[Senate Hearing 112-]
[From the U.S. Government Publishing Office]
DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2013
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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.]