center, VA 
Puget Sound Health Care System, and University of Washington Center for 
Pain Relief. Some of the largest research projects dealing with 
wounded-warrior pain have been facilitated through partnerships with 
VHA research leaders. Collaborations of this type will ensure the 
latest, evidence-based pain-care techniques and protocols are available 
to patients. Pain research in direct support of military requirements 
will also be facilitated by these Federal and civilian partnerships. 
Other partnerships include working with organizations such as the 
Bravewell Collaborative and the Samuelli Institute, both of whom 
provide DOD with expertise in building mature integrative medicine 
capabilities to compliment and improve our existing pain medicine 
resources.
    Another concerning area of emphasis for military medicine that has 
emerged from the current wars is ``dismounted complex blast injury'' 
(DCBI), an explosion-induced battle injury (BI) sustained by a 
warfighter on foot patrol that produces a specific pattern of wounds. 
In particular, it involves traumatic amputation of at least one leg, a 
minimum of severe injury to another extremity, and pelvic, abdominal, 
or urogenital wounding. The incidence of dismounted complex blast 
injuries has increased during the last 15 months of combat in the 
Afghanistan theater of operations (ATO). The number of servicemembers 
with triple limb amputation has nearly doubled this past year from the 
sum of all those seen over the last 8 years of combat. The number of 
genital injuries increased significantly from previous Operation Iraqi 
Freedom (OIF) rates. The severity of these injuries presents new 
challenges to the medical and military communities to prevent, protect, 
mitigate, and treat. Army Medicine has spearheaded a task force 
comprised of clinical and operational medical experts from DOD and VA 
and solicited input from subject-matter experts in both Federal and 
civilian sectors to determine the way forward for healing these complex 
injuries.
    Evidence-based science makes strong soldiers and for this we rely 
heavily on the MRMC. MRMC manages and executes a robust, ongoing 
medical research program for the MEDCOM to support the development of 
new healthcare strategies. I would like to highlight a few research 
programs that are impacting health and care of our soldiers today.
    The Combat Casualty Care Research Program (CCCRP) reduces the 
mortality and morbidity resulting from injuries on the battlefield 
through the development of new life-saving strategies, new surgical 
techniques, biological and mechanical products, and the timely use of 
remote physiological monitoring. The CCCRP focuses on leveraging 
cutting-edge research and knowledge from Government and civilian 
research programs to fill existing and emerging gaps in combat casualty 
care. This focus provides requirements-driven combat casualty care 
medical solutions and products for injured soldiers from self-aid 
through definitive care, across the full spectrum of military 
operations.
    The mission of the Military Operational Medicine Research Program 
(MOMRP) is to develop effective countermeasures against stressors and 
to maximize health, performance, and fitness, protecting the soldier at 
home and on the battlefield. MOMRP research helps prevent physical 
injuries through development of injury prediction models, equipment 
design specifications and guidelines, health hazard assessment 
criteria, and strategies to reduce musculoskeletal injuries.
    MOMRP researchers develop strategies and advise policy makers to 
enhance and sustain mental fitness throughout a servicemember's career. 
Psychological health problems are the second leading cause of 
evacuation during prolonged or repeated deployments. MOMRP 
psychological health and resilience research focuses on prevention, 
treatment, and recovery of soldiers and families behavioral health 
problems, which are critical to force health and readiness. Current 
psychological health research topic areas include behavioral health, 
resiliency building, substance use and related problems, and risk-
taking behaviors.
    The Clinical and Rehabilitative Medicine Research Program (CRMRP) 
focuses on definitive and rehabilitative care innovations required to 
reset our wounded warriors, both in terms of duty performance and 
quality of life. The Armed Forces Institute of Regenerative Medicine 
(AFIRM) is an integral part of this program. The AFIRM was designed to 
speed the delivery of regenerative medicine therapies to treat the most 
severely injured United States servicemembers from around the world but 
in particular those coming from the theaters of operation in Iraq and 
Afghanistan. The AFIRM is expected to make major advances in the 
ability to understand and control cellular responses in wound repair 
and organ/tissue regeneration and has major research programs in limb 
repair and salvage, craniofacial reconstruction, burn repair, scarless 
wound healing, and compartment syndrome.
    The AFIRM's success to date is at least in part the result of the 
program's emphasis on establishing partnerships and collaborations. The 
AFIRM is a partnership among the U.S. Army, Navy, and Air Force, DOD, 
VA, and the National Institutes of Health. The AFIRM is composed of two 
independent research consortia working with the U.S. Army Institute of 
Surgical Research. One consortium is led by the Wake Forest Institute 
for Regenerative Medicine and the McGowan Institute for Regenerative 
Medicine in Pittsburgh while the other is led by Rutgers--the State 
University of New Jersey and the Cleveland Clinic. Each consortium 
contains approximately 15 member organizations, which are mostly 
academic institutions.
    The health of the total Army is essential for readiness, and 
prevention is the best way to health. Protecting soldiers, retirees, 
family members and Department of the Army civilians from conditions 
that threaten their health is operationally sound, cost effective, and 
better for individual well-being. Though primary care of our sick and 
injured will always be necessary, the demands will be reduced. 
Prevention--the early identification and mitigation of health risks 
through surveillance, education, training, and standardization of best 
public health practices--is crucial to military success. Army Medicine 
is on the pathway to realizing this proactive, preventive vision.
    The newest addition to the Army Medicine team is the PHC, having 
reached initial operational capability in October 2010 with full-
operational capability is targeted for October 2011. As part of the 
overall U.S. Army Medical Command reorganization initiative, all major 
public health functions within the Army, especially those of the former 
Veterinary Command and the Center for Health Promotion and Preventive 
Medicine have been combined into a new PHC, located at Aberdeen Proving 
Ground in Maryland. The consolidation has already resulted in an 
increased focus on health promotion and has created a single 
accountable agent for public health and veterinary issues that is 
proactive and focused on prevention, health promotion, and wellness. 
Army public health protects and improves the health of Army communities 
through education, promotion of healthy lifestyles, and disease and 
injury prevention. Public health efforts include controlling infectious 
diseases, reducing injury rates, identifying risk factors and 
interventions for behavioral health issues, and ensuring safe food and 
drinking water on Army installations and in deployed environments. The 
long-term value of public health efforts cannot be overstated:
  --public health advances in the past century have been largely 
        responsible for increasing human life spans by 25 years; and
  --the PHC will play a central role in the health of our soldiers, 
        deployed or at home.
    A significant initiative driven by the PHC which will be 
instrumental to achieving public health is our partnering with Army 
installations to standardize existing Army Wellness Centers to preserve 
or improve health in our beneficiary population. The centers focus on 
health assessment, physical fitness, healthy nutrition, stress 
management, general wellness education, and tobacco education. They 
partner with providers in our MTFs through a referral system. I hold 
each MTF Commander responsible for the health of the extended military 
community as the installation Director of Health Services (DHS).
    Army Medicine has put a closer lens on women's health through a 
recently established Women's Health Task Force to evaluate issues faced 
by female soldiers both, in Theater and CONUS. Women make up 
approximately 14 percent of the Army Active Duty fighting force. As of 
August 2011, almost 275,000 women have deployed in support of OIF/OND/
OEF. The health of female soldiers plays a vital role in overall Army 
readiness. Army Medicine recognizes the magnitude and impact of women's 
health and appreciates the unique challenges of being a woman in the 
Army. In order for women to be fully integrated and effective members 
of the team, we must ensure their unique health needs are being 
considered and met. The Task Force combines talent from different 
disciplines:
  --civilian and military;
  --officer and enlisted; and
  --collaborates with our private industry partners.
    We will assess the unique health needs and concerns of female 
soldiers, conducting a thorough review of the care currently provided, 
identifies best practices and gaps, and revises, adapts, and initiates 
practices so that we may continue to provide first class care to our 
female warriors. The Women's Health Campaign Plan will focus on 
standardized education and training on women's health, logistical 
support for women's health items, emphasis on the fit and functionality 
of the Army uniform and protective gear for females; and research and 
development into the psychosocial effects of combat on women. While 
sexual assault is not a gender specific issue, the Women's Health Task 
Force is working with Headquarters, Department of the Army (HQDA) G-1 
to evaluate theater policy with regards to distribution of sexual 
assault forensic examiners and professionalizing the role of the victim 
advocate. The task force is collaborating with tri-service experts to 
investigate the integration of service policies and make 
recommendations.
    While proudly acknowledging our many healthcare accomplishments at 
home and in theater, I want to turn to the future. It is time we 
further posture Army Medicine in the best possible manner that aligns 
with the MHS strategic vision that moves us from healthcare to health. 
We must ask, where does ``health'' happen, and I have charged Army 
Medicine leadership to spearhead the conversion to health and to fully 
integrate the concept into readiness and the overall strategy of health 
in the force. Improved readiness, better health, better care, and 
responsibly managed costs are the pillars on which the MHS Quadruple 
Aim stands, but between those pillars, or in that ``White Space'', is 
where we can create our successful outcomes. Sir William Osler, 
considered to be the Father of Modern Medicine, said ``One of the first 
duties of the physician is to educate the masses not to take 
medicine.'' A snapshot of the average year with the average patient 
shows that healthcare provider spend approximately 100 minutes with 
their patient during that year. How much health happens in those 100 
minutes? There are approximately 525,600 minutes in that year, yet we 
focus so much of our time, effort, and spending on those 100 minutes; 
the small fraction of a spot on the page. But what happens in the 
remaining 525,600 minutes of that year? What happens in the ``White 
Space?'' I will tell you what I think happens--that is where health is 
built, that is where people live. The ``White Space'' is when our 
soldiers are doing physical fitness training, choosing whether to take 
a cigarette break, or deciding whether they will have the cheeseburger 
or the salad for lunch. It's when family members are grocery shopping 
or cooking a meal. The ``White Space'' is when soldiers spend time with 
their family, or get a restful night of sleep, or search the Internet 
to self-diagnose their symptoms to avoid adding to those 100 minutes in 
the clinician's office. We want to lead the conversation with Army 
leadership to influence the other 525,600 minutes of the year with our 
soldiers . . . the ``White Space''. In order for us to get to health, 
we must empower patients, move beyond the 100 minutes, and influence 
behaviors in the white space. The way ahead is connected, 
collaborative, and patient-centered.
    I have discussed but a few of the important medical issues and 
programs that are relevant to the current wars and vital to the future 
of Military Medicine require solutions and funding that will go years 
beyond the end of the current wars. Our Nation, our Army, and Army 
Medicine have a duty and responsibility to our soldiers, families, and 
retirees. There will be considerable ongoing healthcare costs for many 
years to support for our wounded, ill, or injured soldiers. The 
programs we have established to care for our soldiers and families 
cannot falter as our deployed footprint diminishes. The level of care 
required does not end when the deployed soldier returns home.

                           OPTIMIZE RESOURCES

    One of Army Medicine's greatest challenges over the next 3-5 years 
is managing the escalating cost of providing world-class healthcare in 
a fiscally constrained environment. People are our most valuable 
resource. We will employ everyone to their greatest capacity and ensure 
we are good stewards of our Nation's resources. To capitalize on the 
overall cost savings of procurement and training, we will standardize 
equipment, supplies, and procedures. And we will leverage our 
information technology solutions to optimize efficiencies.
    Despite the cost containment challenges we face, we must accomplish 
our mission with an eye on reducing variance, focusing on quality, and 
expecting and adapting to change. These are our imperatives. Army 
Medicine will focus on collaborative international, interagency, and 
joint partnerships and collective health, including prevention and 
wellness, to ensure the enduring capabilities required to support the 
current contemporary operating environment and those of the future are 
retained.
    We will be methodical and thoughtful in our preparation for budget 
restraints to ensure that the high-quality care our warriors and 
military family demand is sustained. With the anticipated downsizing of 
forces, there will be a need to critically look at where medical 
services could be consolidated. However, we will use this as an 
opportunity to evaluate workloads to maximize efficiencies while 
maintaining effectiveness and focus on what services are best for our 
beneficiary population and dedicate resources to those.
    The rising cost of healthcare combined with the increasingly 
constrained Defense budget poses a challenge to all within the MHS. DOD 
offers the most comprehensive health benefit, at lower cost, to those 
it serves than the vast majority of other health plans in the Nation--
and deservedly so. The proposed changes in TRICARE fees do not change 
this fact--the TRICARE benefit remains one of the best values for 
medical benefits in the United States with lower out-of-pocket costs 
compared to other healthcare plans. Adjustment to existing fees, and 
introduction of new fees are proposed. Importantly, these benefit 
changes exempt soldiers, and their families, who are medically retired 
from Active service, and families of soldiers who died on Active Duty 
from any changes in cost-sharing. I support these modest fee changes 
when coupled by the MHS's shift in focus from healthcare to health, 
maintaining health and wellness, identifying internal efficiencies to 
capitalize on, and instituting provider payment reform.
    A major initiative within Army Medicine to optimize talent 
management and move towards a culture of trust, discussed earlier in 
this testimony, is the Human Systems Transformation, led by a newly 
established Human Systems Transformation Directorate. Army Medicine's 
ability to efficiently transform our culture requires a roadmap for 
achieving planned systemic change. The plan focuses on enhanced 
investment in four human system tiers (lines of effort) to:
  --improve senior leader development (new command teams/designated key 
        staff positions);
  --increase investment in the development of Army Medicine workforce 
        members;
  --establish a cadre of internal organizational development 
        professionals;
  --leverage partnering; and
  --collaboration opportunities with internal and external 
        stakeholders.
    In order to change the culture of our organization, we must invest 
in our people.

                            DEVELOP LEADERS

    At the core of our medical readiness posture is our people. The 
Army calls each of us to be a leader, and Army Medicine requires no 
less. We will capitalize on our leadership experiences in full-spectrum 
operations while continuing to invest in relevant training and 
education to build confident and competent leaders. Within this focus 
area, we will examine our leader development strategy to ensure that we 
have clearly identified the knowledge, skills, and talent required for 
leaders of Army Medicine. We will continue to develop adaptive, 
innovative, and decisive leaders who ensure delivery of highly 
reliable, quality care that is both patient-centered and inherently 
trustworthy. Being good stewards of our Nation's most treasured 
resources, through agile, decisive, and accountable leadership, we will 
continue to build on the successes of those who have gone before us. 
Our recruitment, development, and retention of medical professionals--
physicians, dentists, nurses, ancillary professionals, and 
administrators--remains high. With the support of the Congress, through 
the use of flexible bonuses and special salary rates, we have been able 
to meet most of our recruiting goals. Yet we recognize that competition 
for medical professionals will grow in the coming years, amidst a 
growing shortage of primary care providers and nurses.

                      SUPPORT THE ARMY PROFESSION

    Army Medicine has a rich history of sustaining the fighting force, 
and we need to tell our story of unprecedented successes across the 
continuum of care--from the heroic efforts of our medics at the point-
of-injury to the comprehensive rehabilitation of our wounded warriors 
in overcoming exceptional challenges. After more than 10 years of 
persistent conflict, it is time to renew our collective commitment to 
the Army, its ideals, traditions, and ethos. As we have stood alongside 
our warfighters on the battlefield we have earned the trust of our 
combat-tested warfighters, and it is critical that we continue to 
demonstrate integrity and excellence in all that we do.

                          WORLDWIDE INFLUENCE

    Army Medicine reaches around the world; from those supporting two 
theaters of war and humanitarian relief efforts to those conducting 
militarily relevant research and providing care to our military 
families overseas, AMEDD soldiers and civilians answer our Nation's 
call. The time that two oceans protected our freedom-loving Nation is 
long gone, and replaced with ever-present risks to our way of life. The 
Nation relies on its Army to prepare for and conduct full-spectrum 
operations from humanitarian and civil support to counterinsurgency and 
general war throughout the world. Army Medicine stands committed to 
sustain the warfighter and accomplish the mission, supporting the 
world's most decisive land force and the strength of the Nation.
    In the MHS, one of our biggest challenges lies in integrating the 
shared electronic health record (EHR) information available in our 
systems with the information that is provided through our civilian 
network providers and VA partners. Without that seamless integration of 
data, healthcare cannot be coordinated properly for the patients across 
all providers and settings. To support DOD and VA collaboration on 
treating PTSD, pain, and other healthcare issues, the EHR should 
seamlessly transfer patient data between and among partners to improve 
efficiencies and continuity of care. The DOD and the VA share a 
significant amount of health information today and no two health 
organizations in the Nation share more nonbillable health information 
than the DOD and VA. The Departments continue to standardize sharing 
activities and are delivering information technology solutions that 
significantly improve the secure sharing of appropriate electronic 
health information. We need to include electronic health information 
exchange with our civilian partners as well--a health information 
systems which brings together three intersecting domains--DOD, VA, 
civilian--for optimal sharing of beneficiary health information and to 
provide a common operating picture of healthcare delivery. These 
initiatives enhance healthcare delivery to beneficiaries and improve 
the continuity of care for those who have served our country. 
Previously, the burden was on servicemembers to facilitate information 
sharing; today, we are making the transition between DOD and VA easier 
for our servicemembers. The AMEDD is committed to working 
collaboratively with our partners across the MHS to seek solutions that 
will deliverable a fully integrated EHR that will enhance healthcare 
delivery to beneficiaries and improve the continuity of care for those 
who have served our country.
    At the core of our Army is the warfighter. A focus on wellness and 
prevention will ensure that our warriors are ready to heed the Nation's 
call. Yet in the Army today we have more than a division of Army 
soldiers who are medically not ready (MNR). This represents a readiness 
problem. We created a Soldier Medical Readiness Campaign to ensure we 
maintain a health and resilient force. The deployment of healthy, 
resilient, and fit soldiers and increasing the medical readiness of the 
Army is the desire end state of this campaign. The campaign's key tasks 
are to:
  --provide Commanders the tools to manage their soldiers' medical 
        requirements;
  --coordinate, synchronize and integrate wellness, injury prevention, 
        and human performance optimization programs across the Army;
  --identify the MNR population;
  --implement medical management programs to reduce the MNR population;
  --assess the performance of the campaign; and
  --educate the force.
    Those soldiers who no longer meet retention standards must navigate 
the physical disability evaluation system (PDES). The present 
disability system dates back to the Career Compensation Act of 1949. 
Since its creation problems have been identified include long delays, 
duplication in DOD and VA processes, confusion among servicemembers, 
and distrust of systems regarded as overly complex and adversarial. In 
response to these concerns, DOD and VA jointly designed a new 
disability evaluation system to streamline DOD processes, with the goal 
of also expediting the delivery of VA benefits to servicemembers 
following discharge from service. The Army began pilot testing the 
disability evaluation system (DES) in November 2007 at Walter Reed Army 
Medical Center and has since expanded the program, now known as the 
IDES, to 16 MTFs. DOD has replaced the military's legacy disability 
evaluation system with the IDES.
    The key features of the IDES are a single physical disability 
examination conducted according to VA examination protocols, a single 
disability rating evaluation prepared by the VA for use by both 
Departments for their respective decisions, and delivery of 
compensation and benefits upon transition to veteran status for members 
of the Armed Forces being separated for medical reasons. The DOD and VA 
continue to move towards reform of this process by identifying steps 
that can be reduced or eliminated, ensuring the servicemembers receive 
all benefits and entitlements throughout the process. Within the Army, 
I recently appointed a task force focused on examining the Integrated 
Disability Evaluation Process in parallel with ongoing MHS efforts. The 
AMEDD is committed to working collaboratively with our partners across 
the MHS to seek solutions that will best serve those who have 
selflessly served our country.
    I would like to close today by discussing the Army Medicine 
Promise. The Promise, a written covenant that will be in the hands of 
everyone entrusted to our care over the next year, tells those we care 
for what we, the Army Medicine team, believe they deserve from us. It 
articulates what we believe about the respect and dignity surrounding 
the patient care experience. The Promise speaks to what we believe 
about the value of the care we deliver, about the compassion contained 
in the care we deliver and how we want to morally and ethically provide 
care for those we serve. I'll share two items from the Promise with 
you.

    ``We believe our patients deserve a voice in how army medicine 
cares for them and all those entrusted to our care.''

    Our patients want to harness innovation to improve or change their 
health and we are empowering their efforts via our wellness centers. At 
our premier wellness clinics, we collaborate with patients to not only 
give them the tools they need to change their health but also a 
lifespace partner to help them change their life. Our wellness clinics 
are new and still evolving, but I am committed to increasing their 
numbers and expanding their capabilities in order to dramatically 
impact those more than 500,000 minutes out of the year when our 
patients are living life outside the walls of our hospitals. The 
wellness clinics allow us to reach out to those we care for rather than 
them having to reach in.

    ``We believe our patients deserve an enhanced care experience that 
includes our belief in their desire to heal, be well, and have an 
optimal life.''

    The warrior transition care comprehensive transition plan supports 
this promise by providing countless wounded warriors with a dynamic 
plan for living that focuses on the soldier's future across six domains 
of strength--career, physical, emotional, social, family, and spiritual 
strength. The plan empowers soldiers to take control of their lives.
    In conclusion, the AMEDD has served side-by-side with our sister 
services in Iraq and Afghanistan, and at home we will continue to 
strengthen those collaborative partnerships to provide responsive, 
reliable, and relevant healthcare that ensures a healthy fighting force 
and healthy families. To succeed, we must remain ready and relevant in 
both our medical proficiencies as well as our soldier skills. We will 
continue to serve as a collaborative partner with community resources, 
seek innovative treatments, and conduct militarily relevant research to 
protect, enhance, and optimize soldier and military family well-being. 
Soldiers, airmen, sailors, marines, their families, and our retirees 
will know they are receiving care from highly competent and 
compassionate professionals.
    I am incredibly honored and proud to serve as the 43rd Surgeon 
General of the Army and Commander, U.S. Army Medical Command. There are 
miracles happening at our command outposts, forward operating bases, 
posts, camps, and stations every day because of the dedicated soldiers 
and civilians that made up the AMEDD. With continued support of the 
Congress we will lead the Nation in healthcare, and our men and women 
in uniform will be ready when the Nation calls them to action. Army 
Medicine stands ready to accomplish any task in support of our 
warfighters and military family.

    Chairman Inouye. Thank you very much, General.
    I have a question I'd like to ask the whole panel. In 2003, 
the Nurse Chiefs of all the services had an increase in their 
rank to two stars. Last month, the Congress received a 
directive from the DOD. In this directive, they suggested, or, 
in fact, mandated that this promotion be repealed and nurses 
will become one star again.
    In 1945, when I was in my last hospital stage, the chief of 
the Nurse Corps in the Army was a colonel. The senior nurse in 
my hospital was a captain. And throughout my care, I saw the 
physician once a week. I saw the nurse 7 days a week, every 
day, every hour. And I felt, as most of the men in that ward, 
that something was drastically wrong. And so I was happy when 
the announcement was made to increase it to two stars, but now 
there's one star. I want you to know that I'm against this, and 
I think this is not the right thing to do at this moment in our 
medical history.
    So, I'd like to ask you, what effect will this have on the 
services? Will it have a negative effect? Will it affect the 
morale? Will it affect the service?
    May I start with the Admiral?
    Admiral Nathan. Thank you for the question, Mr. Chairman. 
And may I echo your sentiment about military nursing and the 
role it plays, especially these days, as we compartmentalize 
house staff and physician training, and limit the hours. The 
military nurse is often the most steadfast provider, from a 
continuity perspective, of the patient.

                         CHIEF NURSE CORPS RANK

    That said, I believe that some of the changes they have in 
mind don't prohibit a Navy Nurse Corps officer from obtaining 
the rank of two stars. While it just would not be automatically 
conveyed, they would compete among other one-star admirals and 
generals for the senior healthcare executive rank of two stars.
    I think one of the things that, and, again, you may want to 
get this specifically from your chiefs of the Nurse Corps, but 
one of the benefits that it may bring with it is automatic 
promotion to two stars then does limit, at least in the Navy, 
the number of officers we can promote from captain to one star 
in the Nurse Corps. And so, it may limit the actual numbers who 
are flag officers.
    But there will be--in the Navy, there will always be Nurse 
Corps admirals, and they will, as they have in years past, be 
able to compete for two stars, and many of them do. We have 
Nurse Corps officers who are in charge of many of our major 
medical facilities. They have, in the past, been in charge of 
our major medical centers. They run the major headquarters of 
the Bureau of Medicine and surgery. For those who compete 
successfully for the second star in different arenas, they can 
then relinquish chief of the Nurse Corps, and we're then at 
liberty to pick another one-star admiral to be the chief of the 
Nurse Corps.
    Thank you, Sir.
    Chairman Inouye. Thank you. General Horoho.
    General Horoho. Thank you, Senator. First, I'd like to 
thank you very much, because you've been extremely supportive 
in the rank structure that we've had across our military.
    This has really been a maturation process within Army 
Medicine. Over the last--I'd probably say the last 6 years, we 
have a leader development program that has allowed Army nurses 
to be very competitive for command, which is our stepping stone 
for general officer. And so we have nurses that are extremely 
competitive for a level one and level two command, and now very 
competitive for our branch and material one stars.
    So, since DOD has supported the direction of reducing from 
two stars to one star, I believe we have a leadership 
development program that will allow our nurses to actually 
compete across the board for all of the one stars and then be 
competitive for two stars in the future.
    Chairman Inouye. General Green.
    General Green. Sir, I would expand upon what Admiral Nathan 
said, in terms of not only are our nurses vital to the in-
patient arena but in the patient-centered medical homes, and 
the things that we're doing with--they have much more contact 
with the out-patient as well, because of their roles as case 
managers and disease managers. And so, they do, certainly, I 
agree with you, is what I'm saying, have an extremely vital 
role.
    In terms of general officers, because of the economy and 
the Department's decision to take efficiencies, the Air Force 
concurs. Actually, we're the smallest of the medical services. 
We will lose 1 net general officer, going from 12 to 11. If the 
decision is made to not go directly to two star, we will still 
have a one-star nurse, who will have the same responsibilities 
in terms of oversight of nursing and other important programs.
    We also, like the Army, have a very strong leadership 
development program, and I believe our nurses will compete very 
well, because there's nothing in the proposal that's come to 
you that would restrict them from competition for two star, it 
just doesn't make that particular corps position an automatic 
two star.
    Thank you, Sir.
    Chairman Inouye. Well, I thank you very much, but I can 
assure you that I will be voting and speaking against it.

                              TRICARE FEES

    I'd like to ask this question of the Admiral. In the fiscal 
year 2013 budget, it is assumed that $423 million in savings 
will be based upon new TRICARE enrollment fees and increases in 
co-pay for prescription drugs. The House has just announced 
that this will not pass muster in the House. It will not see 
the light of day. What is your thought?
    Admiral Nathan. Thank you, Sir. This is clearly an issue 
that's front and center among many organizations, both in our 
Nation's leadership, the military leadership, and our 
beneficiary populations.
    We recognize that the cost of healthcare has escalated 
dramatically. In 2001, the Department of Defense (DOD) spent 
approximately $19 billion on its Defense Health Program (DHP). 
And this year, it's approximately $51 billion, and expected to 
reach the $60 billion point in the next few years.
    So, the onus is on us to look for ways to sustain the 
healthcare benefit, to continue to fund it, to keep faith with 
our beneficiaries, to keep faith with those men and women who 
paid with years of service, and often with sacrifice of their 
lives and their families to earn this benefit.
    Given the resource constraints and trying to get a handle 
on healthcare costs, we are looking at organizational changes, 
governance changes, trying to find efficiencies through 
transparency increased efficiency, reducing redundancy among 
the services, and finding more joint solutions. The other was 
to determine if the healthcare cost to the beneficiary has kept 
up over the last 15 years with the total benefit package that 
beneficiaries receive.
    Neither I nor my colleagues here were involved in the 
actual number crunching or the decisions of tiering or levels 
of tiering to the various beneficiaries, but we do understand 
that the cost of the healthcare beneficiary has remained 
unchanged, and actually decreased in relative dollars over the 
last 10 to 15 years. The TRICARE enrollment fees have remained 
static at about $400 to $500 per year, since the 1990s. The 
drug co-pays have changed very little. And, in fact, there have 
been additional programs implemented including TRICARE For 
Life, and others, which have greatly increased the cost to the 
Government for beneficiary healthcare.
    So, the bottom line, Sir, I believe this is an effort to 
try to find a fair increase in the participation of the 
beneficiaries that is commensurate or not above the benefits 
actually received over the last several years.
    And I'll just close by saying, I recognize the emotion 
here. I'm an internal medicine doctor. I take care of a large 
population of patients for whom these changes may affect. We 
always worry about whether or not we're keeping or breaking 
faith with the commitment they made and the benefits they 
should receive. I'm vitally interested in making sure that we 
can have a sustainable program that would allow retirees and 
their family members to continue to get this benefit, and I 
believe this is part and parcel of this effort.
    Thank you, Sir.
    Chairman Inouye. Thank you, Admiral.
    Generals Green and Horoho, do you have any comments to 
make? I'm just curious. The military leadership, in general, 
seems to be supportive, but I'd like to know what the thoughts 
of families and troops may be, because they're not here to 
testify. Have you heard from them?
    General Green. Sir, we're hearing from the coalition the 
same as I'm sure you are now, in terms of their representatives 
to this process, because the proposed fee increases would 
affect the Active Duty and their family members very minimally, 
in terms of some of the co-pays with pharmacy, and if they 
happen to be in TRICARE Prime, the change to the catastrophic 
cap could affect those. We're not hearing too many things from 
our Active Duty population.
    The retirees, who bear the brunt of some of the cost 
increases, I think they're being very vocal, and we're hearing 
from all of the different agencies and representative groups 
telling us that they're not supporting the activities that are 
being proposed.
    The Air Force supports the Department's position. On a 
personal level, obviously, I am going to be someone who is 
joining the ranks of retirees, and will be paying these fees.
    General Green. And I would tell you that there is a 
mismatch right now, over the years, based on the inflation that 
is in the healthcare indexes that goes into the cost-of-living 
increases that's not been brought back to the beneficiaries.
    And so, in other words, we've been giving cost-of-living 
increases to the retirement, but we haven't been increasing any 
of the out-of-pocket costs. And so, although you're getting 
money that's respective of the healthcare inflation, you're not 
actually paying any of the healthcare costs that have come up.
    And so, I believe that the out-of-pocket costs need to 
increase, and on a person that would be willing to pay the fees 
that are proposed. I do think that, you know, there may be 
other ways that we could reach a similar endpoint, but the 
Department has put considerable work and had taskforce that is 
basically brought this forward, which is why the Air Force 
supports the Department's position at this time.
    Chairman Inouye. General Horoho.
    General Horoho. Sir, in addition to what my colleagues have 
said, I think where we've heard back is more from the 
coalitions that are out there. Senior leaders that are retired 
have been very supportive of this, of wanting to ensure that 
our military benefit continues. And so, their feedback has been 
in support of the fee increases.
    And in addition to DOD, or with the fee increases, I think 
really what's at stake is the need for all of us to be 
critically looking at our programs and our processes, and 
figure out where we have redundancies, so that we can look at 
saving dollars in other areas to offset some of the rising 
costs in healthcare for the future.
    Chairman Inouye. Thank you very much.
    Vice Chairman.

                   STATEMENT OF SENATOR THAD COCHRAN

    Senator Cochran. I'm pleased to join you in welcoming our 
distinguished panel in thanking you for the responsibilities 
you've assumed under the jobs that you now have, and the work 
you are doing for our Armed Forces. We think it's very 
important that we provide a standard of hospital and nursing 
care, and medical assistance to our men and women in uniform, 
and we know that you're responsible in your services for seeing 
that that becomes a reality, and it is ministered in a way 
that's sensitive to the needs of our military men and women in 
service, and also sensitive to the retirees as they become more 
concerned about costs, and cost-of-living adjustments, and 
availability of services. And we share those concerns, and we 
know that you'll do your best to help meet the challenges that 
your official duties require.
    So, that's a long way of saying thank you for doing what 
you do. We want to be sure that we provide the resources that 
are necessary to ensure a sensitive and professional standard 
of care that is commensurate with the sacrifice and service, 
and the importance of that to our Nation.
    In your assessment, let me just start here, General Horoho, 
thank you for your comments that you've already made in your 
statement and in your answers to Senator Inouye's questions. 
What, if anything, do you think we could do in terms of 
targeting funding or making changes in the support that we 
provide as the Congress to the Army's medical needs and 
generally speaking to those who are responsible for managing 
these funds? Is the level of funding adequate to carry out our 
responsibilities to the men and women in the Armed Forces?
    General Horoho. Thank you, Vice Chairman, for that 
question.
    Right up front, the funding this year is absolutely 
adequate for us to be able to meet our mission. The area that I 
think will be critical to ensure that we continue with funding 
will be the funding for our scholarship programs that allows us 
to bring in the right talent, so our physicians, our dentists, 
and our nurses, and our social workers, I think, that's very, 
very critical, so that we sustain the right talent to be able 
to care for our warriors in the future.
    The other area that I think is critical to make sure that 
we have the right funding for is the care for our warriors with 
our warrior transition units. As we draw down as an army, we 
will continue to have a large number of patients that we will 
need to care for for their psychological wounds, as well as 
physical injuries that have occurred over the last 10 years. 
And so, those are probably the two most important areas that I 
think we need to ensure that funding remains available.
    Senator Cochran. Thank you.
    General Horoho. Thank you.
    Senator Cochran. Admiral Nathan, what's your response to 
the same question?

                    MILITARY MEDICAL PROGRAM FUNDING

    Admiral Nathan. Thank you, Sir.
    Again, we certainly believe that the funding is adequate to 
meet our mission from the President's budget for fiscal year 
2013. The areas that we remain concerned about, as we see 
looming budget pressures, are, in many ways, in concert with 
what General Horoho said. We want to make sure that our wounded 
warrior programs, especially those that facilitate transition, 
remain intact. We want to continue to partner with not only our 
military but our private sector and academic partners, and 
finding best practices, and to engage them in programs, so that 
we can create a unified approach to some of the more vexing 
challenges from 10 years of war, including post-traumatic 
stress and TBI.
    We're also committed to military medical engagement via 
humanitarian assistance disaster relief in our overseas 
facilities. We believe they are great ambassadors of the 
American passion, the American ethos, and show an American 
military that brings light and help as much as it can bring 
heat. So we're also hoping to make sure that those remain 
robust, and an everlasting presence of what we do in the 
military, as well as our support of the kinetic operations.
    Thank you.
    Senator Cochran. Thank you.
    General Green.
    General Green. And Sir, our budget is also adequate. I mean 
it meets all of our needs this year. All of our programs are 
fully funded.
    I would add one thing to the scholarship request of General 
Horoho, and that is that I would tell you that I think we also 
need to be certain to fund our Uniform Services University, 
because they give us a highly professional officer that stays 
with us much longer than some of the folks who are just with 
the scholarships, and coming from our outside medical schools.
    In addition to that, I would ask that you watch very 
carefully to ensure that we still have funding for research, 
and TBI, and PTSD. I think that we're learning a great deal, 
and we need to learn more because of this burgeoning problem, 
as we bring people home from the wars.
    And finally, one thing that's kind of outside of your 
question, but I would tell you that to make certain that we are 
actually doing the best job possible with the money, I would 
tell you that we need to move towards a single financial 
accounting system for DHP dollars. Whichever one is chosen 
would be fine, but I think to avoid redundancy and to make 
certain that we're delivering the most efficient healthcare, we 
need a single system that actually gives us visibility of all 
programs within the DHP.
    Thank you, Sir.
    Senator Cochran. Thank you.
    For those of us who don't hear the terms used by the 
military every day, TBI means ``traumatic brain injury,'' 
doesn't it?
    General Green. Yes, Sir.
    Senator Cochran. Okay.
    General Green. Yes, Sir. And post-traumatic stress. And 
then the DHP is ``Defense Health Program.''
    Senator Cochran. Good. Thank you.
    Chairman Inouye. Thank you very much.
    Senator Mikulski.

                STATEMENT OF SENATOR BARBARA A. MIKULSKI

    Senator Mikulski. Mr. Chairman, after I conclude these 
questions, I have to go to the NIH hearing, so I just want to 
say to the second panel of nurses, we really salute you for 
your service, and echo the comments made by the chairman. And I 
just want to say to you and to the people who are also part of 
our military Nurse Corps service, you are stars. You are stars. 
We just want to make sure you have the chance to wear them on 
your shoulders. So, we want to thank you for that.
    And also, Mr. Chairman, I hope, as we look at this, we 
continue, as we listen to our Nurse Corps, focus on workforce 
needs, both doctors and nurses, and then other areas of allied 
health, to make sure we have all that we need to do to backup.
    Now, let me go right to my question. First of all, I think 
we want to say to all of those serving in military medicine, 
what stunning results we've achieved in acute battlefield 
medicine. I think you're breaking history books in terms of 
lives saved, and it's an unparalleled seamless network, 
General, from response on the battlefield, to the transport 
through the Air Force, to Germany, back home here. So, we 
really want to thank you for that, and General Green, for you, 
and all of those who serve in the Air Force.
    But, let me get to my question, because it goes to, we have 
two challenges. War is war. So, there are those who suffer the 
injuries, because of the weapons of war. This is a whole genre 
that we're focusing on. But then there's the consequences of 
war, and the consequences of the military, so it's those who 
are Active in duty, and then their families.
    Much has been said now about resiliency. Resiliency. So 
that no matter what happens to you, even going in that white 
space, General Horoho, that you talked about is there.
    So, here is my question, and you refer to it in many of 
your testimony: The medical home. You talk about your new 
partnerships with Samueli Institute, headed by a former Walter 
Reed doc, the Bravewell collaborative. Could you share with me 
what this whole issue of resiliency and the use of 
complementary and integrative techniques, and tell me where we 
are, when the momentum that was created by Admiral Mullen, 
General Schoomaker, and other of our surgeon generals, on this 
whole idea of resiliency wellness that facilitated being ready 
for combat, support that the family embraced, and then, quite 
frankly, in their recovery.
    Did they have a good idea? So, could you tell me what 
you're doing, and does it have efficacy?
    General Horoho. Thank you, Senator, for the question.
    We are continuing to build upon the prior efforts of 
Admiral Mullen, General Casey, as well as General Schoomaker, 
and really looking at how do we ensure that we focus on the 
mind, body, spirit, and soul of our warriors and their family 
members. And we've learned over this 10-year conflict that we 
can't just treat our warriors, that we absolutely have to treat 
the family, because it impacts on both.
    So, we've started with the platform of having patient-
centered medical homes, really focusing on continuity of care, 
and wellness, and managing their care. We've also stood up 
community-based clinics, and so, we have pushed healthcare out 
into the communities where the patients live, with one standard 
of care of being very much focused on embedding behavior health 
in our primary care, as well as our community-based clinics.
    We've stood up a pain management taskforce that is now on 
its second year, and last year it was nationally recognized for 
the work that was done. Those recommendations from the pain 
management taskforce are now going to be implemented this year. 
We'll have nine across each one of our major medical centers, 
and the complimentary and integrative medicine that occurs with 
that, so we're incorporating yoga, acupressure, acupuncture, 
mindfulness, sleep management, and really trying to get to more 
of the prevention when we look at healthcare and wellness. 
We've taken these concepts and integrated some of these on the 
battlefield.
    When I was deployed in Afghanistan, we had many areas where 
we actually coordinated care with behavior health and 
concussive care, and incorporated some of the mindfulness 
training there, and sleep management.
    Senator Mikulski. Has that had efficacy? I mean, you know, 
we make much of evidence-based medicine, and I think we're all 
there. We can't afford to waste time or dollars. So, could you 
talk about the efficacy of those efforts? Were Mullen and all 
of them on the right track?
    General Horoho. I do believe we're on the right track. We 
have seen a decrease in the reliance of poly-pharmacy.
    Senator Mikulski. Does that mean drugs?
    General Horoho. Yes, Ma'am. Multiple drugs. We've had many 
of our warriors that have used yoga, and acupressure, and 
acupuncture vice narcotic pain medicine. So, we are seeing help 
in that area.
    We also have a patient caring touch system that has been 
rolled out that's one standard of care across all of Army 
Medicine. And with that, we have seen a decrease in medication 
errors. We've seen an increase in documentation of pain 
management. We've seen a decrease in left without being seen in 
our emergency rooms. So, increase in continuity of care. So, we 
are seeing critical lab values that are equating to better 
patient outcomes. And we've got a ways to go, as we look at how 
do you measure wellness. What are the metrics that we should be 
looking at that really measures wellness and improved mental 
and spiritual health? So, we've got tremendous work to do in 
that area, but I do believe we're moving in the right 
direction.
    Senator Mikulski. Well, and I think it goes to the recovery 
from them, also, because that deals with many of the 
consequences of frequent deployments, the stresses, et cetera.
    Admiral Nathan, did you want to comment on that, because 
you also, in your testimony, talked about body, mind, spirit 
medicine, which is the whole warrior, and the support of the 
warrior.
    Admiral Nathan. Yes, Ma'am.
    Senator Mikulski. The family support.
    Admiral Nathan. Thank you, Senator. You made two great 
points in your question. One is, how do we support the warrior 
and the family while they're deployed in operations, undergoing 
warfare, and then, how do we support them as a unit when they 
return home as a family unit, seeking care in a garrison 
environment?

              WOUNDED WARRIOR AND FAMILY SUPPORT PROGRAMS

    Some of these things have been touched on. We have 
unprecedented surveys now and assessments of our personnel on 
deployments. We have the behavioral needs assessment study, 
which is done of all our individual augmentees in the Navy. The 
Marines have a similar program, where they are all surveyed. 
We've actually seen, because of this interaction, a decrease in 
the stigma of seeking help. We've seen a decrease in the rate 
of psychotropic drugs, basically antidepressants being used on 
the battlefield, in our populations.
    Senator Mikulski. That's pretty big, isn't it?
    Admiral Nathan. I think so. And I think we can attribute it 
to the engagement that the services now have in training not 
only the medical professionals who are deployed but the line 
officers and the operators who are deployed along with our 
servicemembers.
    In the Navy and Marine Corps, we have the combat and 
operational stress control (COSC) training and the operational 
stress control and readiness (OSCAR) training. These are 
embedded teams, with mental health professionals, and corpsmen 
and medics, who have been trained to engage and embed with the 
war-fighting forces.
    In the Marine Corps, we've trained more than 5,000 marines 
who are battalion commanders, garrison commanders, squadron 
commanders on the signs and symptoms of stress, of depression, 
of looking for those first tips of somebody who's starting to 
bend before they break. I think that has helped us both in 
getting people referred earlier and in destigmatizing the 
scenario where somebody raises their hand and says, ``I'm not 
doing well.''
    In the family units, we have now 23 Families Overcoming 
Under Stress (FOCUS) locations, which are centered on taking 
care of children, families, the warrior themselves. It has a 
variety of outreach programs to take care of kids who are 
either failing in school or suffering from the parent being 
deployed. These can be reached both by walking in, making 
appointments, and virtually by telephone.
    For the Reserve community, we have the Psychological Health 
Outreach Program, which both can be reached by telephone or 
remotely walking in. We also have the Returning Warrior 
Workshops. The returning warrior from Reserves and spouse 
attend one of these, and they're held on the weekends. They're 
an intensive 72-hour program, where all the facilities and 
programs are made available to them.
    Senator Mikulski. Admiral Nathan, I think in the time for 
the subcommittee members----
    Admiral Nathan. Yes, Ma'am.
    Senator Mikulski. And the Chairman's being generous, if we 
could have kind of a white paper or something from you on this, 
because I think all of us want to certainly help our warriors 
who have endured injury from the weapons of war, and I want to 
be sure that we have the right resources for you to be able to 
do the right things, with the consequences of war. And you seem 
to have an excellent program. It has momentum. It has 
demonstrable efficacy. I'd like to have a description of it in 
more detail, and whether, again, you have the resources to do 
it.
    Admiral Nathan. Happy to do that.
    [The information follows:]

    Navy Medicine continues to foster a culture of support for 
psychological health as an essential component to total force fitness 
and readiness. Operational Stress Control programs provide sailors, 
marines, leaders, and families the skills and resources to build 
resiliency. We also address stigma by encouraging prevention, early 
intervention, and help-seeking behaviors.
    We have made remarkable progress in ensuring our wounded 
servicemembers get the care they need--from medical evacuation through 
inpatient care, outpatient rehabilitation to eventual return to duty or 
transition from the military. Our programs of support, which are 
adequately resourced, continue to mature and show progress. Our 
emphasis remains ensuring that we have the proper size and mix of 
mental health providers to care for the growing need of servicemembers 
and their families who need care. Within Navy Medicine, mental health 
professional recruiting and retention remains a top priority.
    Our focus continues to be embedding psychological health providers 
in Navy and Marine Corps units, ensuring primary and secondary 
prevention efforts, and appropriate mental healthcare are readily 
accessible for sailors and marines. The U.S. Marine Corps (USMC) Combat 
and Operational Stress Control program uses Operational Stress Control 
and Readiness (OSCAR) as an approach to mental healthcare in the 
operational setting by taking mental health providers out of the clinic 
and embedding them with operational forces to emphasize prevention, 
early detection, and brief intervention. More than 5,000 marine leaders 
and individual marines have already been trained in prevention, early 
detection, and intervention in combat stress through OSCAR Team 
Training and will operate in OSCAR teams within individual units.
    We are also embedding psychological health providers in the primary 
care setting where most servicemembers and their families first seek 
assistance for mental health issues. This practice enhances integrated 
treatment, early recognition, and access to the appropriate level of 
psychological healthcare. The Behavioral Health Integration Program in 
the Medical Home Port is a new program that is actively being 
implemented across 69 Navy and Marine Corps sites.
    Traumatic brain injury (TBI) care on the battlefield has improved 
significantly since the beginning of Operations Enduring Freedom and 
Iraqi Freedom. Most improvements have targeted early screening and 
diagnosis followed by definitive treatment. In 2010, the Department of 
Defense (DOD) issued the Directive-type Memorandum 09-033, which has 
resulted in improved diagnosis and treatment of battlefield concussion. 
For the Navy and Marine Corps, the primary treatment site for concussed 
servicemembers has been the Concussion Care Restoration Center (CRCC) 
at Camp Leatherneck in Afghanistan. Since its opening in 2010, CRCC 
staff have treated more than 930 servicemembers with concussions, 
resulting in a greater than 98-percent return-to-duty (RTD) rate and an 
average of 10.1 days of duty lost from point-of-injury to symptom-free 
RTD. There is also a Concussion Specialty Care Center (CSCC) at the 
NATO Role III Hospital in Kandahar, with a neurologist on staff.
    Upon return from deployment, enhanced screening methods for TBI and 
mental health conditions are being piloted at several Navy and Marine 
Corps sites. These efforts include additional screening and follow-up 
for any servicemember who was noted to have sustained a concussion in 
theater. Efforts are underway to increase the use of the National 
Intrepid Center of Excellence (NICoE) across DOD and Navy, and the 
development of NICoE satellite sites, to provide state-of-the-art 
evaluation and treatment for those patients who do not improve with 
routine clinical care.
    Additional examples of support programs throughout Navy Medicine 
include:
      Overcoming Adversity and Stress Injury Support.--Overcoming 
        Adversity and Stress Injury Support (OASIS) is a residential 
        post-traumatic stress disorder treatment program at the Naval 
        Medical Center San Diego. It opened in August 2010, onboard the 
        Naval Base Point Loma and is providing intensive mental 
        healthcare for servicemembers with combat-related mental health 
        symptoms from post-traumatic stress disorder, as well as major 
        depressive disorders, anxiety disorders, and substance abuse 
        problems. Care is provided 7 days a week for 1,012 weeks, and 
        servicemembers reside within the facility while they receive 
        treatment.
      Families Over Coming Under Stress.--Families Over Coming Under 
        Stress (FOCUS) is a family psychological health and resiliency 
        building program that addresses military family functioning in 
        the context of the impact of combat deployments, multiple 
        deployments, and high-operational tempo. The application of a 
        three-tiered approach to care: community education, psycho 
        education for families, and brief treatment intervention for 
        families has shown statistically significant outcomes in 
        increasing family functioning and decreasing negative outcomes 
        such as anxiety and depression in both parents and children. 
        The program serves Active Duty and Reserve families. Families 
        can access the program through a direct self-referral, 
        referrals by military treatment facility providers, community 
        providers such as Fleet and Family Service Centers, chaplains, 
        and schools. There are currently 23 FOCUS locations operating 
        at 18 installations.
      Reserve Psychological Health Outreach Program.--Reserve 
        Psychological Health Outreach Program (PHOP) was developed for 
        our Navy and Marine Corps Reserve populations. The program 
        provides psychological health outreach, education/training, and 
        resources a 24/7 information line for unit leaders or 
        reservists and their families to obtain information about local 
        resources for issues related to employment, finances, 
        psychological health, family support, and child care. PHOP now 
        includes 55 licensed mental health providers dispersed 
        throughout the country serving on 11 teams located centrally to 
        Navy and Marine Force Reserve commands.
      Returning Warrior Workshop.--The Returning Warrior Workshop (RWW) 
        is a dedicated weekend designed to facilitate reintegration of 
        sailors and marines returning from combat zones with their 
        spouses, significant others. RWWs are available to all 
        individual augmentees, both Active Duty and Reserve, and are 
        considered the Navy's ``signature event'' within the Yellow 
        Ribbon Reintegration Program. The RWW employs trained 
        facilitators, including the PHOP teams and chaplains, to lead 
        warriors and their significant others through a series of 
        presentations and tailored break-out group discussions to 
        address post-combat stress and the challenges of transitioning 
        back to civilian life. RWWs assist demobilized servicemembers 
        and their loved ones in identifying and finding appropriate 
        resources for immediate and potential issues that often arise 
        during post-deployment reintegration. As of September 2011, 
        more than 10,000 servicemembers and their families have 
        participated in RWWs. RWWs assist demobilized servicemembers 
        and their loved ones in identifying immediate and potential 
        issues that often arise during post-deployment reintegration.
      Substance Abuse Rehabilitation Programs.--Navy Medicine maintains 
        a steadfast commitment to our Substance Abuse Rehabilitation 
        Programs (SARPs). SARPs offer a broad range of services to 
        include alcohol education, outpatient and intensive outpatient 
        treatment, residential treatment, and medically managed care 
        for withdrawal and/or other medical complications. We have 
        expanded our existing care continuum to include cutting-edge 
        residential and intensive outpatient programs that address both 
        substance abuse and other co-occurring mental disorders 
        directed at the complex needs of returning warriors who may 
        suffer from substance abuse disorders and depression or post-
        traumatic stress disorder (PTSD). In addition, Navy Medicine 
        has developed a new program known as My Online Recovery 
        Experience (MORE). In conjunction with Hazelden, a civilian 
        leader in substance abuse treatment and education, MORE is a 
        ground-breaking Web-based recovery management program available 
        to servicemembers 24/7 from anywhere in the world.
    Navy Medicine is committed to connecting our wounded warriors to 
approved emerging and advanced diagnostic and therapeutic options 
within our medical treatment facilities and outside of military 
medicine. We do this through collaborations with major centers of 
reconstructive and regenerative medicine while ensuring full compliance 
with applicable patient safety policies and practices. We will continue 
our active and expansive partnerships with the other Services, our 
Centers of Excellence, the VA, and leading academic medical and 
research centers to make the best care available to our warriors.

    Senator Mikulski. Thank you very much. And thank you, 
everybody, for what you're doing.
    Chairman Inouye. Thank you.
    Senator Murray.

                   STATEMENT OF SENATOR PATTY MURRAY

    Senator Murray. Thank you very much, Mr. Chairman.
    General Horoho, you and I have had a number of discussions 
about the invisible wounds of war and the challenges soldiers 
are facing, seeking behavioral healthcare. And as you well 
know, Madigan Army Medical Center, in my home State of 
Washington, is dealing now with how to handle these wounds and 
provide our soldiers quality consistent care, especially for 
our soldiers who are going through the Integrated Disability 
Evaluation System (IDES).
    Now, I think some of the issues that have been raised at 
Madigan are unique to that facility, but I do continue to have 
a number of concerns, not only about the situation at Madigan 
today but the implication for our soldiers, really, across the 
Army who may have also struggled to get a proper diagnosis, 
adequate care, and an honest evaluation during the integrated 
disability system process.
    I wanted to ask you today, prior to 2007, Madigan did not 
use the forensic psychiatry to evaluate soldiers in the medical 
evaluation board process, and wanted to ask you before the 
subcommittee today, why was that system changed in 2007?
    General Horoho. Thank you, Senator, for the question.
    The first thing that I'd like is just pick up on the word, 
when you said ``invisible wounds.'' I know it has been said 
during this war that the signature wound is an invisible wound. 
I would submit that it's not invisible to the family, nor is it 
invisible to the soldier that is undergoing those challenges, 
behavioral challenges.
    The reason, and I'm guessing on this, Ma'am, because I 
wasn't there, you know, prior to, but prior to 2007, we were a 
Nation that entered into war in about 2001, when we were 
attacked, and 2002 timeframe. And we had a very old system. 
That was the Medical Hold (MEDHOLD) and the Medical Holdover 
(MEDHOLDOVER) system, which was two separate systems on how we 
managed those servicemembers, Active and Reserve component. And 
that was the system that has been in place for many, many 
years.
    And what we found with the large number of deployments and 
servicemembers that were exposed to physical wounds, as well as 
behavioral health wounds is that we found that the Army system 
was overwhelmed, and that really is what was found in the 2007 
timeframe, is that we didn't have the administrative capability 
as well as the logistical support that needed to be there. And 
that's why we stood up our warrior transition units.
    So, we had a large volume going through the disability 
process that was an old antiquated process, and we had an 
overwhelming demand on our Army that we needed to restructure 
to be able to support and sustain.
    Senator Murray. But prior to 2007, there wasn't a forensic 
psychiatry that added an additional level of scrutiny. Is that 
correct?
    General Horoho. I honestly will need to take that for the 
record, because I don't know in 2006 if they had forensics or 
not. So, I can't answer that question for you. I would like to 
give you a correct answer.
    Senator Murray. Okay.
    General Horoho. So, if I could take that one for the 
record.
    [The information follows:]

    While forensic psychiatry has been in the Army inventory for many 
years, there was no separate forensic psychiatry department at Madigan 
Army Medical Center (MAMC) prior to 2007, and they did not provide 
forensic evaluations in routine disability assessments unless it was 
determined that a forensic evaluation was specifically required. 
Forensic psychiatry evaluations are appropriate in civil and criminal 
legal proceedings and other administrative hearings, as well as 
independent determinations of specialized fitness for duty issues where 
the basis of the diagnosis in not clearly determined.

    Senator Murray. I would appreciate that. And as I 
mentioned, I am really concerned that soldiers Army-wide have 
been improperly diagnosed and treated by the Army. What have 
you found, under your investigation, of soldiers getting 
incorrect Medical Evaluation Board (MEB)/Physical Evaluation 
Board (PEB) evaluations at other facilities?
    General Horoho. Ma'am, if I could just, when soldiers are 
getting diagnosed with post-traumatic stress (PTS) or post-
traumatic stress disorder (PTSD), we use the same diagnostic 
tool within the Army, Navy, and the Air Force, which is the 
same tool that is used in the civilian sector. So, it is one 
standard diagnostic tool that is very well-delineated on the 
types of symptoms that you need to have in order to get a 
diagnosis of PTS or PTSD.
    So, we are using that standard across the board, and we 
have been using that standard across the board.
    Senator Murray. Well, we do know now at Madigan there were 
soldiers that were incorrectly diagnosed. And we're going back 
through, there's several investigations going on to re-
evaluate. And my question is, there's been a lot of focus at 
Madigan. I'm concerned about that system-wide. And you're doing 
an investigation system-wide to see if other soldiers have been 
incorrectly diagnosed. Correct?
    General Horoho. Yes, Ma'am. So, if I can just lay things 
out and reiterate some of our past conversations. We have one 
investigation that is ongoing. Actually, it's completed. And 
it's with the lawyers. That's being reviewed. The Deputy 
Surgeon General, General Stone, initiated that investigation. 
And that was to look into----
    Senator Murray. System-wide?
    General Horoho. No, Ma'am. That's the one at Madigan that's 
looking at the forensics.
    Then, there's another investigation that was launched by 
the Western Region Medical Command to look into the command 
climate at Madigan Army Medical Center. And then what I 
initiated was an Inspector General (IG) assessment, not an 
investigation, but an assessment that looked at every single 
one of our military treatment facilities and the provision of 
care to see whether or not we had this practice of using 
forensic psychiatry or psychology in the medical evaluation 
process.
    Senator Murray. Okay. Well, my question was whether you had 
found at other facilities, incorrect diagnosis. And I want you 
to know that I have asked my Veterans Affairs Committee staff 
to begin reviewing cases from throughout the country of 
servicemembers involved in this process, and we are just 
beginning our review right now. But, we have already 
encountered cases in which a servicemember was treated for PTSD 
during their military service, entered the disability 
evaluation process, and the military determined that the 
servicemember's PTSD was not an unfitting condition.
    So, my concern is the significant discrepancy now between 
the Army's determination and the VA's finding that the soldier 
had a much more severe case of PTSD. Now, our review on my 
subcommittee is ongoing, but besides bringing individual cases 
to your attention, I wanted to ask you what specific measures 
do you look at to evaluate whether soldiers are receiving the 
proper diagnosis, and care, and honest evaluation.
    General Horoho. Within the Army, our role as the physicians 
is to evaluate the patients, not to determine a disability. So, 
they evaluate and identify a diagnoses and a treatment plan. 
And then once that is done, during the treatment, and if they 
are determined where they need to go into the disability 
system, then once they're in the disability system, now, 
because of Integrated Delivery Evaluation System (IDES), that 
occurred in 2010, they now have that evaluation done by the VA, 
the compensation exam. That's the compensation and pension 
(C&P) exam that's done by the VA.
    And then they are brought back into the disability system. 
So, the PEB is actually where the determination for disability 
is made. That is not a medical. That's an administrative action 
that falls under our G-1. And so I just want to make sure we 
don't mix what we do within the medical community in treating 
and evaluating and what gets done in the disability process 
that's an administrative process, that is reviewing the 
evaluation from the VA, and then the evaluation from the 
medical to determine disability.
    Senator Murray. My concern is that every single soldier who 
has mental health disability, PTSD, gets the care that they 
need, and that they get the support that they need, and they're 
adequately cared for, whether they leave the service or are 
sent back overseas, or whatever. So, we're going to continue to 
look at the system-wide, and as you know, the problems at 
Madigan were allowed to go on for years, and I'm really 
concerned that that lack of oversight over the disability 
evaluation system is much more broad, and really, you're going 
to be following to see what steps you take to ensure that this 
process is maintained. Not just at Madigan, where there's a 
severe focus right now, but nationwide.
    General Horoho. And Ma'am, what we've done so far, since I 
took over as Surgeon General on the 5th of December, what I've 
done so far is we're pulling behavior health up to the 
headquarters level, and making that a service line, so that we 
have one standard of care across all of Army Medicine, and 
we're able then to shift that capability where the demand is.
    I've got a team that has developed clinical practice 
guidelines for the use of forensics, as well as clinical 
practice guidelines for implementation of behavior health 
capability across Army Medicine.
    Senator Murray. When will that be implemented?
    General Horoho. Those are, right now, being evaluated by 
the experts. So, we've had them written up, and now they're 
being evaluated, and then we'll get that rolled out probably 
within the next several weeks.
    Senator Murray. Okay. So, we have two issues. We need to go 
back and find every soldier that may have not gotten the proper 
diagnosis and evaluation, and we need to move forward quickly 
to make sure there is the same diagnostic tool moving 
nationwide.
    General Horoho. Ma'am, right now, we are using the same 
diagnostic tool as my Air Force, and Navy, and the civilian 
sector for evaluating PTSD.
    Senator Murray. Do you believe we're using the right 
diagnostic tools?
    General Horoho. It's the one standard that's out in the 
civilian sector as well as the military. It is the best 
standard that's out there for diagnosing.
    Senator Murray. Okay. And finally, I just wanted to ask 
you, in your testimony you said that you've created a taskforce 
within the Army to examine the IDES process in conjunction with 
the ongoing MHS efforts. What specific aspects of the IDES 
process are you reviewing?
    General Horoho. Yes, Ma'am. We did this first, from an Army 
perspective. So, prior to General Crowley leaving, we set up a 
taskforce that Brigadier General Lyon, who is a medical corps 
physician, Army, he led that, and that was with U.S. Army 
Forces Command (FORSCOM), the G-1, and as well as Army 
Medicine. So we had a collaborative process looking at every 
aspect within the IDES to ensure that we had metrics, and as 
well as standards across implementation throughout the IDES 
process.
    After that was done, we then stood up an Army Medicine 
taskforce to be able to look at it then, Deepdive, from the 
medical piece that we're responsible for. Brigadier General 
Williams led that taskforce. It was multifunctional in 
capability. Individuals with multiple capabilities sat on that. 
And what we want to do is to be able to launch our standards 
across, so that we have no variance in every place that we have 
soldiers that are going through the IDES process.
    Army is getting ready to put out an all Army activities 
(ALARACT) message Army-wide with the standard. That will be 
going out, I think, in the April timeframe. And then ours, 
we're ready now. As soon as the Army launches that, we'll be 
able to put our standards in that impacts our medical care.
    Senator Murray. When will this be complete?
    General Horoho. Ma'am, right now, we're looking at starting 
that in the April timeframe, and the rollout of those standards 
across. And so I can get back with you on how long that would 
take.
    [The information follows:]

    The Army issued DA EXORD 080-12 on February 17, 2012 which provides 
guidance for standardization of Integrated Disability Evaluation System 
(IDES) across the Army. The U.S. Army Medical Command subsequently 
issued MEDCOM OPORD 12-33 which operationalizes three main efforts to:
  --standardize the process;
  --build capacity; and
  --establish Soldier-Commander responsibilities.
    From 2007 to 2011, the Army deployed IDES across the force to 32 
sites and continue efforts to implement new IDES guidance.

    Senator Murray. Okay. I'd really appreciate that.
    General Horoho. I can tell you that my full focus is 
ensuring that we do have a system, and I believe that everyone 
is focused on caring for our warriors. We're very committed to 
that. And we're looking at everywhere where we have variance, 
so that we can decrease that variance, and be able to ensure 
that we have one standard across Army Medicine.
    Senator Murray. Well, thank you very much. Thank you to 
your attention to this.
    Mr. Chairman, this is a serious issue. I've sat and talked 
with numerous soldiers and families who were diagnosed with 
PTSD, were getting care, and then as they went through the MEB 
process, were told they didn't have PTSD. They're now out in 
the community, and it is tragic that they're not getting the 
care that they need, and certainly, for the families, this has 
been extremely stressful, and my major attention on this, and 
my Veterans Affairs Committee is looking at this system-wide, 
and we'll continue to work with you on this.
    Chairman Inouye. I'm certain the troops and the veterans 
are very grateful to you. Thank you very much.
    Admiral Nathan, General Green, and General Horoho, thank 
you very much for your testimony, and more importantly, thank 
you for your service to our Nation.
    General Horoho. Thank you, Sir.
    Chairman Inouye. Thank you very much.
    General Horoho. Thank you very much. Thank you.
    Admiral Nathan. Thank you, Sir.
    General Green. Thank you.
    Chairman Inouye. I'd like to call the next panel, the panel 
of nurses. I'd like to welcome Major General Kimberly 
Siniscalchi, the Assistant Air Force Surgeon General for 
Nursing Services; Rear Admiral Elizabeth Niemyer, Director of 
the Navy Nurse Corps; and Major General Jimmie Keenan, Chief of 
the Army Nurse Corps.
    Needless to say, I've had a great love for nurses 
throughout my life. They have a very special spark. And so I 
look forward to your testimony, sharing with us the 
accomplishments of your corps, also the vision for the future, 
and problems, if any.
    So, may we begin with General Siniscalchi?

STATEMENT OF MAJOR GENERAL KIMBERLY A. SINISCALCHI, 
            ASSISTANT AIR FORCE SURGEON GENERAL FOR 
            NURSING SERVICES
    General Siniscalchi. Chairman Inouye, thank you for your 
continued support of military nursing and for the opportunity 
to once again represent more than 18,000 men and women of our 
total nursing force. Sir, I am honored to report on this year's 
outstanding achievements and future initiatives.
    This past year, more than 1,100 nursing personnel deployed 
in support of global contingency operations, comprising 47 
percent of all Air Force medical service deployers. The 
transition from Operation Iraqi Freedom to Operation New Dawn 
brought many of our troops home. Joint Base Balad Theater 
Hospital closed as part of this transition, marking the end of 
an era.
    A team of our deployed medics had the honor of retiring the 
historic American flag that covered Balad's Heroes Highway, the 
entry that welcomed more than 19,000 wounded warriors into our 
care. As this flag, which offered hope to our wounded, was 
taken down, the medics stood in awe as they discovered the 
stars from the flag were forever imprinted on the roof of the 
tent covering Heroes Highway.
    Our mission continues in support of Operation Enduring 
Freedom. This year, we introduced the tactical critical care 
evacuation team concept and piloted the first team for inter-
theater transport. Consisting of an emergency room physician 
and two of our nurse anesthetists, this team moved 122 critical 
patients, providing advanced interventions early in the patient 
care continuum, and we now have five teams trained.
    This past year, critical care air transport and air medical 
evacuation teams safely moved 17,800 patients globally. Our 
efforts to advance research and evidence-based practice led to 
new initiatives improving safe patient handoff and pain 
management. To continue building the next information bridge, 
we field tested a new electronic health record during air 
medical transport missions. All documented en route care can 
now be downloaded into the same clinical database used by our 
medical facilities, and can be readily visible to medical teams 
around the globe.
    Based on lessons learned over the past 10 years, we 
completely transformed our air medical evacuation training into 
a more efficient modular format, with increased proficiency 
levels, based on the latest evidence-based clinical protocols. 
This new curriculum reduced overall training time by 130 days.
    As we face current challenges, our total nursing force is 
well-prepared. We've established amazing partnerships with 
Federal and healthcare facilities whose in-patient areas and 
acuity levels provide the optimal environment for initial 
clinical training and skill sustainment. This year, we 
processed 39 training affiliation agreements in nursing. We 
also established three new 12-month fellowships: Patient 
safety, in partnership with the Tampa James Haley VA Patient 
Safety Center; magnet recognition, in partnership with 
Scottsdale Healthcare system; and Informatics, at our Air Force 
Medical Operations Agency.
    This year, we launched our new Air Force residency program, 
aligning with the National Council of State Boards of Nursing. 
Our newly assessed novice nurses complete the nurse transition 
program, and upon arrival at their first duty station enter the 
nurse residency program, where they receive clinical mentoring 
and professional development through their first year of 
practice.
    Whether on the battlefield or at home, our nurses and 
technicians are well-prepared to provide world-class care to 
all beneficiaries. The Federal Nursing Service chiefs have 
partnered in building collaborative plans to better prepare 
nursing teams for their integral roles in providing better 
health, better care, best value.
    Patient-centered care is our highest priority, and high 
touch, high care remains our true north. As we continue the 
journey from healthcare to health, we are committed to improve 
continuity of care, enhanced resiliency, and promote safe 
healthy lifestyles.
    With support from the Tri-Service Nursing Research Program 
(TSNRP), our nurse scientists completed research in the areas 
of patient safety, post-traumatic stress, pain management, and 
women's health. These research initiatives demonstrate our 
commitment to advanced nursing practice by fostering a culture 
of inquiry.
    However, an ongoing challenge is retaining our clinical 
experts. In an effort to explore factors affecting retention, 
the Uniform Services University, of the Health Sciences, 
conducted a study and found the number one reason influencing a 
nurse's decision to remain on Active Duty was promotion. The 
survey findings support our continued efforts to balance the 
Nurse Corps grade structure. Although our nursing retention 
rates have improved with incentive special pay program, and 
we've had continued success in meeting our recruiting goals, we 
must continue every effort to increase fill-grade 
authorizations in order to promote and retain our experienced 
nurses.

                           PREPARED STATEMENT

    Mr. Chairman, Mr. Vice Chairman, we genuinely appreciate 
your support as we continue to deliver world-class healthcare 
anytime, anywhere. We strive to ensure that those who wear our 
Nation's uniform and their families receive safe, expert, and 
above all, compassionate care.
    Again, I thank you, and I welcome your questions.
    [The statement follows:]

      Prepared Statement of Major General Kimberly A. Siniscalchi

    Mr. Chairman and esteemed members, it is indeed an honor to report 
to the subcommittee on this year's outstanding achievements and the 
future initiatives of the more than 18,500 members of our Total Nursing 
Force (TNF). I am proud to introduce a new team this year--Brigadier 
General Gretchen Dunkelberger, Air National Guard (ANG) Advisor; 
Colonel Lisa Naftzger-Kang, United States Air Force Reserve (USAFR) 
Advisor; and Chief Master Sergeant Cleveland Wiltz, Aerospace Medical 
Service Career Field Manager.
    I extend, on their behalf and mine, our sincere gratitude for your 
steadfast support, which has enabled our TNF to provide world-class 
healthcare to more than 2 million eligible beneficiaries around the 
globe. Throughout the past year, Air Force nursing personnel have 
advanced the transition from healthcare to health through patient 
education, research, and evidence-based practice. Our TNF priorities 
are:
  --Global Operations;
  --Force Development;
  --Force Management; and
  --Patient-Centered Care.
    Woven through each of these areas are new initiatives in education, 
research, and strategic communication. Today, my testimony will 
highlight the accomplishments and challenges we face as we pursue our 
strategic priorities.

                           GLOBAL OPERATIONS

    Operation Iraqi Freedom has now drawn to a close, and yet our 
medics remain fully engaged in wartime, contingency, humanitarian 
peace-keeping, and nation-building missions. In 2011, we deployed more 
than 1,100 nurses and technicians in support of these global missions. 
Our TNF made up approximately 47 percent of all Air Force Medical 
Service (AFMS) deployed personnel.
    The transition from Operation Iraqi Freedom to Operation New Dawn 
brought many of our troops home to friends and family. Joint Base Balad 
Theater Hospital closed in November 2011 as a part of this transition. 
During its tenure, more than 7,500 Air Force medical personnel deployed 
to Balad, approximately 50 percent of whom were nursing personnel. This 
premier trauma hospital supported more than 19,000 admissions, 36,000 
emergency patient visits, and 20,000 operating room hours while 
sustaining a 95 percent in-theater survival rate, the highest in 
military medical history. Serving as the last Deputy Group Commander, 
Chief Nurse, and Medical Operations Commander, during the final 
rotation at Balad, was my USAFR Advisor, Colonel Naftzger-Kang. She and 
her team successfully executed end-of-mission planning and the 
transition of $335,000 in equipment and more than 90 personnel with 
facility on-time closure.
    Balad's closure marked the end of an era and was bittersweet for 
all those who had journeyed through the hospital doors. The final 
rotation had the honor of retiring the American flag that covered 
Heroes Highway, the entry that welcomed our wounded warriors into our 
care. As the flag was taken down, our nurses and medics stood in awe as 
they discovered that the stars from the flag were imprinted on the roof 
of the Heroes Highway tent. This flag, which offered hope to thousands 
of wounded soldiers, sailors, marines, and airmen, will be proudly 
displayed at the new Defense Health Headquarters, Falls Church, 
Virginia.
    No matter the setting, high-touch, high-care remains the True North 
of the TNF. When a soldier, who was severely injured by an improvised 
explosive device (IED) blast first awoke in the intensive care unit 
(ICU), at Craig Joint Theater Hospital, Bagram, his first concern was 
not for himself but for his military working dog, also injured in the 
blast. The soldier was being prepared for evacuation to Germany; he 
knew his dog would be distraught if separated from him. Recognizing the 
importance of this soldier's relationship with his dog, Captain Anne 
Nesbit, an Air Force Critical Care Nurse, went above and beyond to 
reunite them. She spearheaded efforts to bring the dog to his bedside. 
The dog entered the ICU and immediately jumped on to the soldier's bed 
and curled up next to his master. Those who witnessed this reunion were 
brought to tears. Even in the midst of war, the nurse's compassion is 
never lost.
    Our medical technicians continue to deploy with our Army partners 
to Afghanistan as convoy medics to provide world-class healthcare at 
forward operating locations. One example, is Senior Airman Jasmine 
Russell, a medical technician assigned to a Joint Expeditionary Tasking 
as a logistics convoy medic with the Army. She traveled with her 
battalion more than 80,000 miles throughout 40 districts and completed 
more than 450 convoys in the Regional Command Southwest, Afghanistan. 
On January 7, 2011, while north of the Helmand Province, her convoy 
encountered 17 IEDs, 3 small arms fire attacks, and 2 missile attacks, 
killing a local national, and injuring coalition forces assigned to the 
convoy. Despite being injured, this junior enlisted member acted far 
beyond her years of experience as she began immediate triage and care, 
preparing the wounded for evacuation. Senior Airman Russell stated, ``I 
wasn't even concerned about myself; my peers were my number one 
priority.''
    While initial stabilization and surgery occurs at forward locations 
close to the point of injury, casualties must be aeromedically 
evacuated for further care. In wartime, contingency, peacetime, and 
nation-building, our aeromedical evacuation (AE) crews and Critical 
Care Air Transport Teams (CCATT) continue to provide world-class care 
and champion advancements in enroute nursing practice. This past year, 
AE moved 17,800 patients globally, with 11,000 from within United 
States Central Command alone. Since the start of Operations Enduring 
and Iraqi Freedom more than 93,000 patients have been safely moved.
    In 2011, we introduced the Tactical Critical Care Evacuation Team 
(TCCET) concept and piloted the first team in Afghanistan. Lieutenant 
Colonel Virginia Johnson, a certified registered nurse anesthetist 
(CRNA), stationed at Langley Air Force Base (AFB), Virginia, led the 
way in closing the gap in enroute care from initial surgical 
intervention to the next level of hospital care. Lieutenant Colonel 
Johnson and Captain Alejandro Davila, also a CRNA, took to the sky in a 
UH-60 Helicopter. This Air Force team of two CRNAs, and an emergency 
room physician moved 122 critical patients, and provided state-of-the-
art enroute care. In May 2012, the Air Force will deploy two more 
TCCETs into Afghanistan.
    This past year, the Air Force field-tested a new electronic health 
record (EHR) during AE missions. Our AE crews carried laptop computers, 
which facilitated documentation and downloading of enroute care into 
the same clinical database used by our medical facilities, and allowed 
all care provided to be readily visible to medical teams around the 
globe. This capability is fully operational for AE missions between 
Bagram and Ramstein Air Base (AB), Germany. Our teams continue to build 
the next information bridge by adding this capability to AE missions 
departing Ramstein AB enroute to Andrews AFB, Maryland and Lackland 
AFB, Texas.
    Air Force nursing leaders are also filling critical strategic roles 
in the joint operational environment. Colonel Julie Stola, the Command 
Surgeon for U.S. Forces-Afghanistan, was instrumental in the 
implementation of the Central Command's mild traumatic brain injury 
(TBI) training and tracking procedures for the Combined Information 
Data Network Exchange Database. As the theater subject-matter expert on 
the use of EHR for servicemembers involved in blast exposures, her 
exceptional leadership and guidance to users resulted in an increase of 
blast exposures documentation from 35 to 90 percent in 2011.
    An Air Force nursing priority for 2011 was to further advance 
research and evidence-based practice initiatives to improve patient 
safety and pain management during AE transport. Lieutenant Colonel 
Susan Dukes at Wright Patterson AFB, Ohio and Major Jennifer Hatzfeld 
at Travis AFB, California, are working closely with medical teams at 
Air Mobility Command and leading efforts to evaluate the effectiveness 
of these safety initiatives and enroute pain management strategies. A 
team of our nurse scientists recently completed a project entitled 
``Enhancing Patient Safety in Enroute Care Through Improved Patient 
Hand-Offs.'' Major Karey Dufour, is member of this team, she will also 
be our first graduate from the Flight and Disaster Nursing Master's 
program at Wright State University, Ohio. She used this study as her 
Capstone project. One aspect of this research project was the 
development of a standardized checklist to facilitate communication 
during the preparation of patients for AE transport and at each patient 
hand-off. Pilot testing of this checklist demonstrated an improvement 
in the safety and quality of care throughout the AE system. 
Implementation of the checklist is ongoing across the AE community.
    In our effort to optimize pain management of patients transitioning 
between ground and air, an in-depth review of care standards and safety 
was performed. As a result, all AE crews were trained in caring for 
patients receiving epidural analgesia. This advanced intervention 
ensures optimal pain management as patients move through the continuum 
of care. Major Hatzfeld, Lieutenant Colonel Dukes, and Colonel 
Elizabeth Bridges, USAFR, are currently evaluating patient outcomes 
from those who have received pain management through epidural analgesia 
and peripheral nerve blocks within the AE environment.
    Our global AE force remains dynamic; 16 additional crews were added 
to the Active Duty inventory to support global requirements. The AFMS 
responded by actively recruiting new AE members. More than 75 
exceptional medics stood up to the challenge and joined the AE team. 
Aeromedical Evacuation Squadron (AES) manning levels are at the highest 
rate since the beginning of the war, with flight nurses at 89 percent 
and AE technicians at 85 percent.
    Another accomplishment this year was a major transformation of our 
AE training. The goal was to incorporate lessons learned from AE 
missions and the latest clinical protocols. We increased focus on 
evidence-based care, patient outcomes, safe patient hand-off, pain 
management, enroute documentation, and raised overall training 
proficiency levels. Currently, the Line of the Air Force Operations 
community is building a formal training unit (FTU) to be co-located 
with the United States School of Aerospace Medicine at Wright-Patterson 
AFB, Ohio. This FTU will focus on enhancing the knowledge and 
performance required to operate in our AE aircraft. The new modularized 
curriculum and the relocation of the FTU will reduce overall training 
time by 130 days, provide flexibility in completing the training 
requirements, eliminate redundancies, and save thousands of dollars in 
travel costs. More importantly, this initiative will standardize 
training across the TNF, better preparing our AE community for any 
operational mission.
    In 2011, our strategic AE mission from Ramstein AB, Germany 
expanded as San Antonio, Texas was added as an additional destination 
for our returning wounded warriors. This new aeromedical staging 
facility (ASF) capitalizes on the available capacity and specialty care 
provided at the San Antonio Military Medical Center. It also allows 
wounded warriors from that region to be closer to their unit, friends, 
and family as they recover. The ASF staff of 57 airmen is a seamless 
team of Active Duty, Reserve, and Guard personnel.
    While we are learning, we are also sharing the knowledge of AE 
execution with our global partners. Our International Health 
Specialists are key to building global partnerships and growing medical 
response capabilities. As subject-matter experts, they are part of a 
team that directs training and education to improve healthcare 
infrastructure and disaster response. Staff Sergeant Amber Weaver, an 
Aeromedical Evacuation Technician with the 187th, AES, Wyoming, ANG, 
expressed her enthusiasm as a member of a team that provided AE 
training for the Democratic Republic of the Congo (DRC) Air Force. Her 
hope is that the Congolese military medical personnel will apply the 
training she provided to help their wounded. Lieutenant Jodi Smith, a 
flight nurse with the same unit, stated, ``The goal was to teach the 
DRC's quick response force how to safely aeromedically evacuate their 
patients.'' The Congolese training staff noted that this effort 
definitely strengthened the partnership and cooperation between the 
United States and the Congolese.
    Continuing around the globe, our Joint and coalition partnerships 
were never more evident than on March 11, 2011, when a 9.0 earthquake 
and tsunami caused catastrophic damage along the eastern coast of 
Japan. This event also posed a potential radiological threat from 
extensive nuclear plant damage. In support of Operation Tomodachi, Air 
Force medics assisted air crews with six passenger transport missions, 
resulting in the safe movement of 26 late term pregnant females and 
their 40 family members to the U.S. Naval Hospital, Okinawa, Japan.
    Another example of our international involvement took place in 
Nicaragua where this year 50 Air Force Reserve medics from the 916th 
Aerospace Medicine Squadron, Seymour Johnson AFB, North Carolina, 
provided medical care to more than 10,000 local citizens during their 
Medical Readiness Training Exercise (MEDRETE). Each day began at 4 
a.m., with hundreds of patients lining the roadway to the medical site, 
waiting to be seen by this team. Some patients traveled for hours on 
horseback, while others had walked countless miles in the August heat 
with their families in tow. Lieutenant Colonel Dawn Moore, commander of 
the MEDRETE mission stated, ``We are proud to collaborate with other 
countries and provide excellent medical care, as well as build 
international capacity.''
    Air Force nursing continues to be vital in their role as 
educational and training instructors for the Defense Institute for 
Military Operations (DIMO) in their efforts to build global 
partnerships and capacity. An example of educational impact was from an 
Iraqi Air Force Flight Nurse who reported that 78 lives were saved by 
Iraqi Air Force AE teams, just months after completing the Basic 
Aeromedical Principles Course. In another example, 10 soldiers were 
badly injured during an insurgent conflict west of Nepal. The follow-on 
forces that came to their relief the next morning were astonished when 
they found the badly wounded soldiers alive as a result of applying the 
self-aid and buddy-care techniques they learned in the DIMO First 
Responders Course. The DIMO medical training missions are making a 
profound difference in patient outcomes.
    These critical partnerships grow not only through formal training 
and joint exercises but also through international professional forums. 
In 2011, we partnered with our nursing colleagues from Thailand and co-
hosted the 5th Annual Asia-Pacific Military Nursing Symposium. The 
theme, ``Asia-Pacific Military Nursing Preparedness in Global Change,'' 
reinforced partnerships to enhance nursing response to pandemics and 
humanitarian crises, and to advance evidence-based nursing practice. 
Twelve countries participated, more than 20 international colleagues 
briefed, and more than 30 presented research posters. During this 
conference, the focus on joint training initiatives in disaster 
response and aeromedical evacuation proved to be critical when Thailand 
experienced severe flooding, which impacted more than 13 million people 
and resulted in 815 deaths. The very concepts discussed during the 
symposium were later applied during the rapid deployment and 
establishment of an Emergency Operations Center and successful 
aeromedical evacuation of patients. We look forward to continuing to 
build our international Asia-Pacific nursing partnerships as we prepare 
to co-host the 6th annual conference in 2012.

                           FORCE DEVELOPMENT

    It is imperative our TNF possess the appropriate clinical and 
leadership skills for successful execution of our mission. We are 
excited to announce three new fellowships:
  --Magnet Recognition;
  --Informatics; and
  --Patient Safety.
    The Magnet Fellowship provides the AFMS with a rare opportunity to 
gain first hand, up-to-date insights into the Magnet Culture; an 
environment that promotes nursing excellence and strategies to improve 
patient outcomes. Our Magnet Fellow will spend 1 year at Scottsdale 
Healthcare System, Arizona, a nationally recognized Magnet healthcare 
facility and one of our current Nurse Transition Program (NTP) Centers 
of Excellence (CoE). The Magnet Fellow will assume a consultant role to 
integrate Magnet concepts across the AFMS.
    The Informatics Fellowship is critical to prepare nurses to 
participate in the development and fielding of computer-based clinical 
information systems, such as the EHR. Nursing is a major end-user of 
these electronic information systems and should be actively involved in 
the development of requirements to enhance patient safety, 
communication, seamless patient handoff, and ease of documentation.
    The Patient Safety Fellowship is a new partnership with the 
Veterans Administration (VA) at the James A. Haley VA Patient Safety 
Center of Inquiry in Tampa, Florida. The Fellow will learn how to 
design and test safety defenses related to the patient, healthcare 
personnel, technology, and organization, to export evidence into 
practice, and facilitate patient safety and reduce adverse events. This 
fellowship is designed to prepare nurses to lead interdisciplinary 
patient safety initiatives.
    In last year's testimony, we previewed our plan to consolidate the 
NTP training sites in order to provide a more robust clinical 
experience. We established four CoE:
  --Scottsdale, Arizona;
  --Tampa, Florida;
  --Cincinnati, Ohio; and
  --San Antonio, Texas.
    Our data shows NTP CoE offer many opportunities to practice a 
variety of clinical skills in an environment with a large volume of 
high-acuity patients, which allows us to confidently decrease our 
program length from 77 to 63 days. Additionally, the resulting 19 
percent improvement in training efficiency allowed us to reduce NTP 
course instructors by 40 percent thus returning experienced nurses to 
the bedside.
    In response to the National Council of State Board of Nursing 
Transition to Practice (TTP) Initiative and the Institute of Medicine 
Future of Nursing recommendations, we have initiated a residency 
program to develop our novice nurses. Beginning in September 2011, all 
novice nurses entering Active Duty were enrolled in the new Air Force 
Nurse Residency Program (AFNRP). In the AFNRP, carefully selected 
senior nurses mentor novice nurses through their transition from nurse 
graduate to fully qualified registered nurse. We were pleased to 
discover that 80 percent of the TTP recommended content was already 
incorporated into the nurses' orientation during the first year of 
military service, allowing us to focus our efforts on weaving the 
remaining content such as evidence-based practice, quality, and 
informatics, into the AFNRP.
    One of the desired outcomes of the NTP and AFNRP is enhanced 
critical thinking skills. Using a validated assessment tool in a pilot 
study, we found a significant increase in the critical thinking skills 
of nurses who completed the NTP. We expanded this assessment to 
systematically evaluate the effectiveness of the NTP and AFNRP. We 
gathered representatives from these CoE to reflect on successes of 
these military and civilian partnerships and to discuss the way ahead.
    Another area where we are working to further develop our nurses is 
through our Critical Care Fellowship. We identified opportunities to 
enhance efficiencies of this training program. After extensive research 
on civilian and military programs, we recommended reduction from three 
training locations to two and initiated a review of curriculum to 
standardize the didactic and clinical experiences. Additionally, we are 
exploring civilian training partnerships which may give our students 
the opportunity to work with a greater volume of high-acuity patients.
    Our new mental health course is an example of our success in 
advancing our practice through education and training. Based on the 
changing needs of the mental health community, and in response to the 
National Defense Authorization Act, we are incorporating outpatient 
mental health case management training for our mental health nurses.
    Advanced Practice Nurses are central to the success of a clinical 
career path that promotes optimal patient outcomes through critical 
analysis, problem solving and evidenced based decisionmaking. Building 
on last year's initiatives, we continue to work with our Sister 
Services and the Uniformed Services University of the Health Sciences 
(USUHS) Graduate School of Nursing (GSN) to launch a Doctorate of 
Nursing Practice (DNP) program. This year, the Air Force has selected 
five Psychiatric Mental Health Nurse Practitioner (PMHNP) DNP students 
and three Doctor of Philosophy students for enrollment in the USUHS 
GSN. In addition, we also have developed a transition plan to meet the 
advanced practice doctoral level requirements for our Family Nurse 
Practitioner and Certified Registered Nurse Anesthetist by 2015.
    In 2011, we moved forward with efforts to clearly define the roles 
of the Clinical Nurse Specialist (CNS), Master Clinician, and Master 
Nurse Scientist. As part of this endeavor, we discovered significant 
variance in the definition and expected educational preparation of the 
CNS. Standardization of qualifications for the title ``Clinical Nurse 
Specialist'' were determined to be paramount for us to match qualified 
nurses with designated positions. As a result, the Air Force Nurse 
Corps Board of Directors (BOD) approved a standard definition for CNS 
and standard qualifications in seven areas of practice. A special 
experience identifier (SEI), for the CNS, was approved by the Air Force 
Personnel Center (AFPC). This SEI allows us to clearly identify our 
CNSs and streamline the assignment process to fill these critical CNS 
requirements. Additionally, the BOD approved standard definitions and 
qualifications for the Master Clinician and Master Nurse Scientist.
    A new AFMS regulation governing anesthesia delivery by Air Force 
CRNAs was published this year, recognizing their full scope of 
practice. This change reflects the recommendations from the 2010 
Institute of Medicine report, ``The Future of Nursing: Leading the 
Change, Advancing Health'', stating that nurses should practice to the 
full extent of their education and training. The president of American 
Association of Nurse Anesthetists, Dr. Debra Malina, CRNA, DNSc 
commended the Air Force for making this change.
    One of our ongoing challenges is to optimize clinical training. It 
is imperative that our nurses and medical technicians maintain 
proficiency in their clinical skills not only for contingency 
operations but also for peacetime operations. We continue to advance 
our partnerships with other Federal and civilian medical facilities 
whose inpatient platforms and acuity levels provide the optimal 
environment for initial specialty development and skill sustainment. We 
have partnered with several civilian medical centers, as well as 
universities. In these partnerships, both civilian institutions and 
military facilities host each other's students and optimize educational 
opportunities available in each setting. This year, the AFMS processed 
180 training affiliate agreements. Of these agreements, 39 were in 
nursing. These partnerships are vital to our training platforms and 
promote professional interaction.
    As we strive to obtain efficiencies in Joint training, we are 
reviewing our electronic and virtual distant learning systems for ways 
to reduce redundancies within the Military Health System. This year, 
the Joint Health Education Council (HEC) facilitated shared access of 
232 training programs between the DOD and the VA. In 2011, more than 
113,000 DOD and VA personnel accessed these sites representing more 
than 800,000 episodes of training. We continue to be an active 
participant on the HEC. Our involvement in this council is crucial, as 
a significant number of training programs are nursing related.
    In last year's testimony, I spoke of the opening of the Medical 
Education and Training Campus (METC). I can now share a few of METC's 
successes in 2011. METC reached full operational capability on 
September 15, 2011, and was recognized nationally for it's 
accreditation process which earns METC graduates transferable college 
credits. Our additional ability to support the medical enlisted 
educational mission will foster international partnerships, and 
contribute to educational research and innovation.
    We are constantly seeking ways to develop our enlisted medics. In 
2011, we selected two airmen to attend the Air Force Institute of 
Technology for graduate education in Information Resource Management 
and Development Management. The most recent graduate of the Development 
Management program, Master Sergeant Carissa Parker, lauded this program 
and stated, ``This is by far, one of the most exciting and unexpected 
opportunities I've had in my Air Force career. This advanced academic 
degree allows me to apply the unique knowledge and skill set to best 
serve my Air Force.'' In order to align candidates for success in these 
programs, we continue to actively force develop our enlisted personnel.
    Deliberate development of our civilian nursing personnel is 
ongoing. This year, we established a career path from novice to expert, 
which offers balanced and responsive career opportunities for our 
civilian nurses. We finalized two new tools, a civilian career path and 
a mentoring guide, to aid supervisors, both have been distributed Air 
Force wide. In January 2012, we conducted our second Civilian 
Developmental Board at AFPC, where civilian Master Clinician positions 
were laid in to allow for career progression and much-needed continuity 
in our military treatment facilities. Our next step is a call for 
candidates to outline the criteria and assist our civilian nurses in 
applying for these targeted positions, which will ultimately enhance 
patient care and job satisfaction.

                            FORCE MANAGEMENT

    The Air Force continues to be successful with recruiting. In 2011, 
we met our recruiting goal as we accessed 113 fully qualified nurses 
and 46 new nursing graduates. This brought our overall end strength to 
95 percent. Our flagship programs for recruiting, the Nurse Accession 
Bonus and the Health Professions Loan Repayment Program, remain the 
primary vehicles for recruiting the majority of our entry-level nurses. 
This year we executed 35 accession and 89 loan repayment bonuses. Other 
accession pipelines include the Reserve Officer Training Corps 
scholarship program, the Nurse Enlisted Commissioning Program, and the 
Health Professions Scholarship Program.
    Nurse Corps retention rates have improved with the implementation 
of the Incentive Special Pay Program, allowing the AFMS to retain high-
quality skilled nurses in targeted clinical specialties. Overall, 
retention has risen 13 percent since 2008 and now stands at 80 percent 
at the 4-year point. Historically, we found retention drops 
precipitously, by at least 44 percent, at the 10-year point.
    In an effort to explore factors affecting retention, USUHS 
conducted a triservice nursing study. The total sample size was 2,574 
with an overall response rate of 30 percent. The results were released 
in January 2012. Significant factors found to influence a nurse's 
decision to remain on Active Duty were promotion, followed by family 
relocation. Overall, deployments were not a significant decision factor 
in determining intent to remain in the service. Most nurses were happy 
to deploy and saw this as part of their patriotic duty. Noteworthy 
comments from the study were, ``the promotion rates in the Nurse Corps 
are behind the rest of the Service'' and ``the reason for my 
consideration for leaving military is due to lack of promotion.'' Other 
findings, specifically related to promotion opportunity, confirmed our 
understanding of the grade imbalance within the Air Force Nurse Corps 
structure.
    Over the past few years, the Air Force Nurse Corps has worked with 
the Office of the Deputy Chief of Staff, Manpower, Personnel, and 
Services, to provide consistent career opportunities for Nurse Corps 
Officers as intended by the Defense Officer Personnel Management Act 
(DOPMA). DOPMA grade tables are applied to the entire Service, not to a 
specific competitive category, so the challenge for the Air Force Nurse 
Corps is a lack of sufficient field grade authorizations for the 
clinical and scientific experience needed. The addition of the CNS and 
Master Clinician at the bedside, both of whom are educated to the 
masters or doctoral level has been crucial in providing the education 
and experience needed in the patient care arena. There is a positive 
correlation between advanced nursing education and experience as it 
relates to clinical outcomes and safety.
    In a continued partnership with the Office of the Undersecretary of 
Defense, Personnel and Readiness, and the Assistant Secretary of the 
Air Force, Manpower and Reserve Affairs, we continue to pursue ways to 
alleviate deficits in field grade authorizations. Our goal is to 
improve retention of the uniquely trained experienced military nurse 
and increase return on investment for advanced education.
    During 2011, we made significant strides in strategic 
communication. We launched the official Air Force Nurse Corps Web site 
and social network page. Our social network page has received more than 
250,000 visits since inception. These Web pages are excellent 
recruiting and retention tools, and serve as a means to reach out to 
our retirees as well as the military and civilian community. In 
addition to the public domain, we have a targeted intra-net capability. 
The Knowledge Exchange (Kx) is a phenomenal information resource for 
all Air Force military members and Government employees to assist them 
with professional development at any level in their career. We launched 
a Kx subscriber campaign this year, highlighting the large amount of 
information available on this site. The number of subscribers increased 
500 percent. The Kx is a venue where our nurses and medical technicians 
can share best practices, innovative suggestions, personal stories, 
accomplishments, and stay connected.

                         PATIENT-CENTERED CARE

    Patient-centered care is at the core of all we do; it is our 
highest priority. Care for our patients crosses into both inpatient and 
outpatient arenas, and has been redefined with a more focused emphasis 
on providing healthcare to promoting health.
    An important contribution of nursing to healthcare is exemplified 
by the integral role of Disease and Case Managers in our Family Health 
Initiative. For example, at Moody AFB, Georgia, the nurses initiated 
disease management interviews with their diabetic patients. The nurses 
used motivational interviews, a face-to-face approach, enabling them to 
provide education, support, and individual goal setting. This 
innovative strategy increased accountability for the patient and 
medical team, and resulted in marked improvement in adherence to the 
treatment plan and control of the patient's disease process.
    Overall, care case manager (CCM) interventions have been found to 
mitigate risk. Major Don Smith, Health Care Integrator, and Director of 
Medical Management, Keesler AFB, Mississippi, implemented a process 
improvement for the identification of wounded warriors as they entered 
the healthcare system and enrollment of these individuals with a CCM. 
This initiative increased the communication and person-to-person 
transfer of care between facility case managers at Keesler, the VA, and 
Gulfport Naval Station. Additionally, Major Smith orchestrated CCM 
services for vulnerable populations to include military retirees, 
Medicare, and Medicaid patients who are eligible for care on a limited 
basis at Keesler, but who are at risk for fragmented care as they 
transition across the healthcare system. Finally, he designed a 
``Medical Management Database'' consisting of a comprehensive set of 
CCM documentation tools and tracking methods for patient volume and 
acuity. The database captures workload, quantitative, and qualitative 
outcomes. The use of this database improved CCM metrics and decreased 
documentation workload by 200 percent. Specific outcomes such as 
avoidance of emergency room visits, hospital admissions, or clinic 
visits were assigned a corresponding and substantiated dollar amount. 
The return on this investment exceeded savings of $1.1 million in 2011. 
This database tool is currently being implemented Air Force wide.
    The TBI clinic at Joint Base Elmendorf-Richardson, Alaska is 
advancing care for wounded warriors. This only Air Force led TBI 
clinic, offers wounded warriors comprehensive care, including 
specialized neurological assessment and testing, mental health 
services, pain management, and the creation of a tailored treatment 
plan.
    Our partnership with the VA through our Joint Ventures has yielded 
improvements with staffing, efficiencies, and patient outcomes. One of 
the most recent Joint initiatives was the formation of a peripherally 
inserted central catheter (PICC) team from the 81st Medical Group, 
Keesler AFB. In the past, VA patients needing central line intravenous 
access were transported to Keesler for the procedure. The PICC team now 
travels to the VA to perform this procedure; resulting in significant 
cost savings associated with patient care. More importantly, patients 
who are too unstable for safe transport can now receive the best care 
in a timely manner at their bedside. Also, at the 81st Medical Group, a 
team of VA and military staff assisted with more than 1,500 cardiac 
catheterizations in 2011.
    The Joint Venture working group at Elmendorf determined there was a 
lack of continuity of care and sharing of medical information with the 
VA clinic for follow-up when VA patients were discharged from the ICU. 
This working group developed a process by which the ICU discharging 
nurse contacts the VA CCM to provide an up-to-date medical history to 
include medication reconciliation and discharge summary. This endeavor 
has assured that the Primary Care Provider has the most current medical 
information available at the follow-up appointment. In addition, a 
template was developed for primary care staff to track all the required 
medical documentation for patients being discharged from the Joint 
Venture ICU. This process was replicated at the Medical Specialty Unit.
    Embedded in our patient-centered care is an emphasis on resilience. 
The Air Force is committed to strengthening the physical, emotional, 
and mental health of our airmen and their families. We continuously 
reinforce the need for our airmen to bolster their ability to withstand 
the pressures of military life. Our Air Force understands that we can 
only be successful when the entire Air Force Community promotes the 
importance of resilience and early help-seeking by all airmen in 
distress. We continue efforts to diminish the negative connotation 
associated with seeking help. All airmen need to perceive seeking help 
as a sign of strength, not a sign of failure.
    We have persevered in our campaign spearheaded by leaders, who 
themselves have suffered post-traumatic stress, and have come forward 
to openly discuss their experiences and encourage others to get the 
care they need from the many support services available. These leaders 
emphasize that their decision to seek care did not adversely affect 
their Air Force career; rather receiving care, made it possible for 
them to continue to be successful. During our nursing leadership 
symposium this year, one of our senior nurses presented her own 
personal, traumatic experiences to the audience and described what 
brought her to the point where she recognized the need to seek mental 
healthcare. Mental Health professionals were in attendance and 
conducted on-site discussion groups for medics with similar 
experiences. Feedback from those who attended the groups was 
overwhelmingly positive.
    Air Force Nurse Scientists are conducting research to enhance the 
resilience of our servicemembers and their families. For example, 
Colonel Karen Weis, Director of Nursing Research, Lackland AFB, Texas 
with support from the TriService Nursing Research Program, is studying 
an innovative strategy using maternal mentors to build family 
resilience. Lieutenant Colonel Brenda Morgan, a recent USUHS graduate, 
identified psychological exercises that can be integrated into a daily 
routine to enhance resilience. We continue to seek avenues that build a 
resilient force, identifying at-risk airmen and treating those in need 
of help.

                     ADVANCING A CULTURE OF INQUIRY

    Air Force nurses are advancing healthcare and improving patient 
outcomes through a culture of inquiry. The ongoing process of 
questioning and evaluating practice, providing evidence-based care, 
creating practice changes through research, and evaluating the outcomes 
of our care reflects our culture of inquiry. In support of this 
culture, the Air Force Nurse Corps sponsored a competition that 
highlighted research and evidence-based projects currently being 
implemented to improve patient care. Some of this work will be 
presented at this year's nursing leadership symposium, demonstrating 
the advancement of evidence-based care not only by our Nurse 
Researchers but, more importantly, by the nurses who provide direct 
patient care.
    An excellent example of this initiative is the nursing staff of the 
Neonatal Intensive Care Unit (NICU), Kadena AB, Okinawa, Japan, who 
have taken patient safety to the next level. In 2011, 185 infants were 
admitted to the NICU. Often, these seriously ill neonates require the 
placement of a central intravenous catheter for administering life 
sustaining medications and fluids. Unfortunately, these central lines 
can be a source of infection, which can lead to life-threatening blood 
stream infections and even death. Although the unit's central line 
infection rate of 3.9 percent was well below the national average of 10 
percent, the staff strived for a zero percent infection rate, due to 
the increased risk of mortality for these vulnerable patients. In 
fiscal year 2011, the nursing staff implemented a new procedure used 
during the care and management of central lines. Following the 
implementation of this innovative solution they achieved their goal: 
zero infections from 69 central lines (representing 393 line days).
    Research initiatives completed this year demonstrate the strategic 
leadership role played by our nurse scientists. In January 2012, 
Lieutenant Colonel Susan Perry, Assistant Professor in the CRNA program 
at USUHS, completed her Ph.D. Her ground-breaking research identified a 
genetic abnormality that may predispose an individual to malignant 
hyperthermia, an inherited muscle disorder triggered by certain types 
of anesthesia. Lieutenant Colonel Perry's research advances our 
understanding of this potentially fatal disease and provides insight 
into strategies to decrease the risk for malignant hyperthermia. Her 
research highlights the unique opportunities given to our students who 
study at the USUHS, as she was able to work in one of the only 
laboratories in the world dedicated to malignant hyperthermia. 
Similarly, current Ph.D. students at the USUHS School of Nursing have 
their introduction to research at the renowned National Institutes of 
Health.
    Lieutenant Colonel Karen O'Connell, who completed her doctoral 
studies at USUHS, identified factors associated with increased 
mortality in combat casualties with severe head injury. According to 
her research, some of these factors are modifiable, which suggests 
areas of care that can be targeted to improve outcomes for these 
patients. Colonel Marla DeJong, Dean of the School of Aerospace 
Medicine, served as chairperson of the Scientific Review Committee for 
brain injury and mechanisms of action of hyperbaric oxygen therapy for 
persistent postconcussive symptoms after mild TBI. She also spearheaded 
the creation of baseline datasets that will be used in a study to 
evaluate the effect of hyperbaric oxygen therapy in casualties with 
post-concussive symptoms after mild TBI.
    The research conducted by our nurse scientists is of the highest 
quality. In 2011, Colonel Bridges, with assistance from the Joint 
Combat Casualty Research Team (JC2RT), completed a study using 
noninvasive methods to monitor critically injured casualties during 
resuscitation. This research described the minute-by-minute changes in 
the combat casualty's vital signs and hemoglobin using a noninvasive 
probe placed on their finger. The results demonstrated the potential 
for earlier identification of clinical deterioration and the tailoring 
of resuscitation. This study received the 2011 Research Poster Award at 
the AFMS Research Conference. Colonel Sean Collins, Commander, 104th 
Medical Group, Westfield, Massachusetts, ANG and a nurse scientist, was 
the first guardsman to serve on the JC2RT. During his deployment at 
Camp Dwyer, Afghanistan, Colonel Collins played a vital role in 
advancing operational research and in articulating the importance of 
nursing research in the care of our warriors. Colonel Collins completed 
a landmark analysis of the relationship between physical symptoms 
reported during deployment and emotional health. Analysis is ongoing to 
further identify those at highest risk for poor health outcomes to 
allow for targeted interventions.
    Research and evidence-based initiatives also focused on readiness. 
Colonel Bridges completed a list of operational nursing competencies, 
which were validated by deployed nurses. These competencies will aid in 
the standardization of training for nurses across all Services. The 
results of this study further validated the content of the TriService 
Nursing Research Program Battlefield and Disaster Nursing Pocket Guide. 
This pocket guide was updated in 2011, and 7,000 copies of the updated 
guide were distributed to Army, Navy, and Air Force nursing personnel. 
The evidence-based recommendations summarized are now the standards for 
Air Force nursing readiness training.
    Along with research and evidence-based practice, we are also 
leveraging our existing collegial partnerships. One such endeavor is 
our participation in the Federal Nurses Service Council. This council 
includes the Service Chief Nurses, Directors of Nursing, Public Health, 
Veterans Affairs, USUHS, the American Red Cross, and Reserve 
counterparts of the Army, Navy, Air Force. This year, the group 
developed a strategic plan that focuses on blending our efforts as a 
single professional voice on three strategic Federal Nursing 
priorities: Role Clarification, Culture of Inquiry, Influence, and 
Collaboration. As a united force, we can tackle tomorrow's healthcare 
challenges today.

                               WAY AHEAD

    The Air Force Nurse Corps is committed to achieving excellence in 
both the art and science of nursing. As a TNF, we will continue to 
invest in nursing research and foster a culture of inquiry to further 
advance quality patient outcomes. We will continue to advocate for and 
invest in academic preparation to retain the Master Clinician at the 
bedside. We will continue to optimize training opportunities and 
efficiencies within the Air Force, jointly, and with our civilian 
nursing colleagues. Above all, we will continue to invest in our nurses 
and technicians by focusing our efforts on enhancing resiliency, 
promotion opportunities, and education in order to retain those 
individuals whose experience makes military nursing the best in the 
world.
    In closing, as Colonel Mary Carlisle, Commander Surgical Services, 
Misawa, AB, Japan stated, ``You will know you're a military nurse when 
you visit the National Mall in Washington DC, and Vietnam Veterans 
visiting The Wall, tell you their stories of how nurses saved their 
lives, and then they thank you for serving. Then you swallow the lump 
in your throat and blink back the tears in your eyes and continue doing 
what you were doing without missing a beat. You can't find the right 
words to explain to anyone what you've just been through. You will know 
you're a military nurse when at the end of the day, at the end of the 
tour, or the career, you say, I'd do it all over again.''
    Mr. Chairman and distinguished members of the subcommittee, it is 
an honor to represent a committed, accomplished Total Nursing Force. 
Our Nation's heroes and their families depend on our nurses and 
technicians to deliver superior, safe, and compassionate care. Grounded 
in high-touch, high-care, our Air Force nurses and technicians proudly 
serve and will continue to deliver world-class healthcare anytime, 
anywhere.

STATEMENT OF REAR ADMIRAL ELIZABETH S. NIEMYER, 
            DIRECTOR OF THE NAVY NURSE CORPS
    Chairman Inouye. Thank you very much, General Siniscalchi. 
May I now recognize Admiral Niemyer?
    Admiral Niemyer. Good morning, Chairman Inouye, Vice 
Chairman Cochran, and distinguished members of the 
subcommittee. I'm extremely pleased to be here and thank you 
for the opportunity to speak on behalf of the Navy Nurse Corps. 
Support of the operational forces continues as the top 
priority. In addition, I've remained focused on five key 
strategic areas: Workforce, nursing knowledge, research, 
strategic partnerships, and communication. My written statement 
has been submitted for the record, and today I will share some 
of Navy nurses' remarkable accomplishments in these vital 
areas.
    The Navy Nurse Corps is comprised of 5,842 Active, Reserve, 
and Federal civilian registered nurses, delivering outstanding 
patient- and family-centered care. At the end of fiscal year 
2011, our Active component was 94-percent manned, and our 
Reserve component was 88-percent manned. We are projecting 
another successful year in attaining our fiscal year 2012 
recruiting goals.
    People are our most vital asset, and I remain committed to 
recruiting and retaining nurses ready to meet the challenges of 
Naval service. The Nurse Accession Bonus and Nurse Candidate 
Programs are top recruiting programs for our Active component, 
while accession and affiliation bonuses, and loan repayment 
programs are most successful with our Reserve component.
    For the past 2 years, the Navy Nurse Corps has sustained 
improvements and retention. The registered nurse incentive 
special pay, Health Profession Loan Repayment Program, and Duty 
Under Instruction for graduate education are key to this 
forward progress. Mr. Chairman, I thank you for your continued 
support of these crucial programs.
    This past year, 342 Active and Reserve Navy nurses served 
throughout the Central Command area of responsibility as 
members of Shock Trauma Platoons, Forward Resuscitative 
Surgical Systems, and other forward-operating medical units. 
They were also vital to medical stability operations, serving 
as members of embedded training and provincial reconstruction 
teams.
    Infants and children comprise approximately 25 percent of 
the trauma patients treated at the Kandahar Role 3 
Multinational Medical Unit. Navy nurses with advanced expertise 
in maternal infant, neonatal intensive care, and pediatric 
nursing played a pivotal role in providing outstanding trauma 
care, staff development, and patient and family education for 
this precious population.
    Integral to the Navy's mission is a ``Global Force for 
Good.'' Navy nurses also supported humanitarian assistance 
missions. In 2011, Active and Reserve Navy nurses, together 
with nurses from nongovernmental organizations and partner 
nations supported the longstanding humanitarian and civic 
assistance operations, continuing promise and Pacific 
Partnership. Their actions further strengthened regional 
cooperation, interoperability, and relationships with partner 
nations.
    Our clinical and leadership roles with the Marine Corps 
continue to expand. For the first time, a Navy Nurse Corps 
officer serves as the First Marine Expeditionary Force 
Headquarters Group Surgeon at Camp Leatherneck, Afghanistan. 
Navy nurses with battlefield injury expertise are also serving 
as clinical advisers at Headquarters Marine Corps, Marine Corps 
Combat Development Command, and the Marine Corps Warfighting 
Lab, assisting Marine Corps Dismounted Complex Injury Teams to 
prevent and treat these devastating injuries.
    Here at home, Navy nurses are recognized clinical experts 
and educators for the care of wounded warriors, with 
psychological health issues and TBI. Nurses are central to the 
new in-patient units, offering convenient, private, holistic, 
and coordinated care for our wounded warriors and their 
families.
    Psychiatric Mental Health Nurse Practitioners can continue 
to enhance the resiliency and mission readiness of our sailors, 
marines, and their families. We responded to the increased 
demand for mental healthcare, and grew our Psychiatric Mental 
Health Nurse Practitioner community from 8 to 23 billets. I'm 
pleased to share that following the graduation of seven 
students this year, this vital community will be 100-percent 
manned.
    The Navy Nurse Corps is committed to doctoral education, 
with 21 nurses in doctoral study, and another 12 selected this 
year for programs taking them directly from bachelor to 
doctoral degrees in advance practice specialties and Ph.D.'s in 
nursing research. I remain committed to increasing and 
diversifying our footprint in nursing research.
    In 2011, the positions of executive Director of the Tri-
Service Nursing Research Program (TSNRP) and Deputy Director of 
the Joint Combat Casualty Research Team overseeing research 
activities in Iraq, Afghanistan, and Kuwait were held by Navy 
nurses. Additionally, Navy nurses were granted $1.5 million in 
TSNRP funds as principal investigators for new and diverse 
projects. Mr. Chairman, I'm extremely grateful, and would like 
to thank you again for your ongoing support of nursing 
research.
    Joint and integrated work environments are the new order of 
business. As such, Navy nurses promote, build, and strengthen 
strategic partnerships, work with our sister services, the 
Department of Veterans Affairs, and other Federal and 
nongovernmental agencies. They also serve as individual 
augmentees and teach at the Uniformed Services University 
Graduate School of Nursing.

                           PREPARED STATEMENT

    Navy nurses are pivotal to the success of every mission 
involving Navy Medicine. We remain focused on improving the 
health of those entrusted to us by providing a care experience 
that is patient- and family-centered.
    Senator Inouye, Vice Chairman Cochran, and distinguished 
members of the subcommittee, thank you for your unwavering 
support of military nursing and the profession of nursing.
    Thank you.
    [The statement follows:]

        Prepared Statement of Rear Admiral Elizabeth S. Niemyer

                              INTRODUCTION

    Good morning. Chairman Inouye, Vice Chairman Cochran, and 
distinguished members of the subcommittee, I am extremely pleased to be 
here again and thank you for the opportunity to speak on behalf of the 
Navy Nurse Corps.
    The Navy Nurse Corps is comprised of 4,059 Active and Reserve 
component and 1,783 Federal civilian registered nurses. Together, they 
are a unified and highly respected team of healthcare professionals 
known for their unwavering focus on delivering outstanding patient- and 
family-centered care for our Active Duty forces, their families, and 
our retired community. The clinical expertise and leadership of Navy 
nurses ensures a fit and ready fighting force vital to the success of 
Navy and Marine Corps operational missions at sea and on the ground. 
Navy nurses also play a key role in medical stability operations, 
deployment of hospital ships and large-deck amphibious vessels and 
humanitarian assistance/disaster relief (HA/DR) efforts around the 
globe. Nurses are central to the provision of outstanding care and 
optimal patient outcomes for beneficiaries and wounded warriors here at 
home serving in various clinical and leadership roles within our 
military treatment facilities (MTFs) and ambulatory care clinics.
    I would like to share some of the remarkable accomplishments of 
Navy nurses over this past year, as well as discuss opportunities and 
challenges before us in 2012. First, I will talk about the 
contributions of Navy nurses serving in unique roles and environments 
supporting operational, humanitarian, and disaster relief missions. 
Second, I will highlight the significant work and resulting successes 
our Corps has achieved in the past year in my five key strategic focus 
areas of:
  --Workforce;
  --Nursing knowledge/Clinical excellence;
  --Research;
  --Strategic partnerships; and
  --Information management/Communication.
    Last, I will discuss our future challenges and opportunities as we 
remain steadfast in our commitment to ensure the provision of the 
highest quality of care to those entrusted to us.

         OPERATIONAL, HUMANITARIAN, AND DISASTER RELIEF SUPPORT

    Our commitment to operational forces remains a top priority. Over 
the past year, Navy nurses continued to be an invaluable presence with 
223 Active and 119 Reserve component nurses actively engaged in 
military operations throughout the Central Command area of 
responsibility for Operation Enduring Freedom (OEF). Navy nurses are 
ready to deploy anytime, anywhere, and they continue to set the 
standard for excellence as clinicians, patient advocates, mentors, and 
leaders providing compassionate and holistic care even in the most 
austere conditions.
    Navy nurses are an integral part of diverse units and teams 
throughout the Helmand and Nimroz Provinces in Afghanistan. They are 
key members of shock trauma platoons (STPs) and forward resuscitative 
surgical systems (FRSSs) assigned to Marine Corps medical battalions, 
expeditionary forces, and logistics groups supporting the immediate 
pre- intra- and post-operative phases of care for traumatically injured 
patients. They are also trained and qualified to provide en-route care 
and medical support in rotary wing airframes during the transport of 
injured U.S. servicemembers, Coalition Forces, Afghan military and 
civilian security personnel, and local nationals to higher levels of 
care.
    A Nurse Corps officer assigned to the Alpha Surgical Shock Trauma 
Platoon at a Role 2 Emergency Medical Care unit located on a remote 
forward operating base (FOB) in Afghanistan served as the senior 
critical care nurse. Her expertise in critical care nursing was crucial 
to ensuring the 100-percent survival rate of personnel receiving 
immediate after injury care in this unit. Additionally, she provided 
exceptional leadership and was an experienced clinical resource for 22 
nurses across six FOBs in the Helmand and Nimroz Provinces.
    Following initial life-saving stabilization at the point of injury 
on the battlefield, critically injured patients are transported to 
comprehensive medical facilities such as the Role 3 Multinational 
Medical Units in Kandahar and Bastion, Afghanistan. In Kandahar's Role 
3 facility, Navy nurses provide unparalleled clinical leadership and 
world-class care to critically injured NATO, coalition, and Afghan 
combat casualties. Focused on providing the best-possible care for 
combat wounded, they developed a comprehensive cross-training program 
for nurses and corpsmen serving in clinical areas outside the 
emergency/trauma specialty. This training gave them the clinical 
expertise and technical skills to competently work as members of the 
multidisciplinary trauma teams vital to this operational emergency/
trauma environment. The ready availability of additional personnel 
trained in emergency/trauma significantly increased the Role 3's 
capability to effectively respond and provide life-saving trauma care 
for several casualties simultaneously. This innovation was put to the 
test and proved invaluable during a real mass casualty situation when 
Role 3 personnel were able to immediately establish seven highly 
functional trauma teams to successfully treat eight severely injured 
servicemembers transported directly from the battlefield. This training 
has also been credited with providing adequate numbers of trained 
personnel to establish additional forward surgical capability while 
still meeting the Role 3 mission.
    A unique challenge at the Kandahar Role 3 Multinational Medical 
Unit is that about 25 percent of the complex trauma cases are infants 
and children. This necessitates a unique clinical knowledge base in 
which Navy nurses have shown their exceptional adaptability and 
flexibility. In addition to nurses with surgical, emergency/trauma, 
critical care, and medical-surgical backgrounds--specialties considered 
to be wartime critical--nurses with experience in maternal-infant, 
neonatal intensive care, and pediatrics are now playing a pivotal role 
in ensuring the provision of outstanding hands-on care, staff 
development, and patient and family education for this precious 
population. These nurses are also volunteering off-duty time serving as 
health educators at the Kandahar Regional Military Hospital, providing 
health promotion and disease education to Afghan soldiers, women, and 
children.
    Although our mission supporting the British Role 3 Multinational 
Medical Unit in Bastion, Afghanistan was completed near the end of 
2011, Navy nurses from all clinical backgrounds demonstrated a 
remarkable ability to integrate into the British medical team. They not 
only gained the advanced clinical skills needed to treat critical and 
complex polytrauma casualties, but they also provided this advanced 
care utilizing British trauma and treatment protocols. Among this 
stellar group are emergency/trauma nurses who rapidly progressed in 
mastering the advanced knowledge and skill required to serve as Trauma 
Nursing Team Leaders in the British hospital. In this role, they 
demonstrated exceptional leadership and nursing skills in the 
management of the most severely injured trauma patients. In accordance 
with nationally recognized trauma scales, patients treated at the Role 
3 in Bastion typically have injury severities scoring twice as high as 
the average patient seen in a Level 1 trauma center in the United 
States. There is no doubt nurses are making a tremendous contribution 
to the unprecedented 95 percent and 98 percent survival rate of 
casualties treated at the British Role 3 in Bastion and Kandahar Role 3 
Multinational Medical Unit, respectively.
    In addition to providing cutting edge care to the wounded, Navy 
nurses are uniquely trained and qualified in illness prevention and 
health promotion. A Navy nurse assigned as a medical/surgical nurse put 
her graduate education in public health to use as the Infection Control 
Officer for the Kandahar Role 3. In her off-duty time, she also served 
as the Role 3 liaison to the Army Preventive Medicine personnel at the 
Kandahar Air Field. In this capacity, she developed infection control 
policies and collaborated in the development of a clinical 
investigation on multiple drug-resistant organisms (MDROs) infecting 
the wounds of our injured servicemembers. This clinical investigation 
is being continued by replacement personnel and will provide meaningful 
data to identify, treat, and alleviate this serious health threat 
facing our troops.
    Throughout Afghanistan, Navy nurses are primary members of medical 
stability operations serving with North Atlantic Treaty Organization 
(NATO) forces and teams led by the other Services as members of 
Embedded Training and Provincial Reconstruction Teams. They provide 
medical support and serve as healthcare system consultants for NATO 
forces, nonmedical United States and Afghan forces, tribal leaders, and 
local nationals to assist in the establishment of a healthcare 
infrastructure in Afghanistan. They also serve as mentors and teachers 
for Afghan military and civilian medical personnel in the Afghanistan 
National Army Hospital. Their contributions in exchange of knowledge 
will enhance the quality of medical care for Afghan military and police 
forces and the people of Afghanistan for generations to come.
    Last year, I spoke of Navy nurses serving as teachers and mentors 
for members of the Afghan National Army Nurse Corps through a Health 
Service Engagement Program project called ``Shana baShana'' (Shoulder-
to-Shoulder) at the Kandahar Regional Military Hospital. Their efforts 
were to support Afghan nurses' professional development and produce 
long-term improvements in nursing practice in the Afghan healthcare 
system. Mr. Chairman, I am extremely proud to report that this 
partnership has significantly increased the clinical knowledge and 
skill level of the Afghan Army nurses. The Kandahar Regional Medical 
Hospital is now receiving and providing medical care and treatment to 
nearly all Afghan Security Forces battlefield injuries with the 
exception of severe head and/or eye injuries, as well as conducting a 
weekly outpatient clinic for Afghanistan civilians.
    Navy nurses also play a key role in civil-military operations and 
health-related activities such as those conducted by the Combined Joint 
Task Force Team--Horn of Africa (CJTF-HOA) whose members are involved 
in the local communities building and renovating clinics and hospitals 
and providing medical care to local populations. In support of the 
personnel conducting this operation in Africa, a Navy nurse assigned to 
the Expeditionary Medical Facility (EMF) in Camp Lemonier, Djibouti, 
Africa, led junior nurses in the provision of care for medical/
surgical, critical care, and primary care patients. As the sole 
experienced perioperative nurse on the medical team, he managed 
clinical operations and provided perioperative care for all surgical 
procedures performed at the only U.S. operating suite within theater. 
His outstanding efforts ensured the delivery of the highest-quality 
care and force health protection for return to duty or transfer to 
higher levels of care for critical, mission essential U.S. Africa 
Command (AFRICOM) personnel.
    In ``A Cooperative Strategy for 21st Century Seapower,'' the U.S. 
lists HA/DR as one of the core components of our maritime power and an 
activity that helps prevent war and build partnerships. Integral to the 
Navy's expanding maritime strategy as a ``Global Force for Good'' are 
Navy nurses who serve in a very different role than on the battlefield 
but an equally important and vital role in the Navy's HA/DR mission. In 
this role, Navy nurses provide outstanding care and education that 
ensures long-term improvements in the health and quality of life by 
enhancing the partner nation's capacity to provide care after the Navy 
departs. The trusting and collaborative relationships they forge with 
our host nation partners strengthens U.S. maritime security and 
facilitates the on-going training for disaster relief scenarios, 
ultimately improving capability to work together with partner nations 
in the event of a disaster in the future.
    From April to September 2011, 93 Active and Reserve component Nurse 
Corps officers, as well as nurses from nongovernmental organizations 
and partner nations embarked aboard the USNS Comfort (T-AH 20) for 
Continuing Promise providing humanitarian civic assistance to nine 
countries in Central and South America and the Caribbean. Navy nurses 
were also key members of the healthcare teams aboard the USS Cleveland 
(LPD 7) for Pacific Partnership 2011 supporting humanitarian efforts in 
Tonga, Vanuatu, Papua New Guinea, East Timor, and Micronesia. Nurses 
served in a variety of roles as direct patient care providers, case 
managers, discharge planners, Medical Civic Action Program (MEDCAP) 
site leaders, patient educators, trainers for partner nation healthcare 
providers, and mentors.
    On March 11, 2011, mainland Japan experienced a 9.1 magnitude 
earthquake. In its aftermath, a catastrophic tsunami and subsequent 
Fukushima nuclear meltdown devastated the Pacific coastline of Japan's 
northern islands. Navy nurses were once again at the ready providing 
reassurance, advocacy, education, and compassionate care for local 
nationals, Active Duty and retirees and their family members during 
Operation Tomodachi. In theater, nurses at sea aboard the USS Ronald 
Reagan (CVN 76), one of the first ships to arrive on station following 
the tsunami, and nurses assigned to Fleet Surgical Team SEVEN aboard 
the USS Blueridge (LCC 19) rapidly prepared for the possibility of a 
mass influx of casualties and provided care for the sailors conducting 
air search and rescue/recovery operations.
    Navy nurses were also actively supporting our military personnel 
and families on the ground. A Navy Certified Nurse Midwife at U.S. 
Naval Hospital, Yokosuka, Japan, led the early identification and 
recall of expectant mothers providing timely and appropriate outreach 
assessment and education for this high-risk, vulnerable patient 
population and coordinated the medical evacuation of 19 families 
transferred to Okinawa, Japan. When low levels of radiation were 
detected, a Navy Family Nurse Practitioner led one of the five 
potassium iodide distribution sites with fellow nurses providing 
educational counseling for the remaining 200 expectant mothers and more 
than 2,800 parents with children under the age of 5. Labor and delivery 
nurses were medical attendants for expectant mothers and family members 
during their transport flight to Okinawa, Japan and provided assistance 
to U.S. Naval Hospital, Okinawa during this influx of obstetric 
patients.
    Nurses stationed at U.S. Naval Hospital, Okinawa provided medical 
and emotional support for 27 expectant mothers medically unable to 
return to the United States and family members arriving from Yokosuka, 
Iwakuni, Misawa, and Camp Zama. The first birth occurred just 2 days 
after arriving on Okinawa with the rest of the births following over 
the course of the next 4 weeks. Nursing support of these families did 
not stop following delivery and discharge from the hospital. Over the 
course of their 3-month stay, the nurses ensured the delivery and 
coordination of the highest-quality care until their safe return home.
    Fleet nurses continue to be a significant part of Navy Medicine's 
medical support and training to our sailors and marines at sea. On 
aircraft carriers, well-rounded nurses, specialized in critical care, 
emergency/trauma, and anesthesia provide care and safeguard the health 
and well-being of 4,000-5,000 crew members and embarked personnel, as 
well as train and prepare the ship's crew to effectively manage a 
disastrous event resulting in mass casualties. Their actions 
significantly contribute to overall mission success by ensuring total 
force readiness while underway.
    Extremely versatile, Navy nurses also provide tremendous support to 
the amphibious fleet as members of Fleet Surgical Teams (FSTs) bringing 
medical and surgical support, inpatient care and training capability to 
Navy vessels for a variety of missions. For example, a FST nurse 
anesthetist worked alongside medical officers of the Royal Singapore 
Navy providing clinical training and leadership during the 3-day 
medical training portion of ``Cooperation Afloat Readiness and Training 
(CARAT),'' an annual exercise between the U.S. Navy, its sister 
services, and the maritime forces of eight Southeast Asian countries. 
His sharing of medical knowledge strengthened regional cooperation, 
interoperability and relationships between partner nations increasing 
regional maritime security and stability.
    FST nurses aboard the USS Wasp (LDH 1) provided the around-the-
clock medical and surgical support required to conduct flight deck 
operations during the 18 days of initial sea trials of the F35B 
Lightening II Joint Strike Fighter. They supported the 22nd Marine 
Expeditionary Unit aboard the USS Bataan (LDH 5) during Joint Task 
Force Odyssey Dawn, a limited military action to protect Libyan 
citizens during a period of unrest. FST nurses aboard the USS Essex 
(LDH 2) were integral members of the medical contingency supporting 
President Obama's attendance at the 19th Association of Southeast Asian 
Nations (ASEAN) Summit in Bali, Indonesia, providing a readily 
available medical platform in the event of an unforeseen crisis.
    Navy nurses continue to serve side-by-side with the marines in 
vital clinical and leadership roles providing invaluable medical 
support and training. For the first time, a Family Nurse Practitioner 
is filling the role as the First Marine Expeditionary Force 
Headquarters Group Surgeon at Camp Leatherneck, Afghanistan. Nurses are 
now also serving in unique roles as clinical advisors at Headquarters 
Marine Corps (HQMC), Marine Corps Combat Development Command and the 
Marine Corps Warfighting Lab giving clinical input and recommendations 
to the Marine Corps dismounted complex blast injury (DCBI) team to 
prevent and treat blast injuries. Their clinical expertise, battlefield 
experience and knowledge of recent theater requirements contributed 
invaluable input for improvements in the equipment carried by marines 
and sailors and implementation of tactical combat casualty care (TCCC) 
recommendations for pre-hospital care that markedly increased the 
chance of survival for casualties. These nurses also collaborated with 
Coalition Forces through American, British, Canadian, and Australian/
New Zealand Armies to implement TCCC and DCBI guidelines throughout the 
pre-hospital phase standardizing care across the nations.
    The recently released National Defense Strategy ``Sustaining Global 
Leadership: Priorities for the 21st Century'' states, ``We will of 
necessity rebalance toward the Asia-Pacific region'' and we will 
``emphasize our existing alliances, which provide a vital foundation 
for Asia-Pacific security.'' Navy nurses assigned to the 3D Medical 
Battalion, 3D Logistics Group are essential leaders and subject matter 
experts in Pacific Medical Stability Operations. These nurses trained 
the corpsmen responding to Operation Tomodachi and provided direct 
medical support and training to FRSS, STP, and en-route care nurses. 
They also trained coalition medics and lay health providers embedded 
with the military medical assets involved in joint training exercises 
for international nation building in the Philippines, Thailand, Korea, 
and Cambodia. Overall, these nurses function as key leaders and 
planners in the development and execution of operational field training 
exercises that encompass Mission Essential Task List requirements for 
global operational readiness. The care, healthcare education, medical 
training, and leadership they provide while serving side by side with 
our marines is unparalleled.
    Through these diverse examples, it is clear that Navy nurses 
personify the Navy's slogan, ``Whatever it takes. Wherever it takes 
us.'' Navy nurses are central to the delivery of safe, comprehensive, 
and high-quality care often in the most demanding, challenging, and 
austere missions supported by Navy Medicine. Our Corps continues to 
make a significant impact on the long-term health and quality of life 
of our sailors and marines, as well as citizens of our international 
partner nations. Mr. Chairman, the remainder of my testimony will 
highlight Navy nursing's achievements in my five strategic focus areas:
  --Workforce;
  --Nursing knowledge/Clinical expertise;
  --Research;
  --Strategic partnerships; and
  --Information management/Communication.

                             OUR WORKFORCE

    The Navy Nurse Corps recognizes its people as our most vital asset, 
and we are committed to maintaining a force of highly skilled and 
adaptable nurses ready to meet the diverse challenges of Naval service. 
The Navy Nurse Corps Active component (AC) was 94-percent manned at the 
end of fiscal year 2011. The Navy Nurse Corps remains an employer of 
choice as evidenced by our projected successful attainment of our 
fiscal year 2012 AC recruiting goal. Although more challenging, our 
Reserve component (RC) is working very hard to attain similar 
recruiting success and was 88-percent manned at the end of fiscal year 
2011. These recruiting achievements are attributed to continued funding 
support for our accession and incentive programs, recruiting activities 
of local Navy Recruiters, active participation of Navy nurses in local 
recruiting efforts, and the public's positive perception of service to 
our country.
    The Nurse Accession Bonus and the Nurse Candidate Program remain 
our two most successful recruiting programs for Active-Duty nurses 
entering the Navy through direct accessions. For our Reserve component, 
officer accession, and affiliation bonuses for critical shortage or 
high-demand specialties such as Certified Registered Nurse Anesthetist, 
Psychiatric/Mental Health Nurse Practitioners, critical care, medical-
surgical, perioperative, and psychiatric nursing, and loan repayment 
programs for Certified Registered Nurse Anesthetist and Psychiatric/
Mental Health Nurse Practitioners remain the most successful recruiting 
tools.
    Last year, the Navy Nurse Corps experienced a significant decrease 
in our loss rates. I am happy to report the 2011 loss rates remained 
consistent with the improvements seen the prior year, particularly in 
our mid-level officers. We will make every effort to sustain these 
gains through long-term retention of these highly trained and qualified 
nurses. The Registered Nurse Incentive Special Pay (RN-ISP) and Health 
Professions Loan Repayment Program (HPLRP) remain central to our 
retention success. Full-time duty under instruction (DUINS) offering 
graduate education leading to advanced nursing degrees remains a major 
program for attracting new nurses as well as retaining those 
experienced Nurse Corps officers who desire advanced nursing education. 
I would like to thank you, Mr. Chairman, Vice Chairman Cochran, and all 
subcommittee members, for your continued support of these vital 
recruiting and retention programs.
    Although we have experienced great success in nurse recruitment and 
retention over the past several years, our efforts to attract and keep 
the best and brightest nurses is still a top priority. Navy nurses 
throughout the United States and abroad are actively involved in nurse 
recruitment and retention efforts to ensure the sustainment of a Corps 
with the most talented nurses. We are currently in the middle of our 
second successful tour with a Nurse Corps Fellow assigned to the Nurse 
Corps Office to monitor recruitment and retention efforts. Her presence 
at professional nursing conferences and job fairs speaking with new 
graduates and nurses across the United States provides an invaluable 
opportunity for us to gain real time information for prioritizing, 
planning, and implementing our recruitment and retention goals.
    Last year, I spoke of our focused efforts to build our psychiatric/
mental health nurse practitioner (PMHNP) community in response to an 
ever-growing healthcare need. PMHNPs continue to have a significant 
impact on building resiliency and enhancing the mission readiness of 
our sailors, marines, and families serving in diverse roles with the 
1st, 2d, and 3d Marine Divisions, in stateside and overseas MTFs and 
clinics, and a myriad of deployments in support of our fighting forces. 
I am pleased to say over the past 5 years, we have increased our PMHNP 
billets from 8 to 23. There are currently 17 nurses practicing in this 
specialty. With the anticipated graduation of seven PMHNPs in May of 
this year, this vital community will be 100-percent manned with several 
remaining in and selected for the training pipeline to maintain maximum 
manning levels in this critical specialty.

                 NURSING KNOWLEDGE/CLINICAL EXCELLENCE

    Clinical excellence in the provision of holistic and compassionate 
patient- and family-centered care is the cornerstone of Navy nursing 
and remains one of my top strategic priorities. Navy nurses are 
respected healthcare professionals actively involved in all levels of 
professional nursing organizations, the advancement of nursing 
practice, and sustainment of clinical excellence. The National 
Conference of the American Academy of Nurse Practitioners inducted two 
Navy nurses into the prestigious Fellows of the American Academy of 
Nurse Practitioners and another was honored as the recipient of the 
Pacific U.S. Territories State Award for Excellence.
    The Navy Nurse Corps remains committed to our nurse practitioners 
and nurse anesthetists attaining doctoral education through our full-
time DUINS program. We currently have 21 nurses in the training 
pipeline in programs that will take them directly from Bachelor's 
education to doctoral study, in specialties that include Certified 
Registered Nurse Anesthetist, Psychiatric/Mental Health Nurse 
Practitioner, Family Nurse Practitioner, Pediatric Nurse Practitioner 
as well as Nursing Research. This year, we selected 12 more nurses for 
doctoral education.
    Nurses new to the Navy face many unique challenges from learning 
the intricacies of patient care and becoming competent in the 
application of newly acquired knowledge, skills, and abilities (KSAs), 
to integrating into the Navy culture as a commissioned officer. 
Developing clinical expertise begins immediately upon the Nurse Corps 
officer's arrival at their first-duty assignment. To ensure novice 
nurses a smooth transition into this challenging clinical role and 
environment, we developed a standardized Nurse Residency Program based 
on the Commission on Collegiate Nursing Education's ``Standards for 
Accreditation of Post-BSN Nurse Residency Programs'' and implemented it 
across Navy Medicine. This program provides an avenue for new nurses to 
gain competence, confidence, and comfort through didactic learning. It 
integrates evidence-based practice concepts, a designated preceptor in 
each clinical rotation site and a list of expected knowledge, skills, 
and abilities to be achieved for competency-based learning. Although 
implemented at all facilities receiving novice nurses, the largest 
impact of the Nurse Residency Program can be felt at our medical 
centers. Recognized for the diverse and complex clinical training these 
large tertiary care facilities provide, they receive the largest 
numbers of novice nurses with more than 200 nurses completing the 
residency program at large MTFs annually.
    Over the past few years, the Nurse Corps has identified nursing 
specialties vital to routine and operational missions, developed 
standardized core competencies for these specialties, and ensured the 
development and sustainment of clinical proficiency for nurses 
throughout the enterprise. This year, significant work was done to 
update the core competencies based on current specialty practice 
standards. Formal policy was also developed to provide guidance for 
nursing leaders to sustain the utilization of these core clinical 
competencies and clinical proficiency in the identified critical 
specialties. This work will ensure nurses sustain the necessary 
clinical knowledge and skills within their clinical specialties to 
continually meet and succeed in any mission they are asked to fulfill.
    Earlier in this testimony, I gave examples of advanced nursing 
knowledge and clinical excellence of Navy nurses who are providing 
heroic care to our Armed Forces in theater at the point of injury for 
initial stabilization, during transport to higher levels of care and 
upon receipt to Role 3 facilities. This nursing knowledge and clinical 
excellence is also pivotal in every facet of care we provide our 
wounded warriors from the time they return stateside through their 
return to Active Duty or medical separation from Active service. Navy 
nurses are essential to creating and implementing innovative approaches 
to convenient and comprehensive treatment that enhances the care 
experience for our wounded warriors.
    Navy nurses serving at Walter Reed National Military Medical Center 
(WRNMMC) continue to do phenomenal inpatient work on the Traumatic 
Brain Injury/Post Traumatic Stress Disorder Unit. They are recognized 
subject matter experts and educators on the topic of nursing care for 
patients with psychological health-traumatic brain injury (PH-TBI). 
They serve as instructors at the Uniformed Services University of the 
Health Sciences (USUHS) on evidence-based nursing interventions so 
nurses new to this specialty have knowledge of current practice trends 
for PH-TBI. This past year, they also taught at Andrews Air Force Base 
instructing members of the Air Force Explosive Ordinance Disposal Team 
about the signs and symptoms of TBI to facilitate earlier 
identification and initiation of treatment for servicemembers.
    Inpatient nurses at the Naval Medical Centers San Diego and 
Portsmouth led the establishment of new inpatient units focused on the 
care of our returning wounded warriors. These units facilitate a smooth 
transition to the stateside MTF and provide comprehensive, convenient 
care in one centralized location. The ``one-stop-shop'' care concepts 
include direct admission to the unit providing a quiet, comfortable, 
and private environment for initial medical evaluations and often the 
first-time reunions with their families. Services brought to the 
patient include physical and occupational therapy, Project C.A.R.E. 
(Comprehensive Aesthetic Restorative Effort), education, and support 
groups for amputees and those experiencing combat operational stress, 
radiography, casting, evaluation by the acute pain service, and complex 
wound care. The care provided on these patient- and family-centered 
units has a tremendous impact on the recovery of our wounded warriors 
and their families.
    Navy nurses continually research best nursing practices and align 
with national healthcare initiatives in an effort to advance the 
outstanding care they provide to our beneficiaries. Nurses were 
instrumental to Naval Hospital Jacksonville's becoming 1 of only 119 
hospitals throughout the United States to have earned the ``Baby 
Friendly'' designation by ``Baby Friendly USA,'' a global initiative 
sponsored by the World Health Organization (WHO) and United Nations 
Children's Fund. To achieve this designation, staff educational and 
facility design requirements must be met as well as passing a rigorous 
on-site survey. To maintain this designation, the staff must provide 10 
clinical practices that include initiating breastfeeding within the 
first hour of life, keeping mothers and babies in the same room, and 
providing support groups for women who breast feed.
    Nurses at Okinawa, Japan introduced evidence-based practice 
initiatives endorsed by the Institute of Healthcare Improvement (IHI) 
and the Robert Wood Johnson Foundation's program Transforming Care at 
the Bedside (TCAB), a national effort to improve the quality and safety 
of care on medical surgical units and improve the effectiveness of the 
entire care team. They led the implementation of multidisciplinary 
patient rounds and change of shift nursing report at the patient's 
bedside. These changes provide an opportunity for the patient and 
family members to be fully engaged in their plan of care with all 
members of the healthcare team. They also started the practice of 
having patient safety huddles throughout the shift to communicate 
changes in patient status or plan of care so all members of the 
healthcare team are aware prior to the care hand-off at the change of 
shift. These nurse-led practices improved the effectiveness of the 
healthcare team's communication with the patient and with each other, 
increased the quality and efficiency of patient care hand-offs, and 
significantly reduced medication errors. These improvements have also 
been major contributors to the unit's overall 93 percent patient 
satisfaction score, the highest of any department in the hospital.

                            NURSING RESEARCH

    Advancing the science of nursing practice through research and 
evidence-based practice to improve the health of our patients is a 
vital strategic focus for the Navy Nurse Corps. Navy nurses authored 
more than 30 nursing publications and provided more than 50 formal 
presentations at various professional forums. We remain committed to 
increasing and diversifying our footprint in the field of research. 
This year, a team of outstanding nurses completed significant work to 
create a culture of scientific inquiry and revitalize nurses' interest 
in research, as well as increase the number of submissions and 
selections for projects funded by the Tri-Service Nursing Research 
Program (TSNRP).
    Fundamental to the growth and development of nurse researchers is 
the availability of experienced mentors to guide and teach research 
novices throughout the process. To address this need, a nurse 
researcher position was developed and filled by experienced researchers 
at Navy Medical Center San Diego, Naval Medical Center Portsmouth, and 
WRNMMC. Additionally, a nursing research network data base listing 
personnel with experience in research along with a list of research 
educational offerings was developed and placed on Navy Knowledge Online 
(NKO) providing a centralized location with easy accessibility for 
nurses throughout Navy Medicine. Last, a Nurse Corps recognition 
program was established to recognize and promote excellence in 
implementing evidence-based nursing practice.
    Mr. Chairman, we are extremely grateful for your continued support 
of the TSNRP, and I am proud to say that Navy nurses in both the Active 
and Reserve component are actively involved in leading and conducting 
Navy and joint research and evidence-based practice projects. In 2011, 
a Navy nurse took the helm as Executive Director of TSNRP and for the 
first time in Navy Medicine's history, a Navy nurse was selected to 
serve as the Deputy Director of the Joint Combat Casualty Research Team 
(JCCRT) overseeing medical and operational research activities in Iraq, 
Afghanistan, and Kuwait. Navy nurses completed research projects funded 
through TSNRP that have provided meaningful information to improve the 
care of our beneficiaries. One such study entitled, ``Stress Gym for 
Combat Casualties'' explored the lived experiences of combat casualties 
and the military nurses who cared for them. That information was used 
to develop and implement a Web-based intervention called Stress Gym, 
which provides an anonymous and private avenue for combat wounded to 
learn about the effects of and methods to manage stress, anxiety, 
anger, post-traumatic stress disorder (PTSD), and symptoms of 
depression. Stress Gym is extremely valuable in assisting nurses to 
address the psychosocial needs of returning warriors.
    Another study entitled ``Psychometric Evaluation of the Triage 
Decision Making Inventory'' resulted in findings that will assist us in 
preparing our nurses for deployment. This study validated the ``Triage 
Decision Making Inventory'' as a reliable tool for assessing nurses' 
clinical competence. Nurses working in any clinical specialty can now 
utilize this tool to evaluate their knowledge and target additional 
clinical experience and training as necessary to ensure optimal 
clinical readiness for operational deployments.
    A recently completed Tri-service study entitled, ``Factors 
Associated with Retention of Army, Navy and Air Force Nurses'' provided 
invaluable insight into why nurses stay in the military. Among the most 
important findings revealed in this study was that deployments, 
originally thought to be a significant factor in determining nurses' 
job satisfaction and retention, were actually not a significant factor. 
Most servicemembers are happy to deploy and saw this as their patriotic 
duty. Other factors influencing job satisfaction and retention in the 
military are based on opportunity for promotion, relocation frequency, 
professional leadership/autonomy, and ongoing opportunity to work in 
their clinical specialty. These findings are vital to the development 
of policy and leadership practices that facilitate continued job 
satisfaction and retention of our highly educated, skilled, and 
dedicated nurses.
    Numerous funded projects are currently in progress, and in 2011, 
Navy nurses were granted $1.5 million in TSNRP funds as Principal 
Investigators (PI) for new projects proposing to study cognitive 
recovery from mild traumatic brain injury, new treatments for 
hemorrhagic shock, elective surgery outcomes for veterans with PTSD, 
and the role of nurses working in Patient-Centered Medical Homes in the 
management of patients and/or populations with high rates of 
utilization of healthcare services. Mr. Chairman and distinguished 
members of the subcommittee, I would like to thank you again for you 
ongoing support of nursing research and I look forward to sharing the 
results of these studies in the future.

                         STRATEGIC PARTNERSHIPS

    Collaboration is absolutely essential in today's environment of 
continued rising healthcare costs and limited financial resources. 
Joint and integrated work environments are now the ``new order'' of 
business. As leaders in Navy Medicine and the Military Healthcare 
System, Navy nurses possess the necessary skills and experience to 
promote, build, and strengthen strategic partnerships with our 
military, Federal, and civilian counterparts to improve the healthcare 
of our beneficiaries.
    Currently, Navy nurses work with the Army, Air Force, the 
Department of Veterans Affairs (VA) and other Federal and 
nongovernmental agencies. They serve as individual augmentees (IAs), 
work in Federal facilities and joint commands, conduct joint research 
and teach at the Uniformed Services University Graduate School of 
Nursing. This past year, a nursing team was chartered to focus on 
exploring methods to further expand collaborative partnerships across 
Federal and civilian healthcare systems. Their diligent efforts 
resulted in the development of a standardized Memorandum of 
Understanding (MOU), approved by the Bureau of Medicine and Surgery 
(BUMED), to assist MTFs and clinics to more easily establish strategic 
partnerships with civilian medical and teaching institutions. These 
partnerships are necessary to increase collaboration and provide 
additional clinical experience and training opportunities for nurses to 
remain deployment ready.
    A unique partnership has been established between Naval Health 
Clinic New England in Newport, Rhode Island, the Naval Branch Health 
Clinic in Groton, Connecticut and the Veterans Affairs Medical Center 
(VAMC) in Providence, Rhode Island. Navy nurses from these clinics work 
two shifts each month in the VAMC emergency room or intensive care 
unit. This partnership benefits both organizations as it provides an 
opportunity for Active-Duty nurses to sustain their critical wartime 
specialty skills while assigned in an ambulatory setting and gives the 
VAMC additional nurses to support the provision of outstanding care to 
our veterans. Nurses involved in this collaboration who have returned 
from deployment, believed their VAMC clinical experience enhanced their 
training and preparation for deployment and instilled the confidence 
necessary to effectively perform in their role while deployed.
    Navy nurses serving at the Captain James A. Lovell Federal Health 
Care Center, the only VA and DOD integrated facility, work side-by-side 
with VA civilian nurse colleagues to provide high-quality care to 
Active-Duty military and their family members, military retirees, and 
veterans. Through this partnership, Navy nurses have increased their 
clinical knowledge and skills in the care of medical-surgical patients 
with more complex and chronic conditions seen in geriatric populations.

                  INFORMATION MANAGEMENT/COMMUNICATION

    Strategic Communication is paramount to the successful achievement 
of the Navy Nurse Corps' mission. In 2008, the DOD's ``The Principles 
of Strategic Communication'' describes Strategic Communication as ``the 
orchestration and/or synchronization of actions, images, and words to 
achieve a desired effect''. One of the nine key principles listed in 
this document is that it must be leadership-driven and ``to ensure 
integration of communication efforts, leaders should place 
communication at the core of everything they do''. I am committed to 
continually improving communication in the Nurse Corps to further 
strengthen our effectiveness.
    Today's global scope and varying degrees of technology venues are 
recognized variables in effective communication. This past year, I 
chartered a team of Nurse Corps officers to promote communication 
across the Nurse Corps by developing methods to sustain, advance, and 
evaluate current communication processes. This team conducted an 
environmental scan to gather data regarding the most preferred and most 
effective communication venues and analyzed the responses from more 
than 1,000 participants. Results obtained from the environmental scan 
survey have been operationalized into a Strategic Communication 
Playbook explaining the types of communication venues available, where 
these venues are located, and when the information is disseminated 
across the enterprise. Additionally, they completed the framework for a 
formalized Navy Nurse Corps Strategic Communication Plan. Our work in 
Strategic Communication will continue in the upcoming year, and I look 
forward to sharing our progress.

                               CONCLUSION

    Navy nurses continually embody the highest caliber of naval 
officers and healthcare professionals. They remain at the forefront of 
clinical and military leadership, pivotal to the success of every 
mission involving Navy Medicine. Their commitment to clinical 
excellence, advanced education, scientific inquiry, operational 
medicine, and global health is unsurpassed. In every mission at home 
and abroad, our efforts remain focused on improving the health of those 
entrusted to our care by providing a care experience that is patient- 
and family-centered, compassionate, convenient, equitable, safe, and 
always of the highest quality.
    Senator Inouye, Vice Chairman Cochran, and distinguished members of 
the subcommittee, thank you again for this opportunity to share the 
remarkable accomplishments of Navy nurses and your unwavering support 
of the nursing profession. I am honored to be here representing the men 
and women of the Navy Nurse Corps and look forward to my continued 
service as the 23d Director of the Navy Nurse Corps.

STATEMENT OF MAJOR GENERAL JIMMIE O. KEENAN, CHIEF, 
            U.S. ARMY NURSE CORPS
    Chairman Inouye. Thank you very much, Admiral.
    Now, may I call on General Keenan.
    General Keenan. Chairman Inouye, Vice Chairman Cochran, it 
is our honor to speak before you today on behalf of the nearly 
40,000 Active, Reserve, and National Guard officers, 
noncommissioned officers, enlisted, and civilians that 
represent Army nursing.
    Nurses have a proud history of more than 236 years of 
standing shoulder-to-shoulder with and caring for this Nation's 
warriors. We've done this in every conflict, from the dawning 
days of the American Revolution, to our current operations in 
Afghanistan. The Army Nurse Corps remains dedicated to 
America's sons and daughters who selflessly place themselves in 
harms way to defend this Nation.
    I'd like to share with you today a story from Captain 
Bujak. She's one of our Army intensive care unit (ICU) nurses. 
She was deployed to Iraq in 2009. Captain Bujak describes her 
experience with the patient she cared for in theater and later 
met back in the United States.
    ``During my deployment to Iraq, I took care of numerous 
patients, from servicemembers, to contractors, to local 
nationals. Two months into my deployment, our ICU received a 
critically injured soldier from a rocket-propelled grenade 
(RPG) attack. From the moment he arrived, nurses, physicians, 
medics on duty came together and worked as a team. He was 
fighting for his life, and we were fighting with him. He was 
stabilized and was later evacuated back to United States.
    ``Fast forward 2\1/2\ years. After the U.S. Army Medical 
Command (MEDCOM) change of command ceremony, I saw a familiar 
face, a face I've never forgotten. It was our soldier from 
Baghdad, wearing ACUs, and walking up the stairs on his 
prosthetics. I was honored to be able to introduce myself and 
speak with him about those 2 days in Baghdad.
    ``Speaking with the man whom I had remembered fighting for 
his life, and now was preparing to leave other soldiers 
assigned to the warrior transition command is an amazing 
experience. I don't have to wonder any more about that soldier 
from 2\1/2\ years ago. Now, I know I completed my mission.''

                          IMPROVE PATIENT CARE

    We're a globally ready medical force. Within the last year, 
483 of our nurses have deployed worldwide. We go with soldiers, 
airmen, sailors, and marines to save lives, support healing, 
and provide comfort. This is demonstrated by our medical 
management of the movement of critically injured patients in 
theater. The en route critical care nurse program is a joint 
Army, Navy, and Air Force endeavor, providing critical care 
transport capabilities on fixed- and rotary-wing evacuation 
platforms. This en route care program is a direct result of 10 
years of caring for wounded warriors.
    In addition to meeting demands, we continue to work to 
integrate our major initiatives to improve patient care. In 
February 2011, Army nursing began implementing a patient-
centered outcomes focus care delivery system encompassing all 
delivery environments: In-patient, out-patient, and deployed. 
The patient caring touch system was designed to reduce clinical 
quality variance by adopting a set of internally and externally 
validated best practices. The patient caring touch system is a 
true enabler of our major healthcare initiative, patient-
centered medical home. It enhances the quality of care 
delivered for America's sons and daughters.
    Nurses are taking a leading role in the implementation of 
and partnership with the delivery of services that focus on 
wellness outside the treatment facility. We serve in Army 
wellness centers and provide lifestyle coaching, health 
education that focuses on the behaviors that lead to 
preventable diseases, empowering our beneficiaries to lead 
healthier lives.
    As members of Army Medicine, we address the white space to 
impact the life space. Nurses are there at the many touch 
points of the comprehensive behavioral health system. We are 
integral in providing continuity and a standardized approach 
for our soldiers and families.
    I envision the Army Nurse Corps' journey toward nursing 
excellence will continue. We in the Army Nurse Corps are 
dedicated to the compassionate and trusted healthcare that we 
provide to America's sons and daughters.
    Chairman Inouye, Vice Chairman Cochran, we appreciate this 
opportunity to speak to you about Army nursing, and we also 
appreciate all of your support to Army nursing. I am very 
humbled and honored to represent the more than 40,000 men and 
women that comprise Army nursing, and also to serve as the 24th 
Chief of the Army Nurse Corps.
    Thank you.
    [The statement follows:]

          Prepared Statement of Major General Jimmie O. Keenan

                              INTRODUCTION

    Chairman Inouye, Vice Chairman Cochran, and distinguished members 
of the subcommittee: It is an honor and a great privilege to speak 
before you today on behalf of the nearly 40,000 Active component, 
Reserve component, and National Guard officers, noncommissioned 
officers, enlisted, and civilians that represent Army nursing. It has 
been your continued tremendous support that has enabled Army nursing, 
in support of Army Medicine, to provide exceptional care to those who 
bravely defend and protect our Nation.
    Nurses have a proud history of more than 236 years of standing 
shoulder-to-shoulder with, and caring for this Nation's warriors. We 
have done so in every conflict from the dawning days of the American 
Revolution to our current operations in Afghanistan.

              GLOBALLY READY NURSING SUPPORTING THE FORCE

    The Army Nurse Corps (ANC) remains dedicated to America's sons and 
daughters who selflessly place themselves in harm's way to defend this 
Nation. They remain our priority, and Army nurses are an invaluable 
presence, with 483 Active Duty and Reserve component nurses engaged in 
military operations in support of Operation Enduring Freedom (OEF) and 
other missions worldwide in 2011.
    I would like to share a story from Captain (CPT) Bujak, one of our 
nurses who deployed to Iraq, on a patient she cared for in theater and 
later met back in the United States.

    ``During my deployment to Iraq, I have taken care of numerous 
patients, from our servicemembers, contractors to local nationals. Each 
patient was unique and my fellow nurses, medics and I provided them 
with the best care we could deliver. Two months into my deployment, our 
intensive care unit (ICU) received a critically injured soldier from an 
rocket-propelled grenade (RPG) attack. Upon arrival to the emergency 
room (ER), he was quickly taken to the operating room and after couple 
hours of surgery, he was transferred to the ICU for recovery and 
stabilization. From the moment he arrived in the ICU, all of the 
nurses, physicians and medics on duty came together and worked as a 
team. Everyone was calm and focused, yet you could sense the concern, 
whether we can make a difference and get this soldier home. He was 
fighting for his life, and we were fighting with him. [The patient was 
stabilized and evacuated back to the United States].
    ``For the next couple of months, we would get updates from Walter 
Reed Army Medical Center on the status of `our soldier', but once I 
redeployed back, I lost the ability to follow up. From time to time, I 
would reflect on that day, my teammates, the hard work and of course 
`our soldier'. Two-and-a-half years later, after the Army Medical 
Command (MEDCOM) Change of Command ceremony, I saw a familiar face; a 
face I have never forgotten. It was `our soldier' from Baghdad, wearing 
Army combat uniforms (ACUs) and walking up the stairs on his 
prosthetics. He looked as healthy and strong as any other soldier in 
the room. I was overcome with peace and joy. I was honored to be able 
to introduce myself to him and speak with him about those 2 days in 
Baghdad. Speaking with a man whom I remember fighting for his life and 
was now preparing to lead other soldiers assigned to the Warrior 
Transition Command is an amazing experience. I wanted to call the rest 
of my deployment ICU team and let them know `We did make a difference'. 
I don't have to wonder anymore about that soldier from 2 years ago. Now 
I know, I completed my mission.''

    The ANC is dedicated to the care of our warriors and continues to 
incorporate lessons learned from supporting over a decade of war. We 
are structuring our capabilities and skill sets to meet the latest 
strategic imperatives of Army Medicine. Let me share with you several 
examples of how we are meeting the needs of the Army.
    As a globally ready medical force, we go with the soldier, airman, 
sailor, and marine to save lives, support healing, and provide comfort. 
This is demonstrated by our medical management of the movement of 
critically injured patients in theater. The Enroute Critical Care Nurse 
Program (ECCN) is the direct result of 10 years of caring for wounded 
warriors. Its legacy is in the over-70-years of aero-medical 
evacuation. Enroute Care is the transport of critical patients via 
helicopter in theater. It is based on a research identified 
capabilities gap for the safe transportation of critically injured 
patients from point-of-injury (POI) to forward surgical resuscitation 
(Level II); from post-operative care Level II facilities to more 
definitive care at our Combat Support Hospitals (Level III); and from 
Level III facilities to the Strategic Evacuation platforms for 
transport to more definitive care in Europe and continental United 
States (CONUS). It encompasses strategically placed critical care 
nursing transport assets across the Combined Joint Operational Area--
Afghanistan (CJOA-A).
    The Army nurses providing this battlefield capability face many 
challenges. They must first meet the rigorous physical challenges 
required for the training and mission support. They must hold the 66H 
(8A) critical care nursing career field identifier and complete flight 
nurse training at the Joint En-route Care Course (JECC). The challenges 
to be overcome in training are minimal to the practice adaptations that 
must be made to provide in-flight care to critically wounded patient on 
life-support in the confined cabin of a rotary wing aircraft at 
altitude in hostile airspace, connected to an aircraft communication 
systems at night. Yet these nurses overcome these challenges, provide 
quality care under sub-optimal conditions and execute precision patient 
hand-offs between levels of care on the battlefield.
    The ECCN program is a joint Army, Navy, and Air Force endeavor 
providing critical care transport capabilities on both fixed and rotary 
wing evacuation platforms. The Army ECCN personnel requirements are 
mission dependent. However, there are currently nine Army nurses and an 
Air Force Team of one Physician and two Certified Registered Nurse 
Anesthetists (CRNA) assigned to the mission. They are attached to 
aviations assets across the CJOA-A supporting the movement of 
critically ill and injured across the battle space. In the last 
calendar year, these flight nurses transported 1,192 patients between 
levels of care within the Afghan theater. Two hundred eighty-two (27.5 
percent) of these transfers were United States service personnel; 303 
(29.5 percent) were Afghan Security Forces; 41 (4.1 percent) were 
coalition partners; 336 (32.7 percent) were Afghan civilians; and 37 
(3.1 percent) were detained personnel.
    ECCN personnel do more than transport the critically ill or injured 
while in theater; they also ensure that they remain relevant and ready 
not only for themselves but insure their team is ready as well. Captain 
(CPT) Ritter and First Lieutenant (1LT) Bester are shining examples of 
this within their aviation companies, as they ensure sustained 
competence of the enlisted flight medics. They are truly integrated 
members of the MEDEVAC team with a vested interest in the team's 
collective mission success.
    We have continued to develop full-spectrum capability to manage 
critical trauma patients in all environments responding to the Army's 
needs, broadening our scope across the battlefield, and consistently 
meeting unprecedented challenges while providing care to America's 
injured and ill sons and daughters. The first Trauma Nurse Course 
(Pilot course) was completed in February 2012, and 15 students 
completed an 18-week program at San Antonio Military Medical Center 
(SAMMC). The Trauma Nurse is a multifunctional Army Nurse with critical 
care theory, knowledge, and highly developed nursing expertise capable 
of optimizing patient outcomes. This nurse will have the foundation to 
care for patients across the continuum of care both in the emergency 
and intensive settings, and during patient movement regardless of the 
environment. This pilot is critical to determine the skill sets 
required to continue to be an agile and flexible medical force for our 
warriors.
    In addition to the trauma skill set, the ANC is developing other 
clinical skills to meet the Army's current and future needs. One of our 
new initiatives is the development and utilization of Psychiatric Nurse 
Practitioners which will be adopted as an area of concentration (AOC) 
for the Army. The Army Psychiatric Nurse Practitioner provides the 
assessment and diagnosis of mental illness and any medical problem that 
may account for or exacerbate a mental illness. They treat mental 
illness through medication management and psychotherapy. Treatment also 
includes the appropriate ordering of diagnostic tests and medical 
consultation/referral when indicated.
    Army Psychiatric Nurse Practitioners serve in as direct provider in 
the outpatient and inpatient behavioral health arena. Additional roles 
in a fixed facility include officer-in-charge of outpatient behavioral 
health clinics or the Chief of Department of Behavioral Health at a 
medical activity (MEDDAC) or medical center (MEDCEN). The senior Army 
Psychiatric Nurse Practitioner currently serves as the Psychiatric 
Nurse Practitioner Consultant to the Surgeon General (TSG). This senior 
Psychiatric Nurse Practitioner works with the other Behavioral Health 
Consultants to address behavioral health policy and procedures.
    Army Psychiatric Nurse Practitioners have deployed since the 
beginning of the Global War on Terrorism primarily to combat 
operational stress control (COSC) units, but also to Combat Support 
Hospital (CSH) in support of detainee care missions. Psychiatric Nurse 
Practitioners provided care to detainees and the soldiers, sailors, 
airman, and marines assigned to this mission. Army Psychiatric Nurse 
Practitioners have served as commander(s) of COSC unit(s) in Iraq and 
Afghanistan.
    One provider, Colonel (COL) Yarber, served as the Chief of 
Behavioral Health for a detainee care mission in Iraq for more than 
20,000 detainees and military/civilian support. Upon redeployment, he 
provided full-time direct outpatient care and served as the officer-in-
charge (OIC) for a 3-week intensive outpatient post-traumatic stress 
disorder (PTSD) treatment program (Fort Hood). Consequently, he was 
selected to serve as the OIC for the Outpatient Behavioral Health 
Clinic at Fort Hood while serving as the Behavioral Health Care manager 
for more than 1,000 soldiers and civilians identified as ``high risk'' 
after the November 5, 2009 SRP shooting incident at Fort Hood. He 
managed the ongoing assessment and coordinated care as required for 
both soldiers and civilians. Later he was selected to serve as the 
Chief, Department of Behavioral Health and subsequently deployed in 
support of OEF. COL Yarber is the Consultant to the Surgeon General for 
Psychiatric Nurse Practitioners, and is a shining example of our 
specialty addressing behavioral health needs of our warriors.
    Despite our efforts in theater, working with our coalition 
partners, the journey of our wounded warriors does not end in theater. 
Army Nurse case managers have been engaged in warrior care efforts 
since June 2003, when as a result of the wars in Iraq and Afghanistan, 
the demand for support and assistance for wounded, ill, and injured 
servicemembers began increasing exponentially. The Warrior Care and 
Transition Program has continued to make improvements to warrior care 
and nurse case managers have been at the forefront of those 
improvements. In December 2011, the Warrior Transition Command 
published the Comprehensive Transition Plan Policy and Execution 
Guidance. The comprehensive transition plan provides a tool that 
supports a soldier's goals to heal and successfully transition back to 
the force or to separate from the Army as a Veteran.
    The primary role of the nurse case manager is to assist each 
wounded, ill, or injured soldier in the development of personal goals, 
and then to oversee the coordination of his clinical care to ensure 
achievement of these goals. Nurse case managers are at the forefront of 
care managed by Triad of Care teams (which are comprised of a nurse 
case manager, primary care manager, and a squad leader or platoon 
sergeant), planned with the input of an interdisciplinary team, and 
outcomes focused on return to duty and the creation of informed and 
prepared Veterans who are armed and confident as they begin a new life 
out of uniform. Today, the Army has more than 500 nurse case managers 
assisting a warrior transition unit population of nearly 10,000 
wounded, ill, and injured soldiers. Case management efforts have 
facilitated the transition of 51 percent of this population back to the 
force.
    While our warrior transition units focus on our most severely 
wounded, ill, and injured soldiers, the number of soldiers requiring 
care for conditions that result in a medically nondeployable condition 
continues to grow. We recognized that there is a value add to provide 
this group of soldiers with nurse case managers in order to maintain a 
force that is ready to fight. The result has been the development of 
Medical Management Centers to facilitate a rapid return to the force of 
these soldiers. We have aligned Nurse Case Managers with our combat 
units in garrison to work with teams of Licensed Practical Nurse (LPN) 
Care Coordinators to quickly identify and coordinate care for our 
``medically not ready'' soldiers. These are soldiers who have temporary 
profiles for ongoing medical conditions that will take 30 days or 
greater to resolve. The Nurse Case Managers and LPN Care Coordinators 
partner with the soldier, the soldier's unit and the patient-centered 
medical home (PCMH) team to develop and execute a soldier-centered plan 
of care. This plan of care focuses treatment to return the soldier to 
full medical readiness as soon as the soldier is able. When a full 
return to duty is not possible, the nurse case manager facilitates the 
soldier's care and transition through the Integrated Disability 
Evaluation System (IDES).
    Our effort toward ensuring a globally ready medical force was 
further realized with the assignment of a senior nurse at U.S. Army 
Africa. As the first Chief Nurse for U.S. Army Africa, COL Armstrong is 
responsible for establishing nursing's role in support of the DOD's 
newest command. This includes researching the ``State of Nursing'' in 
55 African nations, ascertaining the medical activities of 
governmental/nongovernmental agencies to eliminate any overlap of Army 
programs, and serving as a medical ``strategist'' to identify 
opportunities for future engagements. Other activities include serving 
as a clinical expert and facilitator for military to military medical 
exchanges, surveying host nation medical facilities, and ensuring that 
personnel have the appropriate credentials for all Army-led medical 
missions on the continent.
    COL Armstrong also served as the Surgeon for Joint Task Force (JTF) 
Odyssey Guard in support of Libya during its ``Arab Spring'' uprising. 
As the senior medical advisor to the JTF Commander, COL Armstrong and 
her staff played a key role in the joint planning and oversight of 
ground, sea, and air medical assets, coordinated the medical evacuation 
of 26 Libyan war wounded to facilities in the United States and Europe, 
and supported the re-establishment of the United States Embassy in 
Tripoli.

                     ENHANCING THE CARE EXPERIENCE

    In February 2011, Army nursing began implementing a patient-
centered, outcomes focused care delivery system encompassing all care 
delivery environments; inpatient, outpatient, and deployed. The Patient 
Caring Touch System (PCTS) was designed to reduce clinical quality 
variance by adopting a set of internally and externally validated best 
practices. PCTS swept across Army Medicine, and the last facility 
completed implementation in January 2012. PCTS is a key enabler of Army 
Medicine's Culture of Trust and nests in all of Army Medicine's 
initiatives. PCTS is enhancing the quality-of-care delivery for 
America's sons and daughters.
    PCTS has improved communication and multidisciplinary collaboration 
and has created an increased demand and expanded use of 
multidisciplinary rounds (Patient Advocacy--Care Teams). In one large 
Medical Department Activity (MEDDAC), a provider was concerned with 
gaps that he saw in the discharge planning process that he had on a one 
of his wards. He said ``I think that all would agree that the PCTS has 
been a huge success in improving physician/nurse communication. 
Personally, I love being able to round with the nurse taking care of my 
patients and have already seen improvements with accountability and 
performance . . .  Mr. F. approached me this morning with a fantastic 
way to extend this same system of communication to discharge 
planning.'' This provider facilitated the necessary changes, partnering 
with nurses to ensure that the patient remained the focus of the 
change. Several facilities have reported that bedside report, hourly 
rounding, and multidisciplinary rounding are so much a part of the 
routine that they cannot recall a time when it was not part of their 
communication process. During one facility site visit, when the team 
walked into the patient room, the patient was overheard to say, ``Hello 
Care Team! It is so good to see your familiar faces--time to update my 
white board and for me to tell you what kind of day I had and what my 
priorities are tonight!''
    For the first time in the history of Army nursing, we have outcome 
data obtained through the systematic tracking and reporting of 10 
priority metrics, benchmarked against national standards. (Evidence-
Based Practices--Optimized Performance). This has served to increase 
individual and collective accountability, and the use of evidence-based 
practices. In three of our largest military treatment facilities (MTFs) 
we were having challenges in pain reassessment--we knew that it was 
being done, but it was not being documented. Pain reassessment (in the 
inpatient) and pain assessment (in the outpatient) environment is 1 of 
the 10 priority metrics of PCTS. It is also a focus area for the Pain 
Management Task Force, the Joint Commission, etc. We found that just by 
tracking this metric, there has been a significant improvement (on 
average 50-90 percent compliance within the first 60 days) to 98-
percent compliance within 90 days. Staff in these facilities were very 
excited, and instituted simple, cost neutral interventions such as 
using a medication administration buddy system, door signs in the shape 
of a clock, use of hourly rounds, and pager systems to support pain 
reassessment processes. In the outpatient areas, visual cues regarding 
the ``fifth vital sign,'' referring to perceived pain, were created, 
and a modified buddy system was used to support pain assessment 
processes. These interventions have supported pain reassessment rates 
and assessment rates of 98-100 percent which have a positive outcome 
impact for patients. We are seeing decreased rates of falls with 
injury, medication errors and medication errors with injury since 
implementation of PCTS, and are continuing to monitor these data 
monthly.
    PCTS increases the continuity of care by decreasing staff 
absenteeism and reducing staff churn. We have been tracking facility 
absentee rates monthly since PCTS was implemented, and have noted a 
decrease in many facilities. As part of PCTS, we conduct Practice 
Environment Scale of the Nursing Work Index (PES-NWI) surveys, 
completing one in January 2011 and one in July 2011. When we compared 
the data for intent to leave, there saw improvements in the data 
postimplementation. These data are very promising and warrant close 
evaluation. We will continue to monitor absentee rates, and we will 
conduct the survey again in April 2012. We expect this trend continue 
and to be able to link these data to PCTS.
    PCTS increases nurse engagement which positively impacts patient 
outcomes. (Healthy Work Environments--Shared Accountability) At a 
recent site visit to a MTF a registered nurse when asked why she was 
actively engaged in PCTS said, `` . . . for the first time in a long 
time I feel that what I have to say matters, and that nurses are seen 
as an equal part of the healthcare team--that feels good.'' One nurse 
said, ``PCTS has given the practice of nursing back to nurses--others 
used to tell us what we could and could not do and we let them--we have 
to know what our scope of practice is and PCTS has made us have to be 
much smarter about it.''
    Facilities across Army Medicine have implemented shared 
accountability in the development of unit practice councils and 
facility nurse practice councils. This has allowed each to create real 
time examination of practice, to ensure that it is standards based, 
innovative and current, and aligns with the ANA Standards of Practice 
and Professional Performance and Code of Ethics. Several of the 
products from these councils are being prepared for review by the Army 
Nurse Corps Practice Council (ANPC) for consideration as an ANC-wide 
best practice. The ANPC has fielded two Army nursing-wide clinical 
practice guidelines since PCTS implementation; patient falls prevention 
and nursing hourly rounding. Both directly support one of the 10 
priority outcome based metrics and illustrate another first for Army 
nursing.
    PCTS supports licensed personnel to perform at their fullest scope 
of their licensure, and for nonlicensed personnel to perform at their 
fullest scope of competence. In a recent site visit, a 68D 
Noncommissioned Officer shared that he is the Core Component Leader for 
Shared Accountability, and is the leader for the Unit Practice 
Councils. He said that before PCTS, he would never have been able to 
have this role. He now has a better understanding of licensed practice, 
and the scope of competence of unlicensed personnel. He believes that 
this has increased the understanding of exactly what the 68D (operating 
room technician) can do and what the 68W (medic can do). This has 
really helped all across the facility--medics are doing more than just 
taking vital signs. This makes the medics feel valued in their role in 
the clinics.
    PCTS ensures that our patients know that their best interests drive 
all of our care decisions, and that they are part of those decisions. 
As PCTS moves into sustainment, we expect that we will continue to have 
positive impacts in each of the 10 priority metrics and that these 
results will enable similar changes in Army Medicine.
    Another healthcare initiative is the patient-centered medical home 
(PCMH). Nursing engagement and commitment to in the PCMH transformation 
process have been impressive. The PCMH transformation process has been 
a grassroots and top driven endeavor from the regional medical command 
level down to each individual MTF to provide comprehensive and 
continuous healthcare to our beneficiaries.
    Nurses have been on the forefront of PCMH transformation and while 
many had unique PCMH nursing stories the following were ones that are 
the most memorable. Major (MAJ) Gray, Officer-In-Charge Military 
Readiness Clinic and Family Nurse Practitioner (FNP) states that the 
continuity of care that PCMH provides has allowed her, as an FNP, to 
put patients back into the center of care and allowed patients to trust 
that the system works. One story she shared was how a wounded warrior 
was able to decrease his pain meds from four to one over the past 6 to 
9 months. She stated that continuity of care between herself and the 
patient allowed the patient to trust that ``you will take care of me''. 
For the nurses that work in her clinic, ``the spark has been reignited 
. . . you can see it in their eyes'' and in the nursing care that they 
deliver. Often the nurses remark that, ``This is why I got into 
nursing--this is why I went to nursing school. PCMH helps me to make a 
difference and helps me to improve my patient's lives.'' One of MAJ 
Gray's nurse's, Ms. Ingram, a licensed vocational nurse (LVN), states 
that PCMH allows her to be considered a nursing professional. She 
didn't feel as if others regarded her as a professional because she was 
a LVN. She stated, ``Now my patients know me and the team. We have a 
personal relationship. They feel like we care, and we do. When we ask 
them how they are doing, they tell us. They trust the system. Even when 
I am not at work, like the other day I was at Wal-Mart after work, my 
patient call out to me, `Hey! You are my nurse!' PCMH is not about 
numbers but about our relationship with our patients.''
    Nurse Case Managers play a large role in the coordination of all 
phases of patient care in this system. Nurse case managers are having a 
direct impact on savings within our PCMHs. The case manager's early 
identification and care coordination of high-risk patients reduces 
hospitalizations and emergency room visits, improves medication 
adherence and closes care gaps that trigger or exacerbate health 
conditions. The return on investment of embedding Nurse Case Managers 
into the Primary Care Clinics and the Medical Management Centers 
directly supports the MEDCOM's initiatives.
    We recognized a need to educate Army Nurse Case Managers in all 
practice settings. In November 2011, we launched a new nurse case 
management qualification course directed toward the novice case manager 
but open to any case manager joining the Army Medical Department 
(AMEDD) team. Military graduates are awarded the M9 identifier. 
Additionally, graduates should have the core skills to sit and pass a 
national certification exam once they have obtained the clinical 
practice hours to be eligible to take either the certified case manager 
(CCM) or American Nurses Credentialing Center (ANCC) exam.
    During the week of February 6, 44 nurse case management students 
assigned to warrior transition units, community-based warrior 
transition units, and PCMH practice settings worked alongside warrior 
transition unit squad leaders and platoon sergeants at the resident 
course in San Antonio, Texas to practice skills in communication and 
collaboration. The case managers watched a movie outlining the journey 
of four Operation Iraqi Freedom soldiers and their families from 
deployment through recovery. They formed teams and developed care plans 
using the Comprehensive Transition Plan process for one of the four 
soldiers and presented it to the group. That same week, a group of 28 
nurses participated in guided discussions on effective documentation 
and the integrated disability evaluation system from around the 
country. They used Defense Connect Online technology to facilitate 
their discussion, share ideas and continue to develop a standard skills 
set as case managers.
    The Army also recognized a need for ongoing professional 
development of our nursing case managers. To facilitate the education 
of Supervisor Nurse Case Managers, the Warrior Transition Command 
developed a 4.5 day Clinical Leader Orientation Program. This program 
focuses on key leader competencies and provides attendees with 13 hours 
of continuing education. In August of this year, MAJ Steimle will begin 
a course of study to obtain a Master of Science in Nursing Case 
Management. She is our first ANC officer to receive funded graduate 
education support for a Masters in case management. Beginning in fiscal 
year 2013, we have programmed funds to send two nurses to graduate case 
management programs annually.
    Under the direction of Ms. Roberts, the Womack Army Medical Center 
Medical Management team developed a process to examine the essential 
components of appropriately sized caseloads for case managers in MTFs. 
The team developed a model that not only takes into account patient/
family acuity and nurse case manager abilities but also provides for 
capture of quality metrics, return on investment data, utilization 
management data, and peer review.
    The result was the development of the Nurse Case Manager Workload 
and Acuity Tool. This process improvement initiative has had a 
statistically significant and measurable impact on the role of case 
management in patient care, individual and department goal-setting, the 
supervisory process, and performance expectation. The MEDCOM has 
recognized this initiative as a best practice model in caseload 
calculation and the resulting quality implications. As a result the 
tool is being tested Army-wide.
    As we expand the utilization of Nurse Case Managers, so, too, do 
savings generated by their efforts. The case manager's early 
identification and care coordination of high-risk patients reduces 
hospitalizations and emergency room visits of the chronically ill, 
improves medication adherence, return's soldiers to Full Medical 
Readiness and closes care gaps that trigger or exacerbate health 
conditions.

     UNITY OF EFFORT THROUGH JOINT TEAMS AND COALITION PARTNERSHIPS

    As they have selflessly served in the past, Army nurses stand today 
on freedom's frontiers in Afghanistan supporting the International 
Security Assistance Forces (ISAF), our partners in the North Atlantic 
Treaty Organization (NATO), and as members of United States Forces--
Afghanistan. One hundred thirty-six Army nurses from all three Army 
components make up the Army Nursing Care Team--Afghanistan. Ninety-nine 
represent the Active component, 30 represent the U.S. Army Reserves, 
and two represent the Army National Guard. These nurses are delivering 
world class care to our warriors, our NATO partners, Afghan Security 
Forces, and the people of Afghanistan. They provide care in 39 
different facility-based locations, at the four distinct roles in the 
spectrum of battlefield care, at the five theater regional command 
levels, and along the entire continuum of combat care--from point-of-
injury to evacuation from the theater of operation. This care includes 
reception of Afghan casualties, treatment, and responsible discharge 
planning to the Afghan National Care System.
    Multinational partnerships are part of the shared vision for a 
stable, independent, sovereign Afghanistan. This includes the 
coordinated application of all of the available instruments of power to 
aid in stabilizing and legitimizing the Afghan system. Partner 
countries engage in activities to win the hearts and minds of the 
Afghans and a peaceful end to war and enhance efforts toward national 
stability. This includes helping the Afghan people meet their basic 
need for clean food and water, health and security; while 
simultaneously ensuring the health and welfare of the International 
Security Assistance Forces. In September 2011, 87 members of the 10th 
Combat Support Hospital from Fort Carson Colorado joined forces with 
the 208th Field Hospital and a Danish Forward Surgical Teams to provide 
comprehensive Role 3 combat health service support at Camp Bastion in 
Helmand Province, Afghanistan.
    This first ever joint U.S. Army and UK Army health service delivery 
partnership has been an innovation in the responsiveness, flexibility, 
adaptability, and battlefield capabilities supporting coalition forces, 
Afghan Security Forces, and providing much needed trauma support for 
severely injured Afghan civilians. While the partnership is largely 
about the enhanced healthcare capabilities and building reliance on the 
Afghan system of care, it has also transformed how we train, deploy, 
and sustain medical forces in a combat zone.
    The 87 members of the 10th Combat Support Hospital, including 43 
Army Nurses, began their road to war by joining 143 British 
counterparts from the 208th Field Hospital to take part in a 2-week 
Mission Support Validation (MSV) Hospital Exercise (HOSPEX) in 
Strensall, England. The assembled team was specifically formed to 
provide enhanced polytrauma surgical capabilities to care for the 
emerging complexities of blast injuries from improvised explosives 
devices (IEDs) encountered by coalition forces during dismounted 
patrols in south and southwest Afghanistan. This first ever US/UK joint 
training exercise conducted in Strensall, England was a model for 
mission specific team training for deployed operation. During this 
HOSPEX, the newly established team was collectively exposed to the 
mission expectations and facilities at Camp Bastion, including every 
aspect of care from casualty reception to evacuation. Forming teams 
with their specific practice areas the primary focus was on team 
development, familiarizing the team with the equipment and processes of 
care. This collaborative environment provided the healthcare teams with 
the opportunity to share evidence based clinical practice guidelines, 
train on procedures, and rehearse trauma procedures prior to deploying 
to ensure that everybody on the team knew, understood, and was 
validated with every protocol under combat like conditions prior to 
deploying.
    The joint US/UK support mission at Bastion/Camp Leatherneck is a 
critical one and the 43 Army nurses assigned there play an essential 
role in the combat health service support to the more than 54,650 
coalition soldiers at risk within Regional Commands South-West and 
West. They provide compassionate nursing care in the 6-bed emergency/
trauma suite, the operating theater, the 16-bed intensive care unit, 
and the 50-bed intermediate care ward. And while they do so they are 
innovating nursing practice, streamlining the discharge planning 
process, and supporting the Afghan healthcare system.

                         HEALTH SERVICE SUPPORT

    The ANC is fully engaged in joint operations with our sister 
services. One example of the synergy we have created with dedicated 
effort of the Navy and the Air Force is the Joint Theater Trauma System 
(JTTS). The ANC has been providing officers to function as trauma nurse 
coordinators in the JTTS since 2004. These critical care nurses serve 
jointly with Navy, Air Force, and Canadian nurses to collect trauma 
data in-theater and conduct performance improvement at the three U.S.-
staffed military hospitals. In the past year, six Army nurses have 
filled this role in southern and eastern Afghanistan, working closely 
with British forces and the air medical evacuation units in those 
regions. In 2011, these nurses entered more than 2,000 records in the 
military trauma registry, documenting the medical care given to all 
casualties, military and host nation, cared for by Coalition forces 
from point-of-injury to hospital discharge.
    In addition to deployed personnel, the ANC has recently positioned 
two field grade officers at the Joint Trauma System in San Antonio. 
These officers were assigned following postgraduate fellowships at the 
RAND Corporation. Using the analytic skills learned in their training, 
they have completed system-wide performance improvement and evaluation 
projects on a variety of urgent trauma issues, including pre-hospital 
medical evacuation, blood product utilization, en route critical care, 
clinical practice guidelines, and surgical complications. Whether it's 
optimizing care at the bedside in-theater, ensuring the best care at 
each stop on a wounded warrior's journey home, or at the enterprise 
level monitoring delivery of the most current evidence-based care, 
nurses continue to be integral parts of the trauma system of care.
    Another successful example of joint operations is the Walter Reed 
National Military Medical Center (WRNMMC) Inpatient Traumatic Brain 
Initiative/Post-Traumatic Stress Disorder Unit (TBI/PTSD). The TBI/PTSD 
unit, (7 East) is a 6-bed acute care unit with medical/surgical and 
behavioral health capability. Conceptually, it is a short stay unit (2-
3 weeks) where functional deficits are evaluated among wounded and 
injured servicemembers, while simultaneously engaging in early 
interventions for TBI complications. This multidisciplinary approach is 
a major collaborative effort among nurses, therapists, physicians, 
patients, and family members, and it continues to be one of the 
essential pillars that navigate and shape care provided to this complex 
population.
    One of the success stories from this venture was patient J.B. who 
initially came to 7 East with increasing behavioral issues that 
prevented his ability to live unassisted in the community after 
sustaining injuries from an IED blast and a subsequent automobile 
accident. After multiple failed hospitalizations, the family turned to 
WRNMMC for help. The patient's recovery improved with highly 
specialized collaborative treatment interventions including medication 
adjustments and behavioral therapy. A full article was published on 
this patient's case in the September 2011 Washingtonian Magazine.
    We are following the Institute of Medicine's (IOM) recommendation 
to prepare and enable nurses to lead change and advance health through 
the assignment of Army nurses to warrior transition units and our focus 
on public health and behavioral health. I believe that my assignment as 
Commander of USA Public Health Command shows that the Army recognizes 
the importance of nursing in advancing health from a healthcare system 
to a system of health.
    In America, we in DOD spend an average of a 100 minutes each year 
with our healthcare team. The other 525,500 minutes of the year our 
patients are not with us--the same amount of time our environment 
influences the behaviors that determine our health occur. Nurses are 
taking a leading role in the implementation of and partnership with the 
delivery of services that focus on wellness outside the treatment 
facility. They serve in Army Wellness Centers and provide lifestyle 
coaching and health education that focus on the behaviors that lead to 
the manifestation of diseases (e.g., hypertension, diabetes, 
cholesterol) thus reducing dependency on treatment and empowering them 
to lead healthier lives.
    Another initiative to support America's sons and daughters wellness 
outside the treatment facility is the Army healthy weight campaign--a 
comprehensive framework to increase physical activity, redesign how we 
eat and the environments that support both. It is a plan to achieve a 
unified vision of an Army family leading the Nation in achieving and 
maintaining a healthy weight through surveillance, clinical prevention, 
and community prevention. This campaign supports two strategic 
priorities of the National Prevention Strategy, signed by President 
Obama on June 16, 2011. Public health executive nurse leaders were 
instrumental in the development of this National Prevention Strategy, 
and continue to serve as national leaders in the implementation of this 
roadmap for our Nation's health.
    When prevention is insufficient to protect our warriors from health 
threats across the globe, the USA Public Health Command created the 
structure for enhanced public health nursing capability that provides 
centralized oversight with decentralized health protection and wellness 
services world-wide. This public health nursing capability exceeded all 
expectations when tested in September as part of the Rabies Response 
Team efforts when more than 9,000 warriors, DOD civilians and 
contractors across the globe received medical screening and treatment 
services--the majority within 72 hours of notification. Initially, Army 
Public Health nurses reached out to these warriors during the Labor Day 
holiday to provide the human touch that allayed their fears and 
synchronized follow-on care regardless of their remoteness to military 
healthcare facilities.
    The ANC is also engaged with the latest initiatives in the AMEDD. 
Recognizing the magnitude and impact of women's health, the Surgeon 
General identified the need for a Women's Health Task Force (WHTF) to 
evaluate issues faced by female soldiers both in theater and garrison. 
We have several Army nurses assigned to the task force, the Executive 
Officer MAJ Perata is an obstetrics/gynecology nurse. The Task Force is 
currently working on a number of initiatives for Women Health, to 
include research and development on the fit and functionality of 
uniform and protective gear for female body proportions, research of 
the psychosocial affects of combat on women, and to investigate the 
integration of Service policies on sexual assault prevention and 
response programs in theater. Given the large percentage of women in 
our Army, we fully support the TSG initiatives in women's health.

                     DEVELOPMENT OF NURSING LEADERS

    The Nurse Corps is dedicated to the support of lifelong learning by 
providing numerous continuing education opportunities. We created the 
Nursing Leaders' Academy to provide the developmental leadership skills 
within our nursing officers to mold them into future healthcare 
leaders. We send Nurse Corps officers for advanced degrees in clinical, 
research, and administrative degree programs to build our profession. 
We also support contact hours for lectures, conferences, and seminars 
to maintain our officer's licensure.
    We believe that providing a residency program to our novice nurses 
is essential to the training of new graduates. We implemented a 
Clinical Nurse Transition Program which last 6 months and prepares our 
novice nurses for clinical practice. This program, in its third year, 
has resulted in an increase in our novice nurses intent to stay in the 
ANC beyond their initial obligation as well as favorable comments from 
patient surveys. We also have developed a Clinical Nurse Leader pilot 
program and support clinical residency programs for a number of our 
graduate education programs and clinical specialty programs.
    The ANC is also following IOM's recommendation to increase the 
number of nurses with a doctorate. Our advanced practice nurses will 
possess a Doctor of Nursing Practice (DNP) as the standard degree in 
our training and education programs by 2015. We currently fund five 
nurses a year through our robust Long-Term Health Education and 
Training Program for Ph.D. studies.
    An example of one of our recent Ph.D. students is MAJ Yost who 
earned her Ph.D. degree in nursing from the University of Virginia. Her 
dissertation was titled, ``Qigong as a Novel Intervention for Service 
Members With Mild Traumatic Brain Injury''. The purpose of the study 
was to determine the level of interest in and perceived benefit of a 
program of qigong, a Chinese health system that has been practiced for 
thousands of years. In addition to perceived improvements in quality of 
life and pain management, the active meditative movements of qigong 
allowed servicemembers to enjoy benefits of meditation without 
experiencing troublesome flashbacks commonly seen in those with mild 
traumatic brain injury (mTBI) and comorbid PTSD.
    The ANC also values the contributions of our Department of the Army 
civilian nurse leaders. Our consultant for Nursing Research, Dr. Loan, 
is one of our many valued civilian members. Dr. Loan, Ph.D., RNC, just 
completed her second year as the Consultant to the Surgeon General for 
Nursing Research. Her recent contributions include: AMSUS November 2011 
Speaker: Army Nursing Research Evidence-Based Priorities Breakout 
Session; Nursing Research Advisory Board Meeting November 2011 to 
establish 2012 EBP/Research priorities. She recently was published in 
the AMEDD Journal related to the transformation from Nursing Research 
Service to Centers for Nursing Science and Clinical Inquiry October-
December 2011. Dr. Loan was inducted into the Fellows of the American 
Academy of Nursing (FAAN) in October 2011.
    The total civilian nurse (registered nurse (RN), licensed practical 
nurse (LPN), and certified nursing assistant (CNA)) inventory 
constitutes 23 percent of the MEDCOM civilian workforce and 34 percent 
of the civilian medical occupations in Career Program 53--Medical. 
Civilian nurses work in all nursing care settings to promote readiness, 
health, and wellness of soldiers, their family members, retirees, and 
other eligible beneficiaries across the lifespan. It is the dedicated 
civilian nurse workforce that enables and complements the ANC to meet 
full mission requirements by serving as the fibers in the network of 
continuity at fixed facilities. Civilian Nurse Career development has 
been on the forefront of the Nurse Corps agenda for the past decade in 
support of integrated Talent Management and Leader Development. This 
integration fosters development of adaptive leaders and further 
building of highly trained, educated, and confident leaders and 
followers to construct required high-performing integrated teams.
    The ANC has diligently worked to establish sustainable career life-
cycle management strategies such as Student Loan Repayment Program, 
Accelerated Training and Promotion Program, standardized nurse titling, 
nurse competencies, and nursing position descriptions (some dating back 
to the 1970s), and Career Maps which have either been implemented or 
are in progress. For example, the student loan repayment program has 
supported 955 individuals with 299 of them supported for multiple 
years. This has resulted in 85-percent retention rate of these for 
retention purposes and improved educational status of the workforce. 
The Accelerated Training Program allows for new RN placement and 
accelerated promotion of two grades within 1 year with successful 
completion of each phase of training. Fifty-three personnel have 
successfully completed this program which has resulted in advancing 
academic accomplishments and career entry for nursing personnel. The 
DOD Civilian Healthcare Occupations Sustainment Project (CHOSP) has 
been a multiphased initiative that has resulted in updated 
qualification standards for civilian RN and LPN nursing positions and 
the creation of an advanced practice registered nurse (APRN) standard 
to support a relevant and dynamic workforce. These, along with 
standardized titling and competencies, promote value by reducing 
unnecessary variance leveraging the full capabilities of a trained 
workforce, and enhancing unity of effort. The feasibility and 
functionality of Professional Standards Boards (PSBs) continue to be 
explored as a culmination of the nurse career development and 
progression.
    I envision the ANC will continue compassionate care and innovative 
practice in healthcare. Through the PCTS and the PCMH we will 
consistently and reliability meet the needs of our patients and their 
families. We will continue to grow and develop our nurses to fill the 
gaps in our health system while anticipating future needs. The ANC is 
positioned for the changes in our Army and in Military Medicine. We 
will continue to embrace our proud past, engage the present challenges, 
and envision a future of seamless improvement in quality care. We in 
Army nursing are truly honored to care for America's sons and 
daughters. Senator Inouye, Vice Chairman Cochran, and distinguished 
members of the subcommittee, thanks again for the opportunity to 
highlight Army nursing. I am humbled and honored to represent the more 
than 40,000 men and women who comprise Army nursing and serve as the 
24th Chief of the Army Nurse Corps.

    Chairman Inouye. Thank you very much, General Keenan. 
Before I proceed, I'd like to assure all of you that your full 
statements are part of the record, and then we will be 
submitting our more technical questions for your responses in 
writing.

                         CHIEF NURSE CORPS RANK

    I have one question with two parts: Any comments you'd like 
to make on the reduction of rank from 08 to 07, as Chief of new 
nurses? Do you do have any problems with recruiting and 
retention?
    May I start with the Admiral?
    Admiral Niemyer. Thank you, Senator. On the first question, 
first and foremost, we are very grateful for your continued 
support of leadership opportunities for nurses in both the 
profession of nursing as well as military nursing.
    I have had the unique experience among my peers to serve as 
a one star. When I was selected as a one star, it gave me the 
opportunity to have a position that I believe was extremely 
competitive in a leadership role, overseeing the TRICARE 
contract for the western region, a $17 billion contract. I 
believe that opportunities like that, at the one-star level, 
could, in fact, make our nurses continue to be competitive in a 
selection process for a second star.

                    NURSE RECRUITMENT AND RETENTION

    I do not disagree with the efficiencies that have been 
directed by the Department. I would like to say that having an 
important leadership path and competitive support for nurses 
getting exposure to various assignments that will, in fact, 
make them competitive both at the rank of selection for one 
star as well as two is extremely important. And I think as we 
see a group of nurses coming forth, who have the same battle-
tested expertise, fleet assignments and assignments with the 
Marine Corps, we will continue to grow a very competitive group 
of nurses who can compete in any environment.
    In the second question, recruitment and retention, we are 
doing extremely well in both of those areas in the Navy Nurse 
Corps. We have met our recruiting goals in the Active component 
for the last 6 years, and I believe that we have the right 
incentives with special pays and accession bonuses that you've 
been quite instrumental in helping us to attain. That has been 
extremely useful for us in our retention as well, with special 
pays for registered nurses and our advanced practice nurses. 
So, we are doing quite well.
    We do recognize that there is a time where we may not have 
the same kind of economy, where we may see people leaving the 
military, and we look continually for programs and 
opportunities to continue that exposure to the military and 
develop our staff along the way, so that the choice will be 
retention and not movement to the civilian sector.
    Thank you.
    Chairman Inouye. General Keenan.
    General Keenan. Yes, Sir. On the first question, I will 
tell you that I do agree with Lieutenant General Horoho. We 
have developed a very robust leadership development track in 
Army Medicine that truly allows our nurses to compete at any 
level or command. And with that, we want to thank you for your 
continued support to expand fair opportunities for us in 
military medicine to have those abilities to compete for those 
types of inmaterial command.
    But, we do believe that with the leadership opportunities 
that we do have available in military medicine to compete for 
combat commands, in combat support hospitals, we've had several 
nurses who have led combat support hospitals in Iraq and 
Afghanistan. We have Army nurses who have led at the level-two 
medical center level, and then we have the opportunities to 
command other branch and material areas. We believe there is a 
system in place that would support our progression.
    Chairman Inouye. Thank you very much.
    General Siniscalchi.
    General Siniscalchi. Sir, first, I would like to thank you 
for your continued advocacy for nursing. Words just can't 
express how much we appreciate the value that you have placed 
on our profession. And regarding the two-star billets, you 
know, I have just been honored and blessed to serve at this 
rank, and it has served our Air Force Medical Service very 
well.
    However, recognizing the need for efficiencies, the Air 
Force does support the Department's decision. However, until 
the legislation is changed, the Air Force will continue to fill 
this position of responsibility with the two-star.
    And, Sir, in regards to your question on recruiting and 
retention, like my sister services, we also are doing very well 
in recruiting. However, the majority of our recruits are new 
nurses. They're new graduates. Novice nurses. We have great 
opportunities for them to advance professionally and to 
transition into their new profession and into military nursing.
    The incentive special pay has helped a tremendous amount in 
our retention, and we do have professional opportunities for 
advanced academic education and for fellowships. Also like my 
partners, we are very excited about the opportunity to offer 
our nurses the new Director of Nursing Practice (DNP) program. 
We have the new graduate program at the Uniform Services 
University for mental health nurse practitioners. And so that 
is serving as an incentive for our nurses to stay. However, we 
do experience problems with retaining our clinical experts at 
the bedside, tableside and litter side, because of our 
constrained promotion opportunity.
    But, I am very pleased to say that we have received 
tremendous support from the Air Force, and our sister services 
are supporting us in this endeavor. And so we continue to work 
with the Assistant Secretary of the Air Force for Manpower and 
Readiness, as well as the Office of the Secretary of Defense 
for Personnel and Readiness in exploring various policy options 
to help us correct the great constraints that we currently 
have.
    So, we are very hopeful that we will be able to open the 
aperture for promotion and have the grade that we need at the 
field-grade rank, so that we can retain the clinical experts 
that we need in order to grow and mentor our novice nurses 
coming up through the ranks.
    Chairman Inouye. Thank you very much.
    General Siniscalchi. Thank you, Mr. Chairman.
    Chairman Inouye. I asked that question, because as you're 
aware, in the civilian sector, nursing shortage is a major 
problem, and we're trying our best to resolve that, but it's 
very expensive. Thank you very much.
    The Vice Chairman.
    Senator Cochran. Mr. Chairman, thank you.
    I may ask this question of all of our witnesses. We have 
information about a new system called ``Care Case Manager 
System'' that was implemented in my State at Keesler Air Force 
Base Hospital, and it involves supporting patients with a 
communication case manager at both Keesler and the VA Hospital 
in Biloxi. I'm told that this has really helped define needs in 
a unique way, that the Care Case Manager System that was 
implemented at Keesler is innovative and is a big success.
    I wonder if you've heard about this, or if this is 
something that is being replicated at other treatment centers 
or hospitals around the country.
    I'll ask each of you.
    General Keenan. Yes, Sir. We do have nurse case management 
in the Army, and actually, we've had case management. 
Historically, it was in disease management. So, if you looked 
at asthma or high-risk disease processes. In 2007, when we 
stood up the warrior transition units, one of the key 
components that we found was missing in the care of our 
wounded, ill, and injured soldiers was case management, because 
they really provided that holistic support to the soldier and 
their family to coordinate their care.
    From our lessons learned with case management, and also 
with our patient caring touch system, and how we have now 
focused on our major platform of our patient-centered medical 
home, we have implemented not only case management in our 
warrior transition units, but we've also implemented it in our 
patient-centered medical homes, also in our embedded behavioral 
health teams that support our brigade combat teams, as well as 
in our medical management centers for our soldiers, and we 
truly believe, as you do, Sir, that this really empowers our 
patients. It ensures they're getting quality safe care, and it 
coordinates their care, and it gives them a safety net, someone 
that they can go to, they can help them understand what is 
going on in the care process.
    We really envision in Army nursing the next step is in our 
Army wellness centers when we talk about the white space, the 
525,500 minutes that people are not directly in our purview, 
our care, and our Movement Tracking System (MTS), that this is 
really going to give us the ability to affect diet, exercise, 
well-being for their mental and spiritual health. So, we 
totally embrace the concept of our nurse case managers and 
truly see it as an enabler for all we do, not only in Army 
nursing but also in Army Medicine.
    Senator Cochran. Thank you.
    Admiral Niemyer.
    Admiral Niemyer. Thank you, Senator.
    Nurse case management is the very fabric of communication 
and integration for across the enterprise for our wounded 
warriors, for our family members, from pediatrics, to 
geriatrics, to our wounded warriors in between. And it is the 
weaving together of a multidisciplinary effort to take a 
holistic approach with a patient, including that transition, 
perhaps, out of our system, as you recognized, into the VA. The 
Federal recovery coordinators for the VA are in our system, are 
in our MTS, to assist with that warm handoff, so we don't lose 
a patient in that transition.

                         NURSE CASE MANAGEMENT

    Nurse case management, as well as nonmedical case 
management, is so important to helping our patients guide 
through the multitude of administrative systems they have as 
wounded warriors. So we're equally as engaged and partnered in 
ensuring that all of our facilities have robust case management 
programs across the enterprise.
    Senator Cochran. Thank you. General Siniscalchi.
    General Siniscalchi. Yes, Sir. Keesler Air Force Base is a 
great example. So, I'd like to thank you for sharing that.
    Actually, once they initiated the program with case 
management, they were able to notice a difference within the 
first 6 months. And we've seen significant impact as we've 
moved forward the Air Force's pathway to patient-centered 
medical home has been the family health initiative. And within 
that staffing model, we laid in case managers as well as 
disease managers, but we found the impact of the role of the 
case manager has been phenomenal with this process. We've seen 
decreased emergency room and urgent care visits. We've seen 
increased provider as well as patient satisfaction. Better 
communication amongst the team, the family health team, as well 
as increased communication with the nurse, the technicians, and 
the patient. And, you know, in essence, the case manager has 
really been able to step in and navigate, help the patient 
navigate through the healthcare continuum.
    So, if I may share just a few data points, as we've been 
trying to actually monitor and track the success of our family 
health initiative and the role of the case manager in that. The 
case managers have coordinated care for more than 66,000 
patients in fiscal year 2011. And this actually was an increase 
from fiscal year 2010 of more than 6,000. And we have seen 
their coordinated care with our wounded warriors. Their care 
has touched more than 3,200 since fiscal year 2011. So, they're 
having a very significant impact and a strategic reach across 
the healthcare continuum.
    So, as we've tracked several data points, we found that in 
healthcare costs that the impact they're making has actually 
resulted in $2.6 million in savings. So, we've been very 
pleased with the initiative of putting the case management 
model and that role in our patient-centered medical home.
    Thank you.
    Senator Cochran. It's a very impressive report and we 
congratulate you on the initiative and also the leadership in 
all of our healthcare centers throughout the armed services.
    Your leadership, all of you, is really remarkable. It sets 
the United States apart from every other country in the success 
that we've had in managing the care, delivering healthcare 
services to our men and women who have served, and have been 
injured, or become ill in the military service of our country. 
Thank you all.

                     ADDITIONAL COMMITTEE QUESTIONS

    Chairman Inouye. On behalf of the subcommittee, I thank the 
Surgeons General, and the Chief of the Nurses Corps, and we 
look forward to working with you in the coming months.
    [The following questions were not asked at the hearing but 
were submitted to the Department of response subsequent to the 
hearing:]

            Questions Submitted to General Charles B. Green
            Questions Submitted by Chairman Daniel K. Inouye

    Question. General Green, since 2003 the Nurse Corps Chief position 
for each of the Services has been authorized as a two-star billet. The 
Department recently sent over a legislative proposal that would reduce 
the Corps Chief position to the one-star level. What would be the 
negative effects on the Nurse Corps if the Chief positions were 
converted back to one-star billets?
    Answer. A two-star billet, as the Nurse Corps Chief, has served the 
Air Force Medical Service well. Recognizing the need for efficiencies, 
the Air Force supports the Department of Defense's decision. Nurse 
Corps officers receiving in-depth professional development will 
complete well for two-star positions available in the Air Force Medical 
Service without the congressional mandate for the Corps Chief to be a 
two star. Until the legislation is changed, the Air Force will continue 
to fill this position of responsibility with a two star.
    Question. The Department's fiscal year 2013 budget assumes $452 
million in savings based on new TRICARE enrollment fees and increases 
in co-pays for prescription drugs. General Green, I understand that 
military leadership supports these changes, but what are you hearing 
from troops and their families? Do you believe this will impact 
recruiting?
    Answer. Our retiree population actively shapes perceptions of the 
value of military service. Any action that discourages our retiree 
population can adversely impact recruiting activities. Healthcare 
benefits for Active Duty military personnel are minimally impacted 
under the current proposal. TRICARE standard caps will affect the small 
number of Active Duty family members not enrolled in Prime. Pharmacy 
co-pay increases only affect those who do not get their prescription 
filled at a military treatment facility. Although increases in 
healthcare fees may be perceived as a loss of benefit to our 
beneficiaries, the increases are not expected to negatively influence 
retention of Active Duty military personnel.
    Question. General Green, I understand the Air Force has begun using 
vending machine-like kiosks on bases to help alleviate pharmacy wait 
times. What other initiatives are under way?
    Answer. The most significant initiative underway to improve 
pharmacy operations and reduce wait times is the development and 
implementation of the pharmacy staffing model. The model helps us 
balance pharmacy manpower across the Air Force Medical Service (AFMS) 
based on workload. Changes in the long-term program using this model 
begin taking effect in fiscal year 2013, but we are also using it now 
to address the most egregious staffing imbalances with current year 
funding. The Air Force Manpower Agency has also recently begun 
conducting a formal manpower study to more precisely quantify pharmacy 
manpower requirements utilizing management engineering techniques. This 
study will result in a new official manpower standard for Air Force 
Pharmacy.
    We are engaged in a continuing effort of sharing and implementing 
lessons learned from Air Force Smart Operations for the 21st Century 
(AFSO21) events (and other best practices) from site visits and regular 
communications with pharmacy leadership to optimize workflow and 
facility design. We are currently reviewing the results to ensure we 
are taking advantage of what we have learned already and targeting 
future efforts at expanding our knowledge base of best practices for 
application across Air Force pharmacies.
    An additional system-wide initiative is the upgrade of pharmacy 
automation and patient queuing technology. We are working towards a 
full technology refresh Air Force Medical Service wide within the next 
3 years. The new automation equipment will include telepharmacy 
capability, which allows remote review of prescriptions to assist 
pharmacies, particularly smaller ones, during their busiest times or 
when Active Duty pharmacists are deployed. Recent efforts to improve 
wait times have included adding manpower, shifting manpower as needed 
to problem areas (e.g., from in-patient to out-patient pharmacies), 
workflow process improvements, and the addition of or upgrading of 
current patient queuing systems and pharmacy automation equipment. 
Facility expansion and improvements are also underway at several Air 
Force pharmacies.
    Question. General Green, part of the challenge of recruiting 
medical professionals is the divide between private sector and military 
compensation for health specialties. Given the increasing fiscal 
constraints the Department is facing in the coming years, how will you 
manage your resources to sustain the medical professionals required to 
care for servicemembers and their families?
    Answer. AFMS continually reviews current and projected healthcare 
needs and directs appropriate changes within the allocated force 
structure in order to meet our ever-evolving missions. With total 
personnel inventory slightly below our total funded authorizations, the 
AFMS meets the Nation's critical mission needs by apportioning the 
current inventory to meet requirements in the near-term and relying on 
the purchased care system from our TRICARE partners for the noncritical 
mission needs of the Air Force. The AFMS is utilizing Federal service 
employees and contractors within our Medical Treatment Facilities in 
addition to our TRICARE partners to supplement shortfalls of our 
uniformed staff as we provide quality healthcare to our entire 
beneficiary population.
    Even as Air Force retention in general is high, recruiting and 
retention of highly-skilled health professionals is improving with our 
long-term program strategies, albeit tenuously, through a three-prong 
approach. The Air Force continues to fund all available authorities to 
stabilize ailing health professions career fields by:
  --fully utilizing scholarship and educational programs for our long-
        term shortages;
  --effectively targeting accession bonuses and other special and 
        incentive pay programs for our immediate needs; and
  --providing emphasis and support for other nonmonetary programs to 
        retain our quality staff.
    Question. General Green, the Services continue to transition 
patients to a medical home model. This concept organizes health 
professionals into teams to provide a more comprehensive primary 
approach. Each patient's personal physician leads the team and serves 
as a continuous point of contact for care. Has the Air Force seen 
improvements in patient satisfaction or cost control with this 
initiative?
    Answer. Over the course of the past year, we have completed the 
enrollment into Patient-Centered Medical Home (PCMH) for our Air Force 
Family Health and Pediatric clinics. Now more than 945,000 patients are 
currently being cared for under this model. We have seen a steady 
improvement in the satisfaction of our patients seen in a PCMH with the 
percent rating satisfied or completely satisfied with their care rising 
from 91.9 percent in May 2011 to 93 percent in December 2011. Likewise, 
we have seen substantial cost avoidance with notable decline in our 
patients' utilization of Emergency Room/Urgent Care Clinic (ER/UCC) 
care. Over the similar May-December 2011 time period, ER/UCC 
utilization from patients enrolled to a PCMH in the Air Force has 
decreased from 6.87 visits per 100 enrollees per month to 5.59 visits 
per 100 enrollees per month.
                                 ______
                                 
            Questions Submitted by Senator Dianne Feinstein

                               MEFLOQUINE

    Question. In 2009, the Department of Defense (DOD) published 
research that showed that approximately 1 in 7 servicemembers with 
mental health contraindications had been prescribed mefloquine contrary 
to the instructions in the package insert guidance, including to 
servicemembers taking antidepressants and with serious mental health 
conditions such as post-traumatic stress disorder. This research went 
on to highlight that such use may have significantly increased the risk 
of serious harm among those who had been misprescribed the drug.
    What research has the Air Force undertaken to determine whether 
this trend has been reversed, and what efforts has the Air Force 
undertaken to identify and follow-up on those who were misprescribed 
the drug, to determine whether they may be suffering from the adverse 
effects of its use? Can the Air Force assure us that this group has not 
experienced more significant problems associated with this 
misprescribing?
    Answer. The Air Force began enforcing the Food and Drug 
Administration's warnings and precautions regarding mefloquine in 2005, 
several years before the Assistant Secretary of Defense for Health 
Affairs memorandum was issued in 2009. Air Force utilization of 
mefloquine declined considerably between 2005 and 2009. In 2009, the 
Health Affairs memorandum about mefloquine was sent to every Air Force 
medical treatment facility, and subsequently the Air Force mefloquine 
utilization declined an additional 90 percent from 2009 to 2011. Only 
458 prescriptions for mefloquine were issued in 2011.
    Mefloquine is one of the medications that have annual drug 
utilization review requirements from each Air Force medical treatment 
facility, as directed in the 2005 Air Force memorandum. Reviews cover, 
at a minimum, the following:
  --not prescribing mefloquine to those on flying status or with 
        contraindications;
  --correct dosing and directions within prescriptions;
  --patient counseling and documentation;
  --completing the DD 2766; and
  --providing the printed Food and Drug Administration's MedGuide at 
        the pharmacy.
    The reviews from the last quarter of 2011 demonstrated that no 
mefloquine was prescribed to flyers or patients with contraindicating 
conditions, and that the pharmacy provided the patient medical guide 
100 percent of the time.
    Question. What epidemiological research is currently underway to 
investigate the short- and long-term effects of exposure to mefloquine? 
Can you tell me what is the total amount of funding devoted to these 
projects?
    Answer. The Air Force does not currently have any active 
epidemiologic research on the short- and long-term effects of exposure 
to mefloquine. However, the Department of Veterans Affairs Medical 
Follow-up Agency maintains the records and approves research using the 
clinical and laboratory specimens for one of the longest cohort studies 
of servicemembers, the Air Force Health Study. The participants in the 
study may have included members who had received mefloquine for malaria 
prophylaxis. Additionally, the Army and Navy have ongoing research into 
antimalarials through the Walter Reed Army Institute of Research, the 
Naval Medical Research Center, and the overseas laboratories. The 
Department of Veterans Affairs Medical Follow-up Agency, the Army, and 
the Navy can provide figures for the total amount of funding devoted to 
these projects.
    Question. The Department of Defense has specialized centers to 
address traumatic brain injury (TBI) and post-traumatic stress disorder 
(PTSD), including the National Intrepid Center of Excellence and other 
centers within the Centers of Excellence for Traumatic Brain Injury and 
Psychological Health. The Centers for Disease Control and Prevention 
has recently noted that the side effects of mefloquine may ``confound 
the diagnosis and management of posttraumatic stress disorder and 
traumatic brain injury''. Given that the adverse effects of mefloquine 
may often mimic those of TBI and PTSD, has the Air Force provided 
training to those who work within the National Intrepid Center of 
Excellence and Defense Centers of Excellence to include the diagnosis, 
management, and research of mefloquine toxicity?
    Answer. All providers sent by the Air Force to any Center of 
Excellence are fully qualified and expected to practice in accordance 
with current clinical standards such as the Department of Veterans 
Affairs/Department of Defense practice guidelines for TBI and PTSD. The 
symptoms of TBI are nonspecific, thus any evaluation of symptoms 
associated with TBI includes consideration of other causative or 
contributing factors including medications. Likewise, a diagnosis of 
Acute Stress Disorder or Post Traumatic Stress Disorder requires that 
the treating provider reach the conclusion that the observed 
``disturbance is not due to the direct physiological effects of a 
substance (e.g., a drug of abuse, a medication)'' among other factors. 
Therefore, consideration of the effects of any medications the patient 
is currently taking, or has taken recently, are integral to the 
screening and diagnostic processes at the National Intrepid Center of 
Excellence, Defense Centers of Excellence and Air Force medical 
treatment facilities worldwide. When Air Force nonphysician mental 
health providers such as social workers, psychologists, and psychiatric 
nurse practitioners have questions regarding the potential effects of 
any medication, they are encouraged to seek consultation and 
collaboration with psychiatrists or other physicians.
                                 ______
                                 
               Question Submitted by Senator Thad Cochran

                       HYPERBARIC OXYGEN THERAPY

    Question. General Green, I understand that $8.6 million is included 
to fund a clinical trial using hyperbaric oxygen therapy to diagnose 
and treat brain injury. What is your experience with this therapy? Do 
you think it has merit in treating traumatic brain injury?
    Answer. Anecdotal case reports and open-label studies suggest 
benefit of hyperbaric oxygen (HBO2) for treating chronic 
symptoms associated with traumatic brain injury (TBI). However, 
anecdotes and open-label studies cannot discriminate between the 
effects of the HBO2 and the indirect, or placebo, effects of 
study participation. Further, TBI is not endorsed by the Undersea and 
Hyperbaric Medical Society or approved by the U.S. Food and Drug 
Administration as a medical indication for HBO2. The 
Department of Defense and the Air Force are committed to an evidence-
based approach to developing policy on HBO2 use to ensure it 
is safe, effective, and comparable or superior to standard care for 
symptoms associated with TBI. Several recent studies, including the Air 
Force study in San Antonio suggest that HBO2 is safe in 
servicemembers with chronic symptoms associated with TBI. The Air Force 
study found no statistical difference between the treatment group and 
the sham group. Improvements in some test measures, however, were seen 
in both groups. Additional data analysis is underway to determine if 
there are similar demographics in subgroups that showed improvement. We 
continue to support a robust research effort on hyperbaric oxygen for 
chronic symptoms associated with TBI, and data from those studies will 
be frequently re-assessed for evidence of safety and efficacy.
                                 ______
                                 
           Questions Submitted to Vice Admiral Matthew Nathan
            Questions Submitted by Chairman Daniel K. Inouye

                         NURSE CORPS CHIEF RANK

    Question. Admiral Nathan, since 2003 the Nurse Corps Chief position 
for each of the Services has been authorized as a two-star billet. The 
Department recently sent over a legislative proposal that would reduce 
the Corps Chief position to the one-star level. What affect would a 
reduction in rank have on the Navy Nurse Corps?
    Answer. We support the decision to standardize the rank of the 
Director of the Navy Nurse Corps to the grade of 07, and believe this 
change will have no adverse impact on the Nurse Corps. Navy Medicine 
places a priority on our leader development programs, and our Navy 
Nurses continue to demonstrate they have the experience, skill and 
motivation to succeed positions of great responsibility and trust. We 
have Nurse Corps officers in command of our medical treatment 
facilities, serving in senior operational medicine assignments with the 
Fleet and Marine Forces, and managing vital headquarters-level 
responsibilities. The Director of the Navy Nurse Corps will have the 
skills, experience, and opportunity to succeed as a one-star flag 
officer; and correspondingly, be highly competitive for selection to 
two-star. If Director is selected for promotion to two-star, this would 
allow an another flag officer opportunity for the Nurse Corps as an 
officer would then be selected to serve as a one-star flag officer and 
the Director.

                              TRICARE FEES

    Question. Admiral Nathan, the Department's fiscal year 2013 budget 
assumes $452 million in savings based on new TRICARE enrollment fees 
and increases in co-pays for prescription drugs. Will these increased 
fees affect care for servicemembers and their families? How are 
servicemembers and retirees reacting to these proposals?
    Answer. The Department of Navy supports these proposals and 
believes they are important for ensuring a sustainable and equitable 
benefit for all our beneficiaries. The TRICARE fee proposals do not 
affect our Active Duty servicemembers, and specifically exempt 
medically retired servicemembers and their families, as well as 
survivors of military members who died on Active Duty. While the 
proposed increases will primarily impact our retired beneficiaries, 
military medicine provides one of the most comprehensive health 
benefits available. These changes will help us better manage costs, 
provide quality, accessible care, and keep faith with our 
beneficiaries.

                         PHARMACY WAITING TIME

    Question. Admiral Nathan, the structure of the proposed TRICARE 
pharmacy co-pays strongly incentivizes members to fill their 
prescriptions at pharmacies within military treatment facilities. Yet, 
we continue to hear concerns about the current wait times at numerous 
pharmacies. How is the Navy addressing the problem of lengthy pharmacy 
wait times?
    Answer. Our Navy Medical Treatment Facilities (MTFs) strive to 
efficiently balance the staffing of the pharmacy (and other clinical 
areas) with expected demand, while expanding the service and/or hours 
of access provided. Understanding that increases in demand are expected 
in the future and improvements in access could be realized, Navy 
Medicine has engaged in a relook of the outpatient pharmacy workflow 
process as part of the acquisition to replace our existing pharmacy 
automation, which is close to 10 years old.
    Through a review of the existing workflow at our larger sites by 
pharmacy workflow experts (i.e., industrial engineers, operations 
research specialists, and pharmacists), we have developed pharmacy 
workflow and automation requirements. These requirements will support 
up to a doubling of the existing workload while striving for a 90th 
percentile wait time of 30 minutes or less. This goal reflects an 
approximate 50-percent decrease in our current 90th percentile waiting 
time. Moving forward, we will continue to invest in pharmacy automation 
which allows us to address any expected increase in demand at our MTF 
pharmacies and maintain outstanding customer services.

                           SUICIDE PREVENTION

    Question. Admiral Nathan, the Services are seeking to provide early 
identification and treatment of psychological health through a number 
of initiatives; yet, suicides throughout the military continue to rise. 
In 2011, Active Duty, Guard, and Reserve soldiers took their lives at a 
record high rate. How are the Services working together to learn from 
one another and combat the continued rise in suicides?
    Answer. The Services work together closely in the area of suicide 
prevention by sharing lessons learned, research, and promising 
practices in formal and informal mechanisms of suicide prevention. The 
Navy continues to integrate efforts related to personal and family 
readiness programs, not only across the Navy enterprise but in 
collaboration with the other Services, DOD, the VA, and various Federal 
agencies, with the shared goal of reducing the number of suicides. Some 
specific ways the Services have worked together include:
Suicide Prevention and Risk Reduction Committee
    The DOD Suicide Prevention and Risk Reduction Committee (SPARRC) 
with representation from all Services (including Coast Guard) and DOD, 
has now expanded to include VA and Substance Abuse and Mental Health 
Services Administration (SAMSHA) participants. Over the years the 
SPARRC has worked to standardize the process for determining suicide 
numbers and rates, developed a common data collection mechanism (the 
DOD Suicide Event Report), conducted an annual conference, and provided 
a forum for the sharing of observations, promising practices, and 
lessons learned regarding the prevention of military suicides. The 
SPARRC chairmanship moved from its original home in DOD Health Affairs 
to the Defense Center of Excellence, and at the end of 2011, to the new 
OSD Suicide Prevention Office under the Undersecretary of Defense for 
Readiness.

Department of Defense/Department of Veterans Affairs Suicide Prevention 
        Conference
    The Department of Defense (DOD)/Department of Veterans Affairs (VA) 
Annual Conference has grown into the largest meeting of its kind in the 
world. This weeklong conference has multiple tracks that include 
clinical, research, and practical tools for suicide prevention. It 
brings together many of the Nation's leading suicidology theorists and 
researchers, along with military leaders, care providers, and 
policymakers.

Task Force
    The congressionally mandated (Fiscal Year 2009 National Defense 
Authorization Act) Task Force on the Prevention of Suicides Among 
Members of the Armed Forces published its report in the fall of 2010. 
The Services are continuing to implement many of these recommendations 
and one key outcome has been the establishment of an office within OSD.

                           PHYSICIAN STAFFING

    Question. Admiral Nathan, some medical specialties are severely 
understaffed, particularly in the Reserve component. How is the Navy 
ensuring that it has the number of Reserve physicians it needs?
    Answer. Reserve physician recruiting remains one of our greatest 
challenges; our manning at the end of March 2012 was at 55 percent of 
requirements. High Active component physician retention rates are a 
positive for the Navy; however, the second order affect is a decreased 
pool of medical professionals eligible for Reserve affiliation. 
Consequently, there is a greater reliance on attracting civilian 
physicians in a highly competitive Direct Commission Officer (DCO) 
market.
    We have developed strong partnerships with our key Navy 
stakeholders and are exploring a plethora of action items in our 
efforts to recruit and retain the right physician skill sets in our 
Reserve physician inventory. Examples include a Medical Leads 
Assistance Program; affiliation, specialty, and incentive pay 
initiatives; and a change in paygrade billet requirements under an 
Officer Sustainability Initiative. We are optimistic that these 
initiatives as well as a continued reduction in Reserve Individual 
Augmentee assignments will incentivize potential Reserve physician 
recruits.
    Navy Medicine has representation on the Tri-Service Medical Working 
Group that has reviewed the results of the Joint Advertising, Market 
Research and Studies (JAMRS) Physician Recruit Study (Recruiter Guide) 
released in September 2011 and work continues to augment incentive 
capabilities to address the challenges all Services are experiencing in 
recruiting Reserve physicians.

                    MILITARY HEALTH SYSTEM STRUCTURE

    Question. Admiral Nathan, earlier this month the Department 
released its final decision on the structure of the Military Health 
System. The Department decided on a proposal to combine the 
administration and management of the Military Health System into a 
Defense Health Agency. Can you please share with the subcommittee any 
concerns you may have about the final recommendations?
    Answer. Navy Medicine fully supports a joint solution that will 
enhance interoperability of medical care across the MHS both 
operationally and within Services' medical treatment facilities. We 
must, first and foremost, not break a highly functioning patient care 
continuum that can bring a warrior from the point-of-injury to 
definitive care at a level four MTF in 48-72 hours. A thorough 
outcomes-based analysis of any major changes in governance that impacts 
meeting Service operational commitments must first be completed and 
then presented to the Service Chiefs. Although the belief may be that 
consolidation of services or support will be cost effective, an in-
depth effects-based analysis for each shared service prior to 
consolidation must be completed to set a baseline cost to assess the 
need for change or to evaluate future return on investment of system 
changes. The bottom line is that the MHS must proceed in a deliberate 
and measured manner to ensure that our readiness to support our 
Services' missions and core warfighting capabilities will be maintained 
and our excellence in healthcare delivery will be sustained.
                                 ______
                                 
            Questions Submitted by Senator Dianne Feinstein

                               MEFLOQUINE

    Question. In 2009, the Department of Defense (DOD) published 
research that showed that approximately 1 in 7 servicemembers with 
mental health contraindications had been prescribed mefloquine contrary 
to the instructions in the package insert guidance, including to 
servicemembers taking anti-depressants and with serious mental health 
conditions such as post-traumatic stress disorder (PTSD). This research 
went on to highlight that such use may have significantly increased the 
risk of serious harm among those who had been misprescribed the drug.
    What published research has the Navy undertaken to determine 
whether this trend has been reversed, and what efforts has the Navy 
undertaken to identify and follow-up on those who were misprescribed 
the drug, to determine whether they may be suffering from the adverse 
effects of its use? Can the Navy assure us that this group has not 
experienced more significant problems associated with this 
misprescribing?
    Answer. In 2006, medical researchers at the Naval Health Research 
Center in San Diego published a peer-reviewed paper describing a 
retrospective study of health histories of 8,858 Active Duty 
servicemembers who had been prescribed mefloquine between 2002 and 
2004. The health history outcomes of these members were compared 
against a full analysis of the health histories of 388,584 
servicemembers not prescribed mefloquine during the same period. The 
results of that study showed a significantly decreased proportion of 
mefloquine prescribed individuals hospitalized for mood disorders when 
compared to servicemembers assigned to Europe or Japan and no 
difference in mood disorders or mental disorders compared to 
servicemembers in deployed status. These data demonstrated no 
association between mefloquine prescriptions and severe health effects 
as measured by hospitalizations across a wide range of disorders, 
including mental health outcomes.
    Navy Medicine is aware of two articles published in 2008 and 2009 
describing analysis of military medical records of a cohort of 11,725 
servicemembers progressively deployed to Afghanistan over a 6-month 
period in early 2007 of which 38.4 percent had been prescribed 
prophylactic use of mefloquine. Of those so prescribed, 13.8 percent 
had recorded medical history which would pose a relative 
contraindication to its use.
    Navy Medicine has not performed a follow-up on the data or subjects 
described in the 2008 and 2009 articles as this analysis did not 
provide information as to adverse outcome, nor did it break out 
information from the analysis of records that included servicemembers 
from all services which would have identified what proportion of the 
cohort records analyzed pertained to Navy or Marine Corps personnel. 
Navy Medicine stands by the medical outcome data described in the Naval 
Health Research Center study of 2006.
    Question. What epidemiological research is currently underway to 
investigate the short- and long-term effects of exposure to mefloquine? 
Can you tell me what is the total amount of funding devoted to these 
projects?
    Answer. At this time, there is no epidemiological research 
currently underway which would add to or test the findings of the 2006 
published study of prescription of mefloquine to 8,858 Active Duty 
servicemembers which demonstrated a decreased proportion of mefloquine 
prescribed individuals hospitalized for mood disorders when compared to 
servicemembers assigned to Europe or Japan and no difference in 
hospitalizations across a wide range of disorders, including mental 
health outcomes in combined data from individuals assigned to Europe, 
Japan, or otherwise deployed.
    Question. DOD has specialized centers to address traumatic brain 
injury (TBI) and PTSD, including the National Intrepid Center of 
Excellence and other centers within the Centers of Excellence for 
Traumatic Brain Injury and Psychological Health. The Centers for 
Disease Control and Prevention has recently noted that the side effects 
of mefloquine may ``cofound the diagnosis and management of 
posttraumatic stress disorder and traumatic brain injury''. Given that 
the adverse effects of mefloquine may often mimic those of TBI and 
PTSD, has the Navy provided training to those who work within the 
National Intrepid Center of Excellence and Defense Centers of 
Excellence to include the diagnosis, management, and research of 
mefloquine toxicity?
    Answer. Navy Medicine has not specifically provided training on the 
diagnosis, management, and research of mefloquine toxicity to the 
professional staff at the Defense Centers of Excellence (DCoE). 
However, the DCoE staff has reviewed reports, guidance, and DOD policy 
related to the use of mefloquine. Additionally, their staff has 
actively completed reviews of the current science on the use of 
mefloquine for malaria chemoprophylaxis and neuropsychiatric adverse 
reactions, as well as reviews of mefloquine, TBI, and psychological 
health conditions. As reported to Navy Medicine, DCoE staff continues 
to monitor emerging science as it relates to mefloquine, TBI, and 
psychiatric conditions and will work to revise clinical guidance and 
provide input to DOD policy should emerging science indicate clear 
detrimental effects.
    With respect to mefloquine confounding the diagnosis of mild TBI 
and/or PTSD, staff members from the National Intrepid Center of 
Excellence (NICoE) have also not undergone specific training. However, 
personnel who comprise the White Team--the triage team which screen all 
prospective NICoE candidates--include two experienced medical officers 
with extensive combat/deployment experience who understand the 
potential neuropsychiatric contraindications and have utilized 
mefloquine appropriately in the deployed environment. The White Team is 
also backed up by a neurologist and neuropsychologist who, similarly, 
have comprehensive knowledge of compounds, drugs, and exposures which 
may impact the nervous system. Additionally, all members presented to 
NICoE go through an exhaustive medication review, supported by a Doctor 
of Pharmacy (Pharm D).
    Finally, Navy Medicine is currently developing a mefloquine 
training module to serve as a refresher on FDA requirements and DOD 
policy for all providers and pharmacists. This training is expected to 
be implemented by June 2012.
                                 ______
                                 
           Questions Submitted by Senator Barbara A. Mikulski

                         NONMEDICAL CAREGIVERS

    Question. Military family members already make incredible 
sacrifices to support both the soldier deployed and the wounded warrior 
at home. Since 2001, nearly 2 million troops have deployed in support 
of Operation Enduring Freedom and/or Operation Iraqi Freedom; of those, 
nearly 800,000 have deployed more than once. There are nearly 48,000 
wounded warriors from the 10 years of war. For many wounded warriors, 
their spouses and extended families become the front line of care for 
their rehabilitation and recovery. These nonmedical caregivers have to 
choose between their critically injured relative and their careers, 
children, and financial well-being.
    What has the Navy done to enhance care for family members of 
wounded marines and sailors?
    Answer. The Navy's Project FOCUS (Families Over Coming Under 
Stress) is a family psychological health and resiliency building 
program that addresses family functioning in the context of the impact 
of combat deployments, multiple deployments, and high-operational 
tempo. The application of a three-tiered approach to care via community 
education, psychoeducation for families, and brief-treatment 
intervention for families, has shown statistically significant outcomes 
in increasing family functioning and decreasing negative outcomes such 
as anxiety and depression in both parents and children. The program 
takes a de-stigmatized approach to care and is integrated within the 
community context.
    Additionally, the Marine Corps realizes that family members are 
essential to the successful recovery of our wounded, ill, and injured 
(WII) marines. Accordingly, we work to ensure our WII marines' families 
are part of the recovery process, to include supplying them with 
support programs and services. Since the Wounded Warrior Regiment (WWR) 
stood up more than 5 years ago, we have continually enhanced our 
services to ensure that the unique needs of our families are addressed. 
Examples include:
  --Family readiness and support staff at all locations;
  --Recovery Care Coordinators to help WII Marines and their family 
        members map out and attain their recovery goals;
  --The Wounded Warrior Call Center, a 24/7 outreach and reach-back 
        resource and referral capability;
  --District Injured Support Coordinators (DISCs) who help 
        transitioning marines and families in remote locations away 
        from military or Federal resources;
  --Our Medical Cell, a cell that provides medical subject matter 
        expertise, advocacy, and liaison to the medical community; and
  --Enhanced communication efforts to ensure family members receive the 
        right information when they need it through easy-to-understand 
        fact sheets, a Marine Corps-customized ``Keeping It All 
        Together'' Handbook, and a new mobile WWR App.
    Question. What training does the nonmedical caregiver receive to 
ensure continuity of care for their wounded warrior once that marine or 
sailor makes a transition to home?
    Answer. The WWR is working with the Office of Wounded Warrior Care 
and Transition Policy to ensure all caregivers of Marines who are 
receiving Special Compensation for Assistance with Activities of Daily 
Living receive caregiver training materials developed by the Easter 
Seals Foundation (also used by the Department of Veterans Affairs for 
their Caregiver Stipend Program). WWR also provides ``Care for the 
Caregiver'' Workshops as well as FOCUS, the resiliency training program 
referred to above. FOCUS is designed to assist and promote strong 
Marine Corps families to better equip them to contend with the stress 
associated with multiple deployments, combat stress, and physical 
injuries. Additionally, the WWR's DISC Program collaborates with Navy-
Marine Corps Relief Society visiting nurses to make home visits to our 
WII marines and families in need. These nurses can provide a myriad of 
services, to include evaluate of home safety and adaptability, 
emotional support to families, and advocacy for the patient and family 
as they adjust to the enormous life changes resulting from their 
injuries.
    Question. What support do they receive to ensure they can maintain 
their own psychological health and well-being through this process?
    Answer. The WWR's capabilities mentioned above provide reach-back 
resource and referral capabilities for family members to maintain their 
psychological health and well-being. More specifically, the WWR Medical 
Cell is skilled at providing family referrals to the appropriate 
psychological health service, depending upon their needs and 
requirements.
    Question. What has the Navy done to leverage the help the private 
sector can provide?
    Answer. Many individuals and organizations routinely offer gifts to 
the Department of Defense, units, military personnel, and their 
families. The WWR's Charitable Giving Office works within the confines 
of Federal law and policy to ensure WII marines and families benefit 
from private sector help when and where it is appropriate. Support 
includes, but is not limited to, respite opportunities, child care, 
travel assistance, lodging/housing, and social activities.

                        MEDICAL PAIN MANAGEMENT

    Question. Reliance on prescription cocktails to handle mental and 
pain management is having serious negative consequences amongst our 
military servicemembers. Recent studies have found that veterans with 
PTSD were most likely to be prescribed opioids as compared with vets 
with no mental health disorder--33.5 percent compared with 6.5 percent. 
Accidental drug deaths have doubled from 2001-2009, while prescriptions 
for painkillers are up 438 percent since 2001. The ``Defense Survey of 
Health-Related Behaviors'' found ``dangerous levels'' of alcohol abuse 
and the illicit use of drugs such as pain killers by 12 percent of 
military personnel.
    Should the military medical community examine its reliance on 
narcotics to control pain among wounded warriors?
    Answer. The Services are aware and concerned about alarming 
national trends in increased use of opioids and secondary 
complications, including misuse, dependence, higher care cost, and 
adverse outcome (including death). The Fiscal Year 2010 National 
Defense Authorization Act (section 711) directed the Secretary of 
Defense to develop and implement a comprehensive policy on pain 
management. In August 2009, the Army Surgeon General chartered the Army 
Pain Management Task Force to make recommendations for a comprehensive 
pain management strategy that was holistic, multidisciplinary, and 
multimodal in its approach. Task Force membership included 
representatives from the Navy, Air Force, TRICARE Management Activity, 
and the Veterans Administration. The Task Force developed 109 
recommendations. The Office of the Secretary of Defense (Health 
Affairs) released a Policy for Comprehensive Pain Management in March 
2011.
    Navy Medicine has designed the Navy Comprehensive Pain Management 
Program (NCPMP) to improve and expand pain management resources for all 
servicemembers. Key specific NCPMP objectives are to meet NDAA 
requirements and Joint Commission (JC) standards, by providing 
standardized and optimized care in accordance with recently published 
clinical practice guidelines. The current state-of-the-art for 
management of chronic and complex pain is based on the biopsychosocial 
model, which promotes a paradigm of comprehensive, multidisciplinary, 
and multimodal care. In that capacity, an important focus of the NCPMP 
is the expansion of access to health psychologists, physical 
therapists, exercise physiologists, and integrative medicine physicians 
to ensure the effective fusion of mainstream treatments like cognitive 
behavior therapy with Complementary and Alternative Medicine (CAM) 
approaches, including the use of acupuncture. The specific stated 
mission of the NCPMP is ``To aid in the restoration of function and 
relief of pain by broadening access to state-of-the-art, standardized, 
multimodal, and interdisciplinary pain care across Navy Medicine, 
ensuring treatment efficacy through practice guidelines, education, and 
analysis of treatment outcomes.''
    To diminish reliance on narcotics to control pain, Navy Medicine is 
focusing on three general paradigms. First, decrease development of 
pain via prevention of injury (e.g., ergonomics, occupational safety) 
and disease precursors. Second, educate members and healthcare 
providers about risks of opioids and best practices when they are 
prescribed. Two videos are to be released shortly for required training 
of all Navy and USMC personnel (The War Back at Home) and providers (Do 
No Harm). Interim guidance and a subsequent Pain Instruction are to be 
released by BUMED as well, educating providers about up-to-date best 
practices for opioid use (e.g., routine screening for appropriateness, 
sole provider agreements, informed consent, and a multimodal approach). 
Third, provide capability for healthcare providers to utilize a 
multimodal biopsychosocial approach by employing alternative 
capabilities and assets. To that end, the NCPMP will utilize provider 
assets in pain medicine, integrative medicine, CAM, mental health and 
addiction medicine, case management, exercise physiology, physical 
therapy, and athletic training. These pain care assets, functionally 
integrated into Medical Home and SMART Clinics, will enable and promote 
comprehensive management of complex acute and chronic pain throughout 
Navy Medicine. A key component of NCPMP's Concept of Operations is 
tiered rollout of system wide acupuncture capability based on 
systematic and consistent training, certification, and credentialing 
throughout the healthcare enterprise.
    Question. What alternative options of pain management does the Navy 
have in place to give doctors a choice to lessen the use of 
prescription pain killers?
    Answer. Please see answer above. The following is a listing of key 
pain management modalities available to Navy doctors:
  --Disease-specific measures:
    --Tighter glucose control in diabetes;
    --Disease-modifying agents in MS and other inflammatory disorders;
    --Surgery, chemotherapy, radiation therapy for nerve compression;
    --Infection control (HIV, herpes zoster, lyme disease); and
    --Ergonomics and occupational safety.
  --Local and regional treatments:
    --Regional Anesthetics (Pain Specialists): sympathetic, epidural, 
            intrathecal, and selective nerve root blocks; epidural and 
            intrathecal pumps;
    --Stimulation-Based: TENS, spinal cord stimulation, acupuncture 
            (licensed, medical);
    --Complementary and Alternative Medicine (CAM): acupuncture, 
            Osteopathic Manipulation, therapeutic massage;
    --Physical Rehabilitation: PT/OT, splinting, manipulation, 
            assistive devices, range-of-motion exercises, ergonomics; 
            and
    --Ablative Procedures: phenol/alcohol nerve ablation, cordotomy/
            rhizotomy, radiofrequency nerve root ablation.
  --Systemic treatments:
    --Pharmacological: Tricyclic antidepressants, SNRIs, clonazepam, 
            atypical antipsychotic medications, gapapentin, pregabalin, 
            anticonvulsants, NSAIDs, corticosteroids, opioids, mu-
            opioids (e.g., tramadol), muscle relaxants/antispasmodics, 
            and benzodiazepine receptor antagonists (e.g., zolpidem); 
            and
    --Behavioral: Addiction Medicine counseling, Psychologic counseling 
            (cognitive behavioral therapy, biofeedback, guided imagery, 
            other relaxation techniques).
    Question. Does the Navy track rates of addiction to prescription 
pain killers among wounded warriors--how would you know if you had a 
problem?
    Answer. The EpiData Center at the Navy and Marine Corps Public 
Health Center (NMCPHC) in Portsmouth, Virginia, currently provides a 
monthly prescription burden report for Marine specialty groups, and 
provides this report for the Navy and Marine Corps on a semiannual 
basis. The report includes an assessment of chronic prescription pain 
medication use. The report does not define addiction to prescription 
pain medications, but rather is used by local units to determine at 
their level if further action is needed.
    The Navy Health Research Center (NHRC) in San Diego, California, is 
also able to look at trends in diagnoses for opioid addiction and may 
be able to cross-reference this with prescription reissuance patterns 
as that capability continues to build through NHRC's new pharmaceutical 
use project.
    Question. Peer-reviewed studies demonstrate that servicemembers who 
incorporate complementary medicine for pain management rely less on 
prescriptions for pain management. Do you see promise for a more 
widespread application of this program?
    Answer. As noted, Navy Medicine is committed to expansion of 
Complementary and Alternative Medicine (CAM) to enable and promote a 
comprehensive biopsychosocial approach to management of pain by Navy 
healthcare providers. Please see above answers for details.
                                 ______
                                 
               Question Submitted by Senator Thad Cochran

                       HYPERBARIC OXYGEN THERAPY

    Question. Admiral Nathan, I understand that $8.6 million is 
included to fund a clinical trial using hyperbaric oxygen therapy to 
diagnose and treat brain injury. What is your experience with this 
therapy? Do you think it has merit in treating traumatic brain injury?
    Answer. The study for which this referenced funding will provide 
support is being administered and managed by the U.S. Army Medical 
Research and Material Command. Naval facilities at Camp Pendleton and 
at Camp Lejeune are participating in this study as centers where 
enrolled volunteers will be evaluated. To date, there is no outcome 
data available from this study.
    Naval facilities at Camp Lejeune, as well as at Pensacola and 
Panama City, Florida, are also participating in a DARPA-funded dose 
ranging study, conducted by the Naval Operational Medical Institute 
(NOMI), the McGuire VA Medical Center in Richmond, and the Virginia 
Commonwealth University. The study has recruited 60 percent of its 
volunteers, essentially all from Marine Corps Base Camp Lejeune. The 
target completion date is October 2012.
    As of March 28, 2012, there are no data to report from either of 
these two studies. There is, therefore, still no outcome information 
from well-designed, adequately controlled medical research which would 
support the safety and efficacy of use of hyperbaric oxygen for 
traumatic brain injury.
                                 ______
                                 
       Questions Submitted to Lieutenant General Patricia Horoho
            Questions Submitted by Chairman Daniel K. Inouye

               CORPS CHIEF POSITION LEGISLATIVE PROPOSAL

    Question. Since 2003, the Nurse Corps Chief position for each of 
the Services has been authorized as a two-star billet. The Department 
recently sent over a legislative proposal that would reduce the Corps 
Chief position to the one-star level. General Horoho, how has the 
increase in rank benefited the Army Nurse Corps?
    Answer. The rank of Major General afforded the Corps Chief the 
greater impact to sponsor great strides in the advancement of our 
mission in serving America's sons and daughters. A change in the Corps 
Chief's rank will not change the mission nor the importance of Army 
Nursing and our commitment of excellence in nursing care to our 
servicemembers and families will remain steadfast. There are many 
opportunities within the U.S. Army Medical Department (AMEDD) for 
nurses to cultivate leadership experience. The Army has a strong 
developmental path for its leaders, regardless of area of 
concentration.

                                TRICARE

    Question. The Department's fiscal year 2013 budget assumes $452 
million in savings based on new TRICARE enrollment fees and increases 
in co-pays for prescription drugs. General Horoho, did the Department 
consider more modest fee increases for enrollment and prescription 
drugs than the significant fees proposed in the budget? Realizing the 
current difficult fiscal environment, is it fair to levy these 
prescription drug fees on our uniformed men and women who have been at 
war for more than 10 years?
    Answer. I must defer to the Department of Defense (DOD) to comment 
on any alternative strategies they may have used to develop this 
proposal.
    The proposal to raise pharmacy retail and mail order co-pays does 
not affect the Active Duty servicemember. The co-pays apply only to 
retirees and family members in order to encourage the use of mail order 
and generic drugs. Understanding the concern for the rising cost of 
medications to beneficiaries and realizing that a continual rise in 
medication costs to DOD jeopardizes the benefit for all, Army Medicine 
is developing a plan to promote beneficiaries' return to the military 
treatment facility for prescription fills for no or low medication 
costs. Increasing formularies, improving access to pharmacies, and 
providing pharmacists for medication counseling are a few steps towards 
accomplishing this goal.
    Question. General Horoho, the structure of the proposed TRICARE 
pharmacy co-pays strongly incentivizes members to fill their 
prescriptions at pharmacies within military treatment facilities. Yet 
we continue to hear concerns about the current wait times at numerous 
pharmacies. What steps are being taken to alleviate wait times, and 
will current facilities be able to process an increase in 
prescriptions?
    Answer. Initiatives currently underway that ease military treatment 
facility wait times include workflow process changes, permitting 
patients to drop off prescriptions and return at later times, and 
physician-faxed prescriptions. These are a few ways that allow the 
pharmacies to increase workload without affecting wait times. Plans are 
in place to expand pharmacy staffing as workload increases. Expansion 
of Community Based Medical Homes (CBMH) will shift workload from the 
main pharmacies providing the opportunity to recapture prescriptions at 
the current facilities. The pharmacies in CBMH can also provide support 
to beneficiaries in their community, offering another avenue for 
filling prescriptions.

                              SUICIDE RATE

    Question. General Horoho, the Services are seeking to provide early 
identification and treatment of psychological health through a number 
of initiatives; yet suicides throughout the military, and especially in 
the Army, continue to rise. In 2011, Active Duty, Guard, and Reserve 
soldiers took their lives at a record high rate. What more can we be 
doing for our servicemembers to ensure they are receiving the necessary 
behavioral and mental healthcare in order to reverse this disturbing 
trend?
    Answer. The Army's Behavioral Health System of Care continues to 
explore ways to improve behavioral health services. The BHSOC currently 
has an extensive array of behavioral health services and wellness 
resources available to address the strain on servicemembers and their 
families throughout the Army Force Generation Cycle. Soldiers and 
family members have additional counseling options and other avenues to 
deal with stress through Army Chaplain services, Military One Source, 
in-theater combat and operational stress programs, psychological school 
programs, Army Community Service programs, and the Comprehensive 
Soldier Fitness program. Included in the BHSOC is the roll out of new 
and innovative evidenced based programs such as Embedded Behavioral 
Health in Brigade Combat Teams, Patient Centered Medical Homes and 
School Behavioral Health that will significantly change how we provide 
support to our soldiers and families.

           RECRUITMENT AND RETENTION OF MEDICAL PROFESSIONALS

    Question. General Horoho, part of the challenge of recruiting 
medical professionals is the divide between private sector and military 
compensation for health specialties. Given the increasing fiscal 
constraints the Department is facing in the coming years, how will you 
manage your resources to sustain the medical professionals required to 
care for servicemembers and their families? Beyond the compensation 
gap, what other challenges do you face in recruiting and retaining a 
sufficient number of both military and civilian healthcare personnel?
    Answer. Entry into the future fiscally constrained environment will 
present challenges to any increase in the scope or dollar amounts of 
special pays. However, by targeting accession and retention bonuses, in 
coordination with sister services, the Army anticipates success in the 
recruitment of health professionals. DOD has recently delegated the 
authority to use an expedited hiring authority for 38 medical 
occupations. We are working to implement this new appointment 
authority.
    Nationwide shortages of highly trained health professionals remain 
a top challenge to the U.S. Army Recruiting Command (USAREC) in the 
recruitment of physicians, dentists and behavioral health 
professionals. Our student programs continue to be the lifeblood of our 
accession pipeline and accessions into these programs are doing well. 
We continue to partner with USAREC to insure all avenues are addressed 
with regard to recruitment of the necessary personnel to sustain the 
force.

                         MILITARY HEALTH SYSTEM

    Question. General Horoho, earlier this month the Department 
released its final decision on the structure of the Military Health 
System. The Department decided on a proposal to combine the 
administration and management of the Military Health System into a 
Defense Health Agency. What advantages and challenges do you see to the 
jointness among the Services proposed in the new governance strategy?
    Answer. This recommendation represents an opportunity to achieve 
cost savings through reduction of duplication and variation, while 
accelerating the implementation of shared services, identify and 
proliferate common clinical and business practices, and develop 
entirely new approaches to delivering shared activities. I am 
encouraged by the potential benefits achieved by this plan and support 
the DOD's plan to move iteratively towards increased jointness.

                              MEDICAL HOME

    Question. General Horoho, the Services continue to transition 
patients to a medical home model. This concept organizes health 
professionals into teams to provide a more comprehensive primary 
approach. Each patient's personal physician leads the team and serves 
as a continuous point of contact for care. The Army's new community-
based medical homes are located off-post in communities in order to 
provide increased capacity for primary care. What are the Army's plans 
to expand this program, and when will it be available service-wide?
    Answer. The Army currently has 17 medical home practices in 
operation in our military treatment facilities (MTF) and 13 community-
based medical homes open in the communities where our Army families 
live. By the end of this calendar year, 49 additional MTF-based medical 
home practices and 5 more community-based medical homes will open. The 
Army will ultimately transform 100 percent of its primary care to the 
medical home model by the end of calendar year 2014. We are also 
implementing this capability in our TO&E facilities.
                                 ______
                                 
            Questions Submitted by Senator Dianne Feinstein

                               MEFLOQUINE

    Question. In 2009, the Department of Defense (DOD) published 
research that showed that approximately 1 in 7 servicemembers with 
mental health contraindications had been prescribed mefloquine contrary 
to the instructions in the package insert guidance, including to 
servicemembers taking anti-depressants and with serious mental health 
conditions such as post-traumatic stress disorder. This research went 
on to highlight that such use may have significantly increased the risk 
of serious harm among those who had been misprescribed the drug.
    What research has the Army undertaken to determine whether this 
trend has been reversed, and what efforts has the Army undertaken to 
identify and follow-up on those who were misprescribed the drug, to 
determine whether they may be suffering from the adverse effects of its 
use? Can the Army assure us that this group has not experienced more 
significant problems associated with this misprescribing?
    Answer. The U.S. Army Pharmacovigilance Center (USAPC) conducts 
continual review of data for:
  --the potential mis-prescribing of mefloquine with psychiatric 
        medications;
  --the potential mis-prescribing in those servicemembers with a 
        diagnosis of psychiatric illness; and
  --the acceptable use of mefloquine in those patients with a recent 
        (within 1 year) history of psychiatric medication use.
    The USAPC will evaluate the risk of mefloquine use and subsequent 
psychiatric medication prescription or a psychiatric diagnosis.
    Question. What epidemiological research is currently underway to 
investigate the short- and long-term effects of exposure to mefloquine? 
Can you tell me what is the total amount of funding devoted to these 
projects?
    Answer. There is no funded epidemiology research at this time by 
the U.S. Army Medical Research Material Command to investigate the 
short- and long-term effects of exposure to mefloquine. The Army 
Medical Department has not provided training on mefloquine to Defense 
Center of Excellence or National Intrepid Center of Excellence.
                                 ______
                                 
           Questions Submitted by Senator Barbara A. Mikulski

                    SUPPORT FOR NONMEDICAL CAREGIVER

    Question. Military family members already make incredible 
sacrifices to support both the solider deployed and the wounded warrior 
at home. Since 2001, nearly 2 million troops have deployed in support 
of Operation Enduring Freedom and/or Operation Iraqi Freedom; of those, 
nearly 800,000 have deployed more than once. There are nearly 48,000 
wounded warriors from the 10 years of war. For many wounded warriors, 
their spouses and extended families become the front line of care for 
their rehabilitation and recovery. These nonmedical caregivers have to 
choose between their critically injured relative and their careers, 
children, and financial well-being.
    What has the Army done to enhance care for family members of 
wounded soldiers?
    Answer. Caregivers are authorized medical care in a military 
treatment facility (MTF) while in nonmedical attendant (NMA) status. 
The Army recognizes the difficulties our wounded warrior primary 
caregivers face on a daily basis. If NMA is a dependent of the wounded 
warrior, they are entitled to the full range of behavioral health 
services the Army has to offer to support their needs. Additionally, 
the spouse, son, daughter, parent, or next of kin of the covered 
servicemember are entitled to take up to 26 workweeks of leave during a 
``single 12-month period'' to care for a seriously injured or ill 
covered servicemember under new military family leave provisions.
    Additionally, on August 31, 2011, the Department of Defense 
authorized the Special Compensation for Assistance with Activities of 
Daily Living (SCAADL). The Army issued its SCAADL implementing guidance 
on November 21, 2011. The program is applicable to all soldiers--
Active, National Guard, and Army Reserve. The SCAADL stipend provides a 
monthly payment to the soldier to support the caregiver. The basis for 
the level of payment is the severity of the soldier's wound, injury, or 
ailment, the amount of caregiver support required, and the geographic 
location of the soldier. Since implementing the SCAADL stipend, the 
Army has made payments to 347 families. As of May 4, 2012, 310 soldiers 
are currently receiving the SCAADL stipend, with an average payment of 
$1,473 per month.
    Question. What training does the nonmedical caregiver receive to 
ensure continuity of care for their wounded warrior once that soldier 
makes a transition to home?
    Answer. In early April 2012, the Office of the Secretary of Defense 
Wounded Warrior Care and Transition Policy drafted a memorandum of 
understanding between the Under Secretary of Defense for Personnel and 
Readiness and the Under Secretary of Veterans Affairs, Veterans Health 
Administration (VHA) for the purpose of having VHA, through their 
contract provider (Easter Seals), provide training for the caregivers 
assisting eligible catastrophic servicemembers in the SCAADL program.
    Also in early April 2012, the Easter Seals mailed training 
workbooks and CDs to each Army Warrior Transition Unit for distribution 
to the caregivers of soldiers in the process of transition from the 
Army to the VA. Before the VA will certify a caregiver, the caregiver 
must pass a test and the VA will conduct an in-home visit of the 
location where the soldier and caregiver will reside.
    The training workbooks have six modules:
  --caregiver self-care;
  --home safety;
  --caregiver skills;
  --veteran/servicemember personal care;
  --managing changing behaviors; and
  --resources.
    Question. What support do they receive to ensure they can maintain 
their own psychological health and well-being through this process?
    Answer. The Army recognizes the difficulty of wounded warrior 
primary caregivers. If a nonmedical attendant is a dependent of the 
wounded warrior, they are entitled to the full range of behavioral 
health services the Army has to offer to support their needs. 
Additionally, the spouse, son, daughter, parent, or next of kin of the 
covered servicemember are entitled to take up to 26 workweeks of leave 
during a ``single 12-month period'' to care for a seriously injured or 
ill covered Servicemember under new military family leave provisions.
    Many family members who serve as nonmedical caregivers are eligible 
for care in the military health system. These family members have 
access to direct and purchased care providers to address their personal 
psychological health and well-being. Members of the soldier's extended 
family who would not normally be eligible for care in the direct care 
system and who do not have private healthcare coverage may apply for 
access to care through the Secretary of Defense.
    Licensed Clinical Social Workers and Nurse Case Managers are 
required to assess potential family issues with each wounded warrior 
encounter as part of their standard of practice. Both Licensed Clinical 
Social Workers and Nurse Case Managers encourage family/caregiver 
participation in the rehabilitation and recovery process which enhances 
the ability to assess the needs of the nonmedical caregiver.
    Every Warrior Transition Unit has a Family Readiness Support 
Assistant. This individual is charged with reaching out to nonmedical 
caregivers to assess their needs and provide resiliency and support 
activities for spouses and extended families.
    We acknowledge that additional emphasis must be placed on the care 
of the caregiver. In November 2011, Army Family Action Plan Conference 
participants raised caregiver support as a formal issue for the Army to 
address. The Army Family Action Plan recommendation was to implement 
formal standardized, face-to-face training for designated caregivers of 
wounded warriors on self-care, stress reduction, burnout, and 
prevention of abuse/neglect. In June 2012, all Army Nurse Case Managers 
will begin receiving training in Caregiver Support. Nurse Case Managers 
will be educated on how to assess and train caregivers using the same 
training required by VA prior to receiving caregiver compensation in 
order to enhance lifelong learning and further reduce the training 
burden on caregivers. Following the training, Nurse Case Managers 
caring for wounded warriors will be required to invite caregivers in 
for an individual assessment, education using the Easter Seals training 
workbook, and potential referral to the Licensed Clinical Social Worker 
and/or other appropriate resources.
    Question. What has the Army done to leverage the help the private 
sector can provide?
    Answer. The Army recognizes the difficulty of wounded warrior 
primary caregivers. Dependents of wounded warriors are entitled to the 
full range of services the Army has to offer to support their needs. 
These services include those services available to Army beneficiaries 
in the private sector. Additionally, the spouse, son, daughter, parent, 
or next of kin of the covered servicemember are entitled to take up to 
26 workweeks of leave during a ``single 12-month period'' to care for a 
seriously injured or ill covered servicemember under new military 
family leave provisions.

                    MENTAL HEALTH CARE PROVIDER GAP

    Question. Former Vice Chief of Army, General Chiarelli has recently 
talked about a shortage in behavioral/mental healthcare providers. A 
2011 report by American Psychological Association found a 22-percent 
decrease in uniformed clinical psychologists and further characterized 
the approach to helping soldiers and families as a ``patchwork.'' There 
are not enough behavioral health specialists and those who are serving 
are completely overwhelmed by the level of work they have. Furthermore, 
the Guard and Reserve forces have been hit particularly hard by mental 
health issues. A 2011 study found nearly 20 percent of returning 
reservists had mental health problems serious enough for follow-up. 
Guard and Reservists are 55 percent more likely than Active Duty 
members to have mental health problems. Compounding the problem, 
Reservists lack access to the system or networks that experts say are 
needed to assess and treat their injuries.
    Do you have the workforce you need; whether it's mental healthcare 
providers or integrative medicine practitioners--such as 
acupuncturists?
    Answer. Behavioral health remains one of the Army's hardest to fill 
specialties. Specific shortage areas include psychiatrists, social 
workers, and technicians. Emerging capability needs related to 
integrative medicine, the Integrated Disability Evaluation System, 
Patient Centered Medical Homes, and brigade combat team embedded 
behavioral health will require additional providers.
    Question. Does the military health budget address the behavioral 
health providers?
    Answer. Yes, the Defense Health Program provides funding for 
Behavioral Health (BH) providers. The Army Medical Command has an 
historic base budget of more than $125 million for civilian BH 
providers. The fiscal year 2013 President's budget sustains an 
additional $184 million in funding for psychological health 
requirements that includes BH providers (among other BH operating 
costs, including facilities). Further, there is an additional $20.8 
million for BH providers as part of our Patient Centered Medical Home 
initiative; $24 million for our Embedded Behavioral Health initiative; 
and another $21 million for BH providers supporting the Integrated 
Disability Evaluation System.
    Question. What are you doing to attract and retain more mental 
healthcare providers?
    Answer. There are numerous programs to attract mental health 
providers to the Active military force. The Critical Wartime Skills 
Accession Bonus allows us to offer a psychiatrist an accession bonus of 
$272,000 for a 4-year commitment. There are accession and retention 
bonus programs for Clinical Psychiatrists and the Accession Bonus 
Program for Social Work officers. We have expanded our training 
programs to attract more recent graduates into service to accomplish 
the years of supervision required to become independent practitioners. 
Certified Psychiatric Nurse Practitioners are eligible for Incentive 
Special Pays.
    The MEDCOM has been successful in civilian recruiting and retention 
efforts by focusing on recruiting and retention incentives, an 
aggressive outreach recruitment program, and the addition of civilian 
students in the Fayetteville State Masters of Social Work Program. The 
MEDCOM has centralized the recruitment process for mission critical 
specialties, and that effort has reduced the fill time for hiring.

                       ADDICTION TO PRESCRIPTIONS

    Question. Reliance on prescription cocktails to handle mental and 
pain management is having serious negative consequences amongst our 
military servicemembers. Recent studies have found that veterans with 
PTSD were most likely to be prescribed opioids as compared with vets 
with no mental health disorder--33.5 percent compared with 6.5 percent. 
Accidental drug deaths have doubled from 2001-2009, while prescriptions 
for painkillers are up 438 percent since 2001. Furthermore, nearly 30 
percent of Army suicides between 2005 and 2010 included drug and/or 
alcohol use.
    Should the military medical community examine its reliance on 
narcotics to control pain among wounded warriors?
    Answer. The 2010 Army Pain Management Task Force examined not only 
military medicine's but U.S. medicine's overreliance on medication-only 
treatment for pain. The Pain Management Task Force Report made more 
than 100 recommendations to provide a comprehensive pain management 
strategy that was holistic, multidisciplinary, and multimodal. The Army 
has been implementing these recommendations through the Army 
Comprehensive Pain Management Campaign Plan which includes efforts to 
ensure proper use/monitoring of medication use and significant 
expansion of nonmedication pain treatment modalities.
    In June 2011, the Institute of Medicine released the report 
entitled, ``Relieving Pain in America: A Blueprint for Transforming 
Prevention, Care, Education, and Research''. The IOM report confirmed 
that overreliance on medication-only management of pain was an issue 
plaguing medicine in the U.S. and certainly not unique to the military. 
In addition to referencing the Army Pain Management Task Force, the IOM 
report's findings and recommendations largely paralleled those 
contained in the Army Pain Management Task Force Report.
    Question. What alternative options of pain management does the Army 
have in place to give doctors a choice to lessen the use of 
prescription pain killers?
    Answer. The Army's Comprehensive Pain Management Campaign Plan is 
operationalizing the Army Pain Management Task Force recommendations to 
move toward a more holistic, multidisciplinary, and multimodal 
treatment of pain. This includes standardizing availability and 
utilization of traditional treatment modalities such as medications, 
interventional procedures (injections, nerve blocks, and surgeries) and 
several nontraditional complementary modalities (acupuncture, movement 
therapy (Yoga), Biofeedback, and medical massage therapy).
    Army Medicine is developing capability and experience in providing 
multidisciplinary and multimodal pain management at eight 
interdisciplinary pain management centers and their subordinate pain 
augmentation teams.
    Question. Does the Army track rates of addiction to prescription 
pain killers among wounded warriors--how would you know if you had a 
problem?
    Answer. The Army tracks rates of positive urine drug screens among 
soldiers that represent abuse of illicit and prescription medications. 
The Army also tracks the number of soldiers enrolled for treatment of 
substance use disorders. In addition, the Army has put into place 
policies and practices to provide closer monitoring and support of our 
wounded warriors who require treatment for their multiple medical and 
behavioral health conditions, which often includes medications such as 
painkillers and anti-anxiety medications that have abuse potential. 
Because these policies and practices are in place, we have a better 
chance of detecting prescription drug abuse and identifying soldiers in 
need of intervention and treatment.
    Question. Peer-reviewed studies demonstrate that servicemembers who 
incorporate complementary medicine for pain management rely less on 
prescriptions for pain management. Do you see promise for a more 
widespread application of this program?
    Answer. Yes, the Army is developing capability and experience in 
providing multidisciplinary and multimodal pain management at eight 
interdisciplinary pain management centers (IPMC) and their subordinate 
pain augmentation teams. The Army's Comprehensive Pain Management 
Campaign Plan (CPMCP) is operationalizing the Army Pain Management Task 
Force recommendations to move toward a more holistic, 
multidisciplinary, and multimodal approach to the treatment of pain. 
This includes standardizing availability and utilization of traditional 
treatment modalities such as medications, interventional procedures 
(injections, nerve blocks, and surgeries), and several nontraditional 
complementary modalities (acupuncture, movement therapy (Yoga), 
Biofeedback, and medical massage therapy).
                                 ______
                                 
               Question Submitted by Senator Thad Cochran

                       HYPERBARIC OXYGEN THERAPY

    Question. General Horoho, I understand that $8.6 million is 
included to fund a clinical trial using hyperbaric oxygen therapy to 
diagnose and treat brain injury. What is your experience with this 
therapy? Do you think it has merit in treating traumatic brain injury?
    Answer. Case reports have suggested symptomatic improvement and 
more modest cognitive improvement in some individuals, but properly 
designed clinical trials results are still lacking. Departments of 
Defense (DOD), Veterans Affairs (VA) leaders, and medical professional 
societies such as the Undersea and Hyperbaric Medical Association and 
recently the American Psychiatric Association have cautioned that the 
results of randomized, controlled trials are needed before merit in 
treating mild traumatic brain injury (mTBI) can be established. In 
order to evaluate the merit of this potential therapy, the DOD is 
continuing to fund and execute a series of clinical trials to evaluate 
hyperbaric oxygen in the rehabilitation of mTBI.
                                 ______
                                 
       Questions Submitted to Major General Kimberly Siniscalchi
            Questions Submitted by Chairman Daniel K. Inouye

                          JOINT NURSING ISSUES

    Question. General Siniscalchi, how are lessons-learned from joint 
experiences being leveraged to improve the military health system and 
ultimately improving health outcomes?
    Answer. Lessons learned from Joint experiences have enabled us to 
focus our efforts on improving the Military Health System and health 
outcomes by enhancing interoperability through continued partnering 
with our Sister Services, Veterans Administration, Civilian Healthcare 
facilities, and other Federal agencies. The Federal Nursing Chiefs are 
meeting on a regular basis to address common nursing challenges and 
have developed a strategic plan to advance nursing practice and improve 
health outcomes, acting as a single voice with a common mission. We 
continuously strive to decrease variance in patient care delivery as we 
focus on efficiencies to reduce redundancies to advance the Quadruple 
Aim: Ready, Better Health, Better Care, and Best Value.
    Lessons learned from these experiences also refocused our attention 
on clinical currency, competency, and sustainment. We built enhanced 
partnerships with Federal and civilian healthcare facilities to ensure 
our nurses have robust clinical sustainment training platforms. In 
2011, we established 180 training affiliation agreements, 39 of which 
were specifically for nursing. We are working to enhance clinical 
sustainment training at our Sustainment of Trauma and Resuscitation 
Skills Program sites. Training on burn care and pediatric critical care 
was added to our Center for Sustainment of Trauma and Readiness Skills 
Centers. To further improve health outcomes based on lessons learned, 
we changed our clinical skill mix by increasing critical care, 
emergency/trauma, mental health, and aeromedical evacuation capability. 
Our 1-year critical care and emergency/trauma fellowships are 
undergoing major transformations and will be ready to implement in 
2013. Our overall number of mental health nurses and mental health 
nurse practitioners were increased and new roles developed in both the 
inpatient and outpatient settings. The new mental health course was 
established at Travis Air Force Base and the mental health nurse 
practitioner program was established at Uniformed Services University 
of the Health Sciences.
    Our most significant changes, based on lessons learned, were in the 
area of aeromedical evacuation. Overall requirements for flight nurses 
and aeromedical technicians were increased. The aeromedical evacuation 
training platform was redesigned into a modularized, efficient training 
pipeline with increased proficiency levels and overall reduction in 
training by 130 days. New clinical protocols for the use of epidural 
pain management in aeromedical evacuation were established and fielded. 
New research projects in collaboration with Wright State University, 
Dayton, Ohio, Air Mobility Command, and the USAF School of Aerospace 
Medicine were started to improve safe patient hand-offs.

                        NURSING RESEARCH ISSUES

    Question. General Siniscalchi, the TriService Nursing Research 
Program (TSNRP) has supported innovations in nursing care through 
competitive grant programs such as the Military Clinician-Initiated 
Research Award and the Graduate Evidence-Based Practice Award. What are 
some of the military unique topics that have benefited from these grant 
programs?
    Answer. The TSNRP is the only program with the primary mission of 
funding military unique and military relevant nursing research studies. 
Since its beginning in 1992, the TSNRP has funded more than 315 nursing 
research and evidenced-based practice projects. Under Air Force Colonel 
Marla De Jong's leadership, the TSNRP established the Military 
Clinician-Initiated Research Award and the Graduate Evidence-Based 
Practice Award. The Military Clinician-Initiated Research Award is 
targeted to nurse clinicians who are well-positioned to identify 
clinically important research questions and conduct research to answer 
these questions under the guidance of a mentor. The Graduate Evidence-
Based Practice Award is intended for Doctor of Nursing Practice 
students who will implement the principles of evidence-based practice 
and translate research evidence into clinical practice, policy, and/or 
military doctrine. It is critical that the award recipients disseminate 
the results of their studies so that leaders, educators, and clinicians 
can apply findings to practice, policy, education, and military 
doctrine as appropriate. The goal of this grant is to enhance the 
dissemination and uptake of evidence.
    Some of the areas in which research was conducted this year 
include:
  --pain management;
  --patient safety;
  --post-traumatic stress; and
  --women's health.
    Research initiatives in patient safety and pain management 
demonstrated improvement in the safety, quality of care, and management 
of pain as patients move through aeromedical evacuation continuum. 
TSNRP is invaluable to these research initiatives that display our 
commitment to advance nursing practice by fostering a culture of 
inquiry.

                     PATIENT-CENTERED MEDICAL HOME

    Question. General Siniscalchi, how are nonadvanced practice nurses 
being utilized in advancing the Air Force Family Health Initiative to 
realize the DOD focus on Patient-Centered Medical Home (PCMH) as a 
strategy aimed at improving health outcomes while improving 
efficiencies in care delivery within military treatment facilities?
    Answer. The focus of PCMH is to create a partnership between the 
patient and their healthcare team while empowering the patient with 
increased responsibility for self-care and monitoring to achieve their 
goals for health. Our nonadvanced team nurses are integral to the care 
management and the coordination of patients and focus on prevention and 
improved health outcomes. The team nurse ensures a smooth care 
transition as patients pass through the continuum of care. 
Additionally, they vector high-risk patients to be followed by disease 
or case managers. The expanded team nurses' roles include disease or 
case managers; who manage and coordinate care for a target population, 
or the more complex patients, to improve quality and health outcomes 
for these defined populations while advocating and incentivizing 
healthy behaviors. Implementation of PCMH has resulted in decreased 
emergent and urgent care visits; increased provider, patient, and staff 
satisfaction; increased provider continuity associated with better 
health outcomes; and an uncomplicated early transition from a focus on 
healthcare to health.

                        TRANSITION FROM WARTIME

    Question. General Siniscalchi, what specific retention strategies 
are being developed to entice the best junior and mid-level nurses to 
continue their nursing careers in uniform?
    Answer. We offer many programs to inspire our junior and mid-level 
nurses to remain on Active Duty. The Incentive Specialty Pay program 
continues to have a positive impact on retention. We have a robust 
developmental program for our nurses as they transition from novice to 
expert. The nurse residency program develops our nurse graduates into 
fully qualified registered nurses and prepares them for success in 
their new profession and military nursing. The Nurse Transition Program 
for new graduates is conducted at one of four Centers of Excellence, 
two of which are Magnet hospitals. Our developmental career path offers 
three tracks--clinical, command, and academia--giving nurses the 
ability to focus in any one of these three areas, while still allowing 
them to weave in and out at the junior and mid-level points in their 
career.
    Additional force development opportunities include fellowship 
programs such as critical care, trauma, patient safety, magnet 
recognitions, leadership, education and training, administration, 
strategic planning, resourcing, informatics, research, and aeromedical 
evacuation. We offer advanced academic degree programs such as clinical 
nurse specialist (CNS), nurse practitioner, and nurse scientist. We 
partnered with Wright State University, Ohio, in developing a Master's 
program for a Flight and Disaster Nursing CNS. Our first student 
graduates in May 2012. Nurses now have the opportunity to pursue a 
Doctorate of Nursing Practice in the of areas Mental Health, Family 
Nurse Practitioner and Certified Registered Nurse Anesthetist, in 
partnership with the Uniformed Services of the Health Sciences. 
Deployment opportunities provide unique experiences, which were cited 
as ``the most rewarding experience'' in the 2010 Tri-Service Nursing 
Retention Survey. We continue to pursue training affiliations with our 
Federal partners, civilian institutions, and international partners in 
order to advance interoperability and skill sustainment.
                                 ______
                                 
        Questions Submitted to Rear Admiral Elizabeth S. Niemyer
            Questions Submitted by Chairman Daniel K. Inouye

                          JOINT NURSING ISSUES

    Question. Admiral Niemyer, in recent years we have witnessed the 
unprecedented alignment of efforts among service medical departments, 
between Department of Defense (DOD) and Department of Veterans Affairs 
(VA) medical departments, and between governmental and nongovernmental 
nurses to deliver care across the spectrum of military treatment 
facilities, during humanitarian assistance/disaster relief efforts, and 
wartime missions. What is being done to ensure lessons learned from 
these opportunities are embedded in future training evolutions?
    Answer. Joint and integrated work environments are now the ``new 
order'' of business. Navy Medicine enjoys strong collaborative 
relationships with the Army and Air Force, as well as VA and civilian 
counterparts. As leaders in Navy Medicine and the Military Healthcare 
System, Navy nurses possess the necessary skills and experience to 
promote, build and strengthen strategic partnerships with our military, 
Federal, and civilian counterparts to improve the healthcare of our 
beneficiaries.
    Within the military treatment facilities (MTFs), lessons learned 
are shared and implemented into various training evolutions. Nurse 
Residency Programs for newly accessioned nurses and command orientation 
programs are integrated and nurses new to military medicine and/or a 
joint facility are introduced into a joint culture from day one. The 
Directors for Nursing Services assigned to our joint facilities have 
provided video teleconferences throughout Navy MTFs to share lessons 
learned throughout the enterprise and respond to questions from the 
field which has also proven to be a vital educational format as we 
continue to refine a unified culture focused on clinical excellence and 
professionalism.
    A decade of war has resulted in numerous advancements in military 
medicine from lessons learned by all of the Services. These 
advancements are incorporated into clinical and operational training 
evolutions. Examples are the use of tourniquets and procedures for 
resuscitating casualties such as earlier use of blood products, 
medications such as QuikClot and Combat Gauze. The Tactical Combat 
Casualty Care Course has curriculum committee involvement for all 
Services, as well as civilian experts. Improvements in critical care 
transport and rapid Medical Evacuation (MEDEVAC) to definitive care has 
also been incorporated into training. Implementing lessons learned from 
the Air Force's Critical Care Air Transport Team (CCATT), the Navy is 
also training and using critical care physicians and nurses in theater 
to provide critical care transport.

                        NURSING RESEARCH ISSUES

    Question. Admiral Niemyer, in last year's testimony you provided an 
overview of the Navy Nurse Corps' efforts to regionalize nursing 
research efforts and implement research training to junior officers. 
How have these efforts impacted current research activities?
    Answer. Fundamental to the growth and development of future nurse 
researchers is the availability of experienced mentors to guide and 
teach our junior nurses throughout the research process. To this end, 
we aligned our senior nurse researchers regionally to serve in this 
role. We have continued our efforts to ``invigorate nursing research'' 
at all levels of the organization; however, we have focused additional 
efforts to promote a culture of clinical inquiry in our junior nurses.
    A team is completing the development of a 2-3 day course on 
implementing evidence-based practice which we plan to present in all 
three regions by July of this year. This course will educate junior 
nurses on the process of evaluating the existing body of nursing 
knowledge and apply this knowledge to improve their nursing practice 
and advance their skills in the care of patients at the bedside 
ultimately enhancing patient outcomes. Following this course 
completion, our regional researchers will mentor the course 
participants in the initiation of three multisite, regional evidence-
based practice projects. The first annual Navy Nurse Corps recognition 
program to promote and acknowledge excellence in implementing evidence-
based practice was launched in February of this year.
    As a result of these on-going efforts, we are seeing an increased 
level of interest in evidence-based practice and increased level of 
participation in nursing research projects among our junior nurses. 
Throughout our organization, there continues to be an overwhelming 
number of nurses participating in the Tri-Service Nursing Research 
Program Research (TSNRP) Development Course. Navy nurses authored more 
than 30 publications and provided more than 50 formal presentations at 
various professional forums and were awarded $1.5 million in TSNRP 
funds as principal investigators for numerous projects.

                     PATIENT-CENTERED MEDICAL HOME

    Question. Admiral Niemyer, how are advanced practice nurses being 
utilized to forward the Navy Medical Homeport to realize the DOD focus 
on Patient-Centered Medical Home to improve health outcomes while 
improving care delivery within military treatment facilities?
    Answer. Transformation to the Navy Medical Homeport (MHP) has 
changed how patients, team members and providers interact with one 
another. It uses an integrated healthcare team to deliver the right 
care, at the right time, by the right person leveraging the skills of 
all team members to deliver timely, easily accessible quality care.
    Advanced practice nurses are at the forefront of MHP implementation 
across our enterprise. As experienced Primary Care Managers within Navy 
Medicine, advanced practice nurses are expertly prepared to deliver the 
highest quality care with the tenets of wellness and preventive care at 
the center of every encounter. Many are serving as MHP Team Leaders and 
command champions. In these roles, they are leading the efforts towards 
achieving National Center for Quality Assurance (NCQA) recognition, the 
gold standard for recognition of medical home practices in the United 
States.
    Advanced practice nurses have always practiced patient- and family-
centered care and will continue to be recognized leaders in this cost-
effective, high-quality healthcare delivery model.

                        TRANSITION FROM WARTIME

    Question. Admiral Niemyer, Navy Medicine has been involved in 
several humanitarian assistance/disaster relief (HA/DR) operations 
utilizing hospital ships, combatant ships, and land forces over the 
past year. How has the Navy Nurse Corps applied wartime experiences to 
these noncombat missions?
    Answer. Navy nurses are integral members of diverse medical units 
throughout the Helmand and Nimroz Provinces in Afghanistan. They serve 
in medical units at forward operating bases, Shock Trauma Platoons 
(STPs), Forward Resuscitative Surgical Systems (FRSS), and the 
Multinational Medical Units in Bastion and Kandahar supporting the 
immediate pre-, intra-, and post-operative phases of care for injured 
combat casualties.
    In accordance with nationally recognized trauma scales, patients 
treated at the Role 3 in Bastion typically had injuries scoring twice 
as high as those seen in a Level 1 trauma center in the United States. 
The advanced clinical expertise and technical skills of nurses gained 
through their wartime experience have significantly contributed to the 
unprecedented survival rates of greater than 95 percent. The expertise 
from wartime experience of our emergency/trauma, critical care, 
medical/surgical, pediatrics, neonatal intensive care, nurse 
anesthesia, and nurse practitioner specialties is also vital to the 
provision of outstanding patient care during HA/DR missions.
    Navy nurses are also trained and supported the theater's enroute 
care mission providing medical support in rotary wing airframes during 
the transport of casualties to higher levels of care. This skill set is 
also necessary for the critical care transport and rapid medical 
evacuation necessary in HA/DR missions.
    Navy nurses are primary members of medical stability operations on 
Embedded Training and Provincial Reconstruction Teams and served as 
mentors and teachers for Afghan military and civilian medical 
personnel. They gained experience in working with NATO members and 
other services, as well as Afghanistan civilians forging collaborative 
and trusting relationships to improve healthcare delivery systems. This 
is also a crucial skill set gained through wartime experience 
invaluable during HA/DR missions to build relationships with our host 
nation partners and strengthen U.S. maritime security and ultimately 
improving capability to work together with partner nations in the event 
of a future disaster.
                                 ______
                                 
         Questions Submitted to Major General Jimmie O. Keenan
            Questions Submitted by Chairman Daniel K. Inouye

                       PATIENT CARE TOUCH SYSTEM

    Question. General Keenan, the Army Nurse Corps launched the Patient 
Care Touch System in February 2011. How has this approach to nursing 
practice been integrated with the Army Patient-Centered Medical Home 
(PCMH) delivery model?
    Answer. Patient Caring Touch System and PCMH are complimentary 
systems. Facilities that are implementing PCMH report that they 
integrate well and report that the similarities of the team concept 
facilitate transition of other members of the team, and nursing becomes 
an important advocate of change. Shared accountability and the unit 
practice councils help the PCMH team to develop policies and practices 
and processes that are common to both systems and enables improvements 
in communication and multidisciplinary collaboration.

                       TRAINING ARMY NURSE CORPS

    Question. General Keenan, how has the Army Nurse Corps been changed 
by 10 years of war and what steps are being taken to ensure the best of 
the experiences are capitalized upon in training tomorrow's Army Nurse 
Corps?
    Answer. Based upon lessons learned and data in theater, Army Nurses 
are prepared for deployment by completing individual clinical training. 
We have developed new nursing skill sets and capabilities such as 
revision of our critical care nurse training to improve trauma care as 
well as training our nurses to provide MEDEVAC transport. To ensure 
capability gaps are addressed in future operations, Army nurses have 
developed a comprehensive set of policies that address training, 
equipping, sustainment and practice protocols. The Army Nurse Corps 
assigns a senior nurse to the Medical Task Force, who is responsible 
for collaborating with nurses to ensure standards of nursing care are 
in compliance in a deployed environment.
    The Army Nurse Corps has transformed Army Nursing Leader Training 
through the design and implementation of a career-long iterative group 
of courses, guided by nationally accepted nurse leader competencies and 
the Patient Caring Touch System, and gauged by the Leader Capability 
Map.

                      NURSES: SERVICE INTEGRATION

    Question. General Keenan, focusing specifically on the treatment 
facilities impacted by base realignment and closure (BRAC), how are 
nurses from the different services being integrated to deliver seamless 
care to beneficiaries?
    Answer. The joint facilities created by BRAC offer the opportunity 
for the services to collaborate in improving patient care just as we 
have in 10 years of war together. Many of our officers served in a 
joint environment overseas and can leverage that experience working at 
our joint treatment facilities in the continental United States.
    Nurses are integrated at all levels of the organization and are 
delivering seamless care to beneficiaries. Army, Navy, and Air Force 
nurses work side-by-side in clinical environments at Fort Belvoir 
Community Hospital and Walter Reed National Military Medical Center. 
From orientation programs, ongoing training, committee work, and 
process improvement teams to middle and executive level leadership, 
nurses from all services collaborate in a very deliberate and 
integrated environment to provide the best quality care.
    Question. General Keenan, over the course of history nurses have 
risen to the challenges of war providing invaluable contributions that 
have had long-lasting impacts on healthcare. As our Nation has been at 
war for the past 10 years, what are some of the significant research 
findings military nurses have contributed to the body of professional 
knowledge with applications away from the battlefield?
    Answer. The Army Nurse Corps is fully engaged in military research 
related to war. We have nurses assigned to the U.S. Army Institute of 
Surgical Research (USAISR) which is working to develop lessons learned 
from the data they have collected from 10 years of war. At USAISR, 
there is a cell dedicated to Combat Casualty Care Nursing Research.
    We also have nurses deployed with the Joint Theatre Trauma System 
team and the Deployed Combat Casualty Research Team. LTC Elizabeth 
Mann, of the USAISR, recently co-authored a study on mortality 
associated with sepsis in burn and trauma patients, which is one of 
many studies she has been involved with dealing with the challenges 
with the critically ill patients we have seen return from theatre. The 
Army Nurse Corps is proactively changing and improving our nursing 
practice based on the lessons learned.

                          SUBCOMMITTEE RECESS

    Chairman Inouye. The subcommittee will reconvene on 
Wednesday, April 18, at 10:30 a.m. to receive testimony from 
the Missile Defense Agency. Until then, we stand in recess.
    [Whereupon, at 11:44 a.m., Wednesday, March 28, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]
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