[Senate Hearing 112-207]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 112-207
 
 SEAMLESS TRANSITION: MEETING THE NEEDS OF SERVICEMEMBERS AND VETERANS

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 25, 2011

                               __________

       Printed for the use of the Committee on Veterans' Affairs


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                     COMMITTEE ON VETERANS' AFFAIRS

                   Patty Murray, Washington, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Daniel K. Akaka, Hawaii              Johnny Isakson, Georgia
Bernard Sanders, (I) Vermont         Roger F. Wicker, Mississippi
Sherrod Brown, Ohio                  Mike Johanns, Nebraska
Jim Webb, Virginia                   Scott P. Brown, Massachusetts
Jon Tester, Montana                  Jerry Moran, Kansas
Mark Begich, Alaska                  John Boozman, Arkansas
                       Kim Lipsky, Staff Director
                 Lupe Wissel, Republican Staff Director


                            C O N T E N T S

                              ----------                              

                              May 25, 2011
                                SENATORS

                                                                   Page
Murray, Hon. Patty, Chairman, U.S. Senator from Washington.......     1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     3
Isakson, Hon. Johnny, U.S. Senator from Georgia..................     5
Sanders, Hon. Bernard, U.S. Senator from Vermont.................    24
Begich, Hon. Mark, U.S. Senator from Alaska......................    28
Brown, Hon. Scott P., U.S. Senator from Massachusetts............    30
Boozman, Hon. John, U.S. Senator from Arkansas...................    33

                               WITNESSES

Bohn, Steve, OEF Veteran, Representing Wounded Warrior Project...     6
    Prepared statement...........................................     8
    Response to posthearing questions submitted by Hon. Mark 
      Begich.....................................................    10
Horton, Tim, OIF Veteran.........................................    11
    Prepared statement...........................................    13
Lorraine, Lt. Col. Jim, USAF (Ret.), Executive Director, Wounded 
  Warrior Care Project...........................................    15
    Prepared statement...........................................    17
    Response to posthearing questions submitted by Hon. Mark 
      Begich.....................................................    19
Zeiss, Antonette, Ph.D., Acting Deputy Chief Officer, Mental 
  Health Services, Office of Patient Care Services, U.S. 
  Department of Veterans Affairs; accompanied by Shane McNamee, 
  M.D., Chief of Physical Medicine and Rehabilitation, Hunter 
  Holmes McGuire (Richmond) VA medical center; Deborah Amdur, 
  Chief Consultant Care Management and Social Work, Office of 
  Patient Care Services; and Janet E. ``Jan'' Kemp, R.N., Ph.D., 
  VA National Suicide Prevention Coordinator.....................    35
    Prepared statement...........................................    36
    Response to posthearing questions submitted by:
      Hon. Patty Murray..........................................    44
      Hon. Richard Burr..........................................    61
      Hon. Mark Begich...........................................    62
Taylor, George Peach, Jr., M.D., MPH, Deputy Assistant Secretary 
  of Defense for Force Health Protection and Readiness, U.S. 
  Department of Defense; accompanied by Philip A. Burdette, 
  Principal Director, Office of Wounded Warrior Care and 
  Transition Policy..............................................    65
    Prepared statement...........................................    67
    Response to posthearing questions submitted by:
      Hon. Patty Murray..........................................    78
      Hon. Richard Burr..........................................    80
      Hon. Mark Begich...........................................    86


 SEAMLESS TRANSITION: MEETING THE NEEDS OF SERVICEMEMBERS AND VETERANS

                              ----------                              


                        WEDNESDAY, MAY 25, 2011

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:02 a.m., in 
room 418, Russell Senate Office Building, Hon. Patty Murray, 
Chairman of the Committee, presiding.
    Present: Senators Murray, Begich, Sanders, Burr, Isakson, 
Wicker, Brown of Massachusetts, and Boozman.

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

    Chairman Murray. Good morning and welcome to today's 
hearing. We are going to be examining the ongoing efforts of 
the Department of Defense and the Department of Veterans 
Affairs to provide a truly seamless transition for our 
servicemembers and veterans. Last week Deputy Secretary Lynn 
and Deputy Secretary Gould highlighted the challenges and 
successes DOD and VA have encountered on the path toward a 
truly seamless transition.
    Today we are going to be hearing directly from some of our 
Nation's wounded warriors, who will share their views and 
firsthand experiences on how DOD and VA can further improve the 
transition for servicemembers and veterans. Thank you all for 
being here today. I look forward to hearing from you about what 
went well, but also about how you may have been negatively 
impacted by the lack of collaboration between DOD and VA, and 
what you believe can be done to improve the transition for the 
thousands upon thousands of servicemembers still to come home.
    I also look forward to talking with our departments' 
witnesses who are working to improve this critical transition 
period to ensure veterans are not falling through the cracks. I 
know that VA and DOD have big challenges facing them. 
Servicemembers and veterans continue to take their own lives at 
an alarming rate. Wait times for benefits continue to drag on 
for an average of a year or far more, and the quality of 
prosthetic care continues to be inconsistent between the 
departments.
    Now, in some instances, DOD and VA have come to the table 
to make headway on these issues, and they should be commended 
for that. But we still have work to do. In fact, sometimes it 
is the simplest fixes that for some reason the two departments 
cannot come together on.
    A good example of this is the Traumatic Extremity Injuries 
and Amputation Center of Excellence that was mandated to move 
forward on October 14, 2008. This new center was supposed to be 
a place where best practices could be shared and a registry of 
these injuries could begin. But here we are, 2\1/2\ years 
later, and we have not seen any substantial movements toward 
the creation of this center. When I asked Secretary Lynn last 
week what progress had been made, he could not provide an 
answer. That is unacceptable.
    But as our witnesses' testimony today will show, this is, 
unfortunately, not the only area where we need better medical 
collaboration. We have a lot of work to do to make sure that 
each department knows what the other is doing to provide our 
servicemembers and veterans.
    It was evident from last week's hearing that the sheer 
number of programs that are in place have resulted in several 
parallel but not collaborative processes. Last week we also 
discussed the need for the best amputee care that can be 
provided, as well as the divide between the level of technology 
at the DOD and the VA.
    Beyond the Center of Excellence that I mentioned earlier, I 
look forward to hearing about the improvements that are being 
made in this area. Veterans cannot come home to VA facilities 
that cannot care for the devices that our servicemembers are 
getting at cutting-edge DOD prosthetic facilities. We need to 
do everything we can to bring all services up to the standard 
our seriously injured veterans deserve.
    I am optimistic that we can do this because I know there 
are facilities like the new Polytrauma and Amputee Care 
Transition units that are being piloted at the VA medical 
center in Richmond, Virginia. Not only is this an innovative 
and critical component of care, but it is also an example of 
where DOD and VA came together, jointly assessed the problems 
in the system of care, and responded appropriately. I would 
like to see this approach brought to bear on all aspects of 
transition.
    Today we will also further discuss the efforts to expand 
and improve mental health care. We do not need the courts to 
tell us that much more can and should be done to relieve the 
invisible wounds of war. Although some steps have been taken, 
the stigma against mental health issues continue within the 
military, and VA care is still often too difficult to access.
    This has had a tragic impact. Last month, VA's suicide 
hotline had the most calls ever recorded in a single month, 
more than 14,000. That means that every day last month, more 
than 400 calls were received.
    While it is heartening to know that these calls for help 
are now being answered, it is a sad sign of the desperation and 
difficulties that our veterans face, that there are so many in 
need of that lifeline. I look forward to speaking with all of 
our witnesses about this most pressing issue.
    But health care is not the only area that needs better 
collaboration. Last week we discussed the delays and 
dissatisfaction that characterized the Joint Disability 
Process, the program that was supposed to streamline the way 
our veterans get their benefits.
    Instead, however, what we learned is that veterans are 
still waiting for up to 400 days for word on their benefits, 
and that all too often, veterans are committing suicide or 
turning to drugs and alcohol in that time in their lives that 
they are put on hold during this process. Today I want to hear 
how we are going to do much better.
    We must not forget that the commitment we make to our 
servicemembers and to their families when they join the 
military does not end when they return home. Whatever condition 
they arrive in, this Nation will provide them with the care and 
services they need and deserve.
    Just a couple days ago, a Marine whose home base is here in 
the Nation's capital and with whom a member of my staff served, 
was wounded by an IED in southern Afghanistan. He has lost much 
of his leg and doctors are struggling to save one of his arms. 
During one surgery, one of his lungs collapsed. This is in 
addition to serious shrapnel wounds that he received.
    I want that Marine and all Marines, soldiers, sailors, 
airmen, and Coast Guardsmen to have every benefit and every 
service we have available. I want him to receive care that is 
not just excellent, but truly the best in the world. I do not 
want him, or any servicemember or veteran who has sustained 
such injuries, to have to wait months or even years to have a 
claim adjudicated because we cannot make the bureaucracy 
efficient.
    I do not want him to receive anything less than the best 
prosthetic limb we can design and ensure that it has been 
perfectly adapted to him. I want him to receive treatment and 
support as he copes with this new reality. Just as important, I 
want his loved ones to get the support they need, because if we 
cannot be there for them, they will not be able to be there for 
him.
    I know all of us here share those desires and the 
dedication to achieving those goals. We are almost 10 years 
into these conflicts. It is past time to get it right. The 
system is doing many things well, but there is always more than 
can be done, and I believe that all the Members here, and all 
of our VA and DOD employees, share the commitment to excellence 
our veterans deserve.
    So again, I want to thank all of our panelists who are here 
today. I particularly appreciate your sharing with us your 
experiences and look forward to hearing from all of you. With 
that, I will turn it over to the Ranking Member, Senator Burr, 
for his opening statement.

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

    Senator Burr. Thank you, Madam Chairman, and I welcome all 
of our witnesses today. And, Madam Chairman, as I got the 
notice on this hearing, I had to chuckle when I read seamless 
transition after the last hearing that we got through. It is a 
great goal, and I think we both agree we are a long way from 
it.
    Before I continue, I would sort of like to raise for the 
Committee's thoughts, how much is enough time to prepare 
testimony before this Committee. I asked DOD how much time they 
need to be able to submit testimony. The Committee sent an 
invitation to testify on May 11. With less than 24 hours notice 
before this hearing, we had still not received their testimony.
    Madam Chairman, I do not know where the hangup is. If I am 
on ground that I should not be, I apologize to you. But I think 
we have to publicly hold responsible, especially the Federal 
agencies that we invite to testify, to the rules of the 
Committee, and that is that testimony has to be timely. If they 
cannot do that on time, then I have little faith that we can 
ever achieve a seamless transition for some very, very tough 
issues that we have got before us.
    Chairman Murray. Senator Burr, if I can just comment? I was 
as disappointed as you that the Department of Defense was 
extremely late in getting their testimony to us and appreciate 
your comments and want to work with you on what we can do about 
that. But I am going to allow it for today, for the DOD's 
testimony to be read because I think this hearing is very 
important, and I think we need to move forward. I appreciate 
your comments.
    Senator Burr. Well, I thank the Chair for that and remind 
all Members that it seems like occasionally people do not 
believe that it is important in this Committee, and I have seen 
the Chair before refuse to accept testimony and would encourage 
the Chair to consider that as appropriate in the future.
    I appreciate the opportunity to discuss the collaborative 
issues with VA and DOD and hear firsthand from veterans about 
their personal experiences moving from active duty to veteran 
status. Stories from the field like those we will hear about on 
our first panel are invaluable in getting a true assessment of 
what works well and what does not work well.
    Each veteran testifying today has had a different 
experience, and unfortunately, they are all not positive 
experiences, which echoes concerns brought up in last week's 
hearing. For instance, we will hear about the bureaucratic 
hassles, delays, and confusions Specialist Bohn faced after he 
was severely injured in Afghanistan when a suicide bomber 
detonated an explosive at the post near the Pakistan border. 
His story is a real example of the lack of communication 
between two departments.
    We will also hear from Lance Corporal Horton, who suffered 
from TBI, has nerve damage in his hands, had his left leg 
partially amputated after his Humvee hit an IED in Iraq. He 
will share his experiences in obtaining his benefits from the 
VA.
    Another veteran witness, Lieutenant Colonel Lorraine, is 
not only a veteran himself, but a military spouse and the 
founding Director of Special Operations Command and Care 
Coalition. So his personal experience touches the issues of 
collaboration between VA and DOD from all sides. A veteran 
transitioning to VA, a military spouse helping his wife 
transition, and the director of a DOD wounded warrior program.
    While it is critical to hear these personal stories from 
our Nation's veterans, it is just as important to continue our 
dialog with the agencies tasked with ensuring a seamless 
transition for servicemembers from active duty to veteran 
status.
    One area that VA and DOD have worked on together is 
improving the mental health care for servicemembers, veterans, 
and their families. In October 2010, recognizing that two 
agencies serve the same individuals at different stages of 
their lives, VA and DOD adopted a cohesive mental health plan. 
Although it is hard to say after only 7 months whether this 
will improve services, I look forward to hearing about how this 
coordinated effort to improve quality, access, and 
effectiveness helps improve the lives of our Nation's warriors 
and their families.
    Another area that I noted in my opening statement last week 
that needs attention is the Federal Recovery Coordination 
Program. This program was envisioned to help veterans and their 
families access all Federal benefits available to them, not 
simply those benefits available through the VA. I still believe 
this is an example of an idea that looks great on paper, but 
has to live up to its potential, and I look forward to 
exploring ideas to help this program live up to everybody's 
expectations.
    On the benefits side, the worldwide rollout of the 
Integrated Disability Evaluation System has clearly gotten off 
to a rocky start. As Deputy Secretary Lynn testified last week, 
the goal is for veterans to complete the IDES process within 
295 days. But nationwide, it is taking over 394 days, and in 
some cases, such as at Camp Lejeune, much longer than that.
    Also, it will take 1 to 2 years before the agencies will 
actually be able to meet the goal, particularly considering the 
number of suicides, court martials, and other unfortunate 
outcomes among IDES participants. We need to take a serious 
look at what personal toll the delays and uncertainties of the 
IDES process is taking on our wounded servicemembers.
    Madam Chairman, it has been 4 years since the scandal 
surrounding Walter Reed brought this lack of cooperation to 
light, and gauging by the stories of our first panel and what 
was learned in last week's testimony, the bureaucracy we tried 
to cut through may have become worse.
    I look forward to working with you, Madam Chairman, on a 
truly seamless transition for our Nation's wounded warriors. To 
our veterans testifying today and to the witnesses from the 
agency, we are grateful to you not only for your efforts, but 
for your service. Thank you.
    Chairman Murray. Thank you very much, Senator Burr.
    Senator Isakson.

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

    Senator Isakson. Thank you, Madam Chairman. I want to thank 
our veterans, Steve Bohn and Tim Horton, for their sacrifice, 
their service, and their willingness to testify today, and I 
particularly want to welcome Lieutenant Colonel Jim Lorraine. I 
think it is very appropriate that the Committee asked Colonel 
Lorraine to testify today. He is the Executive Director of the 
Wounded Warrior Project in the Central Savannah River Area of 
Georgia where Fort Gordon, the Eisenhower Medical Center, and 
the Charlie Norwood VA are, where General Schoomaker was 
originally stationed, and where they began the pilot for 
seamless transition between Eisenhower Medical Center at Fort 
Gordon and the Augusta--what was then the Uptown Augusta VA.
    He had some very great stories to tell about keeping people 
from falling between the cracks, identifying TBI and PTSD, 
bringing veterans back. In fact, I love to tell the story about 
my visit there 3\1/2\-4 years ago with Lori Ott.
    We were going through the VA Hospital and a staff sergeant, 
female staff sergeant, turned the corner and the Director at 
that time stopped her and said, ``Please meet Senator 
Isakson.'' I shook her hand and I said, ``Thank you for your 
service.'' She said, ``I am going back to Iraq tomorrow.'' And 
she had come back, was diagnosed with Traumatic Brain Injury, 
had been going through a recovery program and a treatment 
program, and returned to active duty in the military. So that 
shows you----
    Chairman Murray. And she was a woman.
    Senator Isakson. And she was a woman. Well, they are always 
stronger than the guys anyway. My wife taught me that a long 
time ago.
    But I want to just thank Lieutenant Colonel Lorraine for 
being here. I think if the Committee will pay close attention 
to his recommendations on the Federal recovery coordinators. It 
will make a marvelous difference in that program, and I thank 
all of you for your service to the country.
    Chairman Murray. Thank you very much.
    With that, I want to turn to our panel this morning, and I 
really do appreciate both your service and your willingness to 
testify here today on a very important topic. We are going to 
begin with Afghanistan veteran, Steve Bohn, who is representing 
the Wounded Warrior Project; followed by Tim Horton, an Iraq 
veteran; and our third witness, as you heard, is Jim Lorraine, 
Executive Director of the Central Savannah River Area Wounded 
Warrior Care Project.
    So, Mr. Bohn, we will begin with you.

  STATEMENT OF STEVE BOHN, OEF VETERAN, WOUNDED WARRIOR CARE 
                            PROJECT

    Mr. Bohn. Good morning. Chairman Murray, Ranking Member, 
and Members of the Committee, I am honored to testify today and 
to share my experience as a wounded warrior in transitioning 
from military service to civilian life. I sincerely hope my 
experience can help this Committee identify and fix the 
problems that many others face every day.
    A little about myself. I was born and raised in Salem, 
Massachusetts. I grew up poor and I worked for everything I 
have. I dropped out of high school with three and a half 
credits left to graduate so I could get a full-time job and 
help support my family.
    I joined the Army in 2007 after learning that a friend had 
been killed in Iraq. After infantry training, I was assigned to 
the 101st Airborne Division, 1/506th Infantry Regiment. I 
deployed to Afghanistan in March 2008 to a remote base near the 
Pakistan border. Conditions were pretty primitive. I enjoyed 
the challenge, but also had to dig deep to deal with losing my 
best friend as well as our first lieutenant who were killed in 
August 2008 by an IED.
    I was badly injured in November 2008 when a suicide bomber 
detonated a dump truck packed with 2,000 pounds of explosives 
next to our outpost. The building I was in collapsed on me, and 
I suffered severe internal injuries and spinal injuries. I was 
hospitalized for a total of 6 months and underwent two major 
surgeries that included resection of the small intestine, 
bladder reconstructive surgery, and spinal surgery.
    I experienced some rough transitions long before my medical 
retirement. After initial hospitalization at Bagram Air Base, 
Afghanistan and then to Landstuhl, Germany, I was flown to Fort 
Campbell, Kentucky, rather than to Walter Reed where I was 
supposed to be sent for surgery. At Fort Campbell, I was 
assigned to a WTU. Doctors finally realized the mistake and got 
me transferred to Walter Reed.
    After undergoing spinal surgery there, I was transferred to 
a spinal cord injury unit at a VA medical facility in Boston, 
but whatever coordination should have taken place apparently 
did not because Fort Campbell threatened to put me on AWOL if I 
did not return. As a result, I was flown back to Fort Campbell. 
Later, I was returned to Walter Reed to undergo bladder 
surgery.
    After post-surgical convalescence at Walter Reed, I was 
assigned to a Warrior Transition Unit at Fort Meade, Maryland. 
That WTU experience involved little more than spending time in 
the barracks. Thanks to Senator Kerry's intervention, I was 
transferred to a community-based Warrior Transition Unit at 
Hanscom Air Force Base in Concord, Massachusetts which enabled 
me to live at home, work on the base, and finish up my medical 
care.
    Over a 12-month period there, I went through a medical 
evaluation board which eventually gave me a 40 percent 
permanent disability rating, 30 percent for my spinal injuries 
and 10 percent for my neck injuries. That rating does not take 
account of my internal injuries. I was finally medically 
retired from the Army on October 27, 2010.
    My transition to the VA began with the WTU in Concord, 
Mass. sending my paperwork to VA 180 days before my estimated 
separation date so that a claims adjudication could be as 
timely as possible. VA contacted me soon after leaving the 
military to schedule compensation and pension examinations, but 
those examiners were backlogged, and I have had long waits to 
schedule the many required exams.
    I still have a neurosurgery exam, which was delayed to get 
another MRI. As I understand it, VA cannot adjudicate my case 
until it has the results of all those exams.
    While I could see some evidence of DOD/VA coordination 
regarding the compensation process, something fell through the 
cracks in terms of getting VA medical care. It was not until 
early this month, more than 6 months after I became a veteran, 
that anyone at VA approached me to discuss my treatment. At 
that time, I was contacted by a social worker who arranged for 
me to get physical therapy. Unfortunately, no one seemed aware 
of my spinal cord injuries. Because of those injuries, physical 
therapy really is not appropriate.
    I still have herniated disks, which are pinching nerves in 
my neck and causing great pain, but I am uncertain what 
additional treatment might still be possible. At this point, I 
still have not been assigned a VA primary care doctor. People 
ask, How are you doing since getting out of the service? I am 
not a complainer, but I have to say I am struggling.
    I still live on my retirement pay of approximately $699 a 
month, not even half the pay as an Army specialist. All of it 
goes to rent for my one-bedroom apartment. I still have other 
bills, which I cannot pay. Given the extent of my injuries, I 
am not physically able to work. My back and neck are in 
constant pain. I applied for Social Security disability, but 
was denied.
    I expect to get additional compensation from the VA that 
takes account of all my injuries, but it is difficult to be in 
this kind of limbo waiting many months for the VA adjudication 
and to live on so little for so long.
    I have always been a hard worker. I am 24 years old. I want 
to work. I completed my GED degree and have worked as a roofer 
and a chef, but with my injuries, I cannot go back to either 
kind of work, and I am not sure what jobs I can do. I did 
attend a Transitional Assistance Program before leaving the 
Army, but that did not give the kind of one-on-one help I need 
and did not really answer my questions about vocational 
rehabilitation or schooling or prepare me for the rough 
transition I have faced.
    The VA claims adjudication process alone has been 
complicated, and I have been lucky to have a great advocate 
from the Wounded Warrior Project to help me with my claim. But 
I wonder if this process could have gone differently. I know 
now that with injuries as extensive as mine, VA and DOD policy 
provides for assigning a senior level nurse and a social worker 
to help coordinate the complexities involved in the transition 
process.
    No one ever discussed with me or my family the possibility 
of having a Federal Recovery Coordinator assigned to my case, 
but I wonder if that kind of help might have made a difference. 
This has not been an easy journey. I have had a long, difficult 
recovery. My injuries still cause me a lot of pain, and I will 
continue to need care and evaluation.
    Neurosurgeons warn me that my condition could deteriorate. 
I can understand and to some extent cope with all that. What is 
more difficult to understand and causes me concern for other 
warriors who may get hurt in the days and months ahead is why 
after so many years, VA and DOD have not solved these 
transition problems. I hope this hearing will help resolve many 
of these problems and spare other warriors the difficulty I 
have encountered.
    Thank you for whatever you can do to help future wounded 
warriors and God bless.
    [The prepared statement of Mr. Bohn follows:]

       Prepared Statement of Steven A. Bohn, Specialist 4 (Ret.)

    Chairman Murray, Ranking Member Burr, Members of the Committee, I 
am honored to have the opportunity to appear before you today, and as a 
wounded warrior, to share my experience regarding the transition from 
military service to civilian life. I believe in my country and I 
believe in my government. This is why I hope you can help fix the 
problems that so many of us wounded warriors are dealing with every day 
after already having gone through so much.
    My name is Steven Andrew Bohn. I was born and raised in Salem, 
Massachusetts. I grew up poor and worked for everything I have. I 
dropped out of high school with 3\1/2\ credits left to graduate, so I 
could get a full time job and help support my family.
    I joined the Army in 2007 after learning that a friend of mine had 
been killed in Iraq by an IED blast. After infantry training, I was 
assigned to the historic 101st Airborne Division, 1/506th Infantry 
Regiment. My unit deployed to Afghanistan in March 2008 to a remote 
base in Wardak province near the Pakistan border. The base was the size 
of a soccer field and held 28 of us. Conditions were pretty basic; 
having no running water, for example, we cleaned ourselves with baby 
wipes, and got to shower once a month at a forward operating base. I 
enjoyed the challenge of our rugged conditions. We went on hundreds of 
missions while holding down our outpost. But I was devastated when my 
best friend, Specialist Paul Conlon, from Somerville, MA, and our first 
lieutenant were killed in August 2008. Still I knew I had to stay 
strong to survive.
    I was badly injured on November 6, 2008, when a suicide bomber 
driving a dump truck packed with 2000 lbs of explosives drove up to our 
outpost and detonated it. The building I was in collapsed on me and I 
suffered severe internal injuries and spinal injuries. I was 
hospitalized for a total of 6 months, and underwent two major surgeries 
that included resection of the small intestine, bladder reconstructive 
surgery and a spinal surgery. I was also diagnosed at Landstuhl, 
Germany with mild Traumatic Brain Injury.

                   FROM INJURY TO MEDICAL RETIREMENT

    While I know your focus today is on the transition from DOD to VA, 
I experienced some rough transitions long before my medical retirement 
from service. After being initially hospitalized at Bagram Air Base in 
Afghanistan and then at Landstuhl Germany, I was flown to Fort 
Campbell, KY rather than to Walter Reed where I was supposed to be sent 
for surgery. At Fort Campbell, I was initially assigned to a Warrior 
Transition Unit (WTU). When I was finally evaluated there by 
physicians, they realized the mistake and I was transferred to Walter 
Reed. After undergoing spinal surgery at Walter Reed, I was transferred 
to the VA Boston Healthcare System's West Roxbury Campus' spinal cord 
injury unit so that I could be closer to my family during that 
convalescence. Whatever coordination should have taken place between 
Walter Reed, West Roxbury, and the Fort Campbell WTU to which I'd been 
assigned apparently didn't occur, because Fort Campbell threatened to 
put me on AWOL if I didn't return. As a result, I was flown back to 
Fort Campbell. Later I was returned to Walter Reed to undergo bladder 
surgery.
    After post-surgical convalescence at Walter Reed, I was assigned to 
a Warrior Transition Unit at Fort Meade, Maryland. That WTU experience 
involved little more than spending time in the barracks. Thanks to 
Senator Kerry's intervention, I was transferred to a Community Based 
Warrior Transition Unit (CBTWU) at Hanscom Air Force Base in Concord 
MA, which enabled me to live at home, work on the base, and finish up 
my medical care. I was assigned there for a period of 12 months. During 
that time, I underwent a Medical Evaluation Board which eventually 
assigned me a 40% permanent disability rating, 30% for my spinal 
injuries, and 10% for my neck injuries. That rating does not take 
account of my internal injuries. I was finally medically retired from 
the Army on October 27, 2010.

                 TRANSITION FROM MILITARY SERVICE TO VA

    Let me try and explain the DOD/VA transition I experienced. 
Initially, the process seemed to begin well, with the CBTWU sending my 
paperwork to VA 180 days before my estimated separation date so that 
the claims-adjudication could be as timely as possible. I was contacted 
by VA soon after leaving the military to schedule compensation and 
pension examinations. But those examiners were backlogged, and I've had 
long waits to schedule the many exams I've had to undergo. I still have 
to have a neurosurgery exam, which had been delayed because of the 
apparent need for another MRI. As I understand it, VA cannot adjudicate 
my case until it has the results of all those exams.
    While I could see some evidence of DOD/VA coordination as it 
related to establishing entitlement to VA compensation, something 
seemed to have fallen through the cracks in terms of getting VA medical 
care. While I've had multiple VA compensation examinations, it wasn't 
until earlier this month that anyone at VA approached me to discuss any 
treatment. At that time, I was contacted by a social worker, who 
arranged for me to get physical therapy. Unfortunately no one seemed to 
have been aware of my spinal cord injuries. Because of those injuries, 
physical therapy really isn't appropriate. I still have two herniated 
discs which are pinching nerves in my neck and causing great pain, but 
I am uncertain what additional treatment might still be possible. At 
this point, many months after becoming a veteran, I have yet to be 
assigned a VA primary care doctor.

                          TODAY AND THE FUTURE

    I was asked recently, ``How are you doing since getting out of 
service?'' Now nearly seven months later, I would have to say, ``I'm 
struggling.'' I'm not by nature a complainer. But I'm still living on 
my retirement pay of approximately $699/month, not even half the pay I 
earned as an Army Specialist. All of that money goes to rent for my one 
bedroom apartment. I still have other bills which I cannot pay. I know 
I'm not the only soldier going through all of this, and that others 
must sometime wonder where their next meal will come from. Given the 
extent of my injuries, I'm not physically able to work. My back and my 
neck are in constant pain. I applied for Social Security disability but 
was denied.
    I grew up in Salem, but now live in Peabody just north of Boston, 
Massachusetts. It's close to home, but it isn't a low cost area. I 
expect to get additional compensation from the VA that takes into 
account of all my injuries. But the case still hasn't been finally 
adjudicated. As you can imagine, it is difficult to be in this kind of 
limbo, waiting many months for VA to adjudicate my case, and to live on 
so little for so long after going through so much.
    People ask me about the future. I grew up poor and I've always been 
a hard worker. I'm 24 years old. I want to work! I completed my GED 
degree, and have worked as a roofer and a chef. But, with my injuries, 
I can't go back to either kind of work, and am not sure what jobs I can 
do. I did attend a Transition Assistance Program before leaving the 
Army. But that kind of program didn't allow for the one-on-one help I 
need, and didn't really answer my questions about vocational 
rehabilitation, or schooling, or prepare me for the rough transition 
I've faced. But I'm determined to persevere.
    I was also recently asked, ``Knowing everything that's happened to 
you, would you do it all over again?'' My answer now and will always 
be, ``of course.'' I joined the service after a close friend of mine 
was killed in Iraq. I understood the risks.
    I know this country isn't perfect and I know things take time but I 
also know that I'm not alone in having to wait so long for all of our 
well deserved benefits to take effect. I understand it's not unusual 
for wounded warriors from Massachusetts who have been medically retired 
to wait 9 to 12 months for the VA to adjudicate their claims. In 
contrast, I'm told that Rhode Island warriors may get claims 
adjudicated in about six months.
    As far as I know, the DOD's Disability Evaluation System, which 
aims to work with VA to simplify and streamline disability evaluations, 
is still not fully employed. Apparently the WTU where I was stationed 
was a pilot site, but that simply meant that a small percentage of 
servicemembers were processed through the pilot. Most face the same 
slow road I'm traveling.
    The VA claims adjudication process alone has been complicated and 
I've been lucky to have a great advocate from Wounded Warrior Project 
who is now helping me with my claim. But I've wondered if this process 
could have gone differently. With injuries as extensive as mine, I 
think it was pretty clear early on that I would not be able to stay in 
the service. I understand that in those instances, VA/DOD policy calls 
for assigning a senior-level nurse or social worker to help coordinate 
all the complexities involved in the transition from military status to 
community reintegration. No one ever discussed with me or my family the 
possibility of having a Federal Recovery Coordinator assigned to my 
case. But I wonder if having had that kind of help might have made a 
difference.
    This hasn't been an easy journey for me. I've had a long, difficult 
recovery. My spinal injuries still cause me a lot of pain and I will 
continue to undergo care and evaluation. Neurosurgeons warn me that my 
condition could deteriorate. I can understand and to some extent cope 
with all of that. What is more difficult to understand, and that causes 
me concern for the warriors who may sustain severe injuries in the days 
and months ahead, is why after so many years VA and DOD haven't solved 
the kind of transition problems I've experienced.
    I hope this hearing will highlight and hopefully help resolve many 
of these problems, and spare other warriors the mental and financial 
anguish I've encountered.

    Thank you for taking the time to listen to my experience and taking 
the time to care.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Mark Begich to 
     Steven Bohn, OEF Veteran, representing Wounded Warrior Project

    Mr. Bohn, the Wounded Warrior Project is an outstanding 
organization that most definitely has the best interest of our Wounded 
Warriors at heart. Your organization strives to ensure that no Wounded 
Warrior must overcome challenges and adversity alone.
    One aspect of the transition process that I focus heavily on is 
employment. As you know, the unemployment rate for our returning 
veterans is completely unacceptable. Your Warriors to Work program, as 
well as several other programs, assist Wounded Warriors with the 
transition to civilian employment.

    Question 1. In your opinion, what can be done to improve the 
civilian employability of our Wounded Warriors?
    Question 2. Are the current DOD efforts such as TAP effective in 
your opinion? Why or why not?
    Question 3. What is the employment success rate of your programs?

    Response. Senator Begich, In my opinion to improve the employ-
ability of other Wounded Warriors, would be to have a lot more 
companies reach out to us. A lot of us are not physically able to work 
with our injuries. If the government provided us with incentives, it 
would make it a lot easier for us to know what kind of jobs are out 
there.
    The TAP program can be effective if we were going through it after 
all of our medical treatment. Like I said before, I don't think it was 
an appropriate time to go through it while I was still going through 
all my medical treatment. I was focused solely on how I was going to 
get better day to day.
    I know that the Wounded Warrior Project has a TRACK program, which 
sends you to FL or TX to live with fellow wounded warriors for a year 
and go to school together. I have not gone through this program yet, 
but I hear a lot of good things about it. You would have to ask the 
Wounded Warrior Project about their success rate.
    I thank you Senator for your concern about our futures and whatever 
you can do to help us. I have a strong passion for helping future 
soldiers overcome their obstacles because I've already been through all 
of the red tape. We definitely need more support from our government.

    Chairman Murray. Thank you very much, Mr. Bohn. Really 
appreciate you sharing that with us. Mr. Horton.

              STATEMENT OF TIM HORTON, OIF VETERAN

    Mr. Horton. Chairman Murray, Ranking Member Burr, Members 
of the Committee, thank you for the opportunity to be here 
today to speak about the challenges facing warriors as they 
transition from the military to the civilian world after 
experiencing what are often profound and life-changing 
injuries.
    My name is Tim Horton, and I joined the U.S. Marine Corps 
in 2003. Just over a year after I enlisted, I was deployed to 
Ramadi, Iraq with the 1st Marine Division Fox 2-5, which at the 
time was the most decorated battalion in the Marine Corps. 
February 5th, 2005 marked the day my transition as a wounded 
warrior began when my Humvee detonated an improvised explosive 
device while I was on a patrol.
    My injuries were severe and extensive. I suffered a 
Traumatic Brain Injury, left leg below the knee amputation, 
multiple fractures to my right and left arms, nerve damage to 
my hands, damage to my eyelid that required several surgeries, 
and still have shrapnel all over my body as a result of the 
explosion.
    I was medivaced from Iraq to Landstuhl, Germany, and then 
taken to Bethesda National Naval Hospital where I completed the 
bulk of my rehabilitation. In June 2006, I was medically 
retired and returned to the Midwest with my family to begin my 
life post-injury.
    I completed the VA compensation and pension process while I 
was still at Bethesda and was assigned a rating of 60 percent. 
While the rating came relatively quickly, it was deeply flawed. 
Most of my injuries were not evaluated to determine my rating 
despite being very clearly documented in my medical records. I 
did not learn until I reviewed my initial rating that the VA 
had not considered my Traumatic Brain Injury in my evaluation.
    I am not sure how this happened as it was well documented 
in my records that I lost consciousness for a sustained period 
of time after the blast. Because of issues like this, I have 
had to reopen my claim more than three times to ensure all my 
injuries were taken into consideration.
    Finally, after 6 years of examinations and providing 
documentation, the VA has assigned me a rating of 100 percent 
permanent and total disabled. Were it not for veterans looking 
out for other veterans, particularly Vietnam veterans I met at 
the VA medical centers, I would not have known how to advocate 
for myself and fight through the compensation and pension 
process. I know too many veterans who have grown tired of 
fighting the VA to receive just a rating for their severely 
injured bodies. It should not take three or four times to get 
this process right.
    While my initial rating was deeply flawed, it did allow me 
to begin utilizing my VR&E benefits shortly after returning 
home. In August 2006, I enrolled in a four-year degree program 
at the University of Oklahoma Baptist College. The process up 
to the college enrollment was relatively smooth. I did not have 
to fight my counselor to establish an educational or employment 
goal. Our appointments were often brief and contained no real 
guidance concerning how to move ahead.
    While I did not have to fight for what I wanted, I 
certainly was not advised of all the benefits that come with 
utilizing VR&E. Had I known the full extent of the benefits, it 
is very possible I would have pursued a path that led to a 
master's or doctorate degree. Today, one more combat veteran 
has a bachelor's degree. It is in education.
    Although my VR&E counselor was very largely receptive to my 
requests and responsive to my calls, utilizing my benefits at 
Oklahoma Baptist College proved challenging. During my 4 years 
at college, I had difficulty getting the VA and the college on 
the same page regarding tuition payments. Each semester was a 
struggle, and had it not been for my persistence in ensuring 
the two institutions worked together, I am not sure I would 
have successfully stayed enrolled.
    I was proud to graduate and receive my Bachelor of Science 
in May 2010, despite the prediction of a VA employee who I 
would characterize as less than supportive of my goals. While I 
was being trained to use a VA-issued Palm Pilot to help me keep 
my appointments straight and assist me with recording class 
assignments, a VA employee told me that because I had suffered 
a Traumatic Brain Injury, I would never be able to graduate 
college unless I cheated my way through.
    Her comment and perceptions of my capabilities and life 
goals were inappropriate and not reflective of the type of 
veteran-centered focus the VA promotes in posters inside their 
buildings. Luckily, I have never been a person to allow other 
people to tell me what I am capable of, and I turned the anger 
I felt into drive and motivation to succeed.
    But for many of my fellow veterans, that type of attitude 
and lack of understanding about TBI, one of the signature 
wounds of this war, is incredibly detrimental. In some, it 
disengages them from the very system that exists solely to help 
us fulfill our lives after fighting in war. I have worked hard 
to ensure my injuries and other people's perceptions of them do 
not define my way of life or limit what I am able to 
accomplish.
    Receiving timely and quality prosthetic care is 
instrumental to maintaining my activity level. The quality of 
care I have received through the Oklahoma City VA medical 
center is great. Their contracted prosthetic specialists were 
familiar with cutting-edge prosthetic technology and able to 
outfit me with the devices I need to maintain a high level of 
physical activity.
    Most importantly, my prosthetics provider really took out 
the time to understand who I am as a person, not just as a 
wounded warrior, and how that shapes my medical needs. So while 
the quality of my prosthetics is good, the process of going 
from DOD to the VA to receive it, and my full benefits, takes 
far too long.
    When I need adjustments or replacement equipment, I must 
schedule an appointment with the medical center to be seen by a 
member of the prosthetics team who will then write the 
prescription to my outside prosthetic specialist. Sometimes it 
can take weeks for the VA to actually send that prescription to 
the provider, further delaying my ability to get an appointment 
and ultimately receive the adjustments or equipment I need.
    Why is this the case? I know other veterans who live in 
close proximity to Walter Reed who are able to walk in and out 
with the services and equipment they need within the same day, 
all without ever needing to go through their local VA. It would 
make sense to me if I were able to see my prosthetics 
specialist first who could then communicate with the VA about 
what I need and get the authorization, eliminating the wait 
time for an appointment.
    While waiting weeks for an appointment might seem like a 
minor inconvenience for a warrior like myself, spending weeks 
without the necessary prosthetics equipment or sometimes even 
worse, equipment that causes extreme discomfort and other 
medical issues, can be wholly disruptive to our daily lives. 
The timeliness and consistency of care should not be a function 
of where warriors happen to live.
    There are so many programs and benefits available to assist 
us; yet, often we are never informed of these programs, or the 
information is delivered at a time and place that is not 
conducive for wounded warriors to absorb it. What I can tell 
you from my experiences is that warriors need real help in 
discovering what benefits exist and how to utilize them so they 
can thrive in their lives post-injury.
    Other veterans are out there spreading the word, but no one 
from the VA is reaching out. That needs to change. My hope is 
that by coming before you today and telling my issues in 
navigating through the system, things will continue to improve 
for the warriors coming behind me. I appreciate your time and 
efforts on improving the transition for my fellow wounded 
warriors and look forward to answering any questions you might 
have. Thank you.
    [The prepared statement of Mr. Horton follows:]

         Prepared Statement of Tim Horton, Lance Corporal (RET)

    Chairman Murray, Ranking Member Burr, Members of the Committee, 
Thank you for the opportunity to be here today to speak about the 
challenges facing warriors as they transition from the military to the 
civilian world after experiencing what are often profound and life 
changing injuries.
    My name is Tim Horton and I joined the United States Marine Corps 
in 2003. Just over a year after I enlisted I was deployed to Ramadi, 
Iraq with the 1st Marine Division Fox 2-5, which at the time was the 
most decorated battalion in the Marine Corps. February 5, 2005 marked 
the day my transition as a wounded warrior began when my Humvee 
detonated an improvised explosive device while I was on patrol. My 
injuries were severe and extensive. I suffered a Traumatic Brain 
Injury, left leg below the knee amputation, multiple fractures to my 
right and left arms, nerve damage to my hands, damage to my eye lid 
that required reconstructive surgery, and still have shrapnel in my 
body as a result of the explosion. I was medevaced from Iraq to 
Landstul, Germany and then taken to Bethesda National Navy Medical 
Center where I completed the bulk of my rehabilitation.

                           UTILIZING BENEFITS

    My time at Bethesda drew to a close in June 2006 when I was 
medically retired and I returned to the Midwest with my family to begin 
my life post injury. I completed the VA compensation and pension 
process while I was still at Bethesda and was assigned a rating of 60%. 
While the rating came relatively quickly, it was deeply flawed. Many of 
my injuries were not evaluated to determine my rating, despite being 
very clearly documented in my medical records. For example, I did not 
learn until I reviewed my initial rating that the VA had not considered 
my Traumatic Brain Injury in my evaluation. I am not sure how this 
happened, as it was clear in my records that I lost consciousness for a 
sustained period of time after the blast. Because of issues like this, 
I have had to reopen my claim more than 3 times to ensure all my 
injuries were taken into consideration. Finally, after 6 years of 
examinations and providing documentation, the VA has assigned me a 
rating of 100% permanently and totally disabled. Were it not for the 
mentorship of other veterans--particularly Vietnam veterans I met at 
the VA medical centers--I would not have known how to advocate for 
myself and fight through the compensation and pension process to 
receive the benefits I have earned. I know other veterans who have 
grown tired of fighting VA to correctly adjudicate their claims. It 
should not take 3 or 4 times to get it right.
    While my initial rating was deeply flawed, I was fortunate to 
receive it in a timely enough manner to begin utilizing my VR&E 
benefits shortly after returning home. In August 2006 I enrolled in a 
four year degree program at Oklahoma Baptist College. The process up to 
college enrollment was relatively smooth. I did not have to fight my 
counselor to establish an educational or employment goal. Our 
appointments were often brief and contained no real guidance concerning 
how to move ahead. While I didn't have to fight for what I wanted, I 
certainly was not advised of all the benefits that come with utilizing 
VR&E. Had I known the full extent of the benefits, it is very possible 
I would have pursued a path that led to a masters or doctorate degree 
in physical therapy. Instead, I pursued a bachelors degree in 
education. Although my VR&E counselor was largely receptive to my 
requests and responsive to my calls, utilizing my benefits at Oklahoma 
Baptist College proved challenging. During my four years at the college 
I had difficulty getting the VA and the college on the same page 
regarding tuition payment. Each semester was a struggle, and had it not 
been for my persistence in ensuring the two institutions worked 
together, I am not sure I would have successfully stayed enrolled.
    I was proud to graduate and receive my Bachelor of Science degree 
in May 2010, despite the prediction of a VA employee who I would 
characterize as less than supportive of my goals. While I was being 
trained to use a VA issued palm pilot to help me keep appointments 
straight and assist me with recording class assignments, a VA employee 
told me that because I had suffered a Traumatic Brain Injury I would 
never be able to graduate college unless I cheated my way through. Her 
comment and perceptions of my capabilities and life goals were 
inappropriate and not reflective of the type of veteran centered focus 
the VA system claims to have. Luckily, I have never been a person to 
allow other people to tell me what I am capable of, and I turned the 
anger I felt as a result of those remarks into drive and motivation to 
succeed. But for many of my fellow veterans, that type of attitude and 
lack of understanding concerning one of the signature wounds of this 
war is incredibly detrimental and disengages them from the very system 
that is supposed to exist to help us thrive.

                            PROSTHETICS CARE

    I have worked hard to ensure my injuries and other people's 
perceptions of them do not define my way of life or limit what I am 
able to accomplish. Receiving timely and quality prosthetics care is 
instrumental to maintaining my activity level. The quality of care I 
have received through the Oklahoma City VA Medical Center is 
outstanding. VA contracts with a number of prosthetics specialists who 
are familiar with cutting edge prosthetic technology and are able to 
outfit me with the devices I need to maintain a high level of physical 
activity. Most importantly, my prosthetics provider has really taken 
the time to understand who I am as a whole person--not just a wounded 
warrior--and how that shapes my medical needs.
    So while the quality of care I am receiving is very good, the 
process of going through the VA to receive those benefits takes far too 
long. When I need adjustments or replacement equipment, I must schedule 
an appointment with the medical center to be seen by a member of their 
prosthetics team who will then write the prescription to my outside 
prosthetics specialist. Sometimes it can take weeks for VA to actually 
send that prescription to the provider, further delaying my ability to 
get an appointment and ultimately receive the adjustments or equipment 
I need. Why is this the case? I know other veterans who live in close 
proximity to Walter Reed who are able to walk in and out with the 
services and equipment they need within the same day, all without ever 
needing to go through their local VA. It would make sense to me if I 
were able to see my prosthetics specialist first, who could then 
communicate with VA about what I need and get the authorization, 
eliminating the wait time for an appointment. While waiting weeks for 
an appointment might seem like a minor inconvenience, for a warrior 
like myself, spending weeks without the necessary prosthetics 
equipment, or sometimes even worse equipment that causes extreme 
discomfort and other medical issues, can be wholly disruptive to our 
daily lives. The timeliness and consistency of care should not be a 
function of where warriors happen to live.

                       ACTING AS MY OWN ADVOCATE

    The most important thing I have learned in navigating my own 
transition and helping my peers through their own journey is that you 
must act as your own advocate. There are so many programs and benefits 
available to assist us, yet often we are never informed of these 
programs or the information is delivered in a time and place that is 
not conducive for wounded warriors to absorb it. We receive so much 
information at the time when we are newly injured. When I was brought 
to Bethesda, I was completely reliant on my mother as my caregiver. It 
took me two and a half months to regain the ability to feed myself. My 
sole focus was on my physical recovery. It was impossible for me to 
take in the vast amount of information coming at me during that time. I 
understand that since I have been injured the Federal Recovery 
Coordination Program has been put into place for severely wounded 
warriors to assist with this challenge. This is not a program I 
benefited from, nor did I know of its existence before preparing for my 
testimony here today. What I do know is that warriors need real help in 
discovering what benefits exist and how to utilize them so that they 
can thrive in their lives post-injury. Other veterans are out there 
spreading the word, but no one from VA is reaching out. That needs to 
change. I have spent the last several years sharing the knowledge I've 
gained through my own recovery and plan to continue that work as an 
outreach worker with the Wounded Warrior Project, but there must a more 
systematic VA effort.
    My hope is that by coming before you today and testifying to some 
of my issues in navigating through the system, things will continue to 
improve for the warriors coming behind me. I thank you for taking the 
time to listen to my story and for your focus on improving the 
transition for my fellow wounded warriors. I look forward to answering 
any questions you might have.

    Chairman Murray. Thank you very much. It is our intent that 
your words will help others coming behind you, sir. I really 
appreciate your testimony today.
    Mr. Lorraine.

  STATEMENT OF JIM LORRAINE, LT. COL. USAF (RET.), EXECUTIVE 
             DIRECTOR, WOUNDED WARRIOR CARE PROJECT

    Colonel Lorraine. Chairman Murray, Ranking Member Burr, 
Members of the Committee, thank you for inviting me to testify 
before you today. I request that my written statement by 
submitted for the record.
    There are a lot of pieces to the DOD and VA system. When 
they work together, it is powerful. When they do not, it can be 
frustrating to the point of quitting. As Executive Director of 
the Central Savannah River Area Wounded Warrior Care Project, 
my focus is to expand community capabilities in warrior care 
while growing community-based partnerships to better serve 
their needs.
    According to VA statistics, there are over 24,000 veterans 
between 17 and 44 years old living in the 13 counties of the 
Central Savannah River Area. In a speech, the Vice Chief of 
Staff of the Army, General Chiarelli, said, ``The reality is, 
as we continue to draw down operations in Iraq and eventually 
in Afghanistan, we are going to see more and more soldiers 
return home, many of them dealing with PTSD, TBI, depression, 
anxiety, and other behavioral conditions.''
    The services estimate approximately 30,000 wounded, ill, or 
injured who are in the process of recovery or undergoing 
medical boards. This is significant, but I am concerned about 
the warrior who served in combat, always redeployed with their 
unit, and then just ended military service to return home. 
Estimates suggest over 300,000 servicemembers suffer from 
unseen injuries. That makes 30,000 warriors we know of just the 
tip of the iceberg.
    Collaboration on warrior and veterans issues is not 
restricted to the Department of Defense and Veterans Affairs. 
Communities are part of this collaboration equation. One 
organization cannot do it alone. The Wounded Warrior Care 
Project has been a model to build communities' unity of effort. 
We have worked with the cities of Charlotte, Denver, 
Huntsville, New York, Dallas. These are the organizations--
these are groups that the Department of Defense and Veterans 
Affairs can partner with to serve our veterans and their 
families.
    History has shown us that with a reduction in combat, there 
is an associated reduction in government funding for defense- 
and veterans-related programs. When these programs are 
stretched thin, communities will play an integral role in 
supporting veterans. By easing restrictions in government 
partnering with community organizations, we can work closer to 
maximize our programs.
    My greatest gap is not knowing when veterans are moving to 
Augusta after they leave military service. I think we have 
heard it here. Greater collaboration to know who is en route 
would assist focusing community efforts and allowing greater 
outreach, rather than waiting for the veterans to seek 
assistance.
    In the military, when you move to a new base, you receive a 
sponsor at your destination. When a soldier transitions to the 
veteran status, there is not a sponsorship program. This 
initiative will go a long way to closing the gap between 
service and veteran status.
    Augusta, Georgia's medical resources are under-utilized. A 
model of Defense and Veterans Affairs collaboration is the 
country's only active duty rehab unit located in the Charlie 
Norwood Veterans Affairs Medical Center. There are only 17 
patients in a 30-bed unit.
    In briefings from Fort Gordon's Eisenhower Medical Center 
leadership, their facilities have the capacity to provide a 
full spectrum of services such as the only dual track Post-
Traumatic Stress Disorder and substance abuse program, a robust 
blind and spinal cord rehab center, and an extensive 
residential pain and addiction management program.
    Augusta would be the ideal location to establish legislated 
Medical Centers of Excellence such as blind or psychological 
help, blind rehab or psychological help. Our extensive 
experience in these areas would surely overcome our distance 
from the national capital region.
    DOD and the VA must close the gap between medical care 
available to servicemembers and that available through TRICARE 
and Veterans Affairs programs. Families are choosing to forego 
increased financial benefits provided by veteran status in 
order to access emerging medical care available to active duty 
in hopes of improved quality of life. Examples are cognitive 
rehab of these--cognitive rehab, residential mental health 
care, and advanced spinal cord injury treatment.
    Madam Chairman, I agree that more emphasis must be placed 
on transition assistance programs before the servicemember 
separates. Training must be mandatory. Servicemembers must be 
registered for all their VA benefits. When they finish their 
TAP program, they should walk out with everything signed and 
ready to go before they become a veteran.
    Recognizing a need, our community launched a very 
successful, our Nation's first, Veteran's Accreditation 
Program, a collaborative program involving the Army, the VA, 
Department of Labor, which provides historical and Native 
American artifact preservation through veterans employment and 
training initiatives. We would ask for continued support for 
this program as it has changed the life for 83 participants in 
the last 2 years.
    As I testified to the House Veterans' Affairs Subcommittee 
on Health, we fully support the Federal Recovery Coordinator 
Program and encourage its continued support and strengthening 
to include maintaining of their credentialing standards, 
greater access to make change, and greater access to work as a 
team.
    Last, collaboration should occur at all levels of the 
community, from the community to Congress. A great deal of 
collaboration could be accomplished by establishing a 
subcommittee on warrior and veterans reintegration, providing 
joint oversight at DOD and VA efforts, as well as synchronizing 
the legislative effort impacting both departments.
    In a letter from General Patton to his wife at the end of 
World War II, Patton wrote, ``None of them, Americans, realizes 
that one cannot fight for two and a half years and be the 
same.'' Yet, you are expected to go back, to get back into an 
identical groove from which you departed. We have been at war 
for 10 years.
    Thank you for providing me the opportunity to present 
before the Senate Veterans' Affairs Committee. I look forward 
to further questions.
    [The prepared statement of Colonel Lorraine follows:]

 Prepared Statement of James R. Lorraine, Executive Director, Central 
           Savannah River Area--Wounded Warrior Care Project

    Chairwomen Murray, Ranking Member Burr, and Members of this 
Committee, thank you for inviting us to testify before you today. I'd 
like to thank this Committee for its continuing efforts to support 
servicemembers, veterans, and their families as they navigate through 
the complex web of Department of Defense, Department of Veterans 
Affairs, and community programs. I've been a member of the military 
community my entire life; as a Reservist, Active Duty Air Force, 
Military Spouse, Retiree, Government Civilian, and Veteran. In my 
previous position as the founding Director of the United States Special 
Operations Command Care Coalition; an organization which advocates for 
over 4,000 wounded, ill, or injured special operations forces and has 
been recognized as the gold standard of non-clinical care management. 
Recognizing a gap in my Special Operations advocacy capabilities, I 
incorporated a Federal Recovery Coordinator as a team member in 
providing input to the recovery care plans for our severely and very 
severely wounded, ill, or injured servicemembers. This one Federal 
Recovery Coordinator dramatically improved how Special Operations 
provides transitional care coordination and made my staff more 
efficient in support of our special operations warriors and families 
throughout the Nation. I've found that when supporting our 
Servicemembers, Veterans, and their families there is always 
opportunity for improvement.
    It's essential that our military and veterans have strong 
advocates, both government and non-government, working together at the 
national, regional, and community levels to improve the recovery, 
rehabilitation, and reintegration of our warriors and families. 
However, one program by itself is not enough when it comes to 
supporting our Nation's most valuable resource--the men and women of 
the Armed Forces, our veterans, and their families. I recently left 
government service to assume duties as the Executive Director of the 
Central Savannah River Area--Wounded Warrior Care Project, where my 
current position is to integrate services by developing a strong 
community based organization that maximizes the potential of government 
and non-government programs in Augusta and throughout our region. The 
Federal Recovery Coordinator Program is one of those resources.
    From my experience, advocates or care coordinators require three 
attributes in order to be successful. The first attribute is the 
ability to anticipate need. This may sound simple, but staying ahead of 
a problem saves a lot of heartache, money, and time. Much like a chess 
master, thinking five to ten moves ahead, this assumes effectiveness 
and competence at various levels of the system. The second attribute is 
the authority to act. A case manager or advocate who anticipates needs 
and develops flawless transition plans, but doesn't have the authority 
to act is powerless to ensure success. In this complex environment of 
wounded warrior recovery, someone who can not act is an obstacle. The 
last attribute is the access to work as a team member. This is 
recognizing that it takes more than one person to reach the goal. Team 
work is probably the most complex of the three attributes, because it 
requires others to be inclusive, sharing of information, trust, and 
requires a great deal of time to coordinate and synchronize efforts. 
Federal Recovery Coordinators are a critical component to the 
successful reintegration of over a thousand wounded, ill, or injured 
and their families, but as I said there ``there is always opportunity 
for improvement.''
    By design a Federal Recovery Coordinator has the education and 
credentials to anticipate need. Their level of professionalism, skill, 
and experience enables the coordinator to function at a high level of 
competence in supporting our warriors. They are the most clinically 
qualified of the warrior transition team. However, not everyone has the 
same clinical expertise and access to perform as a Federal Recovery 
Coordinator. We feel the development of a Federal Recovery Coordinator 
certification program is necessary to prepare these Veterans Affairs 
care coordinators to engage a broad spectrum of resources available in 
areas not only of health care, but with a focus on behavior health, 
family support, and benefits availability.
    Innately, the FRC has the authority to act within the Veterans 
Affairs Health Care system and interface with Veterans' Benefits 
Administration representatives. By reporting to the Veterans Affairs 
Central Office the Federal Recovery Coordinator can influence across 
the Nation and regionally. This ability is unique and should be 
capitalized on by the Department of Defense Service Wounded Warrior 
programs and strengthened by the Veterans Benefits Administration. The 
Federal Recovery Coordinator must have the authority to act at the 
strategic level, to ensure case management is being accomplished, 
services are being provided, and that Veterans Affairs resources are 
being maximized, in concert with other government and non-government 
organizations.
    The greatest challenge for the Federal Recovery Coordinator program 
is their access to work as a team member. As I mentioned earlier, team 
work requires inclusiveness. If the Coordinators do not have timely 
access to the warriors and families in need they can't be effective. As 
the saying goes ``You only know what you know.'' Involvement in a case 
must be timely in order to shape an outcome, vice manage the 
consequences of bad decisions. We must work symbiotically to 
synchronize our efforts, operating transparently, and maximizing the 
capabilities of the Departments of Defense, Veterans Affairs, Labor, 
and Health and Human Services, as well as collaboration with non-
government organizations at the national, regional, and local levels. 
Additionally, the Federal Recovery Coordinators must function in a 
coordination role, working by, through, and with Service Wounded 
Warrior Programs while also leveraging local Veterans Affairs case 
managers and benefits counselors. Relationships are critical and the 
Federal Recovery Coordinator must develop trusting interchange with 
those individuals and organizations with the mission to assist the 
Servicemember, Veteran, and their family.
    Last, the scope of the Federal Recovery Coordinator program should 
be expanded to assist those in the greatest need for a transitional 
care coordinator. We should not only support the most severely wounded, 
ill, or injured, but must include those less severe whose family 
dynamics, behavioral health issues, or benefit anomalies inhibit their 
smooth transition to civilian life. The current practice of providing 
``an assist,'' which is short term without fully involved care 
coordination, has been successful. Additionally, those transitioning 
veterans at the greatest risk for homelessness should have a Federal 
recovery coordinator shepherd the veteran to success. By operating at a 
strategic level Federal Recovery Coordinators can affect the outcome of 
far more Veterans both regionally and locally.
    In conclusion, we have three recommendations to improve the Federal 
Recovery Coordination program.

    1. Maintain the high credential standards for the Federal Recovery 
Coordinator, but augment with a nationally recognized certification for 
Federal system care coordination in order to strengthen their ability 
to anticipate needs.
    2. Ensure the Federal Recovery Coordinators have the authority to 
act on needs they've identified, both on a national and local level.
    3. Make certain the Federal Recovery Coordinator has access to work 
as a team member. Incorporate Federal Recovery Coordinators early in 
the recovery process as strategic partners who can ensure the Veterans 
Affairs resources are maximized to a larger population of transitioning 
Servicemembers, veterans, and their families in need of someone to 
shepherd them through this complex system.

    There is currently a very positive feeling in this country toward 
the service and sacrifice of our military, veterans, their families, 
and a desire to support them. One way to help is to utilize existing 
programs, especially at the local level. The Central Savannah River 
Area--Wounded Warrior Care Project stands as the model for many 
communities throughout the Nation who are at the front line of helping 
our veterans come all the way home from combat and fully reintegrate 
into our community. It's also important to educate the military and 
their families about their transition, but it's frequently too late 
after transition has occurred and life's daily pace takes over.

    Thank you for providing us the opportunity to present before the 
Veterans Affairs Subcommittee on Health.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Mark Begich to Jim 
    Lorraine, Executive Director, CSRA Wounded Warrior Care Project

    Specifically addressing the DOD/VA Federal Recovery Coordination 
Program, GAO published a report in March citing several areas that need 
improvement.

    Question 1. Have you personally seen discrepancies in the FRCP 
enrollment process negatively affect a veteran's recovery and 
transition?
    Response. Yes, I have personally seen discrepacies of exclusion 
from enrollment in the Federal Recovery Coordination program negatively 
affect a veterans recovery and transition. This is the type of program 
where inclusion would not have a negative affect on a Servicemembers 
recovery and transition to veterans status. Highlighting one or many 
similar examples, a Federal Recovery Coordinator (FRC) was not included 
in the case of a severely wounded soldier at Ft Bragg while the soldier 
was on active duty and in medical recovery. Upon the soldier's 
transition to veterans status he encountered access to care, access to 
benefits, and general case management--areas the Army could not assist 
in supporting. I became aware of the issue when one of our special 
operations soldiers referred this recovering soldier to our command 
programs for support. We immediately called in the FRC to provide 
strategic care coordination as this soldier navigated the VA and 
TRICARE system. Unfortunately, finacial and benefits decisions had been 
made by the soldier and his family that could not be changed. I'm 
confident that had the FRC been involved while the soldier was on 
active duty, there would have been better coordination of services and 
access to medical care.

    Question 2. Is the current number of FRCs adequate to properly meet 
the needs of our veterans?
    Response. I believe more FRCs are needed, but their utilization and 
management must be changed.
    The FRCs should be regionally based supporting a local population. 
Most of the FRCs manage cases far from their home station--occasionally 
coordinating care for a warrior who is recovering in the same city as 
another FRC. The FRC's must have the ability to transfer cases between 
FRC--focusing on local support and regional knowledge.
    The FRC must operate in a supporting role while the Servicemember 
is on active duty, supporting the Service/Department of Defense wounded 
warrior program. Then when the wounded warrior becomes a veteran the 
FRC becomes the supported care coordinator with the Department of 
Defense Service program in a supporting role. Much like the Department 
of Defense deconflicts missions across Geographic Combatant Commander 
Areas of Responsibility.
    A properly managed and staffed FRC program will ease the transition 
of our wounded warriors from Servicemember to Veteran status.

    Chairman Murray. Thank you very much to all of you for your 
very compelling testimony. Let me just start by saying, it has 
been 4 years since the news about Walter Reed broke. In that 
time, some has changed. Some of you talked about it, but I 
would like to ask each of you what you think the most important 
thing the two departments should focus on improving over the 
next 4 years is.
    Mr. Lorraine, if you would like to start?
    Colonel Lorraine. Thank you, Madam Chairman. I think the 
most important thing is you have to know what you know. If you 
do not know it, you do not. So finding who the wounded warriors 
are, who the veterans are, identifying--if you want to change 
something, you have to know who the person is you need to 
engage with. Right now, I am not confident we know where the 
veterans are, nor do we know what their needs are. I think it 
is represented by my two colleagues here. That would be the 
number 1 action I would take, is find them.
    Chairman Murray. I think it was you that said that right 
now, nobody reaches out to them, we are waiting for the 
veterans to reach out, too often?
    Colonel Lorraine. Yes, Madam Chairman. What I found is that 
when you talk to different government programs and non-
government programs, my first question is, how do you find the 
veterans in need? Well, 100 percent of the answers are, ``They 
come to us.'' I think in today's world, that is not the way we 
should be reaching to them.
    We know where they are while they are on active duty. It is 
that move from active duty to veteran status where we lose 
them. And that should be tied in a little bit closer, because 
once you know where the folks are and you can maintain contact 
with them, then you can start providing services and offer 
assistance.
    Chairman Murray. Mr. Horton, Mr. Bohn, what do you think we 
should focus on, or the two departments should focus on?
    Mr. Horton. I would say, Chairman Murray, that we should 
focus on, just like he was saying, finding the veterans. A lot 
of veterans get lost in the system when they move back. A lot 
of men and women are from small country towns, and there is no 
one there that can reach them, which is the huge problem.
    Chairman Murray. Mr. Bohn?
    Mr. Bohn. Chairman Murray, my only problem was they did not 
pay for my family to come visit me while I was getting my 
surgeries. My family had to come down out of their own pocket 
the first surgery, my spinal surgery. The second surgery, my 
family could not afford to come down so I went through my 
second surgery alone.
    Chairman Murray. How far away was your family?
    Mr. Bohn. Salem, Massachusetts.
    Chairman Murray. I think many of us forget that it is not 
just the servicemember, but it is their family who is involved 
when somebody is deployed and, specifically, when they are 
injured. Mr. Bohn, let me ask you to expand on that a little 
bit, because we know families and loved ones go through stress 
at this time as well, as long as they are a family member. You 
mentioned just the travel. Tell me a little bit else about what 
difficulties your family had during treatment and share that 
with us.
    Mr. Bohn. Oh, the communication was a big thing, also. They 
did not know--they were not contacted until about 3 hours after 
I woke up in intensive care, to see how I was doing. I know 
they were sitting there back when I was getting my surgery just 
panicking. It is a big communication error, which needs to be 
changed.
    Chairman Murray. OK. Anything else that we should be 
focused on for families, communication, travel, being with the 
wounded warrior?
    Mr. Bohn. Those are the main points that I can think of 
Madam Chairman.
    Chairman Murray. Mr. Horton, I was particularly concerned 
to hear about your difficulties with your prosthetic care. It 
sounds like you got high quality care, but it was not timely or 
responsive and you shared a little bit about how it impacts 
your daily life. You said that--tell me what you mean by that 
if you have to wait months or weeks.
    Mr. Horton. The process is you go into the--you actually 
have to call the VA and set up--there is a certain day they 
have a prosthetics clinic and you have to be seen by them 
first, and you tell them exactly what you need, whether it is a 
new socket or a new ankle on your leg, anything like that. Then 
they write this down. Then they make a 'script and they send it 
to your outside provider. From there, it could take a couple 
months.
    Chairman Murray. What are you experiencing in that time 
period? Is that pain, is it difficult?
    Mr. Horton. A socket that is not fitting right, which for 
an amputee, that is--I mean, it is horrible. Like a little 
rubbing spot on an amputee is like someone having their ankle 
broken like terribly. So it is a big deal to me. So the time in 
there is--that is something that really needs to be addressed.
    Chairman Murray. And how long were you in this period where 
you had a problem and it took you to get care?
    Mr. Horton. It usually--I mean, it is usually a couple 
months between every time I go to the VA. Once I get the care, 
it is great, but the time it takes to get a prosthetic leg or a 
new prosthetic is too long. And I have talked to several 
veterans about this and they would agree on that. If you have 
to go through the VA, it is
    Chairman Murray. So it is waiting for an appointment, 
waiting for a specialty? Is it waiting for the right person?
    Mr. Horton. Waiting for a phone call, basically, and a lot 
of times I call my prosthetics in the VA a couple times and 
say, Where is this 'script? I need to get in here and get a 
leg. And so, I have to advocate for myself a lot.
    Chairman Murray. Not the way it should be.
    Mr. Horton. No.
    Chairman Murray. OK. Mr. Bohn, your experience trying to 
make ends meet was really troubling to hear. I learned of 
another veteran recently, a Marine officer, who is recuperating 
right now in Bethesda and is receiving a housing allowance at 
Camp Lejeune rates. So Senator Burr knows what I am talking 
about when I am saying it is $700 short, and that has a huge 
impact for a family.
    In the case of that Marine, there was a military 
coordinator who went out and looked for non-profit resources to 
help him make up the difference for that, but we should be very 
concerned that this system was unresponsive to a military 
coordinator. At the very least, in this case, the military 
coordinator did take advantage of community resources, but I 
still found that story very troubling.
    I wanted to ask you, Mr. Bohn, if anybody helped assist you 
in trying to access similar community or non-profit resources.
    Mr. Bohn. The Wounded Warrior Project. They directed me to 
a company, Impact Players, out of Cincinnati, Ohio, which 
mailed me a check to help pay the difference in my bills that I 
could not pay. And the Wounded Warrior, they gave me food 
cards, gas cards so I can make my appointments to the VA, which 
is an hour away from where I live in Boston. So, you know, 
having no gas in your car, trying to get to a VA appointment, 
that is kind of a struggle on its own.
    Chairman Murray. And your family, what kind of family do 
you have that you are responsible for?
    Mr. Bohn. I am single. I live by myself, but I try to help 
out my family. Like I said, I grew up poor, so I try to help 
out my niece, my sister, my mom, my dad.
    Chairman Murray. OK. Thank you very much for sharing your 
story. I appreciate all of your testimony. I do have more 
questions. We have a number of Committee members here, so I am 
going to turn it over to each of them for a round of 
questioning. I will start with Senator Burr.
    Senator Burr. Thank you, Madam Chairman. Steve, let me just 
ask, were you ever offered a Federal care coordinator?
    Mr. Bohn. Negative. Me and my family never----
    Senator Burr. Government.
    Mr. Bohn. I have never even heard of that until a couple 
days ago.
    Senator Burr. Were you ever provided a reason about all the 
confusion in your care, what was the reason that you went--
bypassed Walter Reed, the reason that you have sort of been in 
limbo?
    Mr. Bohn. Once again it comes down to the communication, 
and someone needs to step up and take charge.
    Senator Burr. But has anybody stood up and said, Here is 
what went wrong?
    Mr. Bohn. Negative, sir.
    Senator Burr. Anybody ever apologize?
    Mr. Bohn. Negative, Senator.
    Senator Burr. Well, let me apologize to you.
    Mr. Bohn. I appreciate it.
    Senator Burr. It should not happen. You talked a little bit 
about the Wounded Warrior Transition Unit that you first went 
to, and then Senator Kerry helped you get to a second one. I 
think you said in the first one, they did not task you with 
anything?
    Mr. Bohn. Negative.
    Senator Burr. And in the second one, did they task you with 
activities that had some value to them?
    Mr. Bohn. I went to an air show at Andrews Air Force Base 
and that was the only thing I was pretty much interested in 
doing.
    Senator Burr. OK. Jim, let me just ask you real quickly, in 
a meeting with my staff several weeks ago, you shared with them 
a little bit about your wife's experience, and hers was 
separating from the Air Force. And as I understand it, when 
your wife was moved from the temporary disability retirement 
list to permanent retirement, the Air Force insisted she be 
examined by an Air Force neurologist at Eglin Air Force Base, 
an 8-hour drive from where you lived?
    Colonel Lorraine. Yes, sir.
    Senator Burr. You asked could she see a neurologist closer 
to home, gave the options of Augusta VA facility or Eisenhower 
Army Medical Center. Is that an accurate account?
    Colonel Lorraine. Yes, sir. Yes, sir, it is accurate. My 
wife lives outside of Augusta in Aiken, and we had to drive to 
Eglin down in the Gulf Shores area. Drove past--drove past 
Eisenhower, drove past Augusta VA, drove past Benning, drove 
past a number of different facilities.
    She was being treated at Augusta, but the requirement was 
that she see an Air Force neurologist who was a contract 
neurologist who saw her for 30 minutes, never laid a hand on 
her, and just took the records that we had brought and handed 
them back and said, I do not have time to look at these.
    Then we waited for--we waited--we drove back, another 8 
hours back, and waited for the decision.
    Senator Burr. Did you say that the neurologist was a 
contract neurologist?
    Colonel Lorraine. Yes, sir.
    Senator Burr. And did the Air Force ever explain to you why 
your wife needed to be examined at Eglin rather than a closer 
facility?
    Colonel Lorraine. No, sir. You know, this is what I do. 
This is what I was doing for business, so I knew all the people 
to call and the answer was, You have to go see an Air Force 
provider. I had lived in Tampa at the time working in Special 
Operations Command, and I offered to go to Tampa, because it 
would be more convenient for us, and the answer was no, Eglin 
is the place. So despite numerous requests, the answer was no, 
that it had to be an Air Force facility, Air Force provider 
that did the TDRL exam, TDRL, Temporary Disability Retired List 
exam.
    Senator Burr. But, in fact, this was a contract neurologist 
for the Air Force?
    Colonel Lorraine. Yes.
    Senator Burr. That even brings more insanity into it than I 
think one could comprehend.
    Colonel Lorraine. And, sir, at the time--my wife has 
epilepsy and she is not able to drive. So for me, I left SOCOM, 
drove to Augusta, picked my wife up, drove to Eglin, drove back 
to Augusta. So it was 4 days of in-transit. And when you talk 
about a family, it does affect the family pretty significantly.
    Senator Burr. The Chairman has been very kind to listen to 
me on occasion rant about the lack of veterans' abilities to 
get transportation to appointments. Steve, you talked about 
that and, Jim, you just alluded to it. I do not think this 
Committee really today even fully understands, and I certainly 
do not believe that VA understands the challenge it is for our 
country's warriors to meet the requirements that we set at the 
VA.
    For anybody who did not need health care it would be 
challenging if you have no gas in your tank or they ask you to 
drive 8 hours when you can get the service 30 minutes away. Let 
me just ask you in conclusion, how would you improve the 
process of Temporary Disability Retirement List for 
servicemembers in the future that are faced with that?
    Colonel Lorraine. Based on the statistics that I 
understand, and I would have to get back to you specifically, 
but I would do away with TDRL. It is just not a--when you look 
at the number of people who are TDRL who are then permanently 
retired, the percentage is above 60 percent, maybe high 80s, 
and I would have to--I would have to ask the Department of 
Defense for the specifics.
    But when you look at that, the cost of the benefit is--you 
have to question, why are we doing this when so few people 
return to duty from a TDRL status.
    Senator Burr. Thank you.
    Colonel Lorraine. Yes, sir.
    Chairman Murray. Senator Sanders.

              STATEMENT OF HON. BERNARD SANDERS, 
                   U.S. SENATOR FROM VERMONT

    Senator Sanders. Thank you, Madam Chair, for holding this 
very important hearing, and thank you all very much for being 
here. It goes without saying that you have established your 
bravery on the battlefield, but let me tell you what you are 
doing here today in speaking out for your brothers and sisters, 
and raising issues is equally great. I know it is not easy. It 
is not what you trained to do, but it is very important, and we 
thank you very much for being here.
    First point that I want to make, and I think Jim touched on 
this. You know, we go through periods where this country is in 
war. We are now in two wars. Then we do not have wars. 
Sometimes it is easy to forget about the people who fought in 
the wars when the parades are over and the media is not 
covering the issue.
    So you have people who have got permanent injuries for the 
rest of their lives, and I think we should agree that if we go 
to war, that 30 years from now, or 50 years from now we do not 
forget about these people. Frankly, it is an expensive 
proposition, but that is what it is about. So I would hope that 
we make sure that for the rest of the lives of all of those 
people who have served that this Congress accepts the moral 
responsibility to make sure that they have all the care that 
they need. That is what it is about.
    Number 2, let me give you, Madam Chair, maybe some positive 
news, if you like. I think what I have heard from Steve and Tim 
and Jim is, you have got men and women coming back from war, 
they are injured physically, they are injured psychologically. 
They have to weave their way through a very difficult and 
complicated bureaucracy.
    What I am hearing is that there is no entity out there 
which says, OK, we are with you, and it is complicated, but we 
are going to guide you through it. These are what your benefits 
are. We are going to deal with your transportation. You are a 
human being. You are not 18 silos. You are one person. We are 
going to deal with the needs of you and your family.
    That is kind of what I have been hearing from Steve and 
Tim. And understand when people come back, they are in trauma 
already and we have to be aggressive in reaching out. Madam 
Chair, let me mention something to you which I think we can 
learn from.
    In Vermont a couple of years ago--and we are a rural State 
so we do not have a large military base. We had a lot of people 
over in Iraq. We had a lot of people over in Afghanistan. These 
guys are coming home to a rural area without a military base.
    What we established in Vermont was what we call an outreach 
program, and it was funded through the--we got money through 
the National Guard, who then accepts the responsibility of 
hiring a team of people, mostly veterans who served in the war, 
to go out knocking on doors, sitting down with the soldiers and 
their families, ascertaining what the problems are, using their 
own judgment, playing that role of getting people to the VA 
when they need it, playing the role of getting people to 
services that they needed. I am happy to say that that program 
has now expanded. I think there are eight States in the country 
which are doing something similar.
    But let me ask, start off with Steve and Tim. Am I correct 
that assuming that maybe the main point that you are making is 
that when you come back, you want somebody to be at your side 
to deal with all of the many problems that arise? Steve, did 
you want to----
    Mr. Bohn. That is correct. There is a lot of red tape when 
you come back, and after worrying about your health constantly 
and every day is a struggle, you know, just getting out of bed, 
you want someone to actually take care of the red tape and the 
paperwork and try to find out the best way to get your 
treatment.
    Senator Sanders. I mean, that seems clear. We are all 
Senators, and we have large staffs. It is hard for us to get 
through the bureaucracy. Imagine somebody coming back with a 
variety of problems all by himself or herself trying to get 
through the bureaucracy. Tim, did you want to maybe comment on 
that?
    Mr. Horton. When I was injured, I was pretty much strapped 
down to a bed for about two and a half months, and my mom was 
there, and if she was not there, I probably would have died 
because some of the nurses and the staff were going to put 
something in my IV that could have killed me. So definitely 
having somebody by your side is important, and I have heard 
that from numerous veterans. Like, just a simple error for us 
could kill us in that kind of shape. So definitely having 
somebody by our side would be very, very important.
    Senator Sanders. Within the system now, it would seem to 
me, I mean, call it a social worker or call him or her whoever 
you want, there should be somebody available 24 hours a day who 
can respond to a problem that the family is having or whether 
the soldier is having. Jim, did you want to comment on that?
    Colonel Lorraine. Yes, sir. You know, I think that having 
come out of the Department of Defense doing this, there are a 
lot of people. You know, I have had families who have 
difficulty, and then when I finally get to them and say, Why 
did you not call me, they give me a stack of business cards 
that are this big and they say, Everyone in this--every card 
said call me if I need something. And when I called, very few 
people could act because it was a very specific thing.
    Senator Sanders. Right.
    Colonel Lorraine. And I think--I think, as I said, we 
talked about the Federal Recovery Coordinators, the linkage 
between what the services, DOD, are doing and what the Federal 
Recovery Coordinators have the ability to do in the VA, if they 
can work together as a team, they could provide this seamless 
advocacy. And really, that is what these guys are saying they 
needed, somebody who has advocacy who can anticipate needs, act 
on those needs, and then follow up with it.
    Senator Sanders. So I think the pity of it is, we spend a 
fortune, and sometimes, at the end of the road, the care is 
excellent if people can get to it. And yet, I suspect there are 
thousands of young men and women who have returned that do not 
even know what they are entitled to, what is available to them, 
how to access it. So on one hand, we spend a fortune; on the 
other hand, we do not connect the people to the services that 
are available.
    I would hope, Madam Chair, as somebody who really has a 
strong detestation of bureaucracy in general, that we can work 
toward a system where these guys will have somebody who they 
trust that they can call up 24 hours a day who will help guide 
them through the system. I think that would be an important 
step forward. Thank you very much. And thank you.
    Chairman Murray. Thank you very much. Senator Isakson.
    Senator Isakson. Well, thank you, Madam Chairman. I want to 
call each member's attention to the last four paragraphs of 
Lieutenant Colonel Lorraine's testimony. I am going to read two 
sentences from that because I think it hits at the heart of 
what Bernie is talking about and what we are talking about.
    It says, ``Last the scope of the Federal Recovery 
Coordinator Program should be expanded to assist those in the 
greatest need for a transitional care coordinator. We should 
not only support the most severely wounded, ill, or injured, 
but must include those less severe whose family dynamics, 
behavioral health, or benefit anomalies inhibit their smooth 
transition to civilian life.''
    Those are two critical sentences that I think address 
everything raised by Tim and Steve. I want to ask you a couple 
of questions about this, Colonel Lorraine. It is my 
understanding--I know we have got well over 100,000 people 
deployed in the Middle East right now and we have 22 Federal 
Coordinators, Recovery Coordinators; is that right?
    Colonel Lorraine. Yes.
    Senator Isakson. That is 22 coordinators, and we have got 
people coming home every day with the same needs that Tim and 
Steve have talked about.
    Second, and I am not trying to put words in your mouth so 
correct me if I am wrong, Colonel, but in your recommendations 
on the Federal Recovery Coordinators, you state three things. 
We should strengthen their ability to anticipate needs, one. 
Two, give them the authority to act on those needs that they 
have identified both at a national and a local level. And 
finally, give them access to work as a team member.
    What is so important about that is you have got LDRH, the 
Department of Labor, Veterans Affairs, the Department of--there 
are lots of agencies in the Federal Government that have 
programs available to help these guys, but Bernie is right. We 
cannot get through the maze. How in the world do we expect 
these guys to do it dealing with the injuries that they have?
    So rather than ask a lot of questions or talk a lot, 
Colonel, I would just like you to expound on your 
recommendations on the Federal Recovery Coordinators because I 
think that strikes at the heart of the difficulties these two 
gentlemen have had.
    Colonel Lorraine. Yes. Thank you, Senator Isakson. The 
credentialing--the Federal Recovery Coordinators are really the 
most credentialed, most qualified in terms of clinically and, I 
would argue, non-clinically to transition to the VA. One thing 
that all of us have in common is that we were servicemembers 
and we are now veterans. It is like sort of death. If you are 
alive, you are some time going to die. If you are a 
servicemember, some time you are going to be veteran.
    And so, that Federal Recovery Coordinator being involved in 
the DOD side, not primarily, but as a support to the Recovery 
Care Coordinators that DOD has, and then being part of that 
transition is important, but they have to have the authority to 
reach into the VA and push the VBA buttons and push the VHA 
buttons to provide the services that these wounded warriors 
receive.
    Additionally, as I said in my testimony today, these are 
folks who we knew about. These are guys who were in the WTUs. 
There are far more who are leaving service, far more of their 
counterparts that were in their blast with them, that just 
redeployed and just got out, separated, and returned to their 
home. And we do not have any visibility of them at all. And 
their number far exceeds the number of wounded warriors that we 
have put through the program.
    So that is why, sir, that expanding the program to go after 
those and help those who are having trouble just in the process 
is important.
    Senator Isakson. Steve, you were in the Army, correct?
    Mr. Bohn. Yes, sir.
    Senator Isakson. Where did you exit from, what base?
    Mr. Bohn. I was part of a community-based Warrior 
Transition Unit at Hanscom Air Force Base, but they were 
attached to Fort Dix, New Jersey. So I had to fly to Fort Dix 
for 3 days to actually out-process even though I never even 
stepped foot at Fort Dix.
    Senator Isakson. You were in a Wounded Warrior Transition 
Unit; is that correct?
    Mr. Bohn. Yes, sir.
    Senator Isakson. I have been through the Wounded Warrior 
Transition Unit at Fort Stewart and at Fort Benning and at Fort 
Gordon. I want to ask you this question. My recollection, each 
one of those, by the way, is different, and I want to focus 
just on my visit at Fort Stewart.
    They had a separate barracks where the Wounded Warrior 
Transition soldiers stayed, and they had a one-stop shop, for 
lack of a better word, where you could go for resources pending 
your transition from the military. Did you go through that same 
thing?
    Mr. Bohn. Yes, Senator, I did.
    Senator Isakson. When you left, besides getting a DD-214, 
what did they give you to facilitate your communication as a 
veteran with those same services?
    Mr. Bohn. All's they gave me was a flag and a retirement 
pin and said, Thank you for your service.
    Senator Isakson. You know, you talk, Madam Chairman, about 
the number of calls to the Suicide Prevention Center. The 
reason we have that center is to have a place a veteran can 
seek help at a difficult time. The same thing is true at 
transition, and that may be something we think about asking DOD 
to look at--a phone number and a human being they can talk to 
in that critical time transitioning from active duty to veteran 
status.
    I thank you for your service, all of you, and thank you for 
your time.
    Chairman Murray. Excellent suggestion. Thank you very much 
for that.
    Senator Begich.

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

    Senator Begich. Thank you, Madam Chair. I sit here probably 
not as frustrated as you, but it is just very frustrating to 
hear what you had to go through and the lack of coordination at 
times on the part of the Federal Government to make sure those 
services are delivered.
    Let me try a couple things, if I can. Lieutenant Colonel, 
let me ask you, in regards to your organization, can I just--
give me a sense of, you know, the funding of it. How big is it, 
in other words? Give me a sense of it.
    Colonel Lorraine. The Central Savannah River Area Wounded 
Warrior Care Project is relatively small. There is myself and 
two other gentlemen. Our funding is privately funded and again, 
our energy is bringing people together, especially in Augusta 
in the Central Savannah River Area where you have two VA 
hospitals, a DOD medical center, large civilian medical 
community, and a large--a post, Fort Gordon, and a large 
veteran population.
    Senator Begich. You know, I represent Alaska and I was 
hearing your story of your wife. We do not have roads in lots 
of areas, so about 80 percent of our State is not connected by 
roads. And we struggle up there, as you can imagine, with a 
veteran in a small village. But what we do have is incredible 
care facilities that are managed by our Native corporations. I 
mean, high quality. We are about to finish out a $180 million 
facility in Nome, Alaska, to service the region, not paid for 
by State recovery money. It is going to be an incredible 
service.
    But the veterans who are in that community will not be able 
to use it. They will have to go to Anchorage. And again, we do 
not drive from Nome to Anchorage; we fly. So I am curious, as I 
was listening to your story and about your program, do you 
think places like Alaska have an opportunity to partner with 
what you are doing and trying to figure out how--you know, it 
is frustrating.
    The best stories I hear are organizations like yours, the 
Wounded Warrior organization, that are really bringing veterans 
to the services they need. How do we--maybe we have to have a 
radical change and look at organizations like yours and say, 
Look, you are going to be the group that helps us, because we 
are--I do not want to say incapable of, but we are not doing a 
really good job.
    Colonel Lorraine. Senator, as I said in my testimony, there 
are cities throughout our Nation that are coming together and 
recognizing that there are veterans who are returning and that 
they are really the ones who are going to lead the effort.
    There is a small disparate group of us that are getting 
together right now, and talking on the phone, I think we would 
obviously welcome Alaska. But I think that is where the energy 
is. If you look 10 years from now and 15 years from now, it is 
really the communities who are going to have to--and Nome and 
Anchorage--who are going to have to take care of these 
veterans.
    Senator Begich. That is right.
    Colonel Lorraine. And so, it is really--the Chairman of the 
Joint Chiefs of Staff laid out a Sea of Goodwill concept where 
there is a lot of support out there, it is just sort of 
harnessing it, and that is what we are trying to do, is harness 
all that goodwill that is out there.
    Senator Begich. Do you think--and I have got one quick one 
here. Do you think the DOD culture--and I sit on the Armed 
Services Committee, and I would offer a recommendation to the 
Chair that maybe we should have a joint meeting with Armed 
Services Committee and Veterans on this issue because there is 
almost like a cultural shift you have to have, because as you 
describe, it is kind of like once you are done, they say, Thank 
you very much, here is your flag, here is your pin, thanks for 
your service, and then VA is out there trying to do it and you 
kind of get in the middle, or other groups like yourself, are 
trying.
    Do you think we will be able to get DOD to take more 
responsibility earlier in the transition? Do you think that is 
possible? I know what I deal with over at Armed Services. I 
know Senator Brown probably has similar experiences.
    Colonel Lorraine. Sir, I think that, you know, the people 
that, you know, my counterparts in the Department of Defense, 
everyone wants to help. Everyone has a huge heart. They 
recognize that they want to do it. So is there the ability to 
do it? Absolutely.
    Senator Begich. Let me ask, if I can. My time is almost up. 
First to you, Steve. You had indicated that you were denied 
Social Security disability benefits. Are you still in the 
process of trying to appeal that or what is your situation?
    Mr. Bohn. I gave up on that.
    Senator Begich. You gave up? OK. Well, I guess--I know 
Senator Kerry's office would probably be very helpful. I just--
we are going to ask a question how it works with Social 
Security and veterans in regards to disabilities, but I just 
wanted to follow up on you.
    On the flip side, if I can, Tim, just a very quick one, 
when you said you had to get the university or the college you 
were at and VA on the same page on the funding, was it just--
explain that just so I understand.
    Mr. Horton. Every semester, it seemed like that they knew 
the VA was paying for it, but it was a new financial aid 
counselor. That was the problem. Someone new would come in and 
they were not really a veteran-friendly school, so everything--
they would say, ``You owe us this.'' I was like, ``No, I do 
not.'' The VA--I am going through the Voc Rehab Program. So 
that was the problem. They did not understand it. It was every 
semester.
    Senator Begich. OK. Very good. Let me end there. Thank you, 
Madam Chair, for the moment there.
    Chairman Murray. Thank you. Senator Brown.

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

    Senator Brown of Massachusetts. Thank you, Madam Chair, and 
I thank you again for holding this hearing. And thanks to our 
witnesses. I know Steve and I had a good meeting yesterday and 
I appreciate you sharing a lot of your experiences with regard 
to the transition from DOD to the VA. The goal is to be seen 
much sooner. If you are a Guard or Reservist in Massachusetts, 
we have kind of addressed this.
    We actually have a one-shop stop for returning veterans 
where they get that A to Z transition. I know you brought this 
up before about trying to get that to happen in the regular 
Army, too, so we can get our heroes the care and coverage and 
treatment that they need. The first I am hearing about a lot of 
what you are going through and I am hopeful that we can work 
through a lot of the issues.
    You know, obviously you are from Massachusetts and I would 
be happy to speak to Senator Kerry's office and we will try to 
work together to work through these kind of mine fields.
    When Senator Sanders said, You know, well, we have trouble 
as Senators getting through the bureaucracy, what does that 
tell us? We have too much bureaucracy, so let us fix it. So 
that is maybe one of the things we can try to do from here.
    And with regard to the actual--the rating system, Steve, 
you were separated from the Army in October, but as of today, 7 
months later, 7-plus, you still do not have an official VA 
rating, right?
    Mr. Bohn. Negative. Actually, 2 days before I came here, 
they mysteriously called me and said they have the rating, but 
they cannot tell me over the phone. So when I get home, I will 
get it in the mail. But I do not know how much the rating was.
    Senator Brown of Massachusetts. Well, we would appreciate 
you----
    Senator Begich. Senator, you should invite everyone that is 
still on the list to the Committee, and I think they will be 
approved immediately.
    Chairman Murray. I wish we could just have continuous 
hearings here, but that should not be what this Committee has 
to do.
    Senator Brown of Massachusetts. I would appreciate you 
letting us know what it is, and if we are having a similar 
situation like Tim, we can continue to try to work through 
that. I am sure you being here actually played a role, and as 
you pointed out, that is not the way it should be.
    In addition, what impact--and you were never assigned a 
Federal Recovery Care Coordinator either, right? So what impact 
did that have on you? I know you said you actually went to--
they transferred you to the wrong base.
    Mr. Bohn. I was supposed to, from Landstuhl, Germany, be 
transferred to Andrews Air Force Base, and from there, they 
were supposed to take me to Walter Reed. They ended up flying 
me back to Fort Campbell, assigning me to a WTU there, and 
then, they brought me to a hospital on base and the doctors 
were like, Why are you here? You obviously need surgery. So 
later on that week, they flew me to Walter Reed.
    Senator Brown of Massachusetts. So at what point did you 
know that you were not going where you were supposed to go and, 
in fact, what did you do about it?
    Mr. Bohn. There was nothing I could do.
    Senator Brown of Massachusetts. Did you bring it up to your 
chain of command? Did you speak----
    Mr. Bohn. My chain of command was still in Afghanistan at 
the time, and I know that I had a couple of guys on Rear D back 
there. I talked to them about it and they said, ``Well, 
obviously the doctors corrected the mistake, so----''
    Senator Brown of Massachusetts. So when you got to the 
second place where you really were not supposed to be and they 
recognized that, in fact, you needed surgery, can you explain 
what that was like? Was it like instantaneous? Was it like in a 
month? What happened?
    Mr. Bohn. It was about a month period where I went to 
Kimbrough Hospital at Fort Campbell. After that, I was briefly 
assigned to the WTU, but they put me on TDY to Walter Reed so I 
was still attached to the WTU at Fort Campbell while I was in 
surgery. And the coordination after my spinal surgery, they 
sent me to the West Roxbury Unit, the Spinal Cord Injury Unit, 
so that I could be close to my family.
    But the communication, like I was mentioning earlier, no 
one contacted the WTU at Fort Campbell to tell them that, so 
Fort Campbell threatened, you know, If you are not back here 
within 5 days, you are going to be AWOL.
    Senator Brown of Massachusetts. So basically, there is a 
complete lack of communication----
    Mr. Bohn. That is the main thing.
    Senator Brown of Massachusetts [continuing]. When you get 
hurt and when you were transitioning. You are asking us to look 
into--you want a mentor. You want somebody there who is your 
career--not a career counselor, but your medical treatment 
counselor that says, OK, Steve, listen, this is where you are 
going, this is what you are doing, this is where you have got 
to go, this is what you have got to do, this is who you are 
going to see, and there is nothing like that with you?
    Mr. Bohn. There is nothing.
    Senator Brown of Massachusetts. I understand, also, when 
your mom--I know your folks, they wanted to come down and they 
did not have a checking account and the DOD requires, for 
reimbursements for travel, to have a checking account.
    Mr. Bohn. Exactly.
    Senator Brown of Massachusetts. So as a result of them not 
having a checking account----
    Mr. Bohn. My parents had to pay for their own hotel, and 
then once I woke up out of surgery, they had to leave to go 
right back home. Then my second surgery, I was completely 
alone. I did not have my family come down at all.
    Senator Brown of Massachusetts. There was no one, through 
the DOD or any VA or any other, your unit, nobody that--because 
you were still with a unit, technically. Was there anyone in 
the unit that was keeping an eye on you or others like you?
    Mr. Bohn. Well, at Walter Reed, we had a 101st Airborne 
liaison, but I met him twice the whole period I was there.
    Senator Brown of Massachusetts. And when you were there, 
did you complain? Did you try to push the buttons at all? Or 
you just kind of gave up?
    Mr. Bohn. Infantrymen do not complain, sir.
    Senator Brown of Massachusetts. No, there is some truth--
there is a lot of truth to that. I mean, it is kind of like you 
do not want to rock the boat. And, Tim, you on the other hand, 
you felt compelled to and I understand that as well. If I could 
ask one more question, Madam Chair?
    Chairman Murray. Yes.
    Senator Brown of Massachusetts. So, I mean, Jim, you hear 
these stories. Colonel, you are hearing these stories. I mean, 
what is up? I mean, where is the breakdown and what can we do? 
What can the Chairwoman do and us do to kind of make sure these 
things do not happen again?
    Colonel Lorraine. You know, Senator, where is the 
breakdown? I am not really sure. It surprises me that it 
happens. I know that when I was on active, when I was working 
for Special Operations Command, we had liaisons that were at 
the bedside, and honestly, I will tell you, in 6 years, I never 
had a need that did not get met, was not met.
    We never had families that traveled not on invitational 
travel orders, and if they did not have a checking account, we 
would figure out a way to do it. It is really just taking the 
action. I think that is where it is the--it is going that next 
step to do whatever it takes to make sure that that 
servicemember and their family are taken care of, specifically 
the family, because they are getting the medical care.
    The family is the ones who are sort of--they are the odd 
man out because you have to really focus on them. Everything is 
new, especially to a mom and dad who are not part of the 
service. They do not know the acronyms, they do not know their 
way around, and it may be completely new to them.
    Senator Brown of Massachusetts. Thank you. Steve, thank 
you, and Tim and Colonel, we will be in touch, Steve.
    Chairman Murray. Senator Boozman.

                STATEMENT OF HON. JOHN BOOZMAN, 
                   U.S. SENATOR FROM ARKANSAS

    Senator Boozman. Thank you, Madam Chair, and we appreciate 
you all being here. Your testimony is really very, very helpful 
and, you know, this is really what we need, is the view from 
somebody that has gone through this. I wish that--and I do not 
know how we get it done--but I would love to hear from the--you 
know, it is great that we have got the people that run the 
programs here, but I really would like, at some time, maybe if 
we could hear from the liaisons themselves, you know, that are 
actually doing this work, whether it is through a field hearing 
or bringing you up here, maybe an informal, to really see what 
we are doing, you know, if we are bogging down the system too 
much.
    I know that the people that are dealing with you all are 
good people that are working hard, and as being part of a huge 
organization being in the military, you understand how things 
get bogged down.
    But again, we are hearing firsthand from you that have gone 
through it and it would be good to hear firsthand from the 
group that is out there fighting the battle trying to minister 
to people like you.
    Steve, you mentioned that you went through the TAP program 
and had some concerns, did not really feel like that program 
provided you the--in looking at your testimony, I do not want 
to put words in your mouth, you could comment, but maybe we are 
a little bit concerned that you did not really know, as a 
result of the program, that it really helped you as to what you 
were going to do in the future, you know, some of the skill 
sets you needed.
    Can you comment about that, and then perhaps how we can 
improve that, because we talk about mental health and all of 
these things? One of the big things is just having the 
realization that you can get out, you know, get back in the 
real world and support yourself and support a family and make a 
living.
    Mr. Bohn. At the time I was going through the TAP program, 
I was still going through all my medical treatment. I do not 
think that is really an appropriate time to be going through 
all that while you are seeing doctors every day and focused on 
how you are going to get better every day and how you are going 
to get through the next day. The last thing I was really 
focused on, was what I was going to do after. So I was just 
trying to get by day to day.
    Senator Boozman. So for somebody like yourself then, you 
would advocate that once you started feeling a little bit 
better and moving in that direction, you would do it then?
    Mr. Bohn. Definitely.
    Senator Boozman. OK. Very good. Well, again, thank you all 
for your testimony. We really do appreciate your service and 
your advocacy.
    With that, I yield back, Madam Chair.
    Chairman Murray. Thank you very much. And I want to thank 
all three of you for your very important testimony. You have 
given this Committee a lot to work on 10 years into these 
conflicts. I think it is important that as a country, we 
remember that we have men and women who are coming home who are 
injured, who are going through what you are going through. We 
cannot just figure we did it 4 years ago after the Walter Reed 
scandal broke. We have to be very vigilant and keep working.
    We obviously have work in front of us, and your testimony 
today helps highlight that so that this Committee and this 
Congress can continue to do what we need to do to make sure we 
are not letting anybody fall through the cracks. So I really 
appreciate your being here and your testimony, and I want to 
thank you for that today.
    With that, we are going to move on to our second panel, so 
this panel can go ahead and get up. As our second panel is 
coming to us, I want everyone to know that we now do have the 
departments in front of us. They have had the opportunity to 
hear this testimony. We will be asking them about that. Also, I 
know we have got several Members of the Committee who will be 
coming in and out.
    I would like to ask the second panel to come and sit down. 
I will give you just a minute to settle in. If we could have 
our witnesses in the second panel please take their seats, and 
I will do the introductions while you are doing that.
    We have Dr. Toni Zeiss, who is the Acting Deputy Chief 
Officer, Mental Health Services for the Office of Patient Care 
Services for the Department of Veterans Affairs. She is 
accompanied by two specialists from the Department, Dr. Shane 
McNamee, the Chief of Physical Medicine and Rehab at the 
Richmond VA medical center, and Dr. Jan Kemp, VA's National 
Suicide Prevention Coordinator.
    Following the VA, we have Dr. George Peach Taylor, Jr., the 
Deputy Assistant Secretary of Defense for Force Health 
Protection and Readiness. Dr. Taylor is accompanied Philip 
Burdette, DOD's Deputy Director of the Wounded Care and 
Transition Policy Office.
    I do want to mention again that I am very disappointed by 
the lateness of your testimony, Dr. Taylor. The Department has 
known about this hearing since May 9th and this is a 
continuation of the discussion that we had with Deputy 
Secretary Lynn last week. As you heard earlier from Senator 
Burr, the rules of this Committee do require that testimony be 
received 48 hours in advance.
    We received your testimony very close to the end of 
business last evening, and it is very difficult for Members to 
prepare for a hearing when testimony is received so late. As I 
indicated, however, given how strongly I feel about this issue, 
I will let you testify today and answer the serious questions 
that were raised by the first panel.
    The Ranking Member and I will be reaching out to DOD and to 
OMB to address this issue because in the future the Department 
does need to get their testimony in on time.
    Dr. Zeiss, with that, I would like to begin with you and 
your testimony.

   STATEMENT OF ANTONETTE ZEISS, Ph.D., ACTING DEPUTY CHIEF 
    OFFICER, MENTAL HEALTH SERVICES, OFFICE OF PATIENT CARE 
 SERVICES, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY 
      SHANE McNAMEE, M.D., CHIEF OF PHYSICAL MEDICINE AND 
  REHABILITATION; HUNTER HOLMES McGUIRE (RICHMOND) VA MEDICAL 
  CENTER; DEBORAH AMDUR, CHIEF CONSULTANT CARE MANAGEMENT AND 
  SOCIAL WORK, OFFICE OF PATIENT CARE SERVICES; AND JANET E. 
    ``JAN'' KEMP, RN, Ph.D., VA NATIONAL SUICIDE PREVENTION 
                          COORDINATOR

    Ms. Zeiss. Good morning, Chairman Murray, Ranking Member 
Burr, and members of the Senate Veterans' Affairs Committee. I 
am Dr. Antonette Zeiss, Acting Deputy Chief, Patient Care 
Services Office for Mental Health at VA Central Office.
    I am pleased to be here today with my colleagues from the 
Department of Veterans Affairs and from the Department of 
Defense to discuss how VA and DOD are meeting the needs of 
returning and injured veterans and servicemembers and certainly 
welcome the opportunity to think about how we can do that 
better. I appreciate also the important testimony that we heard 
in the panel before this.
    We will always need to continue to try to improve our 
efforts and increase the amount of collaboration that is going 
on, and we welcome the chance to think with you about that 
process.
    Accompanying me from VA and joining me at the witness table 
are Dr. Janet Kemp, the National Mental Health Director for 
Suicide Prevention in the Office of Mental Health Services, and 
Dr. Shane McNamee, Chief of Physical Medicine and 
Rehabilitation Service at Hunter Holmes McGuire VA medical 
center in Richmond, Virginia. I would ask that our combined 
written statement be included in the record.
    Also from VA, seated immediately behind us in the first row 
of the audience are Deborah Amdur, the Chief Consultant for 
Care Management and Social Work in Patient Care Services; Mr. 
Cliff Freeman, the Director for VA/DOD Health Information 
Sharing; Mr. Larry Fink, the Director of the IDES Program 
Management Office; and Mr. Tom Pamperin, Deputy Under-Secretary 
for Disability Assistance. And they will help us when it is 
time for questions.
    Again, it is a pleasure for me to be here today. I have 
worked for VA over 28 years and have been at VA Central Office 
for almost 6 years. My area of expertise is treatment of 
eligible veterans with mental health problems, and VA's 
policies and procedures for providing such care.
    In my statement today, I will particularly focus on the new 
integrated mental health strategy developed collaboratively by 
VA and the Department of Defense. That strategy was developed 
to address the growing population of servicemembers and 
veterans with mental health needs.
    Mental health care provides challenges for the two 
organizations. We have separate missions in that we serve the 
same population, but at different times in their lives and 
careers. Therefore, the integrated mental health strategy 
centers on a coordinated model to improve access, quality, 
effectiveness, and efficiency of mental health services across 
the departments.
    Recipients of services include active duty servicemembers, 
National Guard and Reserve component members, veterans, and 
their families. The development of the strategy was a major 
focus of the two departments in fiscal year 2010 and was 
improved in final form in October, 2010. It followed from the 
first ever National Mental Health Summit co-hosted by VA and 
DOD in October 2009, designed to make recommendations for how 
the departments can work more effectively together to meet 
mental health needs.
    The strategy derives from the summit and subsequent joint 
efforts of subject matter experts from both departments. It 
identifies 28 strategic actions that fall under four strategic 
goals. The first is to expand access to behavioral health care 
in VA and DOD. Second is to ensure quality and continuity of 
care across the departments for servicemembers, veterans, and 
their families.
    Third, to advance care through community partnership and 
education and reduce stigma through successful public 
communication and innovative technological approaches. And 
fourth, promote resilience and build better behavioral health 
care systems for tomorrow. All of these actions have been 
developed into full implementation plans and are underway.
    Each one of the actions has defined end states to define 
success, and those actions were developed with metrics related 
to those end states. Some are outcomes, some are process 
depending on the structure of the activity. The most objective 
and measurable of the metrics will be tracked in next year's 
joint strategic plan metrics, and progress in implementation is 
tracked bimonthly in the VA/DOD Health Executive Council.
    This collaboration is providing unique opportunities to 
better coordinate our mental health efforts across the two 
departments for the benefit of all our servicemembers, 
veterans, and eligible family members. Thank you again for the 
opportunity to appear before your Committee, and I look forward 
to your questions.
    [The prepared statement of Ms. Zeiss follows:]

   Prepared Statement of Antonette Zeiss, Ph.D., Acting Deputy Chief 
   Officer, Mental Health Services, Office of Patient Care Services, 
  Veterans Health Administration, U.S. Department of Veterans Affairs

    Chairman Murray, Ranking Member Burr, Members of the Senate 
Veterans' Affairs Committee: I am pleased to be here today to discuss 
how the Department of Veterans Affairs (VA) and the Department of 
Defense (DOD) are meeting the needs of returning and injured Veterans 
and Servicemembers. I am accompanied today by Ms. Deborah Amdur, Chief 
Consultant, Care Management and Social Work, Office of Patient Care 
Services; Mr. Cliff Freeman, Director, VA/DOD Health Information 
Sharing; and Shane McNamee, M.D., Chief of Physical Medicine and 
Rehabilitation Service at the Hunter Holmes McGuire (Richmond) VA 
Medical Center.
    You heard last week from Deputy Secretary Gould about many of our 
efforts in this area, and my testimony will re-emphasize some of the 
points he made while expanding on several key areas of collaboration 
and support such as mental health services, prosthetics and 
rehabilitation, electronic health records, and care coordination, per 
your request.

                         MENTAL HEALTH SERVICES

    VA offers mental health services to eligible Veterans through 
medical facilities, community-based outpatient clinics (CBOC), and in 
VA's Vet Centers. VA has been making significant advances in its mental 
health services since 2005, beginning with implementation of the VA 
Comprehensive Mental Health Strategic Plan utilizing special purpose 
funds available through the Mental Health Enhancement Initiative. In 
2007 implementation of the strategic plan culminated in development of 
the VHA Handbook on Uniform Mental Health Services in VA medical 
centers and Clinics, which defines what mental health services should 
be available to all enrolled Veterans who need them, no matter where 
they receive care, and to sustain and extend the enhancements made up 
to that point. VA is still in the process of fully implementing this 
Handbook, and has made extensive progress to date. We continue to 
emphasize additional areas for final development.
    VA's enhanced mental health activities include outreach to help 
those in need to access services, a comprehensive program of treatment 
and rehabilitation for those with mental health conditions, and 
programs established specifically to care for those at high risk of 
suicide.
    VA ensures that treatment of mental health conditions includes 
attention to the benefits as well as the risks of the full range of 
effective interventions, with emphasis on all relevant modalities, 
including psychopharmacological care, evidence-based psychotherapy, 
peer support, vocational rehabilitation, and crisis intervention. 
Making these treatments available incorporates the principle that when 
there is evidence for the effectiveness of a number of different 
treatment strategies, the choice of treatment should be based on the 
Veteran's values and preferences, as well as the clinical judgment of 
the provider.
    To reduce the stigma of seeking care and to improve access, VA has 
integrated mental health into primary care settings to provide much of 
the care that is needed for those with the most common mental health 
conditions, when appropriate. Mental health services are incorporated 
in the evolution of VA primary care to Patient Aligned Care Teams 
(PACT), an interdisciplinary model to organize a site for holistic care 
of the Veteran in a single primary health care location. In parallel 
with the implementation of these programs, VA has been modifying its 
specialty mental health care services to emphasize psychosocial as well 
as pharmacological treatments and to focus on principles of 
rehabilitation and recovery. VA also has a full range of sites of care, 
from inpatient acute mental health units, to extended care Residential 
Rehabilitation Treatment Programs, to outpatient specialty mental 
health care (as well as care in the PACT), to mental health care in 
geriatrics and extended care settings, to mental health staff as a 
component of Home-Based Primary Care, delivering mental health services 
to eligible home-bound Veterans and their caregivers in their own 
homes.

                VA/DOD INTEGRATED MENTAL HEALTH STRATEGY
 
   The development of the VA/DOD Integrated Mental Health Strategy 
(IMHS) was a major focus of the Departments in fiscal year (FY) 2010 
and was approved in final form in October 2010. In October 2009, VA and 
DOD convened the first-ever joint Summit meeting to make 
recommendations for how the two Departments can more effectively work 
together to meet the mental health needs of America's military 
personnel, Veterans and their families. The IMHS derives from this 
Summit and subsequent joint efforts of subject matter experts. It was 
developed to address the growing population of Servicemembers and 
Veterans with mental health needs. Mental health care provides unique 
challenges for the two organizations with separate missions in that 
they serve the same population, but at different times in their lives 
and careers. As such, the IMHS centers on a coordinated public health 
model to improve the access, quality, effectiveness, and efficiency of 
mental health services. Recipients of these services include Active 
Duty Servicemembers, National Guard and Reserve Component members, 
Veterans, and their families.
    The IMHS identifies 28 Strategic Actions that fall under the 
following four strategic goals: (1) Expand access to behavioral health 
care in VA and DOD; (2) Ensure quality and continuity of care across 
the Departments for Servicemembers, Veterans, and their families; (3) 
Advance care through community partnership and education and reduce 
stigma through successful public communication and use of innovative 
technological approaches; and (4) Promote resilience and build better 
behavioral health care systems for tomorrow. The first goal of 
expanding access to behavioral health care includes specific actions 
such as integrating mental health services into primary care settings; 
expanding eligibility to Vet Center services to members of the Armed 
Forces who served in Operations Enduring Freedom, Iraqi Freedom, or New 
Dawn (OEF/OIF/OND); sharing mental health staff between the 
Departments; and developing processes for implementing joint DOD and VA 
tele-mental health services. The second goal of ensuring quality and 
continuous care includes specific actions such as coordinating and 
standardizing training in evidence-based psychotherapies; developing 
quality measures for mental health services based on VA/DOD Clinical 
Practice Guidelines; evaluating patient outcomes and using this data to 
support clinical decisions and improve our programs; and implementing 
the ``inTransition'' mental health coaching program. The third goal of 
advancing care through community partnerships, education, and 
successful public communication includes specific actions such as 
exploring methods to help family members identify mental health needs 
through education and coaching; coordinating the Departments' 
communications plans to improve public health messaging; facilitating 
access to Web-based resources; and promoting a better understanding of 
military culture for providers. The final goal of promoting resilience 
includes specific actions such as exploring methods to distribute 
knowledge on suicide risk and prevention; recommending and promoting 
family resilience programs; building from lessons learned in DOD's 
resilience programs; and translating mental health research into 
innovative programs. This unprecedented level of collaboration is 
providing unique opportunities to coordinate our mental health efforts 
across the two Departments, for the benefit of all of our 
Servicemembers, eligible Veterans, and their eligible family members.

                SUICIDE PREVENTION/VETERANS CRISIS LINE

    The VA Suicide Prevention Program is based on the concept of ready 
access to high quality mental health care and other services. All VA 
Suicide Prevention Program elements are shared with DOD, and a joint 
conference is held annually to encourage use of all strategies across 
both Departments, including educational products and materials. One of 
the main mechanisms to access enhanced care provided to high risk 
patients is through the Veterans Crisis Line. The Crisis Line is 
located in Canandaigua, New York and partners with the Substance Abuse 
and Mental Health Services Administration National Suicide Prevention 
Lifeline. All calls from Veterans, Servicemembers, families and friends 
calling about Veterans or Servicemembers are routed to the Veterans 
Crisis Line. The Call Center started in July 2007, and the Veterans 
Chat Service was started in July 2009. To date the Call Center has:

     Received over 400,000 calls;
     Initiated over 15,000 rescues;
     Referred over 55,000 Veterans to local VA Suicide 
Prevention Coordinators for same day or next day services;
     Answered calls from over 5,000 Active Duty Servicemembers; 
and
     Responded to over 16,000 chats.
              readjustment counseling service: vet centers
    Vet Centers are community-based counseling centers that provide 
community outreach, professional readjustment counseling for war-
related readjustment problems, and case management referrals for combat 
Veterans. Vet Centers also provide bereavement counseling for families 
of Servicemembers who died while on Active Duty. Through March 31, 
2011, Vet Centers have cumulatively provided face-to-face readjustment 
services to more than 525,000 OEF/OIF/OND Veterans and their families. 
As outlined in Section 401 of Public Law 111-163, VA is currently 
drafting regulations to expand Vet Center eligibility to include 
members of the Active Duty Armed Forces who served in OEF/OIF/OND 
(includes Members of the National Guard and Reserve who are on Active 
Duty).
    In addition to the 300 Vet Centers that will be operational by the 
end of 2011, the Readjustment Counseling Service program also has 50 
Mobile Vet Centers providing outreach to separating Servicemembers and 
Veterans in rural areas. The Mobile Vet Centers provide outreach and 
direct readjustment counseling at active military, Reserve, and 
National Guard demobilization activities. To better serve eligible 
Veterans with military-related family problems, VA is adding licensed 
family counselors to over 200 Vet Center sites that do not currently 
have a family counselor on staff.

         OTHER SIGNIFICANT VA/DOD MENTAL HEALTH COLLABORATIONS

    The Defense Centers of Excellence (DCoE) for Psychological Health 
(PH) and Traumatic Brain Injury (TBI) was created in November 2007 to 
assess, validate, oversee and facilitate prevention, resilience, 
identification, treatment outreach, rehabilitation and reintegration 
programs for psychological health and Traumatic Brain Injury to ensure 
DOD meets the needs of Servicemembers, eligible Veterans, military 
families and communities. VA personnel occupy three key leadership 
positions within DCoE: Deputy Director for VA, VA Senior Liaison to 
DCoE for Psychological Health, and VA Senior Liaison to DCoE for TBI. 
DCoE and VA also collaboratively plan and participate in multiple 
continuing education conferences each year, including the joint suicide 
prevention conference.
    Under the auspices of the VA/DOD Evidence Based Practice Guidelines 
Work Group, personnel from VA and DOD serve on clinical practice 
guidelines committees for developing, updating and deploying joint 
clinical practice guidelines for mental health conditions. The VA/DOD 
guideline for evidence-based management of Post-Traumatic Stress was 
updated in 2010. Other evidence-based clinical practice guidelines for 
mental health include Major Depressive Disorder, Substance Use 
Disorders and Bipolar Disorder.

                     PROSTHETICS AND REHABILITATION

    VA is vigilant in its search for new technologies that will benefit 
the men and women with medical needs who have served our country. Any 
technology that is commercially available and medically indicated may 
be provided to eligible Veterans. These devices cover every aspect of a 
Veteran's life, including wheeled mobility, aids for the blind, 
artificial limbs and bracing, and vehicular and home adaptations. 
Serving those eligible Veterans and Servicemembers with amputation is 
an area of extensive collaboration between VA and DOD. We evaluate new 
technologies, develop joint VA/DOD patient and family education 
materials, and produce Clinical Practice Guidelines related to care. VA 
and DOD have further partnered with the Amputee Coalition of America 
(ACA) to establish Peer Visitation Programs for Veterans and 
Servicemembers with amputation. The principal mechanism for delivery of 
these services is through the new VA Amputation System of Care.
    VA's Amputation System of Care began rollout in 2009, and is 
expected to be fully operational by the end of FY 2011. This model of 
care provides specialized expertise in amputation rehabilitation, 
incorporating the latest practice in medical rehabilitation management, 
rehabilitation therapies, and technological advances in prosthetic 
componentry. The System is comprised of four distinct tiers that mirror 
the hub-and-spoke model of VA's Polytrauma System of Care. These tiers 
include:

     Seven (7) Regional Amputation Centers, which provide 
comprehensive rehabilitation care through interdisciplinary teams and 
which serve as a resource across VA for tele-rehabilitation. These 
Centers provide the highest level of specialized expertise in clinical 
care and technology and are located in the Bronx (NY), Denver (CO), 
Minneapolis (MN), Palo Alto (CA), Richmond (VA), Seattle (WA), and 
Tampa (FL).
     Fifteen (15) Polytrauma Amputation Network Sites, which 
provide a full range of clinical and ancillary services to eligible 
Veterans closer to home.
     One hundred (100) Amputation Clinic Teams, which provide 
outpatient amputation care and services;
     Thirty-one (31) Amputation Points of Contact, who 
facilitate referrals and access to services. At least one person at 
these facilities is knowledgeable of the Amputation System of Care and 
can provide appropriate consultation, assessments and referrals based 
on this knowledge.
    The Amputation System of Care is available to all eligible Veterans 
and Servicemembers and provides the appropriate level of care and 
expertise based on the specific rehabilitation needs of each 
individual. While the System is not yet fully operational, our efforts 
to date have increased access for eligible Veterans in need of 
specialty amputation care. We have seen a 55 percent increase in 
workload and a 40 percent increase in the number of Veterans served by 
the Regional Amputation Centers through the end of FY 2010. Moreover, 
VA has served 191 percent more Veterans requiring amputation or 
prosthetic services through telehealth because of expansions in these 
programs. VA has 65 Prosthetic Labs that are accredited by the Board 
for Orthotist/Prosthetist Certification or American Board for 
Certification in Orthotics and Prosthetics. The Department also 
maintains more than 600 contracts with private prosthetics companies 
and two national providers of upper extremity prosthetics to ensure 
eligible Veterans have access to any commercially available and 
prescribed technologies.
    As of April 30, 2011, VA's cohort of Veterans from OEF/OIF/OND 
includes a total of 1,228 Servicemembers who have sustained major limb 
amputations. While these patients' initial rehabilitation and recovery 
has mainly been completed within DOD medical treatment facilities, 748 
of these members have transitioned to Veteran status and have received 
prostheses and amputation care services from VA. Based on a mutually 
recognized need to better serve this new cohort of combat injured 
Servicemembers, VA and DOD are establishing a 3 year pilot program at 
the Hunter Holmes McGuire VA Medical Center in Richmond, VA, to provide 
residential transitional rehabilitation. This pilot program will focus 
on improving the health and wellness outcomes of patients with 
amputations and facilitating successful transition of active duty 
Servicemembers to return to unrestricted military duty, or civilian 
vocations.
    Another key area of collaboration between VA and DOD is research to 
identify and incorporate, the best practices and technological 
advancements for amputation care. In 2003, clinicians and researchers 
from both departments outlined joint initiatives to further prosthetics 
research and improve care for military and Veteran amputees. This 
meeting was held in response to the needs of an increasing number of 
soldiers suffering limb loss due to combat in Iraq and Afghanistan, 
resulting in a number of research projects that are now underway.
    One such project is the Defense Advanced Research Projects Agency 
(DARPA) ``Revolutionizing Prosthetics'' research program initiated in 
2005, which has culminated in development of the first prototype 
advanced prosthetic arms for clinical testing in VA. The first VA 
research subject was studied in April 2009. The Next-Generation DARPA 
Prosthetic Arm System incorporates major technological advances such as 
flexible socket design and innovative control features, hardware, and 
software that together enable enhanced functionality that promises to 
surpass any currently available prosthetic device. Ongoing results of 
this VA clinical research are informing design efforts leading to the 
optimization of a revised version of the Next-Generation DARPA 
Prosthetic Arm System. VA will employ a similar design to conduct 
usability research on the revised arm system. The expectation is that 
the results of these efforts will lead to commercialization of a 
refined, highly usable product. Since April 2009, 26 research subjects 
have been fitted with the arm during their participation in the VA 
research study.
    Establishment of the DOD Center of Excellence on Traumatic 
Extremity Injuries and Amputations (CoE) will also be a key 
collaboration between DOD and VA to further advance amputation care and 
services. A joint Memorandum of Understanding (MOU) for establishment 
of the Center was signed by the Assistant Secretary of Defense for 
Health Affairs (ASD (HA)) and Under Secretary of Health (VA) on 
August 18, 2010. A primary focus of this CoE will be on research 
efforts aimed at saving injured extremities, avoiding amputations, and 
preserving and restoring function of injured extremities.
    A working group comprised of representatives from the Services, VA, 
and Health Affairs has developed the concept of operations for the 
structure, mission and goals for the Center. Pending final approval by 
DOD, this plan will be sent to VA for review and concurrence prior to 
implementation.

                       ELECTRONIC HEALTH RECORDS

    In the last 2 years, we have made major strides in sharing health 
and benefits data between our two Departments, and made significant 
progress toward our long-term goal of seamless data sharing systems. 
Our objective is to ensure that appropriate health, administrative, and 
benefits information is visible, accessible, and understandable through 
secure and interoperable information technology to all appropriate 
users. For the past several years, we have shared increasing amounts of 
health information to support clinicians involved in providing day-to-
day health care for Veterans and Servicemembers. Our clinicians can now 
access health information for almost four million Veterans and 
Servicemembers between our health information systems. Veterans and 
Servicemembers are able to access increasing amounts of personal health 
information from home or work sites through our ``Blue Button'' 
technology, using VA and DOD secure Web sites.
    For the last 2 years, we have worked together on a Virtual Lifetime 
Electronic Record (VLER). This project takes a phased approach to 
sharing health and benefits data to a broader audience, including 
private health clinicians involved in Veteran/Servicemember care, 
benefits adjudicators, family members, care coordinators, and other 
caregivers. We are in the first phase of this project, with five 
operational ``pilot'' sites where we are sharing health information 
between VA, DOD, and private sector health providers. VLER will be 
fully developed by 2014, providing health and benefits data to all 
authorized users in a safe, private, secure manner, regardless of the 
user's location.
    More recently, Secretary Gates and Secretary Shinseki formally 
agreed that our two Departments would work cooperatively toward a 
common electronic health record. We call this effort the ``integrated 
Electronic Health Record,'' or iEHR. As I speak to you today, our 
functional and technical experts are meeting to develop and draft 
detailed plans on executing an overall concept of operations that the 
two Secretaries will utilize to determine the best approach to 
achieving this complex goal. Once completed, the iEHR will be a 
national model for capturing, storing, and sharing electronic health 
information.

                           CARE COORDINATION

    The two Departments continue to drive toward providing a 
comprehensive continuum of care to optimize the health and well being 
of Servicemembers, Veterans, and their eligible beneficiaries. Our 
joint efforts to provide a ``single system'' experience of life-time 
services are supported by three common goals: 1) efficiencies of 
operations; 2) health care; and 3) benefits. The goal of efficiencies 
of operations describes the Department's efforts to reduce duplication 
and increase cost savings through joint planning and resource sharing. 
Our health care goal is a patient-centered health care system that 
consistently delivers excellent quality, access, and value across the 
Departments. We also strive to anticipate and address Servicemember, 
Veteran, and family needs through an integrated approach to delivering 
comprehensive benefits and services. There are five key areas where VA 
and DOD are collaborating to promote better care coordination for 
transitioning Servicemembers and Veterans: the Federal Recovery 
Coordination Program, the VA Polytrauma/Traumatic Brain Injury System 
of Care, VA Liaisons for Health Care, OEF/OIF/OND Care Management, and 
caregiver support.

              FEDERAL RECOVERY COORDINATION PROGRAM (FRCP)

    The Senior Oversight Committee (SOC established FRCP, in 
October 2007, as a joint VA and DOD program designed to coordinate 
access to Federal, state, and local programs, benefits, and services 
for severely wounded, ill, and injured Servicemembers, Veterans, and 
their families. The SOC maintains oversight of the FRCP. The program 
was specifically charged with providing seamless support from the time 
a Servicemember arrived at the initial Medical Treatment Facility in 
the United States through the duration of care and rehabilitation. 
Services are now provided through recovery, rehabilitation, and 
reintegration into the community. Federal Recovery Coordinators (FRC) 
are Masters-prepared nurses and clinical social workers who provide for 
all aspects of care coordination, both clinical and non-clinical. FRCs 
are located at both VA and DOD facilities.
    FRCs work together with other programs designed to serve the 
wounded, ill, and injured population including clinical case managers 
and non-clinical care coordinators. FRCs are unique in that they 
provide their clients a single point of contact regardless of where 
they are located, where they receive their care, and regardless of 
whether they remain on Active Duty or transition to Veteran status.
    FRCs assist clients in the development of a Federal Individual 
Recovery Plan and ensure that resources are available, as appropriate, 
to assist clients in achieving stated goals. More than 1,300 clients 
have participated in the FRC program since its inception in 2008. 
Currently, FRCP has more than 700 active clients in various stages of 
recovery. There are currently 22 FRCs with an average caseload of 33 
clients. A satisfaction survey conducted in 2010 reported that 80 
percent of FRCP clients were satisfied or very satisfied with the 
program.

   VA/DOD COLLABORATIONS FOR POLYTRAUMA/TRAUMATIC BRAIN INJURY (TBI)

    VA and DOD share a longstanding integrated collaboration in the 
area of TBI. Providing world-class medical and rehabilitation services 
for Veterans and Servicemembers with TBI and polytrauma is one of VA's 
highest priorities. Since 1992, VA and the Defense and Veterans Brain 
Injury Center (DVBIC) have been integrated at VA Polytrauma 
Rehabilitation Centers (PRC), formerly known as Lead TBI Centers, to 
collect and coordinate surveillance of long-term treatment outcomes for 
patients with TBI. From this collaboration, VA expanded services to 
establish the VA Polytrauma/TBI System of Care to provide specialty 
rehabilitation care for complex injuries and TBI.
    Today, this system of care spans more than 100 VA medical centers 
to create points of access along a continuum, and integrates 
comprehensive clinical rehabilitative services, including: treatment by 
interdisciplinary teams of rehabilitation specialists; specialty care 
management; patient and family education and training; psychosocial 
support; and advanced rehabilitation and prosthetic technologies. In 
addition to specialty services, eligible Veterans and Servicemembers 
recovering from TBI receive comprehensive treatment from clinical 
programs involved in post-combat care including: Primary Care, Mental 
Health, Care Management and Social Work, Extended Care, Prosthetics, 
Telehealth, and others.
    VA's provision of evidence-based medical and rehabilitation care is 
supported through a system-wide collaboration with the Commission on 
Accreditation of Rehabilitation Facilities to achieve and maintain 
national accreditation for VA rehabilitation programs. Collaboration 
with the National Institute on Disability and Rehabilitation Research 
TBI Model Systems Project enables VA to collect and benchmark VA 
rehabilitation and longitudinal outcomes with those from other national 
TBI Model Systems rehabilitation centers. With clinical and research 
outcomes that rival those of academic, private sector, and DOD 
facilities, VA leads the medical and scientific communities in the area 
of TBI and polytrauma rehabilitation.
    Since April 2007, VA has screened more than 500,000 Veterans from 
Operation Enduring Freedom (OEF)/Operation Iraqi Freedom/(OIF)/
Operation New Dawn (OND) entering the VA health care system for 
possible TBI. Patients who screen positive are referred for 
comprehensive evaluation by a specialty team, and are referred for 
appropriate care and services. An individualized rehabilitation and 
community reintegration plan of care is developed for patients 
receiving ongoing rehabilitation treatment for TBI. Veterans who are 
screened and report current symptoms are evaluated, referred, and 
treated as appropriate.
    Additionally, 1,969 Veterans and Servicemembers with more severe 
TBI and extensive, multiple injuries were inpatients in one of the 
specialized VA Polytrauma Rehabilitation Centers between March 2003 and 
December 2010. VA and DOD collaborations in the area of TBI include: 
developing collaborative clinical research protocols; developing and 
implementing best clinical practices for TBI; developing materials for 
families and caregivers of Veterans with TBI; developing integrated 
education and training curriculum on TBI for joint training of VA and 
DOD heath care providers; and coordinating the development of the best 
strategies and policies regarding TBI for implementation by VA and DOD.
    Recent initiatives that have resulted from the ongoing 
collaboration between VA and DOD include:

     Development and deployment of joint DOD/VA clinical 
practice guidelines for care of mild TBI;
     A uniform training curriculum for family members in 
providing care and assistance to Servicemembers and Veterans with TBI 
(``Traumatic Brain Injury: A Guide for Caregivers of Servicemembers and 
Veterans'');
     Implementing the Congressionally-mandated 5-year pilot 
program to assess the effectiveness of providing assisted living 
services to Veterans with TBI;
     Integrated TBI education and training curriculum for VA 
and DOD health care providers (DVBIC);
     Revisions to the International Classification of Diseases, 
Clinical Modification (ICD-9-CM) diagnostic codes for TBI, resulting in 
improvements in identification, classification, tracking, and reporting 
of TBI;
     Collaborative clinical research protocols investigating 
the efficacy of various TBI treatments; and
     Development of the protocol used by the Emerging 
Consciousness care path at the four PRCs to serve those Veterans with 
severe TBI who are slow to recover consciousness.

                      VA LIAISONS FOR HEALTH CARE

    VA has a system in place to transition severely ill and injured 
Servicemembers from DOD to VA's system of care. Typically, a severely 
injured Servicemember returns from theater and is sent to a military 
treatment facility (MTF) where he/she is medically stabilized. A key 
component of transitioning these injured and ill Servicemembers and 
Veterans are the VA Liaisons for Health Care, who are either social 
workers or nurses strategically placed in MTFs with concentrations of 
recovering Servicemembers returning from Iraq and Afghanistan. After 
initially having started with 1 VA Liaison at 2 MTFs, VA now has 33 VA 
Liaisons for Health Care stationed at 18 MTFs to transition ill and 
injured Servicemembers from DOD to the VA system of care. VA Liaisons 
facilitate the transfer of Servicemembers and Veterans from the MTF to 
the VA health care facility closest to their home or the most 
appropriate facility that specializes in services that their medical 
condition requires.
    VA Liaisons are co-located with DOD Case Managers at MTFs and 
provide onsite consultation and collaboration regarding VA resources 
and treatment options. VA Liaisons educate Servicemembers and their 
families about VA's system of care, coordinate the Servicemember's 
initial registration with VA, and secure outpatient appointments or 
inpatient transfer to a VA health care facility as appropriate. VA 
Liaisons make early connections with Servicemembers and families to 
begin building a positive relationship with VA. VA Liaisons coordinated 
7,150 transitions for health care in FY 2010, and have facilitated more 
than 25,000 transitions since the program began in 2003.

                    VHA OEF/OIF/OND CARE MANAGEMENT

    As Servicemembers recover from their injuries and reintegrate into 
the community, VHA works closely with FRCs and DOD case managers and 
treatment teams to ensure the continuity of care. Each VA Medical 
Center has an OEF/OIF/OND Care Management team in place to coordinate 
patient care activities and ensure that Servicemembers and Veterans are 
receiving patient-centered, integrated care and benefits. Members of 
the OEF/OIF/OND Care Management team include: a Program Manager, 
Clinical Case Managers, and a Transition Patient Advocate (TPA). The 
Program Manager, who is either a nurse or social worker, has overall 
administrative and clinical responsibility for the team and ensures 
that all OEF/OIF/OND Veterans are screened for case management. 
Clinical Case Managers, who are either nurses or social workers, 
coordinate patient care activities and ensure that all clinicians 
providing care to the patient are doing so in a cohesive and integrated 
manner. The severely injured OEF/OIF/OND Veterans are automatically 
provided with a Clinical Case Manager while others may be assigned a 
Clinical Case Manager if determined necessary by a positive screening 
or upon request. The TPA helps the Veteran and family navigate the VA 
system by acting as a communicator, facilitator, and problem solver. VA 
Clinical Case Managers maintain regular contact with Veterans and their 
families to provide support and assistance to address any health care 
and psychosocial needs that arise.
    The OEF/OIF/OND Care Management program now serves over 54,000 
Servicemembers and Veterans including over 6,300 who have been severely 
injured. The current caseload each OEF/OIF/OND case manager is managing 
on a regular basis is 54. In addition, they provide lifetime case 
management for another 70 Veterans by maintaining contact once or twice 
per year to assess their condition and needs. This is a practical 
caseload ratio based on the acuity and population at each VA health 
care facility.
    VA developed and implemented the Care Management Tracking and 
Reporting Application (CMTRA), a Web-based application designed to 
track all OEF/OIF/OND Servicemembers and Veterans receiving care 
management. This robust tracking system allows clinical case managers 
to specify a case management plan for each Veteran and to coordinate 
with specialty case managers such as Polytrauma Case Managers, Spinal 
Cord Injury Case Managers, and others. CMTRA management reports are 
critical in monitoring the quality of care management activities 
throughout VHA.
    OEF/OIF/OND Care Management team members actively support outreach 
events in the community, and also make presentations to community 
partners, Veterans Service Organizations, colleges, employment 
agencies, and others to collaborate in providing services and 
connecting with returning Servicemembers and Veterans.

                           CAREGIVER SUPPORT

    Caregivers are a valuable resource providing physical, emotional, 
and other support to seriously injured Veterans and Servicemembers, 
making it possible for them to remain in their homes. Recognizing the 
significant sacrifices made by family caregivers of certain Veterans 
and Servicemembers who incurred or aggravated a serious injury in the 
line of duty on or after September 11, 2001, the new Caregivers and 
Veterans Omnibus Health Services Act of 2010, signed into law by 
President Obama on May 5, 2010, enhances existing services for 
caregivers of Veterans who are currently enrolled in VA care. It also 
provides unprecedented new benefits and services to family caregivers 
who care for certain eligible Veterans and Servicemembers undergoing 
medical discharge who are in need of personal care services. These new 
benefits, which are being implemented through an Interim Final Rule 
published earlier this month, include, for designated primary family 
caregivers of eligible Veterans and Servicemembers, a stipend, mental 
health services, and health care coverage if the primary family 
caregiver is not otherwise entitled to care or services under a health 
plan contract.
    Starting May 9, 2011, VA began accepting applications for this 
program; we processed more than 625 applications in the first week. 
Caregiver Support Coordinators at each VA medical center are available 
to assist Veterans and their family caregivers with the application 
process, which can be done online, in person, or by telephone. The 
benefits under this program are in addition to the range of benefits 
and services that support Veterans and their family caregivers. These 
include such things as in-home care, specialized education and 
training, respite care, equipment and home and automobile modification, 
and financial assistance for eligible Veterans. VA is enhancing its 
current services and developing a comprehensive National Caregiver 
Support Program with a prevention and wellness focus that includes the 
use of evidence-based training and support services for caregivers. 
VA's Caregiver Support Coordinators are the clinical experts on 
caregiver issues; these Coordinators are most familiar with the VA and 
non-VA support resources that are available to support family 
caregivers in successfully caring for Veterans at home. VA has a 
Caregiver Support Web site (www.caregiver.va.gov) and Caregiver Support 
Line (1-855-260-3274) that provide a wealth of information and 
resources for Veterans, families, and the general public. More than 
6,000 Veterans and caregivers have received assistance from the 
clinical social workers staffing the Support Line since its inception 
on February 1, 2011.

                               CONCLUSION

    VA and DOD continue to work together diligently to resolve 
transition issues while aggressively implementing improvements and 
expanding existing programs. While we are pleased with the quality of 
effort and progress made to date, we fully understand our two 
Departments have a responsibility to continue these efforts. We 
appreciate the opportunity to discuss these programs with you and to 
hear your recommendations.
    Thank you again for your support to our wounded, ill, and injured 
Servicemembers, Veterans, and their families and your interest in the 
ongoing collaboration and cooperation between our Departments. My 
colleagues and I are prepared to respond to any questions you may have.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Patty Murray to 
   Antonette Zeiss, Ph.D., Acting Deputy Chief Officer Mental Health 
Services, Office of Patient Care Services, U.S. Department of Veterans 
                                Affairs

    Question 1. Please provide a list of the number of claims of 
recently separated veterans who were awarded compensation benefits 
under section 4.28 of title 38, Code of Federal Regulations for each 
regional office during FY 2010. Please separately state the number of 
prestabilization ratings of 50 percent and 100 percent for each 
regional office.
    Response. In fiscal year 2010, 143 Veterans (52 at 50 percent and 
91 at 100 percent) were awarded compensation benefits under 38 CFR 4.28 
(pre-stabilization ratings). Please see Enclosure 1 for the breakdown 
of pre-stabilization ratings for 50 percent and 100 percent by regional 
office.

    Question 2. The Departments have numerous programs and projects to 
inform servicemembers of their rights and benefits upon separation from 
the military. Yet, there are repeated reports from young men and women 
that the transition assistance was not available or they were given too 
much information at a time when their focus was on returning to their 
family.
    Question 2a. What are the Departments doing to jointly manage the 
information flow related to separation?
    Response. The Department of Veterans Affairs (VA) and the 
Department of Defense (DOD) teams collaborate to coordinate care to 
ensure that Servicemembers, Veterans, their families, and caregivers 
have comprehensive information regarding benefits and services 
available in VA, DOD and local communities. Together, the Departments 
ensure that Servicemembers and Veterans access the right care and 
services at the right time in the right place. The Departments 
recognize that a multi-faceted approach is necessary to ensure that 
information about benefits and services is delivered to all 
Servicemembers in a timely and understandable manner. Together, VA and 
DOD have implemented a comprehensive process and put complimentary 
resources in place that serve as a layered approach to transition.
    VA's participation in outreach activities increases access to VA 
healthcare and benefits. VA believes that information provided to 
Servicemembers, Veterans and their families at scheduled, regular 
intervals enhances and reinforces understanding of the content and 
promotes retention. Thus, VA, in partnership with DOD, reaches out to 
Veterans at multiple venues throughout the deployment cycle (from pre-
deployment, at demobilization, post-deployment, and separation from 
service). The goal is to help them recognize that it is in the best 
interest of their health to seek VA care soon after returning from 
combat, to ensure timely addressal of their combat-related conditions.
    The key to managing the flow of information related to military 
separation is the Transition Assistance Program (TAP). This program is 
a joint effort by the Departments to ensure all separating 
Servicemembers understand and have access to their earned benefits. 
Departments participate in quarterly TAP steering committee meetings. 
These meetings discuss program operations and plan enhancements. In 
late 2011, VA will implement a TAP online courseware curriculum and a 
survey tool to determine participation and assess the effectiveness of 
the information presented for continual process improvements.
    VA medical centers (VAMCs) support outreach efforts with DOD 
partners. Operation Enduring Freedom/Operation Iraqi Freedom/Operation 
New Dawn (OEF/OIF/OND) Care Management team members host outreach 
events including annual Welcome Home events, which are held in the 
community and serve as outreach to Veterans and family members. OEF/
OIF/OND Care Management team members also participate with DOD in 
demobilization, Yellow Ribbon Reintegration Program (YRRP), Post 
Deployment Health Reassessment events (PDHRA), and Individual Ready 
Reserve (IRR) musters.
    VA actively participates in DOD's mandated PDHRA, a health care 
screening for all National Guard and Reserve Servicemembers returning 
from deployment. The PDHRA is conducted between 90 and180 days post-
deployment, allowing for Servicemembers to have time with their 
families and then more readily engage in post-deployment care. The 
intent of the PDHRA is to identify deployment-related physical health, 
mental health and readjustment concerns, and to identify the need for 
follow-up evaluation and treatment.
    VA and DOD partner at demobilization sites to inform reserve 
component combat Veterans of their enhanced VA health care and dental 
benefits during mandatory demobilization separation briefings where 
they are introduced to VA. Servicemembers are enrolled in VA healthcare 
onsite and provided with contact information for their local OEF/OIF/
OND Program Managers, who coordinate initial health and dental 
appointments at the VAMC. Similarly, VA partners with the US Marine 
Corps and US Army Reserve to provide the same services to Soldiers and 
Marines during their mandatory IRR Muster.
    The YRRP is a DOD-wide effort, in which VA is a major participant, 
to support National Guard and Reserve Servicemembers and their families 
to increase awareness and utilization of VA benefits, programs, and 
services throughout the deployment cycle, i.e., before, during and 
after deployments. YRRP events are hosted by military units and held 
throughout the year in every state. VA staff provides support and 
information on benefits, services, and programs available to Guard and 
Reserve members; enroll Veterans in VA's health care system; and 
coordinate referrals to other VA services and/or programs. VA staff may 
also provide specialized briefings on issues such as PTSD and TBI. 
Additionally, VA has placed a dedicated, full-time liaison in the YRRP 
Office at the Pentagon.
    To support VA programs and services, VA maintains an internet 
webpage for OEF/OIF/OND Veterans. In addition to providing information 
about VA benefits and services, this site contains blogs and other 
social media tools to engage this new generation of Veterans. This site 
includes a section for family members as well as links to other Federal 
and military resources. The Website is www.oefoif.va.gov.
    National Guard Transition Assistance Advisors (TAAs) serve in the 
field at the state level. TAAs assist National Guard Servicemembers and 
their families in accessing VA benefits and services, VA medical 
centers, and VBA regional offices.
    Question 2b. How do E-Benefits and the Veterans Relationship 
Management program fit into a joint VA/DOD plan to keep all separating 
servicemembers informed?
    Response. The eBenefits portal is a collaborative effort between VA 
and DOD to provide Veterans, Servicemembers, and their families 
personalized access to benefit information, resources, and self-service 
capabilities.
    The eBenefits portal deployed a communication tool in 
December 2010. This tool enables VA and DOD to provide messages 
throughout an individual's military career and after separation. These 
messages provide Servicemembers with important benefit and health 
services information, state and local government information, 
employment, education, housing, or any other relevant demographic 
information as the separating Servicemembers transition back into their 
communities' and civilian employment.
    Veterans Relationship Management (VRM) is a broad multi-year 
initiative to improve Veterans' secure access to health care and 
benefits information and assistance. VRM will provide VA employees with 
up-to-date tools to better serve Veterans and their families, and will 
empower Veterans through enhanced self-service capabilities such as 
those found within the eBenefits portal.

    Question 3. In the Department's view, how will a single electronic 
health record strengthen the transition for servicemembers leaving 
active duty?
    Response. The integrated Electronic Health Record (iEHR) is a key 
strategic resource in improving the care of Servicemembers before, 
during and after the transition from active duty to Veteran status. The 
implementation of common medical terminology will greatly enhance the 
ability to exchange computable, interoperable patient-centered data. A 
single record for each Servicemember and Veteran will add new 
capabilities for clinicians at both the DOD and the VA to quickly find 
needed information, improve operational efficiency and reduce the need 
for redundant evaluations and testing. Jointly developed decision 
support resources and evaluation measures will help maintain a similar 
high standard of care and patient safety across both Departments while 
improving the ability to both benchmark and identify patterns and 
trends over time. A common record for each Servicemember and Veteran 
will provide a foundation for improved communication across Departments 
in the form of electronic referrals, consultation requests, orders 
portability, and provider-provider messaging enhancing the continuity 
and timeliness of patient care. Transition for Servicemembers includes 
not only medical care, but evaluation for disability and benefits, 
which will also be enhanced as both Departments adopt matching terms 
and a common language to describe the care received by our 
beneficiaries. Our future electronic health record will contain not 
only resources for providers and clinical teams, but provide rich 
access to information for both Servicemembers and Veterans. Patient-
facing resources in the form of web portals, personal health records, 
eHealth and mobile applications which will remain consistent and 
familiar across the continuum from active duty to Veteran status, will 
highly increase the engagement of the Servicemember and Veteran in his 
or her care, and as a result, improve the patient care experience and 
improve health.

    Question 4. Over the years, VA and DOD have increased 
servicemembers' opportunities to file a ``pre-discharge'' disability 
claim, yet the Departments estimate that less than half of all 
servicemembers currently have access to file a claim. With the use of 
contractors and the potential of filing an electronic claim, it is 
reasonable that 100 percent of servicemembers would be able to 
participate in this process.

    Question 4a. Do both Departments intend to provide 100 percent of 
transitioning servicemembers with the opportunity to file a ``pre-
discharge'' disability claim, and if so, what is the timeline for 
completion of this goal?
    Response. Currently, VA has programs that allow 100 percent of 
transitioning Servicemembers the opportunity to file a pre-discharge 
claim. In July 2008, VA expanded the Benefits Delivery at Discharge 
(BDD) program to accept claims from any Servicemember who is within 60 
to 180 days of separation or retirement from active duty and is able to 
report for a VA examination prior to discharge. VA also has the Quick 
Start program, which provides Servicemembers within 59 days of 
separation, or Servicemembers within 60-180 days of separation who are 
unable to complete all required examinations prior to leaving the point 
of separation, to be assisted in filing their disability claim. 
Servicemembers in the DOD Integrated Disability Evaluation System 
(IDES) complete VA Form 21-0819, the VA/DOD Joint Physical Disability 
Evaluation Board Claim, which initiates a claim for VA compensation. 
The Seriously Injured Program was implemented to solicit pre-discharge 
claims from Servicemembers who are seriously injured in OEF/OIF/OND and 
awaiting discharge for these disabilities. Therefore, 100 percent of 
transitioning Servicemembers have the opportunity to file pre-discharge 
disability claims.

    Question 4b. What obstacles stand in the way of providing 100 
percent of transitioning servicemembers with the opportunity to file a 
``pre-discharge'' disability claim?
    Response. As noted in response to question 4a, 100 percent of 
transitioning Servicemembers have the opportunity to file a pre-
discharge claim. However, some Servicemembers decide not to file a pre-
discharge claim. VA defers to DOD to address mission-essential 
obstacles which may make it difficult for Servicemembers to attend 
these program briefings.

    Question 5. VA recently briefed the Committee on a plan to provide 
servicemembers in the IDES process with early eligibility for the 
Vocational Rehabilitation and Employment (VR&E) program. As you know, a 
prerequisite for services under VR&E is a VA disability rating. 
However, many veterans in the IDES process do not receive their 
disability ratings prior to discharge. How does VA plan to enroll 
servicemembers for VR&E without a disability rating?
    Response. VR&E provides outreach and transition services to 
Servicemembers transitioning through the IDES. By physically placing 
VR&E counselors at IDES locations, benefits delivery timeliness will be 
improved. VR&E services range from a comprehensive rehabilitation 
evaluation that determines abilities, skills, and interests for 
employment purposes to support services that identify and maintain 
employment. The objective is to have every Servicemember attend a 
mandatory appointment with a Vocational Rehabilitation Counselor at the 
point of referral to a Physical Evaluation Board. These services can be 
provided through the use of Chapter 36 Educational and Vocational 
Counseling services, which can be provided to transitioning 
Servicemembers within six months of discharge from active duty, within 
one year following discharge from active duty, or at any time an 
individual is eligible for one of VA's educational benefit programs. 
Therefore, the complete evaluation, including the development of a 
proposed employment objective, can be completed under Chapter 36 
authority without the need for a rating. VR&E service delivery may 
commence with a memorandum rating (the rater establishes this based on 
service medical records that the final rating will be at least 20%) or 
an IDES proposed rating. VA and DOD are working to identify sites to 
test the concept prior to larger scale implementation in FY 2012. 
Memorandums of understanding have been drafted between VA and DOD to 
formalize this expansion initiative.

    Question 6. The Department's budget submission for FY 2012 includes 
among its performance measures that VA will screen patients at required 
intervals for PTSD, and that final data for FY 2011 indicate 97 percent 
performance for that measure. Another measure calls for a specified 
percentage of OEF/OIF Veterans with a primary diagnosis of PTSD to 
receive a minimum of 8 psychotherapy sessions within a 14-week period; 
but actual performance for FY 2010 was that only 11 percent of patients 
received that minimum amount, which is only about half the (20 percent) 
projection for that year made in the FY 2011 Budget Submission. (10P4: 
a-d)

    Question 6a. Why, relative to the high expectations for screening, 
is the bar for receiving that minimum number of psychotherapy sessions 
within 14 weeks set as low as it is?
    Response. The higher target established for Post Traumatic Stress 
Disorder (PTSD) screening than for the utilization of specific 
treatments reflects important and inherent differences between the 
targeted focus and goals for screening and for specific interventions. 
Screenings are typically universally applied to a specific group or 
subgroup to identify the possible presence of a condition or illness in 
as many people as possible. Further, because screening is not the same 
as a full assessment, screening commonly identifies individuals as 
being ``positive'' on the screener for a specified condition who, after 
a full psychodiagnostic evaluation, are determined not to have the 
condition. Thus, one would not expect the target established for 
screening to be equivalent to the target set for intensive treatment.
    In addition, the target established for psychotherapy is designed 
to reflect a full course of evidence-based psychotherapy (EBP); 
however, not all Veterans will initially engage in a full course of 
psychotherapy, sometimes for appropriate or understandable reasons. For 
example, some Veterans may not be psychologically ready to engage in a 
full course of exposure-based psychotherapy for PTSD and may start out 
with a briefer course of psychotherapy to build coping skills. Further, 
the target set for the psychotherapy performance measure reflects the 
fact that many Veterans with PTSD choose to receive psychotherapy or 
counseling services at Vet Centers. These Veterans may be included in 
the denominator of this measure, if a diagnosis was made at a VA 
facility or clinic, but they would not be included in the numerator, 
since VHA administrative databases do not usually include Vet Center 
service utilization data. The Vet Center program closely maintains 
confidentiality of services it provides, in order to promote a sense of 
comfort among Veterans seeking their services.
    Other Veterans may initially receive medication, particularly 
selective serotonin reuptake inhibitors (SSRIs) or selective 
norepinephrine reuptake inhibitors (SNRIs). SSRIs and SNRIs are 
evidence-based psychopharmacotherapies with a Grade A level of evidence 
in the VA/Department of Defense (DOD) Clinical Practice Guideline for 
PTSD. Data from a VA-sponsored research project examining the use of 
evidence-based medication practices for PTSD indicate that in Fiscal 
Year (FY) 2009, 59 percent of all patients with a PTSD diagnosis 
received a SSRI or SNRI. This is up from 50 percent of Veterans with a 
PTSD diagnosis in 1999. Veterans opting to receive only medication 
would typically be included in the denominator of this measure, but 
they would not be included in the numerator.
    Furthermore, some Veterans may choose not to participate in weekly 
psychotherapy due to difficulties with obtaining time off from work or 
due to transportation or related physical access challenges. VA is 
working to promote the delivery of evidence-based psychotherapies 
through telemental health modalities to try to further increase access 
to these services and help Veterans overcome such challenges. VA's 
efforts in this area are unique. VA is currently in the process of 
developing an EBP for PTSD Telemental Health Toolkit, to help program 
managers and front-line staff who implement these services.
    In summary, Veteran choice is critical to providing patient-
centered care and some Veterans may, at least initially, choose not to 
receive a sustained course of psychotherapy for PTSD or choose to 
receive services at Vet Centers. These factors appropriately are 
reflected in the target for the measure of minimum number of 
psychotherapy sessions. However, VA is committed to making these 
important services widely available to Veterans so that when they do 
wish to receive such services, they can do so. VA's efforts utilized to 
implement that commitment include:

     VA has established policy in VHA Handbook 1160.01, Uniform 
Mental Health Services in VA medical centers and Clinics, that requires 
that all Veterans have access to Cognitive Processing Therapy (CPT) or 
Prolonged Exposure Therapy (PE) for PTSD, as designed and shown to be 
effective;
     VA has developed national initiatives to disseminate and 
implement CPT and PE (Karlin et al., 2010). As part of this effort, VA 
has implemented national competency-based staff training programs in 
these therapies. To date, VA has provided training in these therapies 
to more than 3,400 VA mental health staff;
          - A national survey of VA facilities conducted in July 2010 
        evaluated the extent to which these therapies were being 
        provided by facilities. The survey found that all facilities 
        are providing CPT or PE, and 98 percent of facilities are 
        providing both of these therapies. Survey results further 
        indicate that the level of capacity to provide these therapies 
        varies throughout the system;
          - Training in CPT and PE in FY 2011 is using a targeted 
        approach placing important focus on sites that have fewer 
        trained staff; and
          - The availability of clinics with weekly 60-90 minute 
        sessions, as these therapies require, is also an important 
        requirement. VA is working to ensure such clinics are 
        consistently available throughout the system.

    VA also would like to increase the proportion of Veterans who 
receive a full course of evidence-based psychotherapy for PTSD; the 
above efforts are designed to take steps to do exactly that, and VA is 
exploring other ideas about how to encourage more Veterans to fully 
participate in this important approach to care. VA will be 
progressively increasing the target for this performance measure in 
each of the next three fiscal years, as VA continues its ongoing 
dissemination of and training in evidence-based psychotherapies for 
PTSD.

    Question 6b. Emphasizing provision of evidence-based psychotherapy 
for PTSD does not appear to have resulted in high percentages of 
Veterans completing these recommended courses of therapy. Are Veterans 
not entering these treatment programs, or are they discontinuing 
participation in such treatment programs? Please provide data to 
support this.
    Response. Current Procedural Terminology codes used for tracking 
health care services do not allow distinction of different types of 
psychotherapy, nor do they provide information about an individual's 
level of participation, such as the number of therapy sessions received 
as compared to the number recommended within a given therapy protocol. 
VA's Office of Mental Health Services has developed documentation 
templates for each of the evidence-based psychotherapies (EBP) and is 
disseminating these templates nationally. These templates will allow 
for precise tracking of EBP delivery and treatment completion, as well 
as facilitate documentation of session activity, promote fidelity to 
therapy protocols, and capture data elements to help track more 
detailed information about participation in EBP activities than is 
available through standard encounter form data. The templates have been 
piloted at several facilities and are scheduled for full system 
deployment in FY 2012.
    While awaiting development of these new informatics processes, VA 
has conducted surveys of the field to obtain information on the extent 
to which Operation Enduring Freedom/Operation Iraq Freedom/Operation 
New Dawn (OEF/OIF/OND) Veterans with PTSD have been offered and 
provided Cognitive Processing Therapy (CPT) or Prolonged Exposure 
Therapy (PE), as well as the extent to which these Veterans have 
completed a full course of one of these treatments. As reported above, 
responses to this survey indicated that all facilities are providing 
either CPT or PE, as required by VHA Handbook 1160.01, Uniform Mental 
Health Services in VA medical centers and Clinics, and all but two 
facilities reported providing both CPT and PE. Further, the survey 
results revealed that approximately between October 1, 2009 and May 31, 
2010, 30 percent of Veterans offered CPT or PE began treatment at that 
time. Of those Veterans that initiated treatment, 51 percent completed 
a full course of therapy. It is important to note that these survey 
data are approximations reported by facilities based on locally 
available data collected by facility staff, since centralized 
administrative data for tracking specific types of psychotherapy are 
not available. These data are comparable to data in published 
literature; one of the most extensive reviews of psychotherapy 
completion rates in the published literature, conducted in 1993, showed 
that the average completion rate for psychotherapy was 53 percent 
(average from a meta-analysis of 125 studies; Wierzbicki & Pekarik, 
1993). This meta-analysis of studies conducted outside VA provides a 
baseline against which to measure VA's success in sustaining Veterans 
in psychotherapy.
    Various factors, as noted above, contribute to Veterans not 
completing a course of psychotherapy, including the emotional 
challenges of full participation, as well as logistical issues such as 
transportation difficulties, employment-related issues, child care 
responsibilities, and other factors. Seal et al. (2010) reviewed the 
factors that contributed to failure of OEF/OIF/OND Veterans to engage 
in mental health treatment; these included: (1) having a new diagnosis 
of PTSD from a non-mental health clinic (VA primary care or VA 
specialty clinic other than mental health); and (2) living more than 50 
miles from a VA facility. As was noted earlier about 56 percent of 
mental health diagnoses originate in non-mental health clinics (Seal, 
et al., 2010). Veterans diagnosed with PTSD in these non-mental health 
clinics were less likely to meet the 8 sessions in 14 weeks measure, 
during the time of her study. Factors that Seal and colleagues found 
were associated with increased treatment engagement were: (1) having 
other comorbid diagnoses in addition to PTSD thus likely to be more 
distressed and more functionally impaired; (2) being 25 years of age or 
older, and (3) receiving care through a VA community-based outpatient 
clinic (CBOC). The reasons for the associations she reports between 
various factors and completion of treatment are unclear, although it is 
important to note that Dr. Seal collected data only up through 2008, 
and much of the major effort in dissemination of these therapies, 
integration of mental health staff into primary care clinics, and 
expansion of telemental health in CBOCs has occurred since 2008.
    We also have examined internal VA data to explore other issues 
related to completion of psychotherapy. For example, we examined 
patients with diagnoses of both PTSD and a substance use disorder 
(SUD), a common pattern of comorbidity, and found that those seen 
within specialty SUD treatment programs are about 2 times more likely 
to receive a full course of psychotherapy for PTSD than those seen only 
in general mental health. Additional data indicate that patients who 
did not manage to complete a full-course of psychotherapy in a first 
attempt often came back later and completed a full-course of treatment. 
In FY 2008, 40 percent of SUD and 48 percent of PTSD patients who 
attempted outpatient psychotherapy had at least two outpatient 
psychotherapy episode starts in a single year. Among those who 
completed at least 9 outpatient psychotherapy visits within 15 weeks, 
between 22 percent of SUD to 26 percent of PTSD patients failed to 
complete at least 9 sessions within a 15-week timeframe from the start 
of treatment in their first therapy attempt but were successful in 
their second or later attempt. This suggests that even though life 
circumstances or difficulties handling symptomatology or treatment may 
abort initial treatment attempts, patients do come back. Thus, 
performance measures that look for treatment completion over a year 
will not reflect the true level of care that patients may be receiving, 
due to the actual pattern of treatment initiation, which suggests that 
Veterans should be followed not only on their first participation in 
psychotherapy, but over time as they become better able to sustain 
participation. Accordingly, VA is working to adjust it's performance 
measure to account for and capture psychotherapy utilization that may 
occur across multiple fiscal years.

    Question 6c. What factor or factors account for the dramatic 
shortfall from the 20 percent projection for FY 2010 to an actual 
performance for that fiscal year of only 11 percent? Specifically, what 
role does access to care--in terms of difficulty in getting timely 
appointments, transportation challenges, lack of evening hours for 
those who work, and other such factors--play in the high number of 
Veterans who discontinue treatment?
    Response. We would like to clarify that the 20 percent figure was 
not a ``projection for FY 2010.'' Rather, the 20 percent projection was 
set as an aspirational target for OEF/OIF/OND Veterans, since VA is 
still in the process of its unprecedented efforts to nationally 
disseminate and implement evidence-based psychotherapies for PTSD, but 
was designated without a true baseline on which to gauge an appropriate 
target or to make a ``projection'' of expected utilization. The 11 
percent figure referenced in the question refers to the subset of OEF/
OIF/OND Veterans with a primary diagnosis of PTSD who had at least one 
visit in a mental health clinic (the measure denominator). The typical 
standard for mental health performance measures is to include a two-
visit requirement, such that the measure would include only OEF/OIF/OND 
Veterans with a primary diagnosis of PTSD who had at least two visits 
in a mental health clinic as the measure denominator. The two-visit 
criterion is a better measure of those who are appropriate for and 
willing to be treated in a mental health clinic. Actual national 
performance on the measure in FY 2010 using this criterion was 14 
percent, with the facility range 2.4 percent to 38 percent. Notably, 55 
facilities exceeded the national average, and many exceeded the 
aspirational projection. As noted in the answer to Question 6a, this 
does not include Veterans who may have received one of the EBPs at a 
Vet Center, whose staff also have been trained to provide evidence-
based therapy EBP for PTSD.
    With respect to your specific query about possible barriers to 
access to care, barriers to receiving a full course of EBP for PTSD 
include transportation and physical access difficulties for some 
Veterans, difficulty obtaining time off for work, and other life 
demands. Anecdotally, clinicians indicate that given recent gas prices, 
Veterans report that the cost of travel can be prohibitive for many 
Veterans, especially when weekly attendance to treatment is required. 
OEF/OIF/OND Veterans who do not yet have service connection do not 
qualify for travel pay.
    Other barriers remain, though we cannot put statistical values to 
their role. Stigma of receiving mental health care is still a factor. 
Related to stigma, many Veterans may prefer taking medications versus 
receiving psychotherapy, believing that it implies less ``fault'' and 
that PTSD is due to factors outside their control without chemical 
correction. As noted before, committing to an individual therapy that 
asks for intense emotional participation can be difficult.
    In addition, clinic scheduling procedures have been barriers to 
fully implementing EBPs at some sites. Specifically, it is essential 
that appointment scheduling systems allow for the scheduling of 60-, 
90-, or 120-minute sessions as EBPs require. Older scheduling systems 
based on case management, medication management, or other service 
models have often not been set up to support appointment lengths of 
this type. Many facilities have successfully addressed this, for 
example, by developing clinic profiles with a default time increment of 
30 minutes, which allows the clinician to specify to the scheduler 
whether a 30-, 60-, 90-, or 120-minute session is required. In 
addition, scheduling practices must be appropriately flexible to enable 
clinicians to deliver full courses of EBP, which typically require that 
the same clinician be available on a weekly basis through the length of 
the therapy protocol. A scheduling strategy that has often been 
successful for addressing this is to schedule the entire course of 
weekly EBP sessions prior to the initiation of treatment (using a 
specific function of the scheduling software). This ensures the 
therapist does not have their schedule otherwise fully booked with 
other appointments, which would prevent the therapist from implementing 
an EBP protocol. VHA will continue to closely monitor the performance 
of its sites on this issue and has developed detailed guidance that 
will be sent to all VISNs related to scheduling and other local 
requirements and strategies for fully implementing EBPs . We will 
continue to try to address all possible barriers and to increase the 
availability of and acceptability of these therapies to Veterans. 
Additional details on these efforts are provided in response to 
Question 6d.

    Question 6d. What specific actions has VA taken by way of a 
national strategy to materially increase the number of Veterans both 
enrolling in and staying in recommended psychotherapy programs?
    Response. Increasing utilization of these therapies is a very high 
priority for VA. VHA has taken a number of actions to try to increase 
the number of Veterans enrolling in and remaining in recommended 
psychotherapy programs:

     VA expanded core mental health staff by over 6,600 full-
time equivalent staff between the end of FY 2007 and May 31, 2011, to 
increase availability of staff and decrease difficulty getting timely 
appointments. VA's tracking of outpatient appointments for new and 
established patients demonstrates that standards for accessible care--
within 14 days of referral for patients new to mental health or within 
14 days of desired next appointment for established patients--are met 
95 percent of the time;
     VA requires that all medical centers have extended hours 
for mental health services;
     VA has developed a national evidence-based psychotherapy 
(EBP) staff and public awareness campaign. As part of this campaign, 
the Office of Mental Health Services has developed EBP brochures, fact 
sheets, and posters designed to provide education on and promote 
awareness of evidence-based psychotherapies among staff and Veterans at 
VA facilities and community agencies. This is designed to promote 
requests for evidence-based psychotherapy and asking of questions of 
patients to their providers (e.g., primary care providers) and other 
staff that ultimately will promote engagement in treatment;
     VA has appointed a local EBP Coordinator at each VA 
medical center to serve as a champion for EBPs at the local level and 
provide longer-term consultation and clinical infrastructure support to 
allow for the full implementation and ongoing sustainability of 
evidence-based psychotherapies at each VA site. These Coordinators also 
share success stories of Veterans who have successfully participated in 
EBP to promote interest and engagement among other Veterans.
     VA has developed and just launched a national initiative 
to disseminate and implement Motivational Interviewing (MI) to promote 
initial and ongoing engagement in treatment. MI is a collaborative, 
person-centered form of guiding that is used to elicit and strengthen 
motivation for change. MI has strong empirical support for facilitating 
treatment and promoting initial and ongoing behavioral change (see 
Hettema, Steele, & Miller, 2005 for a review). MI can be incorporated 
into evidence-based psychotherapy and has particular utility and value 
for promoting ongoing engagement in this context. As part of VA's MI 
dissemination initiative, the Office of Mental Health Services has 
developed a national, competency-based MI training program, which began 
training in July 2011.
     VA, in coordination with the Department of Defense, has 
developed a mobile phone PTSD application, called ``PTSD Coach.'' This 
app is designed to promote skills for managing PTSD and can serve as a 
complementary tool to evidence-based psychotherapy for PTSD. It is also 
designed to promote interest and engagement in evidence-based 
psychotherapy. This app, which was just recently launched, has already 
been downloaded over 14,000 times and is available in both iPhone and 
Android formats.
     VA is working to promote initial and ongoing engagement in 
evidence-based psychotherapy for PTSD by promoting the implementation 
of these therapies through telemental health modalities. EBP for PTSD 
telemental health services offer an opportunity to overcome physical 
and related access barriers (e.g., physical distance, transportation 
costs and difficulties, job responsibilities) to initial and ongoing 
participation in EBP.
          - As part of this effort, VA formed a Task Force that has 
        issued recommendations for a national strategy to promote the 
        implementation of evidence-based psychotherapy for PTSD 
        telemental health services, which are already provided at some 
        facilities and have been shown to be effective with Veterans 
        (Tuerk et al., 2010).
          - VA is currently in the process of developing an EBP for 
        PTSD Telemental Health Toolkit to help program managers and 
        front-line staff implement these services.
          - An all-day workshop on the delivery of CPT and PE via 
        telemental health will be conducted at VA's national mental 
        health conference in August 2011.
          - Finally, as noted before, VHA will send a letter shortly to 
        direct having appointment scheduling options that match the 
        requirements of the evidence-based psychotherapies. In 
        addition, plans for site visits of mental health programs in 
        the field will include review of the scheduling practices.

References

Hettema, J., Steele, J., & Miller, W.R. (2005). Motivational 
            interviewing. Annual Review of Clinical Psychology, 1, 91-
            111.
Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting, D.I., & 
            Koffman, R.L. (2004). Combat duty in Iraq and Afghanistan, 
            mental health problems, and barriers to care. New England 
            Journal of Medicine, 351, 13--22.
Karlin, B. E., Ruzek, J. I., Chard, K. M., Eftekhari, A., Monson, C. 
            M., Hembree, E. A., Resick, P. A., & Foa, E. B. (2010). 
            Dissemination of evidence-based psychological treatments 
            for Post Traumatic Stress Disorder in the Veterans Health 
            Administration. Journal of Traumatic Stress, 23, 663-73.
Seal, K.H., Maguen, S., Cohen, B., Gima, K.S., Metzler, T.J., Ren, L., 
            Bertenthal, D., & Marmar, C.R. (2010). VA mental health 
            services utilization in Iraq and Afghanistan veterans in 
            the first year of receiving new mental health diagnoses. 
            Journal of Traumatic Stress, 23, 5-16.
Tuerk, P., Yoder, M., Ruggiero, K. J., Gros, D. F., & Acierno, R. 
            (2010). A pilot study of prolonged exposure therapy for 
            Post Traumatic Stress Disorder delivered via telehealth 
            technology. Journal of Traumatic Stress, 23, 116-123.
Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy 
            dropout. Professional Psychology: Research and Practice, 
            24, 190-195.

    Question 7. Data indicate (a) that only about half of returning 
OEF/OIF Veterans have been seen in VA health care facilities, (b) that 
high percentages of those who have not sought VA care are at risk of 
war-related mental health conditions, and (c) that--of those whom VA 
has diagnosed as having PTSD--large numbers have dropped out of 
treatment. Please comment on those observations and the potential 
conclusion that VA's effectiveness in actually reaching and 
successfully treating the very large number of OEF/OIF Veterans with 
PTSD (as measured by the Department's own performance indicator) is 
very limited.
    Response. (a & b) As of the end of the first quarter of FY 2011, 
approximately 51 percent of all separated OEF/OIF/OND Veterans had 
obtained VA health care since 2002. This rate of treatment engagement 
is higher than that reported in the National Vietnam Veterans 
Readjustment Study (Kulka, et al., 1988), which was conducted in 1986-
87. Specifically, Kulka and colleagues found that only 30 percent of 
Vietnam Veterans reported ever using VA mental health services; for 
physical health problems, 26 percent and 12 percent reported ever using 
VA outpatient and inpatient care, respectively.
    Epidemiological research suggests that approximately 15 percent of 
OEF/OIF/OND Servicemembers and Veterans have current PTSD. VA 
administrative data show that, of those OEF/OIF/OND Veterans who have 
utilized VHA healthcare, over 50 percent of those individuals have a 
provisional diagnosis of a mental disorder with just over half of those 
being provisionally diagnosed with PTSD (Healthcare Utilization data as 
of First Quarter FY 2011, VA Environmental Epidemiology Service). It is 
important to recognize that the OEF/OIF/OND Veterans utilizing VA 
health care very likely are not a representative sample of the entire 
returning Veteran population, and thus VA may well be reaching most of 
those OEF/OIF/OND Veterans with significant mental health problems--
i.e., those who need mental health care are seeking VA services 
disproportionately. It is also important to note that those OEF/OIF/OND 
Veterans who do not seek care from VA may be seeking care for mental 
health outside VA (i.e., preferring local community or State 
resources). In order to enhance mental health care for returning 
Veterans both within and outside VA, VA has actively collaborated with 
DOD and other State and community partners through such activities as 
the Federal Partners Senior Workgroup on Returning Veterans and their 
Families, the VA/DOD Integrated Mental Health Strategy, and the 
Substance Abuse and Mental Health Services Administration (SAMHSA) 
Policy Academy programs of the Department of Health and Human Services 
in 2008 and 2010 that served to enhance coordinated care for returning 
Veterans and their families in 16 States and two U.S. Territories.
    From VHA administrative data, a potential conclusion can be drawn 
that VA may be very effective in actually reaching and successfully 
treating the very large number of OEF/OIF/OND Veterans with PTSD. Of 
those Veterans treated in FY 2010 for PTSD, 83,864 (20.5 percent) were 
OEF/ OIF/OND Veterans. VA continues to improve rates of treatment for 
OEF/OIF/OND Veterans; VA data indicate that the number of OEF/OIF/OND 
Veterans engaging in PTSD treatment has increased annually. 
Specifically, between FY 2007 and FY 2010, the number of Veterans 
treated for PTSD has increased by an average of 17,000 additional 
Veterans per year. Data from the Office of Environmental Epidemiology 
indicate that for OEF/OIF Veterans who had a primary diagnosis of PTSD 
in the years between 2007 and 2010, 70 percent had three or more 
clinical encounters for PTSD each year. This suggests that the majority 
of OEF/OIF Veterans are engaged in treatment.
    Response. (c) As noted in the response to question 6 above, 
dropping out of a specific treatment is not a clear indication that the 
Veteran will leave the treatment process. Some Veterans may not be 
psychologically ready to engage in a full course of exposure-based 
psychotherapy for PTSD and may start out with a briefer course of 
psychotherapy to build coping skills. As noted in that response, data 
indicate that patients who did not manage to complete a full-course of 
psychotherapy in a first attempt often came back later and completed a 
full-course of treatment. In FY 2008, 40 percent of SUD and 48 percent 
of PTSD patients who attempted outpatient psychotherapy had at least 
two outpatient psychotherapy episode starts in a single year. Among 
those who completed at least 9 outpatient psychotherapy visits within 
15 weeks, between 22 percent (SUD) to 26 percent (PTSD) patients failed 
to complete at least 9 sessions within a 15-week timeframe from the 
start of treatment in their first therapy attempt but were successful 
in their second or later attempt. This suggests that even though life 
circumstances or difficulties handling symptomatology or treatment may 
abort initial treatment attempts, patients do come back. Thus, 
performance measures that look for treatment completion over a year 
will not reflect the true level of care that patients may be receiving, 
due to some Veterans having multiple episodes of psychotherapy 
initiated before a single course of treatment is actually completed.
    Dropping out of mental health treatment is a problem throughout all 
health care. In the response to 6b above, we note that comparable data 
in the research literature show that the average completion rate for 
psychotherapy is 53 percent (average from a meta-analysis of 125 
studies; Wierzbicki & Pekarik, 1993). VA is addressing this reality and 
will continue to seek and implement strategies to increase our ability 
to deliver the best possible treatments to Veterans. We are confident 
those efforts are crucial, because of the very positive outcomes being 
obtained for those who do complete therapy. Data indicate successful 
outcomes for the majority of the many OEF/OIF/OND Veterans who complete 
evidence-based treatment for PTSD experience significant symptom 
reduction. Clinical outcome data from VA's Prolonged Exposure Therapy 
(PE) therapy and Cognitive Processing Therapy (CPT) staff training 
programs are summarized below.

    1. PE Results: Veterans who completed PE decreased from an average 
pre-treatment PTSD Checklist (PCL) score of 62.1 to an average post-
treatment PCL score of 42.1. This reduction is statistically 
significant and indicates a 32 percent drop in self-reported PTSD 
symptoms. At pre-treatment, 14 percent of Veterans in PE had a PCL 
score below 50, the clinical cutoff for PTSD. At post-treatment, 67 
percent of the Veterans fell below the PCL clinical cutoff for PTSD. 
Improvement as a result of treatment was similar across Veteran 
cohorts. The average pre-treatment Beck Depression Inventory-2 (BDI-2) 
score was 28.0, and the average post-treatment BDI-2 was 17.3. This 
reduction is statistically significant and indicates a 38 percent drop 
in self-reported symptoms of depression.
    2. CPT Results: Veterans who completed CPT decreased from an 
average pre-treatment PCL score of 63.8 to an average post-treatment 
PCL of 45.5. This reduction is statistically significant and indicates 
a 29 percent drop in self-reported PTSD symptoms. At pre-treatment, 9.9 
percent of Veterans in CPT had a PCL score below the PTSD cutoff of 50. 
At post-treatment, 59.0 percent of the Veterans fell below the PCL 
clinical cutoff. Treatment gains were similar across Veteran cohorts. 
The average pre-treatment BDI-2 score was 30.4, and the average post-
treatment BDI-2 was 19.2. This reduction is statistically significant 
and indicates a 37 percent drop in self-reported symptoms of 
depression.

    Question 8. What steps--other than those cited in the Department's 
testimony, and other than programs that have long been in place--has 
the Department taken (a) to reach the approximately half million OEF/
OIF Veterans who have not been seen at VHA facilities, (b) to identify 
methodically the factors that lead OEF/OIF Veterans to discontinue 
treatment for PTSD, and (c) to improve very substantially the rate of 
sustained retention in treatment of OEF/OIF Veterans with PTSD?
    Response. VA has many additional longstanding programs as well as 
new programs that are designed to reach OEF/OIF/OND Veterans who have 
not been seen at VHA facilities. The following list of mental health 
specific outreach efforts is extensive, but not fully exhaustive of all 
efforts. Many local VA facilities provide outreach to returning 
Veterans; not all of these efforts are tracked by VA Central Office.

    Question 8a. Outreach to Veterans not seen at VHA facilities:

     The Services for Returning Veterans-Mental Health (SeRV-
MH) teams have been established across the VA system since 2005. These 
programs focus on outreach, early identification and management of 
stress-related disorders and may decrease the long term disease burden 
on returning troops. Since FY 2005, 93 SeRV-MH teams have been 
established across the VA system. They work in close collaboration with 
the OEF/OIF/OND post-deployment primary care teams.
     VA continues to actively participate in activities and 
presentations related to Post Deployment Health Reassessment (PDHRA) 
and Yellow Ribbon Reintegration Program (YRRP) events, which continue 
to enroll and refer Veterans to VA health care.
     VA has been actively collaborating with DOD and other 
State and community partners through such activities as the Federal 
Partners Senior Workgroup on Returning Veterans and their Families, the 
VA/DOD Integrated Mental Health Strategy, and the SAMHSA Policy Academy 
programs, which help promote mental health services for those Veterans 
who prefer to seek their care outside of the VHA system of care.
     New web-based mechanisms designed to reach OEF/OIF/OND 
Veterans include an enhanced VA presence on social media sites such as 
Facebook and Twitter. In April 2011, VA launched the first in a suite 
of VA/DOD mobile apps--the PTSD Coach. This app can be downloaded free 
from iTunes and was downloaded over 6,000 times in 28 countries within 
hours of its release. As of July 11, 2011 the app had been downloaded 
over 16,000 times in 43 countries. The app is free and available in 
Android and iPhone formats.
     The Readjustment Counseling Service Call Center is a 
relatively new effort that is increasingly being utilized by Veterans. 
Additionally the rebranding of VA Crisis Line, formally the VA Suicide 
Hotline, has had a subsequent upsurge of calls.
     VA has a new initiative to place VA staff in colleges and 
universities where Veterans are attending with funding from the GI 
Bill. These efforts are being developed in collaboration with student 
Veteran organizations, such as Student Veterans of America. This 
initiative is currently being implemented at sites in five VISNs. These 
are VISN 1: Bedford VA Medical Center (VAMC) , VISN 7: Tuscaloosa VAMC, 
VISN 11: Ann Arbor Healthcare system, VISN 17: Central Texas Veterans 
Healthcare System: Austin Clinic, and VISN 21: San Francisco VAMC. 
Eventual implementation in all VISNs is planned, but broad 
implementation will be designed based on results of the pilot project.
     Another strategy for increasing the number of Veterans who 
are accessing VA care will launch in the fall of 2011. This is a 
national mental health anti-stigma campaign to reduce stigma associated 
with mental illness and promote acceptance of and Veteran comfort with 
accessing mental health care. This also will remind Veterans that VA 
care is quickly available for them.

    Question 8b. Efforts to identify factors that lead OEF/OIF/OND 
Veterans to discontinue treatment for PTSD:

     While VHA does not have comprehensive, national data on 
specific factors that lead OEF/OIF/OND Veterans to discontinue 
treatment for PTSD, VA has utilized structured surveys of subsets of 
Veterans to obtain such information (e.g., the New York State RAND 
Study, 2011). These surveys suggest that barriers to continuing 
treatment include time away from work or school, distance from home to 
treatment sites, concerns about stigma should employers learn about the 
Veteran being in treatment, and concerns about efficacy of treatment.
     Numerous initiatives currently exist to address these 
potential barriers. In addition to programs and initiatives mentioned 
in the replies to questions addressed within this set of questions and 
replies, the VA Uniform Mental Health Services Handbook is designed to 
reduce potential distance barriers as well as the time away from work 
or school by requiring PTSD care to be available at CBOCs (either on 
site or via telemental health) and by requiring that all VAMCs provide 
some evening or weekend hours.

          - For PTSD care available at medium to very large size CBOCs, 
        national compliance rates are between 96.08 percent and 97.67 
        percent.
          - For provision of evening and weekend hours, national 
        compliance rates are at 97.1 percent.
  Question 8c. Efforts to improve participation in evidence-based care:
     VA has developed a national evidence-based psychotherapy 
staff and public awareness campaign. As part of this campaign, the 
Office of Mental Health Services has developed evidence-based 
psychotherapy (EBP) brochures, fact sheets, and posters designed to 
provide education on and promote awareness of evidence-based 
psychotherapies among staff and Veterans at VA facilities and community 
agencies. This is designed to promote requests for evidence-based 
psychotherapy and asking of questions of patients to their providers 
(e.g., primary care providers) and other staff that ultimately will 
promote engagement in treatment.

          - VA has appointed a local EBP Coordinator at each VA medical 
        center to serve as a champion for evidence-based 
        psychotherapies at the local level who provide education to 
        Veterans and staff in evidence-based psychotherapies and share 
        success stories of Veterans who have successfully participated 
        in evidence-based psychotherapy to promote interest and 
        engagement among other Veterans.
          - VA has incorporated Veteran testimonials on VA social media 
        sites and videos about efficacy of treatment.

     As stressed in the reply to Question 6, VA is working to 
promote engagement in evidence-based psychotherapy for PTSD through 
telemental health modalities which remove several barriers to 
treatment. As part of this effort, VA has formed a Task Force that has 
issued recommendations for a national strategy to promote the 
implementation of evidence-based psychotherapy for PTSD telemental 
health services, which are already provided at some facilities and have 
been shown to be effective with Veterans (Tuerk, Yoder, Ruggiero, Gros, 
& Acierno, 2010). VA is currently in the process of developing an EBP 
for PTSD Telemental Health Toolkit to help program managers and front-
line staffs implement these services. An all-day workshop on the 
delivery of CPT and PE via telemental health will be conducted at VA's 
national mental health conference in August 2011. Again, as mentioned 
above, VA has also launched a national initiative to disseminate and 
implement competency-based Motivational Interviewing (MI), a promising 
treatment approach with strong evidence to suggest it enhances 
Veterans' engagement in initial and ongoing psychotherapy.
     VA has requirements for close follow-up on missed 
appointments, which is designed to ensure the safety of Veterans who do 
not show for planned appointments, address problems or dissatisfactions 
with care, and maintain clinical continuity and engagement. At least 
three separate attempts must be made to reach Veterans who miss 
appointments, and each attempt is required to be documented in the 
patient's medical record.

    Question 9. VHA Handbook 1160.03 (relating to VA PTSD services) 
issued in March 12, 2010 states, ``All new patients requesting or 
referred for mental health services must have an initial assessment 
within 24 hours and their first full evaluation appointment within 14 
days. Established patients require follow-up appointments within 30 
days.'' How often in the most recent fiscal year did VA meet these 
timeliness standards? Where it did not, in what percentage of instances 
were Veterans afforded needed evaluation or treatment through fee-basis 
or other contract mechanisms?
    Response. VHA administrative data from May, 2011 indicates that 95 
percent of new mental health patients are seen for a full mental health 
evaluation appointment within 14 days. VHA administrative data as of 
May, 2011 also indicates that 96 percent of established mental health 
patients are seen for a follow-up mental health appointment within 30 
days of the desired date. The metric pertaining to whether or not a new 
mental health patient is seen for an initial assessment within 24 hours 
is not a metric that is readily available in current VHA administrative 
databases.
    VHA currently is meeting its performance standards for new patient 
access (as evidenced by VHA administrative data). VA does not have data 
regarding whether fee-basis or other contract mechanisms were used in 
the 4 percent to 5 percent of cases where the access timeliness 
standards were not met. It should be noted that this 4-5 percent 
bracket includes patients who failed to show up for scheduled 
appointments or who asked to be scheduled for a time later than the VHA 
timeliness standard.
    While language regarding fee-basis or other contract mechanisms is 
not specifically mentioned in VHA Handbook 1160.03, VHA Handbook 
1160.01 (VA Uniform Mental Health Services Handbook) includes required 
PTSD services, and that Handbook is the primary document guiding VA 
mental health services. It specifies the services that must be 
``available,'' i.e., those that must be made accessible when clinically 
needed to patients receiving health care from VHA. They may be provided 
by appropriate facility staff, by telemental health, by referral to 
other VA facilities, or by sharing agreements, contracts, or non-VA fee 
basis care to the extent that the Veteran is eligible. Further data are 
not immediately available on the proportion of patients who receive 
care through fee basis or contract means, since such decisions are made 
at the local level. More specific data is currently being gathered by 
the VHA business office as pertains to the use of fee basis/contracts 
for outpatient mental health and PTSD care.

    Question 10. VA is still in the process of implementing the VHA 
Handbook on Uniform Mental Health Services, issued in 2007, which 
defines the mental health services that should be available to all 
enrolled Veterans. That Handbook directs that where VA facilities are 
unable to provide needed services directly they are to provide them 
through fee-basis or other contractual arrangements. This is a very 
basic element of ensuring access to care.
    What is the status of implementation of the directive that care be 
provided under fee or contract arrangements when VA cannot provide it 
directly (whether as a matter of geographic inaccessibility, lack of VA 
specialists, etc.)?
    Response. To date, the rate of implementation of the VHA Uniform 
Mental Health Services Handbook across networks is 91.68 percent. While 
current handbook implementation data exist, data only indicate whether 
or not a facility provides a service; Handbook implementation survey 
data do not indicate how that service was provided (i.e. on site, 
telemental health, or fee basis and contract). Of note, implementation 
rates of the Uniform Services Handbook have increased steadily over 
time, with national implementation rates increasing 5.8 percent between 
August 2009 and June 2010. While there are some networks that are below 
other networks in terms of implementation rates, the Office of Mental 
Health Services, the Office of Mental Health Operations, and the 
Improve Veterans Mental Health Initiative, a major effort by the 
Department to ensure that all Veterans have access to a full continuum 
of recovery-oriented, evidence-based, integrated mental health 
services, provide technical assistance to assure that all networks 
achieve at least 95 percent implementation by second quarter, FY 2012.
    VHA Handbook 1160.01 (VA Uniform Mental Health Services Handbook) 
specifies the services that must be ``available'' are those that must 
be made accessible when clinically needed to patients receiving health 
care from VHA. They may be provided by appropriate facility staff, by 
telemental health, by referral to other VA facilities, or by sharing 
agreements, contracts, or non-VA fee basis care to the extent that the 
Veteran is eligible.'' Processes for authorizing fee basis and contract 
care are fully in place and used frequently by VA facilities and their 
CBOCs and data regarding use of fee basis or contract agreements for 
mental health care are tracked by VA's business office. As pertains to 
all mental health care, in FY 2010, the VA disbursed $176,433,666.42 in 
fee basis or contract services for mental health and served a total of 
68,911 unique Veterans. As pertains to PTSD-specific care, in FY 2010 
VHA nationally disbursed $10,774,144.00 for fee or contract services 
and served 8,975 unique Veterans.

    Question 11. Please provide data by VISN to document the extent to 
which VA has provided ambulatory mental health treatment for Veterans 
with service-connected PTSD or other mental health conditions in the 
most recent year for which such data is available.
    Response. The following table provides the requested data. Some 
data definitions:

    a. The unique Veterans in column B are Veterans who are alive, have 
an active service-connected (SC) disability claim for a mental health 
condition, and have a home zip code in the VISN in question. Note that 
5,412 either have no zip code (e.g., live out of country) or have a zip 
code that did not match with the current zip code in data from the 
Planning Systems Support Group (PSSG), a field unit of the VA Office of 
Policy and Planning.
    b. The Veterans in column C are those from B who received any 
mental health outpatient care in FY 2010, defined according to current 
business rules established by the VHA Mental Health (MH) Program 
Evaluation Center that produces these data.
    c. The Veterans Integrated Service Networks (VISN) numbers are 
unduplicated, in that a Veteran can only reside in one VISN (column B). 
Care did not have to occur in the VISN where they live. Therefore, 
column C will have duplicates across VISNs, when Veterans get care in a 
different VISN than their residence, or in more than one VISN. This 
happens frequently for some Veterans, e.g., those who may have 
different summer and winter residences.


------------------------------------------------------------------------
          A                  B                C                 D
------------------------------------------------------------------------
                                       Unique Veterans   Percent Unique
                          Unique        from column B     Veterans who
                       Veterans  SC    who receive any   receive any VA
        VISN            for MH who      VA ambulatory      ambulatory
                        live in the     mental health     mental health
                           VISN        services in FY    services in FY
                                            2010              2010
------------------------------------------------------------------------
1...................          37,014            20,968            56.65%
2...................          16,459            10,863            66.00%
3...................          26,443            15,631            59.11%
4...................          34,744            21,203            61.03%
5...................          18,818             9,723            51.67%
6...................          54,422            29,746            54.66%
7...................          57,873            35,222            60.86%
8...................          59,087            37,579            63.60%
9...................          39,140            24,582            62.81%
10..................          21,929            14,160            64.57%
11..................          29,164            16,534            56.69%
12..................          25,632            16,131            62.93%
15..................          27,029            17,276            63.92%
16..................          76,093            41,952            55.13%
17..................          46,761            26,212            56.06%
18..................          36,367            21,702            59.67%
19..................          30,040            16,666            55.48%
20..................          46,936            22,848            48.68%
21..................          35,852            21,672            60.45%
22..................          40,969            22,505            54.93%
23..................          34,642            20,302            58.61%
                     ---------------------------------------------------
Nationally..........         800,826           451,158            56.34%
------------------------------------------------------------------------


    Question 12. At the Richmond, Virginia VA Medical Center, officials 
earlier this year terminated on-site clinician-led PTSD support groups 
and encouraged participants instead to join yet-to-be-established peer-
led community-based groups. (We understand that in response to 
advocates' concerns, you advised that similar actions had taken place 
at other VAMCs around the country.) We understand that the changes at 
Richmond, in particular, have been traumatic for many of those who had 
participated in the group sessions, and in one documented instance, 
attendance at the new community-based, peer-led groups dropped from 40 
to an average of 2-7 individuals per session. In this regard:

    Response to the general issues in Question 12:

    We will respond to each of the sub items below, but it is important 
to begin by clarifying the actual situation at Richmond, and 
nationally, as VA understands it. We also would be very interested in 
arranging briefings with the SVAC staff to review the situation and to 
discuss any concerns you have. The following overall points are 
essential to understand VA's rationale for supporting changes along the 
lines of those made at Richmond and as context for the following 
specific answers:

     Groups like the one that was previously held at Richmond 
are a vestige of PTSD care offered when there was little knowledge 
about appropriate treatment of PTSD. They were created as a well-
meaning option at a time when staff had no empirical literature on 
which to base effective treatments. They have not proved to be 
effective and are not recommended in the VA/DOD PTSD Clinical Practice 
Guidelines (CPGs), by the Institute of Medicine in their review of 
treatment for PTSD, by VHA's Handbook 1160.01--Uniform Mental Health 
Services in VA medical centers and Clinics, or by any other scholarly 
or professional group to our knowledge. VA's National Center for PTSD 
has never promoted the continuation of such programs and has instead 
emphasized psychosocial and psychopharmacological approaches with known 
efficacy.
     Consequently, VA has encouraged facilities to transform 
care from this long-standing but ineffective model to models that have 
been shown to have positive impact and which are presented in the VA 
Uniform Mental Health Services Handbook. VA agrees that the process of 
transition at any facility from older, ineffective, but familiar models 
of care to newer models with greater potential, but which are 
unfamiliar, can be a difficult one. VA's national, system-wide PTSD 
Mentoring Program, led by the National Center for PTSD, has provided 
guidance on such transitions, and that mentoring program now includes a 
PTSD Consultation Service, that can help guide sites in orchestrating 
such change. In the process, the Consultation Center also can guide 
facilities in how best to assure Veterans that their needs will 
continue to be met, with care that can optimally treat their PTSD and 
support the psychosocial challenges they face.
     There have been several presentations to the PTSD Mentors 
as well as PTSD Clinic Managers nationally on the successful 
implementation of the transition from clinician-led, supportive therapy 
groups to those led by peers. These presentations have emphasized best 
practices in making this transition. This is an ongoing topic for 
discussion: presentations have been made on PTSD Mentor conference 
calls and also at the PTSD Mentor Meeting at the July 2010 Mental 
Health Conference. This issue also will be addressed at the 
September 2011 PTSD Mentor Conference, in a presentation titled, 
``Identifying need for transition to peer-led groups, best practices 
for implementing the transition and clinical outcomes of the 
transition.''
     The question suggests that the decrease in attendance for 
this group from 40 (and we have heard higher numbers in other contexts) 
to 2-7 individuals is a negative result. In fact, a group of 40 or more 
absolutely cannot be considered ``psychotherapy'' and there is no 
evidence anywhere that such a group can improve psychological 
functioning. Such groups can be useful for education, and that was the 
original function of the Richmond group. Local clinical decisions about 
transition were based on the facts that the stable larger membership of 
the group had received a full scope of psychoeducational training about 
PTSD and therefore it was appropriate to transition attendees to 
individual therapies or other therapy options. In addition, because 
members expressed positive value in the social connections within the 
group, Richmond offered to support a transition to a peer-led ongoing 
support (not therapy) group that would take place in a suitable venue 
off VA grounds. That process is ongoing in phases, with the group 
currently still led by a VA mental health professional, not a peer, but 
with the group now meeting off VA grounds, at a nearby American Legion 
post building. Richmond will continue to provide regular updates on 
next steps as the transition continues.
     Because of concerns expressed by the Wounded Warrior 
Project about the transition at Richmond, VA Central Office has worked 
closely with the site leadership to track actions and suggest further 
actions to enhance the transition. VA supports the Richmond VAMC in 
continuing to transform their PTSD treatment program; they offer a full 
spectrum of effective PTSD services and are engaged individually with 
each Veteran to ensure an individualized plan of care drawing on the 
VA/DOD PTSD CPGs to guide their portfolio of care.
     In summary, Richmond and VA facilities throughout the 
system are engaged in an important transformation of care for PTSD to 
models that have been shown to be most effective, with broad support 
from local Veterans and many VSOs.

    Question 12a. Other than the Richmond VAMC, what other VA medical 
centers within the last two years have terminated or otherwise ended a 
PTSD support group (or other PTSD therapy group) that was situated at a 
VA facility?
    Response. Decisions about such transitions are under the guidance 
of local VISN and facility mental health leadership. VA's tracking of 
service delivery is focused on whether facilities are providing the 
mandated PTSD resources required in the Uniform Mental Health Services 
Handbook.

    Question 12b. Where Veterans have made a transition from a VAMC-
based provider-led group to a community-based peer-led group, what 
steps has VA taken to track the attendance of Veterans in the peer-led 
groups, and what steps will the VA take if participation significantly 
diminishes?
    Response. Such details are best tracked at the local level. As 
noted above, decreased participation would not be seen as an intrinsic 
problem, since groups of the sizes noted (40, and in some cases more) 
cannot be considered group psychotherapy. We would instead have concern 
if the Veterans who had been participating were not transitioning to 
more appropriate forms of care. We do have IT projects in place to 
develop a national ability to track many of these issues--requiring 
symptom-level monitoring, using the PTSD Check List, plus an item on 
level of psychosocial functioning, utilizing progress note templates to 
track delivery of evidence-based psychotherapies, and tracking of 
numbers of therapy sessions for those newly diagnosed with PTSD. The 
Information Technology (IT) projects to support these new tracking 
abilities are expected to be completed in FY12.
    Based on information provided by the Richmond VAMC, we do know that 
at every community-based, peer-led group (Vietnam and post-Vietnam 
eras) since the transition in January 2011, a VA representative (Dr. 
Benesek) has monitored and guided the proceedings and maintained a 
record of participant attendance. The Vietnam group has grown from 40 
to 60 Veterans, while the post-Vietnam group now has grown from 6 to 
13. Steps taken to increase participation include: regular e-mails sent 
to the participants one to two days before the scheduled group; 
reminder phone calls; public posting and reminders on the PTSD bulletin 
board located in a central location; and word of mouth.

    Question 12c. Where consideration is being given to ending a VAMC-
based, provider-led program and referring patient-participants to a 
non-VA community program, would VA policy require that those Veterans 
be evaluated individually for their preparedness for such a change? 
Please advise as to whether such individual evaluations were conducted 
at Richmond and each of the other VAMCs discussed in (a) above.
    Response. Yes, we would expect an individual evaluation to design 
an appropriate regimen of treatment for any Veteran when treatment 
changes are considered. That might be conducted by a single provider or 
by an interdisciplinary team following the Veteran. Our understanding 
is that this was not initially done at Richmond; however, we have 
provided guidance on including this step in transition, and the latest 
information provided by the Richmond VAMC is that this has been done. 
Although the question cites an initial group size of 40, Richmond's 
records indicate that there were 45 original members of the post-
Vietnam Veterans group; of those, 44 have been individually interviewed 
and assessed regarding their current function and needs (one could not 
be reached). Of these, approximately 10 indicated that they would be 
interested in a transition-type group at the VAMC and upon completion, 
would go to the peer-led group. The Richmond evidence-based 
psychotherapy coordinator (Dr. Lynch) has agreed to conduct a time-
limited group of this nature. A majority of the remaining Veterans 
indicated that they were either agreeable with the current arrangement 
or were interested in other groups such as anger management, stress 
management, or insomnia, for which they were referred. The remainder 
opted for either individual follow-up or no additional follow-up.
    This topic also is included in the discussions led by the national 
PTSD Mentoring Program described above, to guide transitions at other 
medical facilities. The presentations have made the point that 
individual assessment of the Veteran's skills and stability are 
essential to a smooth transition to peer-support led groups, as well as 
always ensuring the Veteran has had the opportunity to receive an 
individual evidence-based PTSD treatment. Veterans are also informed 
that we have learned a lot about treating PTSD in the last decade, that 
we now know that large support groups aren't the best way to manage 
PTSD symptoms, and that there are individual treatments that are 
effective.

    Question 12d. How does the termination of a PTSD support group at a 
VA medical facility, over the unanimous objection of the participants 
in the Richmond case, align with the recovery model's principle of care 
being individualized and Veteran-centered?
    Response. In Richmond's case, they actually have not terminated any 
mental health support groups. The PTSD group has moved locations, and 
is still led by the same Psychologist. Several of the participants were 
agreeable to the proposed model. There needs to be a differentiation 
between active treatment and support. Richmond's active treatment 
component has actually been expanded to include 10 new PTSD Recovery 
groups, including within the OEF/OIF/OND program and with providers 
from other areas of the hospital. Active treatment includes groups that 
address current PTSD symptomatology and functioning as well as trauma 
work through the use of PTSD Recovery groups, skills groups, evidence 
based therapies (Prolonged Exposure [PE]; Cognitive-Processing Therapy 
[CPT]; Eye-Movement Desensitization and Reprocessing [EMDR]), and 
individual follow-up. The Vietnam and post-Vietnam (Young Guns) groups 
were originally designed as ``drop-in'' support groups allowing 
Veterans who had completed the PTSD program to be able to touch base 
for ``booster'' sessions as needed. There has been a national movement 
to better prepare our Veterans to go back to their communities more 
educated and equipped with the skills to effectively manage their 
symptoms without the need to indefinitely attend VA-sponsored groups.
    The question cites as a potentially compelling reason not to 
discontinue such groups the fact that it was done ``over the unanimous 
objection of the participants in the Richmond case.'' It is helpful to 
consider other examples of discontinuing treatments that are familiar 
and well-liked by the recipients, but in fact are not helpful. The most 
salient example is Critical Incident Stress Debriefing, an approach to 
responding rapidly to the experience of potentially traumatic events 
with the intention of preventing long-term problems, such as PTSD. This 
approach rapidly became popular and widely used, for example by the 
military and first responder organizations such as firefighters and 
police. Both those who offered the approach and those who received it 
reported high satisfaction with it. However, when well-designed 
research was conducted, not only did it show that the approach was no 
more effective than no response at all, but that it also had the 
potential to increase the likelihood of long-term problems, including 
PTSD, in an uncomfortably high proportion of recipients. It is no 
longer widely used, but in many circles, there was great resistance to 
discontinuing this approach and using other approaches with more 
evidence of effectiveness, with supporters citing the satisfaction 
rates, rather than demonstrating any positive outcomes for recipients. 
We believe the situation in Richmond is very analogous to this history.
    The question also asks how decisions at Richmond are consistent 
with the Recovery model of care. VHA has adopted the definition of 
recovery as developed by SAMHSA, which states: ``Mental health recovery 
is a journey of healing and transformation enabling a person with a 
mental health problem to live a meaningful life in a community of his 
or her choice while striving to achieve his or her full potential.'' 
Recovery-oriented care is strengths-based, individualized, and person-
centered. By participating in recovery-oriented care, Veterans are able 
to realize their goals and gain hope that symptoms of mental illness 
can be managed and that integration into the community can be achieved. 
They rely on support from clinical staff, family, friends, and the 
community to achieve their treatment goals.
    Veteran-centered care focuses on the unique strengths and abilities 
of the Veteran in addition to any needs and challenges he or she faces. 
In a collaboration between the Veteran and his/her treatment providers, 
a unique set of goals and objectives is developed that will result in 
improved mental and physical health functioning. Recovery-oriented care 
is typically divided into two categories: recovery-oriented services, 
and recovery-oriented supports.
    Recovery-oriented services are time-limited, needs-based, and 
typically delivered by health care professionals to achieve short-term 
goals. Recovery-oriented services transition to recovery-oriented 
supports, which are often ongoing and strengths-based. They are usually 
delivered in community settings and may include coaching and mentoring, 
peer support, and the use of self-care tools. Therefore, it is common 
for recovery-oriented PTSD treatment to be transitioned from VA medical 
center-based services provided by mental health professionals to 
community-based support provided by peers. Such a transition enables 
ongoing support for Veterans with PTSD and facilitates integration with 
the Veteran's community.
    In summary, we believe the transition at Richmond, and in other VAs 
where PTSD care is being transformed, are in full alignment with the 
goals of recovery-oriented, Veteran-centered care. As noted in the 
opening bullets, recipient satisfaction with a treatment approach is 
one consideration, and when evidence suggests that the approach does 
not, in fact, have demonstrated effectiveness, Veteran-centered care 
requires that clinicians and Veterans discuss this and that the Veteran 
be guided in choosing care from among options that have a reasonable 
chance of helping the Veterans reduce symptoms and improve function.

    Question 12e. In attempting to explain decisionmaking in the 
Richmond instance, VA officials suggested the lack of an evidence base 
for PTSD groups. However, the VA/DOD Clinical Practice Guidelines for 
Management of Post-traumatic Stress, adopted in the fall of 2010, 
state, ``The empirical literature on group treatment for PTSD has grown 
since the publication of the first edition of the Treatment Guidelines 
for PTSD, although there remain methodological weaknesses in study 
designs, and there is no empirical evidence to support a conclusion 
that group treatment is superior to individual treatment for trauma. 
Nonetheless, it does appear that group-based treatment for individuals 
diagnosed with PTSD is associated with improvements in symptoms of 
PTSD, and there is growing belief that some unique attributes of the 
group treatment format provide benefits that are superior to individual 
treatment for trauma. Identified benefits include efficiency in 
treatment provision and development of support and understanding 
between group members that may counteract isolation and alienation.'' 
Please explain the apparent inconsistency between these guidelines and 
actions and explanations afforded in the Richmond matter.
    Response. To address this matter, it is useful, first, to discuss 
group therapy. There are three different kinds of group therapies: 
those based on cognitive behavioral therapeutic (CBT) principles, those 
which utilize a psychodynamic focus, and those designed to provide 
emotional support (e.g., supportive group therapy). In all cases, 
trauma survivors learn about PTSD and support each other, usually with 
the aid of a professional clinician. Group therapy has been 
particularly popular for individuals who have all survived the same 
type of trauma, such as Veterans who have served in a war zone. As 
members share experiences, they become connected to one another by 
recognizing their common human fears, frailties, guilt, shame, and 
demoralization. Validation and normalization of these thoughts, 
feelings, and behaviors can occur, and group members may acquire more 
adaptive coping strategies, symptom reduction, and/or derivation of 
meaning from the traumatic experience.
    With that background, there are three major issues in this 
component of the question, 12e:

    i. The evidence base for group therapy
    ii. The value of peer led support groups for PTSD, and
    iii. What constitutes ``group therapy''

i. Evidence-base for group therapy
    Group therapy is not recognized as first-line evidence-based 
treatment for PTSD, although some evidence suggests that group therapy 
may be beneficial in some circumstances, and with a clear understanding 
of what constitutes ``group therapy.'' Based on this, the 2010 VA/DOD 
PTSD Clinical Practice Guidelines (CPG) rates group therapy as a 
second-line approach in the ``somewhat helpful'' category and 
encourages clinicians to ``consider group therapy as a useful 
treatment'' if first line treatments have been unsuccessful. In this 
regard, current research suggests that the group, itself, seems to be 
the major vehicle through which benefits are mediated since all types 
of groups (e.g., CBT, psychodynamic, and supportive) appear to perform 
equally well. It is also recognized that one of the major benefits 
provided by Group Therapy appears to be peer support which ``may 
counteract isolation and alienation.'' It must be emphasized that 
nowhere in the 2010 VA/DOD PTSD CPG is group therapy recommended as a 
first-line treatment for PTSD. Whereas the Guideline does acknowledge 
that group therapy may alleviate some symptoms of PTSD, it strongly 
recommends Prolonged Exposure, Cognitive Processing Therapy, Eye 
Movement Desensitization and Reprocessing, and Stress Inoculation 
Therapy as the treatments of choice for PTSD.

ii. The value of peer-led support groups for PTSD
    As stated, participation in either clinician- or peer-led group 
therapy may have benefit, though neither constitutes first-line 
therapy. At this time, the benefits of group therapy are best 
understood where the primary objective is not remission of symptoms but 
rather improving the quality of the Veteran's life. We have learned 
through the PTSD Mentoring Program that peer-led groups are a good fit 
for the principles of the Recovery Model as implemented in the 
utilization of one approach to group therapy--i.e., supportive group 
therapy. It appears that this has also been the case at Richmond. The 
high attrition noted among OEF/OIF/OND Veterans is a pervasive problem 
with this cohort of Veterans and probably has much less to do with the 
specific treatment offered to them, and more to do with their general 
ambivalence toward treatment. Such ambivalence would be expected to be 
amplified by the avoidance symptoms of PTSD which can suppress 
treatment seeking behavior among Veterans with this disorder. We expect 
that these Veterans will continue to need contact with VA clinicians 
and to utilize the spectrum of effective first-line treatments offered 
at Richmond, while the peer-led group being developed can provide a 
context for ongoing mutual support.

iii. What constitutes ``group therapy''
    Finally, as noted above, group size is an important factor that has 
significant impact on the value of a group labeled as ``group 
therapy.'' Psychotherapy literature recommends no more than 8-10 
members for optimal treatment (Yalom, 1995) in any such group, in order 
to sustain group cohesion, to ensure the group leader can sensitively 
attend to the specific emotional/psychological status of each group 
member, and to offer the opportunity for active participation by group 
members who want to speak up. For many groups doing cognitive-
behavioral treatment work, an even smaller size is optimal, 5-8. Thus, 
we expect that as Richmond and other VA sites successfully transform 
care, Veterans will be able to obtain the benefits of 1) clinician-led 
individual or group therapy that has fidelity to known effective 
treatment models, 2) appropriate psychoactive medication, and 3) 
support groups led by peers that are of manageable size with clear 
goals that focus on mutual support and understanding. Active, 
diagnosis-focused treatment would be provided in the first two options, 
but would not be provided in the third option.
    In Richmond's case, in their active treatment component, they have 
actually increased the number of treatment groups made available to 
Veterans, including the use of staff outside of the core PTSD team. The 
bulk of active clinical activity at Richmond consists of group therapy, 
as defined in option 1) above. Rather than eliminate the support groups 
altogether, the mental health services program at Richmond has decided 
to coordinate with a local Veterans Service Organization, with whose 
Commander the Richmond VAMC has a solid relationship, for space for our 
Veterans to continue to meet in a supportive environment free from any 
obligation to join or participate in that particular organization's 
activities.
    Richmond VAMC believes that this has been an effective mechanism 
that will continue to grow and help our Veterans become more self-
reliant. It should also be noted that no matter what course a Veteran 
chooses (recovery group, skills group, evidence-based treatment, 
support group, individual follow-up, taking a break from treatment), 
all are reminded that their primary mental health provider will remain 
their point of contact should they have any additional needs or 
requests in the future. Should their primary mental health provider be 
unavailable (no longer with the program or VAMC), a new one will be 
assigned.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Richard Burr to 
   Antonette Zeiss, Ph.D., Acting Deputy Chief Officer Mental Health 
Services, Office of Patient Care Services, U.S. Department of Veterans 
                                Affairs

    Question 1. According to a report by GAO on the Federal Recovery 
Coordination Program, Federal Recovery Coordinators (FRC) ``cannot 
readily identify potential enrollees using existing data sources.'' The 
Senior Oversight Committee developed a categorization system to 
identify those servicemembers that would benefit from an FRC. However, 
these are purely administrative categories and do no line up with VA or 
DOD's medical and benefits systems.
    What steps have been taken to align the categories set out by the 
Senior Oversight Committee with the medical and benefits system of VA?
    Response. Department of Veterans Affairs (VA) has not set out 
specifically to align its systems with the categories outlined by the 
Senior Oversight Committee. The categories established by the Senior 
Oversight Committee are administrative not operational. They were 
intended to be used as a guideline for making referrals to the Federal 
Recovery Coordination Program. However, as currently structured, FRCP 
is a voluntary referral program and, as such, relies on the 
identification and referral of those who might benefit from the FRCP 
services by others (case managers, Command, Wounded Warrior Programs, 
etc.).
    VA medical and benefits systems do not rely on these categories for 
eligibility, enrollment, or entitlement decisions with respect to VA 
benefits and services.
    What is needed is a mechanism that will trigger an automatic 
referral to FRCP when certain conditions are met. The Senior Oversight 
Committee in early 2011 requested that the Line of Action 3 Co-chairs 
develop such an automated referral system. The development of the 
system was deferred pending the outcome of a joint executive committee 
assembled to identify potential for a joint recovery program.

    Question 2. The GAO report points to challenges coordinating with 
other programs supporting the FRC program. Although, these programs are 
not just for the most severely injured servicemembers, they have 
similar case management functions and many recovering servicemembers 
are enrolled in more than one program. This has lead to a duplication 
of efforts and could lead to confusion for the servicemember.
    What steps have been taken to better share information on 
servicemembers enrolled in the Federal Recovery Coordination Program to 
reduce confusion and redundancy in the recovery process?
    Response. The Federal Recovery Coordination Program (FRCP) has a 
comprehensive data management system. In January of this year, FRCP 
completed the System of Records Notice necessary to share information 
with other coordinating organizations including Service wounded warrior 
programs. FRCP is currently updating Data use Agreements to provide 
access to appropriate individuals. FRCP is also updating the data 
management system to allow for such role-based access.
    Additionally, FRCP is engaged in an Information Sharing Initiative 
(ISI) with DOD. The first deliverable planned for ISI is a data 
exchange of names of case managers, selected benefit information, and 
problem lists among participating programs. The first exchange is 
scheduled to take place by the end of FY11.

    Question 3. The United States Court of Appeals for the 9th Circuit 
Court recently ruled ``that unchecked incompetence'' by the Department 
of Veterans Affairs led to poor mental health care and slow processing 
of disability claims for Veterans.

    Question 3a. Does VA have access standards for behavioral health 
services?
    i. If so, what are they?
    ii. What happens if you don't meet those access standards?
    iii. How often do you not meet the access standards?

    Response. VA does have access standards for behavioral health 
services. New patients to mental health are required to have an initial 
assessment within 24 hours and their first full evaluation appointment 
with 14 days. Established patients are required to have follow-up 
appointments within 30 days.
    VISNs and facilities review access data for all clinics on a 
regular basis to develop action plans as needed. If these access 
standards are still not met, technical assistance is available through 
the VA Mental Health Operations Office (MHO) in the VA Office of 
Operations and Management. As well, MHO is currently developing a 
process to independently monitor compliance with the access standards 
at a more granular level.
    Performance standards for mental health are currently being met 
nationally. Data as of May, 2011, indicate that 95 percent of new 
patients are seen for a full evaluation appointment within 14 days and 
96 percent of established patients are seen for a follow-up appointment 
within 30 days of the desired date. The metric regarding whether a new 
patient is seen for an initial assessment within 24 hours is not a 
metric that is readily available.

    Question 3b. Does VA have performance metrics that measure the 
effectiveness of their mental health services? If so, can you please 
explain how this is measured?
    Response. VA has evidence-based psychotherapy protocols in place 
for PTSD that incorporate weekly symptom monitoring with the PTSD 
Checklist (PCL). In addition, current standards require the 
administration of the PCL every 90 days for all OEF-OIF Veterans in 
active treatment for PTSD, as defined by at least 2 visits to an 
outpatient mental health clinic within the previous 6 months. PCL data 
have recently been extracted into a national database allowing for 
total population sampling for clinical review and aggregate analyses. 
While symptom monitoring is an important element in measuring treatment 
effectiveness, broader, systematic outcome evaluation is also critical 
for evaluating program effectiveness. Outcome measures for evaluation 
of symptom level during treatment for substance abuse and depression 
are under development and will be available dependent on availability 
of informatics tools which is scheduled for deployment in FY 2012. In 
addition to monitoring patients receiving active mental health 
treatment, an aspirational goal that is in development would involve 
centralized tracking of patient functioning through systematic symptom 
monitoring that would occur regardless of whether the Veteran was in 
active treatment.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Mark Begich to 
   Antonette Zeiss, Ph.D., Acting Deputy Chief Officer Mental Health 
Services, Office of Patient Care Services, U.S. Department of Veterans 
                                Affairs

    Question 1. Ms. Zeiss, in Alaska, the HUD-VASH Voucher Program has 
been a success. I know that mental health issues are a major 
contributing factor in veteran homelessness. I would love to see the 
HUD-VASH voucher program continue and expand to provide much needed 
relief to Alaska's homeless veterans.

    Question 1a. In your opinion, is the HUD-VASH voucher program part 
of the answer to eliminating veteran homelessness?
    Response. Yes, the HUD-VASH program's permanent supportive housing 
is a critical part of VA's Plan to End Homelessness Among Veterans. The 
primary goal of HUD-VASH is to move Veterans and their families out of 
homelessness. A key component of the HUD-VASH program is VA's case 
management services. These services are designed to support the 
Veteran's recovery goals by providing stability in safe, decent, 
affordable, and permanent housing of the Veteran's choice. While VA 
provides case management services, HUD provides permanent housing 
stability to Veterans and their immediate families by allocating rental 
subsidies from its Housing Choice Voucher (HCV) Program.

    Question 1b. What is the future plan for HUD-VASH vouchers? Will 
Alaska receive a larger share of vouchers in future years?
    Response. For FY 2011, Congress appropriated $50 million for 
approximately 7,000 additional HUD-VASH vouchers. This is a reduction 
from the approximately 10,000 vouchers that were allocated in each of 
the three previous fiscal years. Voucher allocation is based on the 
``relative need'' of the state and local community. VA and HUD identify 
``relative need'' by utilizing VA Homeless outreach data and HUD Point 
In Time (PIT) data. Adjustments in voucher allocation are made based on 
past performances by both the VA medical center and the Public Housing 
Authority that administers the housing vouchers. HUD (with VA input) 
then makes the final adjustment of voucher allocation based on 
priorities such as rural communities or high priority target 
communities. It is VA's goal to assist states and local communities to 
obtain the needed resources to end Veteran homelessness.

    Question 1c. Will you explain how VA allocates the vouchers?
    Response. HUD utilizes a relative need-based formula and 
performance data in determining how the HUD-VASH vouchers will be 
allocated. HUD heavily relies on the most recent Point in Time data 
which indicates by state the number of homeless Veterans on any given 
night. The latest information was released in Veteran Homelessness: A 
Supplemental Report to the 2009 Annual Homeless Assessment Report 
(AHAR) to Congress. VA does provide input based on local reports from 
the medical centers, but HUD makes the final determination of where the 
vouchers will be allocated.

    Question 2. Ms. Zeiss, the Grant and Per Diem (GPD) Program assists 
eligible entities in establishing new community-based programs to 
furnish outreach, supportive services, and transitional housing to 
homeless Veterans. Anything community-based that directly benefits 
veterans helps Alaska because of the extreme isolation of many Alaska 
communities.
    Can you explain how the Grant and Per Diem Program is benefiting 
Alaska?
    Response. The VA's Homeless Providers Grant and Per Diem (GPD) 
Program is a critical part of the VA's Plan to End Homelessness Among 
Veterans; the GPD Program benefits homeless Veterans and the state of 
Alaska by providing per diem payments and a capital grant to homeless 
providers in Anchorage and Fairbanks, Alaska. Presently, there are two 
GPD Programs that are operational and provide transitional housing to 
homeless Veterans in Alaska. The Fairbanks Rescue Mission is a 30-bed 
Per Diem Only program in Fairbanks, Alaska that began receiving a per 
diem in October 2008. Salvation Army, Inc. was awarded a 20-bed Capital 
Grant in Anchorage, Alaska that became operational in December 2007.

    Question 3. Mr. McNamee, I have heard great things about your 
facility and rehabilitation services down in Richmond. There are 
currently several Alaska Soldiers recovering in Richmond, and we wish 
them a speedy recovery. In Alaska, there is no advanced care facility 
for treating and rehabilitating veterans with TBI beyond mild exposure.

    Question 3a. I know the Defense and Veteran Brain Injury Center has 
received high marks, so I would like to hear what sets it apart from 
other brain injury rehabilitation programs.
    Response. VA and DOD share a longstanding integrated collaboration 
in the area of Traumatic Brain Injury (TBI) through the Defense and 
Veterans Brain Injury Center (DVBIC). Since 1992, DVBIC staff members 
have been integrated with VA Lead TBI Centers (now Polytrauma 
Rehabilitation Centers) to collect and coordinate surveillance of long-
term treatment outcomes for patients with TBI. In clinical partnership 
with DVBIC, VA coordinates the referral and admissions process to 
community integration and vocational rehabilitation programs at the 
four VA Polytrauma Transitional Rehabilitation Programs, and the two 
DVBIC Clinical Rehabilitation sites. VA providers coordinate regularly 
with DVBIC's Regional Care Coordinators to ensure access to services 
for Veterans who are diagnosed with TBI. The TBI screening tool 
utilized by VA providers to evaluate OEF/OIF Veterans, and the DOD/VA 
Clinical Practice Guidelines for Mild TBI, were developed in 
collaboration with DVBIC.
    With respect to education and training, VA worked with DVBIC to 
create a uniform training curriculum for family members in providing 
care and assistance to Servicemembers and Veterans with TBI: 
``Traumatic Brain Injury: A Guide for Caregivers of Servicemembers and 
Veterans.'' The distribution of this valuable tool to caregivers is 
being coordinated by both VA and DOD providers. Finally, VA works 
closely with DVBIC in TBI education and training curriculum 
development, with assistance in planning and presentations at the 
annual DVBIC TBI Training Conference and co-sponsorship of the annual 
Blast Injury Conference.

    Question 3b. What are some of the current cutting-edge brain injury 
rehabilitation treatments that you use?
    Response. The Richmond VA Medical Center (VAMC) and other lead 
Polytrauma Centers continually seek to provide effective, cutting edge 
treatments and technologies to our Veterans and Servicemembers 
recovering from TBI and polytrauma. All Veterans and Servicemembers 
receiving care in VA for TBI receive evidence-based, and consensus-
based standardized treatments for TBI, developed in collaboration with 
DOD, academic and private sector clinicians. Treatment varies by the 
type and severity of the initial injury and subsequent residual 
symptoms, and is delivered within the context of an individualized 
treatment plan for each Veteran.
    Specific examples of these progressive brain injury treatments and 
resources at Richmond and other Polytrauma Rehabilitation Centers (PRC) 
include:

     Assistive Technology Center that offers comprehensive 
evaluations and employs state-of-the-art technologies including 
environmental control units, adaptive communication devices, and a host 
of computer interface devices and software to support the individual 
patient during recovery;
     Provision of effective cognitive rehabilitation practices 
and interventions in accordance with recent literature guidelines 
published by Dr. Cicerone in March 2011. Systematic delivery of 
cognitive rehabilitation services in VHA began in 1992 at the TBI Lead 
Centers (Minneapolis, Palo Alto, Richmond, Tampa) in conjunction with 
the implementation of the Defense and Veterans Brain Injury Center 
(DVBIC) clinical trials. The cognitive rehabilitation protocols 
developed for those clinical trials served as a model for future 
innovative cognitive interventions spearheaded by our rehabilitation 
specialists;
     The Emerging Consciousness program for patients with 
disorders of consciousness utilizes both high technology (assistive 
communication devices, advanced seizure monitoring and quantitative EEG 
analysis) and state-of-the-art sensory stimulation and regulation 
techniques;
     Transitional Rehabilitation Programs developed and 
implemented at each PRC. These residential units provide rehabilitation 
in a home-like environment to facilitate community reintegration for 
Veterans and their families; and
     The Richmond Polytrauma Program is the leader in educating 
the next generation of polytrauma rehabilitation specialists through 
the only approved Polytrauma/TBI medical fellowship in the country.

    Question 3c. How would you handle transitioning Alaska 
servicemembers with moderate and severe TBI injuries provided that 
there are very few treatment options in Alaska, and therefore few 
treatment options once they depart your facility?
    Response. Discharge planning for all Veterans and Servicemembers at 
the Richmond PRC is intensive and individualized. It is always our goal 
to return the patient back to the community of choice. Fortunately, our 
continuum of care at the Richmond VAMC includes a Polytrauma 
Transitional Rehabilitation Program on campus to support the community 
re-entry needs of our patients with Moderate-Severe TBI. A 
rehabilitation plan is formulated for each patient and matched to 
regional resources within the patient's home community. Typically, 
support comes from a network of providers across VHA, DOD and the 
private sector.
    Telehealth also provides VA with a useful means of extending 
medical care services and support to more than 260,000 Veteran 
patients, including Veterans in Alaska and in rural locations in other 
states. VHA Telehealth has increased access to VA medical center 
service and support to 500 Community-Based Outpatient Clinics (CBOCs), 
and to 41,000 Veteran patients at home. Staff from the Veteran 
Integrated Service Network (VISN) for Alaska participates in the Alaska 
Brain Injury Network, a non-profit organization created by the Alaska 
mental health trust to provide resources to Alaska residents with TBI 
and integrate and share services from different sectors (Federal, 
State, Native, Private) for individuals with TBI.
    Telehealth is also used to provide follow-up comprehensive TBI 
evaluations from a VA Medical Center provider to Veteran patients at 
rural clinics. Such a telehealth link has been established with the 
community based outpatient clinic (CBOC) in Fairbanks, Alaska, with 
plans for the Kenai and Juneau CBOCs. In total, we make it our goal to 
support each patient through a comprehensive continuum of care based 
upon their needs and regional resources both on campus and following 
discharge.

    Question 3d. GEN Chiarelli stated that as of February 1, 2011, 64 
percent of the Army's Wounded Warrior population suffered from brain 
injury or PTSD. Are VA and DOD doing enough to fully care for and 
address the needs of our Wounded Warriors suffering from these 
injuries?
    Response. While there are always opportunities to improve services, 
VHA has moved rapidly to anticipate and implement support for the 
critical needs of our Veterans and Servicemembers with TBI and Post 
Traumatic Stress Disorder (PTSD). For over 7 years VA has routinely 
screened new Veterans entering VA for health care for possible PTSD, 
depression, and alcohol abuse. Since 2007, VA screens all OEF/OIF/OND 
Veterans entering VA for health care for possible TBI. Further, VA has 
implemented clinical practice guidelines, case management, and 
dedicated treatment programs such as the Emerging Consciousness 
Program, Polytrauma Transitional Rehabilitation Program, and Amputation 
System of Care over the past decade. VA continues to expand and 
coordinate its broad-based efforts in collaboration with DOD and 
academic medical institutions to advance our understanding, and provide 
the best services that science and clinical practice has to offer to 
America's Veterans.
    Significant expansions in existing TBI services being implemented 
in FY 2011 and planned for FY 2012 include:

     Improving access to specialized TBI care by using diverse 
methods such as telehealth and improved efficiencies;
     Leverage technological advances to reduce the impact of 
disabilities on community re-integration, including living 
independently and return to work;
     Provide continued education opportunities to providers, 
both VA and private sector, on recognizing signs and symptoms of PTSD 
and concussion (since only 50% of Veterans from OEF/OIF/OND have 
accessed the VA for services);
     Increase use of the VA/DOD Clinical Practice Guidelines 
for mild TBI/concussion to guide treatment based on the best medical 
evidence available;
     Continue efforts to screen for TBI in order to identify 
issues early and provide appropriate treatment;
     Continue to educate health care providers to limit 
fragmentation of care, and promote team approach to care and awareness 
of co-occurring symptoms associated with TBI and PTSD.

    Chairman Murray. Dr. Taylor.

  STATEMENT OF GEORGE PEACH TAYLOR, JR., M.D., M.P.H., DEPUTY 
ASSISTANT SECRETARY FOR FORCE HEALTH PROTECTION AND READINESS, 
U.S. DEPARTMENT OF DEFENSE; ACCOMPANIED BY PHILIP A. BURDETTE, 
    PRINCIPAL DIRECTOR, OFFICE OF WOUNDED WARRIOR CARE AND 
                       TRANSITION POLICY

    Dr. Taylor. Chairman Murray, Ranking Member Burr, on behalf 
of myself and Phil Burdette, I wanted to thank you for the 
opportunity to appear in front of you today to discuss the 
Department of Defense's collaboration with the VA and our 
shared efforts to improve the transition of veterans, 
particularly those injured while serving.
    I would like to start off with personally apologizing for 
the lateness of the written testimony. I assure you I am going 
to investigate the reasons for that and take the appropriate 
action to better ensure that does not happen again in the 
future.
    In every arena of our shared engagement strategy the two 
departments have made significant demonstrable progress, and we 
are posed to continuing to improve upon the achievements of the 
past several years. Our efforts cut across virtually every 
aspect of our operations, clinical care, medical facilities, 
the disability evaluation, medical research, and central to all 
these activities are electronic health records.
    Our clinical experts are learning and sharing critical 
information from each other. The DOD and VA research into 
prevention, identification, diagnosis, and treatment of 
Traumatic Brain Injury is informing not just our own systems, 
but the larger American medical community on what evidence 
indicates the best approaches in protecting and caring for our 
servicemembers and veterans.
    Our mental health experts are working closely in 
disseminating joint clinical practice guidelines for a number 
of clinical conditions. PTSD, depression, and suicide 
prevention are serious issues with which both the DOD and the 
VA are addressing, both immediate and long-term issues for our 
servicemembers and veterans.
    Together we have identified, as Dr. Zeiss mentioned, 28 
strategic actions to better align and coordinate those mental 
health services across the two departments, including near-
term, mid-term, and long-term solutions. I am personally deeply 
engaged in our efforts to further integrate, on behalf of the 
patients we serve, the vast amounts of medical information in 
our respective health information systems.
    At the critical point of transition from one system to the 
other, the Federal Health Information Exchange has served as a 
critical path, ensuring that important medical information is 
passed from the DOD to the VA. More than 5\1/2\ million 
veterans have benefited from this data transfer since 2001. For 
those beneficiaries who receive care from both the DOD and VA 
facilities, we have introduced significant enhancements to the 
Bidirectional Health Information Exchange in January of this 
year, and we are very pleased with the results of that effort.
    For the most severely wounded servicemembers who are 
transitioning into the VA's polytrauma centers, we have 
instituted a number of record transfer processes to ensure the 
right information gets to the right people quickly and 
securely.
    The DOD is also working with the VA to move forward on the 
implementation of the Integrated Disability Evaluation System. 
There are several primary goals for this system that we have 
been striving to meet to solve many of the problems that you 
heard earlier today.
    Servicemembers in IDES receive their disability benefits as 
soon after discharge as the VA is legally permitted to provide 
them. We know before discharge what level of VA disability 
paying benefits they and their families will receive. They only 
have to go through the evaluation process once. They receive 
ratings that are consistent between the VA and the military 
services, and they complete an integrated process more quickly 
than they would in the Legacy system.
    We are discovering obstacles as we deploy IDES through the 
entire force, but we are working hard to bring the time of 
completion down to the 295-day goal. As of May 15, the 
cumulative dual-eligibles enrollment is 23,350 servicemembers 
with 7,546 completing the program by medical separation, 
retirement, or return to duty.
    We are working to strengthen our Transition Assistance 
Program, TAP, and reinforce its values to servicemembers and 
their families. DOD and our partners in the VA and the 
Department of Labor are committed to moving TAP from a 
traditional event-driven approach to a modern life-cycle 
approach.
    We are shifting from events at the end of military service 
to an outcome-based model that will assist servicemembers and 
their families with their life goals, military career 
progression, and even new careers or meaningful employment 
outside the uniform service.
    I am grateful for the leadership of Secretary Gates and 
Secretary Shinseki to move our systems down a path that is more 
cohesive, more servicemember focused, and also more cost 
effective and less bureaucratic. We are heading in the right 
direction.
    Thank you for the opportunity to be here today, with you 
today, on behalf of the Department of Defense, and we look 
forward to answering your questions.
    [The prepared statement of Dr. Taylor follows:]

Prepared Statement of Dr. George Taylor, Deputy Assistant Secretary of 
 Defense, Force Health Protection and Readiness; and Philip Burdette, 
 Principal Director, Wounded Warrior Care and Transition Policy Office

    Chairman Murray, Ranking member Burr, and members of this 
distinguished Committee, thank you for inviting us to testify before 
you on the care and transition of our wounded warriors from the 
Department of Defense to the Department of Veterans Affairs. Taking 
care of our wounded, ill and injured Servicemembers is one of the 
highest priorities of the Department, the Service Secretaries and the 
Service Chiefs. The Secretary of Defense has said, other than the War 
itself, there is no higher priority. Reforming cumbersome and sometime 
confusing bureaucratic processes is crucial to ensuring Servicemembers 
receive, in a timely manner, the care and benefits to which they are 
entitled. The Department's leaders continue to work to achieve the 
highest level of care and management and to standardize care among the 
Military Services and Federal agencies, while maintaining focus on the 
individual.

  DISABILITY EVALUATION SYSTEM/INTEGRATED DISABILITY EVALUATION SYSTEM

    The genesis of the Disability Evaluation System (DES) is the Career 
Compensation Act of 1949, after which the system went relatively 
unchanged for 58 years, until 2007. As a result of concern within the 
Department of Defense (DOD) and the Department of Veterans Affairs 
(VA), as well as Congressional and public concern, the Senior Oversight 
Committee (SOC) chartered the DES Pilot in November 2007.
    We have several goals for the DES Pilot. We are determined to stop 
making Servicemembers go through the disability evaluation process 
twice--once before discharge and once after discharge while awaiting 
benefits. The DES Pilot accomplished this by assigning the Military 
Services the tasks they do best--determining fitness for duty--and VA 
the tasks they do best--performing medical evaluations in accordance 
with the VA Schedule for Rating Disabilities and assigning proposed 
disability ratings for use by DOD and VA--all while the Servicemembers 
and their families were receiving military pay and benefits.
    We are also determined to eliminate inconsistent disability ratings 
between VA and the Military Services. The Pilot achieves this because 
VA- provides a proposed disability ratings that can be used to 
determine eligibility for both military and VA compensation and 
benefits. This was effective because the conditions the Military 
Services are allowed by law to include in their disability ratings are 
a subset of the disabilities for which VA is allowed to compensate. In 
the Pilot, both ratings were presented and explained to Servicemembers 
to ensure transparency.
    And, we are determined to enable Servicemembers to complete the 
integrated processes more quickly than they could complete the 
processes one after the other. The DES Pilot accomplished this, cutting 
out steps that Servicemembers previously had to perform twice.
    To test our ability to meet these goals consistently, we expanded 
the DES Pilot from the original three major military treatment 
facilities (Walter Reed, Bethesda, and Malcolm Grow) in the National 
Capital Region to 18 more locations in October 2008. The Pilot 
continued to meet all five of these goals. In January 2010, we expanded 
the test to six more locations. The Pilot continued to meet all five of 
these goals.
    DOD and VA found the integrated DES to be a faster, fairer, more 
efficient system and, as a result, the SOC Co-chairs (the Deputy 
Secretary of Defense and Deputy Secretary of Veterans Affairs) on 
July 30, 2010, directed worldwide implementation of the process 
beginning in October 2010 to be completed at the end of September 2011. 
On December 15, 2010, the first Integrated Disability Evaluation System 
(IDES) site became operational, which marked the end of the pilot, and 
the name was formally changed to the IDES.
    As in the Pilot, the IDES continues to meet the five primary goals. 
Servicemembers in the IDES receive their disability benefits as soon 
after discharge as VA is legally permitted to provide them, know before 
discharge what level of VA disability compensation and benefits they 
will receive, they only have to go through the process once, receive 
ratings that are consistent between VA and the military Services, and 
complete the integrated processes more quickly than they could complete 
them one after the other.
    In designing the integrated system, we tried to move Servicemembers 
through the integrated processes even faster than they move through 
just the military process in the existing system. At first, we 
succeeded. However, we are discovering obstacles as we deploy IDES 
through the entire force. Thus far in May 2011, Active Component 
Servicemembers completed the IDES process in an average of 404 days 
from referral to post-separation VA Benefits decision, including 
Service-department appeals and pre-separation leave. This exceeds the 
295-day IDES goal, but is still 27 percent faster than the 540 day 
benchmark for the Legacy disability process. We attribute the 
lengthening queue time to the fact that more complex and intricate 
cases are matriculating in the system, and Servicemembers are opting 
for more due process and administrative reviews, as well as opting to 
take leave while on active duty versus selling it back at date of 
separation. However, the Servicemembers and families who are 
methodically processing through the IDES continue to receive full pay, 
allowances, compensation, medical and base support care and benefits as 
they prepare transition to civilian life and VA care. As of May 15, 
2011, cumulative IDES enrollment is 23,350 Servicemembers with 7,546 
completing the program by medical separation, retirement, or return to 
duty.
    We will never rest on the fact that we have historically improved 
the DES in almost four short years. We know we can and ought to do even 
better. The Departments are continuously exploring new ways to improve 
the current system. The Secretaries of Defense and Veterans Affairs are 
currently exploring several options to shorten the overall length of 
the disability evaluation process from its current goal of 295 calendar 
days. We are looking closely at the stages of the IDES that are outside 
of timeliness tolerances and developing options to bring these stages 
within goal. Examples of items we are working on are: streamlining 
medical case narrative summary to improve Medical Evaluation Board 
(MEB) timeliness; improving IDES disability examination timeliness by 
increasing VA capacity; and providing better expectation management 
service and transparency to Servicemembers. The Secretaries have also 
commissioned a group of operational subject matter experts to take a 
fresh look at additional avenues (both requiring changes in statute and 
those that can be accomplished with quick policy changes) to make the 
system more efficient. The group hopes to conclude their work in 
October of this year and provide the Secretaries with actionable 
recommendations.
    Nonetheless, the IDES, which has proven to be faster, fairer (based 
on customer satisfaction surveys) and substantially reduced the DOD/VA 
benefits gap, constitutes a major improvement over the legacy DES and 
both DOD and VA are fully committed to the worldwide expansion of IDES. 
Both Departments are partnering closely as we aggressively move toward 
IDES implementation at all 139 CONUS and OCONUS sites by September 30, 
2011.
    The impact of each stage of the IDES expansion and cumulative DES 
population is shown below:

     Stage I--West Coast & Southeast (October-December 2010)--
(Completed)--58%
     Stage II--Rocky Mountain & Southwest Region (January-
March 2011)--(Completed)--74%
     Stage III--Midwest & Northeast (April-June 2011)--90%
     Stage IV--Outside Continental United States (OCONUS)/CONUS 
(July-September 2011)--100%

    We are committed to working closely with Congress in exploring new 
initiatives that can further advance the efficiency and effectiveness 
of the disability evaluation process.

                     RECOVERY COORDINATION PROGRAM

    The DOD Recovery Coordination Program (RCP) was established by 
Section 1611 of the FY 2008 National Defense Authorization Act. This 
mandate called for a comprehensive policy on the care and management of 
covered Servicemembers, including the development of comprehensive 
recovery plans, and the assignment of a Recovery Care Coordinator for 
each recovering Servicemember. In December 2009, a Department of 
Defense Instruction (DODI 1300.24) set policy standardizing non-medical 
care provided to wounded, ill and injured Servicemembers across the 
military departments. The roles and responsibilities captured in the 
DODI are as follows:

     Recovery Care Coordinator: The Recovery Care Coordinator 
(RCC) supports eligible Servicemembers by ensuring their non-medical 
needs are met along the road to recovery.
     Comprehensive Recovery Plan: The RCC has primary 
responsibility for making sure the Recovery Plan is complete, including 
establishing actions and points of contact to meet the Servicemember's 
and family's goals. The RCC works with the Commander to oversee and 
coordinate services and resources identified in the Comprehensive 
Recovery Plan (CRP).
     Recovery Team: The Recovery Team includes the recovering 
Servicemember's Commander, the RCC and, when appropriate, the Federal 
Recovery Coordinator (FRC), for catastrophically wounded, ill or 
injured Servicemembers, Medical Care Case Manager and Non-Medical Care 
Manager. The Recovery Team jointly develops the CRP, evaluating its 
effectiveness and adjusting it as transitions occur.
     Reserve/Guard: The policy establishes the guidelines that 
ensure qualified Reserve Component recovering Servicemembers receive 
the support of an RCC.

    There are currently 147 DOD trained RCCs in 69 locations placed 
within the Army, Navy, Marines, Air Force, United States Special 
Operations Command (USSOCOM) and Army Reserves. Care Coordinators are 
hired and jointly trained by DOD and the Services' Wounded Warrior 
Programs. Once placed, they are assigned and supervised by Wounded 
Warrior Programs but have reach-back support, as needed, for resources 
within the Office of Wounded Warrior Care and Transition Policy. DOD 
RCCs work closely with FRCs as members of a Servicemember's recovery 
team.
    In the DODI, we have codified that severely injured and ill who are 
highly unlikely to return to duty and will most likely be medically 
separated from the military (Category III) will also be assigned an 
FRC. The DODI 1300.24 establishes clear rules of engagement for RCCs. 
The RCC's main focus is on Servicemembers who will be classified as 
Category II. A Category II Servicemember has a serious injury/illness 
and is unlikely to return to duty within a time specified by his or her 
Military department and may be medically separated. The FRC's main 
focus is on the Servicemembers who are classified as Category III. A 
Category III Servicemember has a severe or catastrophic injury/illness 
and is unlikely to return to duty and is likely to be medically 
separated.
    While defined in the DODI, Category I, II and III are all 
administrative in nature and have been difficult to operationalize. The 
intent of the controlling DODI is to ensure that wounded, ill, and 
injured Servicemembers receive the right level of non-medical care and 
coordination. DOD is working with the FRCP to make sure that 
Servicemembers who need the level of clinical and non-clinical care 
coordination provided by a FRC are appropriately referred.
    Earlier this year, the SOC directed the Recovery Coordination 
Program (RCP) and the Federal Recovery Coordination Program (FRCP) 
leadership to establish a DOD/VA Executive Committee on Care/Case 
Management/Coordination to identify ways to better coordinate the 
efforts of FRCs and RCCs and to look to where to better integrate our 
two programs where possible in order to avoid the problems of 
duplicative or overlapping case management. The Committee conducted its 
first meeting in March and its final two-day meeting May 10-11. The 
results of the Committee's efforts will be briefed to the SOC at its 
June meeting.
    In March 2011, DOD also conducted an intense 2\1/2\ day Wounded 
Warrior Care Coordination Summit that included focused working groups 
attended by subject matter experts who discussed and recommended 
enhancements to various strategic wounded warrior issues requiring 
attention. One working group focused entirely on collaboration between 
VA and DOD care coordination programs. Another group focused on best 
practices within recovery care coordination and a third group focused 
on wounded warrior family resiliency, employment and education. 
Actionable recommendations are currently being reviewed, have been 
presented to the Overarching Integrated Product Team (OIPT) and will 
continue to be worked until approved recommendations and policies are 
implemented.
    DOD is committed to working closely with the Federal Recovery 
Coordination Program leadership to ensure a collaborative relationship 
exists between the DOD RCP and the FRCP. The Military Department 
Wounded Warrior Programs will also continue to work closely with FRC's 
in support of Servicemembers and their families.

                TRANSITION ASSISTANCE FOR SERVICEMEMBERS

Transition Assistance Program (TAP)
    To strengthen our Transition Assistance Program (TAP) and reinforce 
its value to Servicemembers and their families, the Department, in 
collaboration with our partners at the Departments of Veterans Affairs 
(VA) and Labor (DOL), is committed to moving TAP from a traditional 
event-driven approach to a modern, innovative lifecycle approach. We 
are shifting from an end of military life-cycle event to an outcome 
based model that will measure success not only on the number of 
Servicemembers who use the TAP process, but also on the number of 
transitioning servicemembers and their families who find the TAP 
process beneficial in assisting them with their life goals, military 
career progression, and/or new careers/meaningful employment outside of 
uniformed service. We will be implementing this strategic plan with 
focuses on information technology, strategic communications, and 
resources and performance management. The end-state for the TAP 
overhaul will be a population of Servicemembers who have the knowledge, 
skills, and abilities to empower themselves to make informed career 
decisions, be competitive in the global work force and become positive 
contributors to their community as they transition from military to 
civilian life.
    As part of this effort, we launched the DOD Career Decision Toolkit 
in August 2010. Available both online and in CD format, the Toolkit was 
developed in collaboration with the Military Services and our TAP 
partners at the Department of Veterans Affairs and Department of Labor 
to help simplify the learning curve for transitioning Servicemembers 
with the information, tools, and resources they need to succeed in the 
next phase of their lives. The toolkit uses the latest technology to 
consolidate the very best teaching materials from all the Service 
branches and provides thousands of on-demand resources to 
Servicemembers. It is interactive, simple to use and portable. The 
toolkit includes:

     More than 3,000 on-demand information and planning 
resources
     Transition subjects such as career exploration, financial 
planning, resume creation, interviewing skills and compensation 
negotiation
     Tools that enable Servicemembers to catalogue their 
military skills, training, and experience in ways that transfer to 
civilian sector
     Post-Service benefits and resources
     Resources that allow users to self-assess individual 
transition needs and plan personalized options

    In addition to the Toolkit, we began offering a series of virtual 
learning opportunities to transitioning Servicemembers and military 
spouses on March 1st of this year. The free online classes are 
available to any Servicemember worldwide and provide them with an 
interactive educational forum to delve into employment and career 
related topics, such as ``Building Better Resumes'' and ``Financial 
Planning for a Career Change.'' The classes are highly encouraged for 
any Servicemembers looking bolster their transition-related knowledge, 
especially rurally located members of the National Guard and Reserves 
and Wounded Warrior in recovery. To date, there have been more than 900 
hundred registrations for these online seminars including registrations 
by military personnel stationed overseas in Diego Garcia, BIOT; 
Guantanamo Bay, Cuba; Italy, Japan, Korea, Germany and members deployed 
to Afghanistan and Iraq. Military spouses are also among the many 
participants who have enjoyed this new delivery methodology.
    The TAP Virtual Learning Seminars have also been enthusiastically 
embraced by senior military leadership and prominent figures in 
business and academia. Some of which now participate in online seminars 
as ``surprise celebrity guests.'' Leaders such as Army Reserve Command 
Sergeant Major Michael D. Schultz; Navy Reserve Force Master Chief 
Ronney A. Wright; Philip Dana, Amazon's Military Recruiting H.R. 
Manager; and Dr. Timothy Butler, Harvard Business School's Director of 
Career Development Programs have made guest appearances to motivate the 
attendees, stress the importance of proper transition planning, and 
also to participate in the online classes along with the Servicemembers 
and families.
    The Toolkit and the virtual classes are just the beginning of our 
effort to move TAP into the digital spectrum. We are developing an 
``end-to-end'' virtual TAP delivery vehicle delivery platform that will 
provide the back-bone of the transformed TAP program, integrating the 
Guard and reserve components, as well as expanding services available 
to family members.
    DOD is partnering with the Office of Personnel Management and the 
Departments of Labor, Veterans Affairs and Homeland Security on 
President Obama's Veteran's Employment Initiative. The Initiative 
directs 24 large and independent Federal agencies to improve employment 
opportunities for veterans in their agencies. TAP is one of the 
programs we will use to educate and inform Servicemembers about Federal 
Service career opportunities.
    DOD has also played a supporting role with the Office of Personnel 
Management on the initiative to increase hiring veterans in all Federal 
agencies. This is now recognized as President Obama's Veterans 
Employment Initiative that directs all Executive Agencies to increase 
veteran employment. TAP is one of the programs we will use to educate 
and inform Servicemembers about Federal Service career opportunities.

Focus on Credentialing
    The Department continues to provide licensure and certification 
information in a range of ways and in different formats in order to 
appeal to individual learning styles and ensure the widest possible 
dissemination. It is important to note, the Department of Defense does 
not serve as a credentialing body. These bodies are typically well-
defined for licensure requirements by Governmental agencies--Federal, 
state, or local--who grant licenses to individuals to practice a 
specific occupation, such as a medical license for doctors. State or 
Federal laws or regulations define the standards that individuals must 
meet to become licensed.
    Non-governmental agencies, associations, and even private sector 
companies grant certifications to individuals who meet predetermined 
qualifications. These qualifications are generally set by professional 
associations (for example, National Commission for Certification of 
Crane Operators) or by industry and product-related organizations (for 
example, Novell Certified Engineer). Certification is typically an 
optional credential; although some state licensure boards and some 
employers may require certification. For many occupations, more than 
one organization may offer certifications.

Verification of Military Experience and Training
    The Verification of Military Experience and Training (VMET) 
document was established by Public Law 101-510, Section 1143(a), 
5 November 1990, National Defense Authorization Act for Fiscal Year 
1991 to assist departing servicemembers transitioning to civilian life 
by providing a verification of their military skills and training and 
translating them into civilian terms. Eligibility was all military 
(Army, Navy, Marine Corps, and Air Force) members on active duty on or 
after 1 October 1990. The Defense Manpower Data Center (DMDC), a 
Department of Defense activity that supports the Office of the Under 
Secretary of Defense for Personnel & Readiness (OUSD/P&R), has the 
responsibility for producing the VMET documents and maintaining the 
VMET Web site.
    The issuance of the DD Form 2586 Verification of Military 
Experience and Training has been enhanced and now available on demand 
directly from the Defense Manpower Data Center Web site at 
www.dmdc.osd.mil/vmet. Access to the document is protected by secure 
login protocols. The document is an ``all-services'' integrated form 
which displays demographic, training, and experience information that 
is retrieved from various automated sources, including the master 
military personnel records of each Service.
    The VMET document lists military experience and training which may 
have application to employment in the private sector. The document was 
designed as a tool to prepare resumes and job applications, in concert 
with evaluation reports, training certificates, awards, transcripts, 
and other pertinent documents. It is not an official transcript for 
purposes of granting college credit, but it can be used to support 
verification of having met training and/or course requirements to 
qualify for civilian occupations, certificates, licenses, or programs 
of study. Credit recommendations from the American Council of Education 
(ACE) for occupations and/or courses are listed when they are 
available; academic institutions determine which credits are applicable 
to a program of study.

A Lifecycle of Credentialing Education
    The Department has realized that the key feature of effective 
licensure and certification programs are that they are introduced to 
Servicemembers early in their careers, not just at the time of 
separation. We continue to provide licensure and certification 
information in a range of ways and in different formats in order to 
appeal to individual learning styles and ensure the widest possible 
dissemination. The information is provided through classroom delivery 
from an instructor, by online interaction and internet research, and 
through one-on-one coaching. This ensures that Servicemembers have 
current and accurate information at their fingertips in order to make 
informed decisions about their future. We are taking full advantage of 
the Department of Labor's Career One Stop (www.careeronestop.org) 
online resource as promoting utilization throughout the entire military 
lifecycle to reinforce the value of military training and experience. 
In this application, Servicemembers link to the Credentials Center, 
which they can use to locate State-specific occupational licensing 
requirements, agency contact information and information about 
industry-recognized certifications. There are also associated workforce 
education and examinations that test or enhance knowledge, experience 
and skills in related civilian occupations and professions.

     WOUNDED, ILL AND INJURED SERVICE MEMBER EMPLOYMENT INITIATIVES

Operation Warfighter (OWF)
    OWF is a DOD-sponsored internship program that offers recuperating 
wounded, ill and injured Servicemembers meaningful activity that 
positively impacts wellness and offers a process of transitioning back 
to duty or entering into the civilian workforce. The main objective of 
OWF is to place recuperating Servicemembers in supportive work settings 
that positively benefit the recuperation process.
    OWF represents a great opportunity for transitioning Servicemembers 
to augment their employment readiness by building their resumes, 
exploring employment interests, developing job skills, benefiting from 
both formal and on-the-job training opportunities, and gaining valuable 
Federal Government work experience that will help prepare them for the 
future. The program strives to demonstrate to participants that the 
skills they have obtained in the military are transferable into 
civilian employment. For Servicemembers who will return to duty, the 
program enables these participants to maintain their skill sets and 
provides the opportunity for additional training and experience that 
can subsequently benefit the military. OWF simultaneously enables 
Federal employers to better familiarize themselves with the skill sets 
of wounded, ill and injured Servicemembers as well as benefit from the 
considerable talent and dedication of these transitioning 
Servicemembers.
    To date, the program has placed approximately 1,800 Servicemembers 
across more than 100 different Federal employers and sub-components. 
The program currently has 390 active internship placements.

Education and Employment Initiative (E2I)
    Contributing factors to unemployment among wounded warriors include 
the lack of a focused employment, educational, and rehabilitation 
process that engages Servicemembers as soon as they begin treatment at 
a Medical Treatment Facility (MTF), as well as a lack of qualified 
career counselors who can administer career assessments and match 
Servicemembers to careers. DOD, in collaboration with VA, DOL, and the 
Office of Personnel Management (OPM), is developing E2I to address 
these shortfalls. E2I will leverage best practices and the good work 
already being done from existing employment and training initiatives in 
both Federal and private sectors. The first phase is a tiered pilot 
program scheduled to launch in by this summer.
    The goal of the E2I pilot is to engage Servicemembers early in 
their recovery to identify skills they have, the skills they need and 
the employment opportunities where those skills can be put to good use. 
The E2I process will begin within 30-90 days of when a Recovering 
Servicemember (RSM) arrives at a MTF, taking advantage of a recovery 
time that averages 311 days but can be as long as five years. At the 
very beginning of the E2I process, all applicants will be administered 
a comprehensive skills assessment that includes understanding their 
current disability, Military Occupational Specialty (MOS) experience, 
career desires, education and training background, and special 
accommodations that may be required for a particular type of position. 
This assessment will be conducted by a trained career and vocation 
counselor who has extensive knowledge of the issues facing wounded 
warriors.
    The E2I counselor will work with the RSM from the initial stages of 
creating an individual development plan (IDP), setting goals, course 
selection, and education requirements, through to the completion of 
training/certification and their return to duty or an alternate job 
placement. A Mentor and Coach will be assigned to all E2I applicants at 
the beginning of the process to provide personalized assistance and 
guidance throughout the E2I process from recruitment at the MTF into 
the program, through placement in their new MOS or chosen career.
    Our plan is to evaluate the E2I program over the next 12 months to 
18 months and refine the process with new ideas and best practices. 
Once this evaluation is complete, our plan is to continue our E2I roll-
out, which will include partnering with OPM, VA and DOL to ensure we 
have standardized practices and comprehensive handoffs as the RSM 
leaves the responsibility of the DOD.

                  INTERAGENCY ELECTRONIC HEALTH RECORD

    The collaborative Federal partnership between DOD and VA has 
resulted in increased integration of healthcare services to 
Servicemembers and Veterans. DOD and VA spearhead numerous interagency 
electronic health data sharing activities and are delivering IT 
solutions that significantly improve the secure sharing of appropriate 
electronic health information.
    Today's interagency health information exchange (HIE) capabilities 
leverage the existing electronic health records (EHRs) of each 
Department. Both Departments are currently addressing the need to 
modernize their EHRs. We are working together to synchronize EHR 
planning activities and identify a joint approach to EHR modernization.
    Current HIE sharing capabilities support electronic health data 
sharing between DOD and VA. The Federal Health Information Exchange 
(FHIE), Bidirectional Health Information Exchange (BHIE), and the 
Clinical Data Repository/Health Data Repository (CHDR) support 
continuity of care for millions of Servicemembers and Veterans by 
facilitating the sharing of health care data as beneficiaries move 
beyond DOD direct care to the VA. The data shared includes information 
from DOD's inpatient documentation system which is in use in DOD's 
inpatient military treatment facilities, including Landstuhl Regional 
Medical Center, Germany, the evacuation and treatment center 
Servicemembers pass through if they have a medical problem while 
deployed in the current theater of operations. The health data shared 
assists in continuity of care and influences decisionmaking at the 
point of care.
    The Blue Button is another example of how DOD and VA are working 
together to shape the future of health care IT collaboration, 
interoperability and transparency for the patients and families we 
serve. The Blue Button allows beneficiaries to safely and securely 
access personal health data at TRICARE Online, the Military Health 
System's Internet point of entry.
    The Blue Button capability allows beneficiaries to safely and 
securely access and print or save their demographic information, 
allergy and medication profiles, lab results, patient history and 
diagnoses, and provider visits. The level of data available is 
dependent on where treatment occurs--with the most data available to 
those who regularly get care at military hospitals and clinics.

Transmission of Data from Point of Separation
    At separation, the Federal Health Information Exchange (FHIE) 
provides for the one-way electronic exchange of historic healthcare 
information from DOD to VA for separated Servicemembers since 2001. On 
a monthly basis DOD sends: laboratory results; radiology reports; 
outpatient pharmacy data; allergy information; discharge summaries; 
consult reports; admission/discharge/transfer information; standard 
ambulatory data records; demographic data; pre- and post-deployment 
health assessments (PPDHAs); and post-deployment health reassessments 
(PDHRAs). DOD has transmitted health data on more than 5.6 million 
retired or separated Servicemembers to VA. Of these 5.6 million 
patients approximately 2.1 million have presented to VA for care, 
treatment, or claims determination. This number grows as health 
information on recently separated Servicemembers is extracted and 
transferred to VA monthly.

Access to Data on Shared Patients
    For shared patients being treated by both DOD and VA, the 
Departments maintain the jointly developed Bidirectional Health 
Information Exchange (BHIE) system that was implemented in 2004. Unlike 
FHIE, which provides a one-way transfer of information to VA when a 
servicemember separates from the military, the two-way BHIE interface 
allows clinicians in both Departments to view, in real-time, health 
data (in text form) from the Departments' existing health information 
systems. Accessible data types include allergy, outpatient pharmacy, 
inpatient and outpatient laboratory and radiology reports, demographic 
data, diagnoses, vital signs, problem lists, family history, social 
history, other history, questionnaires and Theater clinical data, 
including inpatient notes, outpatient encounters and ancillary clinical 
data, such as pharmacy data, allergies, laboratory results and 
radiology reports.
    Use of BHIE continues to increase. The number of patients, 
including Theater patients, available through BHIE increased during FY 
2010 by approximately 400,000 shared patients. There are more than 4.0 
million shared patients including health data for over 243,000 Theater 
patients, available through BHIE.
    To increase the availability of clinical information on a shared 
patient population, VA and DOD collaborated to further leverage BHIE 
functionality to allow bidirectional access to inpatient discharge 
summaries from DOD's inpatient documentation system. Use of the 
inpatient documentation system at Landstuhl Regional Medical Center 
plays a critical role in ensuring continuity of care and supporting the 
capture and transfer of inpatient records of care for wounded warriors. 
Information from these records is accessible stateside to DOD providers 
caring for injured Servicemembers and inpatient discharge summaries are 
available to VA providers caring for injured Servicemembers and 
Veterans. As of April 2011, discharge summaries are available for all 
DOD inpatient beds. DOD's inpatient documentation system is now 
operational at all 59 DOD inpatient sites.
    Recent improvements to BHIE include the completion of hardware, 
operating system, architecture, and security upgrades supporting the 
BHIE framework and its production environment. This technology refresh, 
completed in January 2011, resulted in improved system performance, and 
reliability.

Exchange of Computable Pharmacy and Allergy Data
    The Clinical Data Repository/Health Data Repository (CHDR) supports 
interoperability between AHLTA's CDR and VA's HDR, enabling 
bidirectional sharing of standardized, computable outpatient pharmacy 
and medication allergy data. Since 2006, VA and DOD have been sharing 
computable outpatient pharmacy and medication allergy data through the 
CHDR interface. Exchanging standardized pharmacy and medication allergy 
data on patients supports improved patient care and safety through the 
ability to conduct drug-drug and drug-allergy interaction checks using 
data from both systems.
    In FY 2010, the Departments exchanged computable outpatient 
pharmacy and medication allergy data on over 250,000 patients who 
receive healthcare from both systems. This was a more than 400 percent 
increase from the 44,000 patients whose computable pharmacy and 
medication allergy data was being exchanged in FY 2009. By the second 
quarter of FY 2011 the Departments have exchanged computable outpatient 
pharmacy and medication allergy data on over 741,000 patients who 
receive healthcare from both systems.

Wounded Warrior Image Transfer
    To support our most severely wounded and injured Servicemembers 
transferring to VA Polytrauma Rehabilitation Centers for care, DOD 
sends radiology images and scanned paper medical records electronically 
to the VA Polytrauma Rehabilitation Centers. Walter Reed Army Medical 
Center, National Naval Medical Center Bethesda, and Brooke Army Medical 
Center are providing scanned records and radiology images 
electronically for patients transferring to VA Polytrauma 
Rehabilitation Centers in Tampa, Richmond, Palo Alto, and Minneapolis. 
From 2007 to the present, images for more than 375 patients and scanned 
records for more than 470 severely wounded warriors have been sent from 
DOD to VA at the time of referral.

Virtual Lifetime Electronic Record
    The Departments are firmly focused on enhancing our electronic 
health data sharing and expanding capabilities to share information 
with the private sector through Nationwide Health Information Network 
(NwHIN) and the Virtual Lifetime Electronic Record (VLER). NwHIN will 
enable the Departments to view a beneficiary's healthcare information 
not only from DOD and VA, but also from other NwHIN participants. To 
create a virtual healthcare record--and achieve the VLER vision--data 
will be pulled from EHRs and exchanged using data sharing standards and 
standard document formats. A standards based approach will not only 
improve the long-term viability of how information is shared between 
the Departments, but will also enable the meaningful exchange of 
information with other government providers and with civilian 
providers, both of which account for a significant portion of care 
delivered to the Departments' beneficiaries.
    The VLER pilot projects are demonstrations of exchanges of 
electronic health information between VA, DOD and participating private 
sector providers. The pilots continue to provide evidence of the power 
and effectiveness of coordinated development between the Departments 
for increasing the secure sharing of electronic health information 
while leveraging existing EHR capabilities. DOD's VLER pilots are 
underway in San Diego, California; Tidewater, Virginia; and Spokane, 
Washington. The fourth and final pilot will be launched in Puget Sound, 
Washington in late FY 2011. In addition, VA is participating in seven 
other pilots with the private sector to expand the VLER capability. 
Those pilots are in Asheville, NC, Richmond, VA, Rural Utah, 
Indianapolis, IN and three other sites that have not yet been publicly 
announced. By September 2011, VA will be operational in a total of 11 
pilot sites, with at least 50,000 Veterans participating who have 
provided written consent to share records with the private sector.

Modernizing the EHR--The Foundation for Interagency Data Sharing
    We believe there are many benefits in pursuing a joint way ahead 
for EHR. The Departments will be able to delivera seamless health 
record from accession through end of life for all servicemembers and 
veterans. Improvements to the quality of care delivery will reduce 
errors and improve adherence to care guidelines. Strategic 
organizational use of health information, including evidence-based 
alerts and reminders, will improve effectiveness. Improved enterprise-
wide use of health information will also lead to enhanced management of 
population health, resulting in improved health status and reduced need 
for health care services. Savings in staff time and materials 
associated with system support of transactional tasks will be achieved 
by replacing manual, paper-based processes.
    While significant data sharing has existed between DOD and VA for 
years, until recently both Departments were embarked upon separate 
paths to replace our legacy EHR systems. Faced with a need to modernize 
these systems to enhance clinical decisionmaking capabilities and 
improve the quality of care for servicemembers and veterans, DOD and VA 
have agreed to implement a joint, common EHR platform going forward, 
purchasing commercially available components for joint use whenever 
possible and cost effective.
    The Departments expect to benefit from increased interoperability 
and reduced sustainment costs by implementing a common architecture, 
data and services, data centers, interface standards, and presentation 
layer. Alignment to a common data model will enable the exchange of 
information at unprecedented levels between the Departments and serve 
as an example for the Nation. Both Departments will use common data 
centers run by our Defense Information Systems Agency, which is tasked 
with continuously operating and assuring DOD's global net-centric 
enterprise. We have also agreed to use common measures of success and 
establish standard end-to-end business processes.
    In order to oversee the planning and execution of this critical 
endeavor across both Departments, we have agreed to a high-level joint 
governance structure. The effort will be led by a Program Executive and 
Deputy Director selected by the Secretary of Defense and Secretary of 
Veterans Affairs, and will leverage existing statutory authorities. An 
Advisory Board will be established and co-chaired by the DOD Deputy 
Chief Management Officer and the VA Assistant Secretary for Information 
and Technology, and will also include key stakeholders and functional 
leaders from both DOD and VA.

North Chicago
    Activated in October 2010, the Captain James A. Lovell Federal 
Health Care Center in North Chicago, Illinois is currently testing a 
unique management concept of full vertical integration of all DOD and 
VA health care functions in a single location. On an annual basis, the 
JAL FHCC in North Chicago will be responsible for ensuring the medical 
readiness of nearly 40,000 Navy recruits and caring for nearly 67,000 
eligible military and retiree beneficiaries.
    In standing up the JAL FHCC, the Departments developed reusable 
capabilities to address challenges in both DOD and VA health systems. 
Joint Patient Registration enables users to register and search for 
patients using a common graphical user interface. Medical Single Sign 
On with Context Management enables role-based access to both DOD and VA 
systems using a single login process with the ability to maintain 
patient context. Orders Portability enables users to order laboratory 
or radiology procedures from one Department's system and have that 
order fulfilled in the other's with the status and results returned to 
the ordering system. These groundbreaking capabilities are in demand 
throughout our respective enterprises, and will be fully leveraged by 
our joint EHR modernization activities.

Traumatic Brain Injury (TBI)
    The DOD has made significant advancements in TBI management and has 
implemented numerous programs during the past several years to ensure 
early detection and state of the science treatment in those who sustain 
a TBI from concussion to more severe and penetrating brain injuries. 
The Department is aggressively working to improve the diagnosis and 
treatment of TBI in-theater. In June 2010, the Directive Type 
Memorandum (DTM) 09-033, ``Policy guidance for the management of 
concussion/mild TBI in the deployed setting'' was released. This 
guidance ensured comprehensive evaluation of servicemembers who were 
exposed to potential concussive events.
    TBI research continues to be fast-tracked to assist our 
Servicemembers with close collaboration among the line, medical, and 
research communities. Key areas of promise include understanding blast 
dynamics, rapid field assessment of mild TBI to include objective 
biomarkers to be used in the diagnosis of concussion and TBI innovative 
treatment modalities. In addition, the DOD created the National 
Intrepid Center of Excellence (NICoE), a new state-of-the-art facility 
dedicated to advancing the treatment, research, and diagnosis of 
complex combat related psychological health and TBI conditions.
    Clinical care instructions, representing the state-of-the-art care, 
for all levels of TBI severity have been developed and cover both the 
deployed and the non-deployed environments. Educational materials 
include a pocket guide for CONUS TBI care, Co-occurring Conditions 
Toolkit: Mild Traumatic Brain Injury and Psychological Health, and web-
based case studies in TBI diagnosis and treatment and education 
modules. Family resources for TBI include an Online Family Caregiver 
Curriculum and educational materials available at dvbic.org, 
brainline.org and www.traumatic braininjuryatoz.org. All materials are 
aimed at line commanders, providers, Servicemembers and their families.

                             MENTAL HEALTH

    Maintaining and enhancing the psychological health of 
Servicemembers and their families is a top priority for DOD. Screening 
for mental health conditions before and after deployment on a periodic 
basis is essential for force health protection and readiness and for 
the well-being of Servicemembers. We recently established guidance to 
administer a person-to-person mental health assessment for each member 
of the Armed Forces who is deployed in connection with a contingency 
operation. The purpose of the mental health assessment is to identify 
mental health conditions including Post-Traumatic Stress Disorder, 
suicidal tendencies and other behavioral health conditions that require 
referral for additional care and treatment.
    To ensure that suicide prevention is a coordinated, joint Service 
effort, we have consolidated standard surveillance information about 
suicide events, risk and protective factors across the Services. In 
addition, we have strengthened the Suicide Prevention and Risk 
Reduction Committee (SPARRC), and have created a Web-based information 
clearinghouse called www.suicideoutreach.org.
    The Department has developed clinical support tools and guidance 
that establish DOD standards of care for mental health. Clinical 
guidance packages have been created for depression, substance abuse, 
and mild TBI and co-occurring psychological health disorders. In 
addition, there are clinical tools such as the VA/DOD Major Depressive 
Disorder Toolkit and the Co-occurring Conditions Toolkit.
    DOD and VA are working together on the Integrated Mental Health 
Strategy--a joint effort to implement 28 strategic actions, to provide 
ready access to quality clinical services, and to better align and 
coordinate the mental health services of the two Departments.
    Training for health care providers is offered on topics such as: 
PTSD, sleep disorders, depression, substance misuse, virtual reality, 
and prolonged exposure therapy. We have developed guidelines for 
training providers in evidence-based practices for PTSD. In addition, 
clinical consultation, education and dissemination of deployment health 
care best practices are available from the Deployment Health Clinical 
Center (DHCC). DHCC developed the RESPECT-Mil program, a collaborative 
care model, to enable health care providers to screen patients for 
posttraumatic stress and depression in primary care clinics.
    The Department is exploring the use of telehealth services to 
increase access to care for Servicemembers and their families, focused 
on establishing a collaborative network to rural and underserved 
locations. We have developed Mobile Telehealth Units to expand mental 
health care services to DOD beneficiaries who might not otherwise have 
access to or seek care; developed a web-based assistance program; 
developed smart phone applications to aid in the management and 
treatment of PTSD, and fielded the Virtual PTSD Experience--an 
immersive, interactive learning activity that educates users about 
combat-related post-traumatic stress.
    Servicemember and family services include: the Defense Centers of 
Excellence for Psychological Health and TBI (DCoE) Outreach Center, a 
24/7 resource available by phone, online chat or email; online self-
help tools at www.militarypathways.org and www.afterdeployment.org; and 
inTransition, a coaching and assistance program to bridge the potential 
gaps in mental health treatment during transitional periods for 
Servicemembers and veterans. DCoE partnered with Sesame Workshop to 
develop outreach programs to help children cope with deployments and 
injured parents, including the Sesame Street Family Connections Web 
site, which allows families and friends to stay in touch throughout 
deployments.
    The Real Warriors Campaign and Military Pathways online self-
screening program are two of DOD's public education initiatives that 
encourage help-seeking behavior among Servicemembers and veterans for 
psychological health concerns. Both campaigns provide regular public 
service announcements--featuring real Servicemembers who have reached 
out, obtained care, and continue to lead productive military and 
civilian careers--reach over 1.5 million servicemembers each week.

                           SUICIDE PREVENTION

    DOD is very concerned about the number of suicides in the Total 
Force over the past decade. While the overwhelming majority of 
Servicemembers effectively cope with the stress of serving in a 
military at war, there are those who have difficulty adapting to the 
stress and strain that an increased operational tempo often places on 
them and their families. The loss of even one life to suicide is 
heartbreaking; it degrades the readiness of the force and has a 
profound impact on both the unit and the family members left behind. In 
2010 there were 293 Servicemembers who died by suicide while on active 
duty, down from a total of 310 in 2009. While this is not a significant 
decrease, we have slowed the steady increases in overall active duty 
suicides that began in 2006. We believe this is due largely to the 
focus of Service senior leaders on this issue and the increasing 
emphasis on resilience across the Department highlighted by programs 
such as the Army's Comprehensive Soldier Fitness. This program is 
designed to develop and institute a holistic fitness program for 
Soldiers, families, and Army civilians in order to enhance performance 
and build resilience. To date, the Army has trained 3,253 Master 
Resilience Trainers to facilitate this goal. The other Services are 
developing or enhancing similar programs.
    We are concerned as well about the number of suicides recently in 
our Reserve Component. The Army National Guard and Reserve reported a 
combined 145 suicides in 2010 which was up significantly from the 
previous year (80 total Army Guard/Reserve). This already complex issue 
becomes even more complex when dealing with our Reserve Component 
because of their continuous transition from military to civilian life. 
Nevertheless, the Department is committed to addressing this issue. We 
currently have a Director of Psychological Health in each of our 54 
states and territories who acts as the focal point for coordinating the 
psychological support for Guard members and their families. We have 
also embedded behavioral health counselors in a small number of our 
high risk Guard units and are exploring the possibility of increasing 
this practice much more widely. The National Defense Authorization Act 
(NDAA) for Fiscal Year 2010 mandated that the Department expand suicide 
prevention and community healing and response training under the Yellow 
Ribbon Reintegration Program. . We have made some progress here and are 
in the process of reinvigorating this effort with input from a Reserve 
Component Stakeholder Group comprised of all of the Reserve and 
National Guard Components, Reserve Affairs Yellow Ribbon 
representatives and members of the Defense Centers of Excellence. 
Additionally, we are examining ``peer-to-peer'' programs to see what 
role these types of programs can play in reducing suicides.
    There have been several studies and task force reports (DOD, Army 
and RAND) released over the past year, each with multiple observations 
and recommendations. The Deputy Assistant Secretary of Defense for 
Readiness is currently leading a team of senior Officers and Executives 
from the Department in an effort to examine these reports and devise an 
implementation plan based on the recommendations that will enhance our 
suicide prevention efforts across the Department. We plan to act 
quickly on one of the main recommendations contained in the 
Congressionally mandated Final Report of the DOD Task Force on the 
Prevention of Suicide by Members of the Armed Forces and establish an 
OSD office on suicide prevention to provide strategic direction, 
oversight, and policy standardization to enhance and better coordinate 
the Department's efforts in this area with a focus on the Total Force.

                  BURN PIT SMOKE EXPOSURES IN THEATER

    A topic of concern over the past several years has been the 
possibility of long-term health risks to our Servicemembers and other 
deployed individuals associated with inhalation of burn pit smoke. DOD 
fully understands the importance of addressing this issue and takes 
very seriously the concerns of our Servicemembers and veterans 
concerning burn pit smoke exposures. Because accumulated solid waste 
can result in health risks by attracting disease-carrying insects and 
vermin, engineers determined it was necessary to implement an expedient 
means of waste disposal. Burn pits provided the means with the lowest 
risk to personnel.
    Over the past four years, there has been an ongoing and very 
successful effort in US Central Command to reduce the number of burn 
pits and replace them with incinerators or other waste disposal 
technologies and practices. All U.S. operated burn pits in Iraq at 
locations with greater than 100 U.S. personnel were closed effective 
December 31, 2010. There are presently 29 incinerators operating in 
Afghanistan, an additional 58 on order, and 11 in the planning stages.
    U.S. Central Command Regulation 200-2, ``Contingency Environmental 
Guidance,'' requires that when a basing location exceeds 100 U.S. 
personnel for at least 90 days, a plan must be developed for 
installation of adequate waste management technologies, including 
incinerators, to replace any burn pits. On February 15, 2011, the DOD 
published DOD Instruction 4715.19 ``Use of Open Air Burn Pits in 
Contingency Operations'' that established policy for burn pit use in 
contingencies and implements Section 317 of Public law 111-84. When 
burn pits are used, they must be located away from occupied areas and 
where prevailing winds blow smoke away from those areas. In addition, 
there is a prohibition against burning any hazardous materials in the 
burn pits that might generate any hazardous exposures.
    Epidemiological studies accomplished in May 2010 by the Armed 
Forces Health Surveillance Center and the Naval Health Research Center 
entitled ``Epidemiological Studies of Health Outcomes among Troops 
Deployed to Burn Pit Sites'' do not provide evidence at this time on a 
population-wide basis that burn pit smoke exposures pose long-term 
health risks for smoke-exposed individuals. While no long-term health 
risks have yet been identified, we believe it is plausible that some 
Servicemembers may be affected by long-term health effects, possibly 
due to combined exposures (such as sand/dust, industrial pollutants, 
tobacco, smoke and other agents) and individual susceptibilities, such 
as preexisting health conditions or genetic factors. This population 
will continue to be followed and monitored for any future health 
effects that have not yet manifested.
    In the meantime, DOD is continuing to reduce exposures to burn pit 
smoke by closing burn pits, installing incinerators and ensuring the 
elimination of potentially harmful materials from the waste streams. 
DOD will continue to study inhalational exposures in theater, including 
the contribution from the smoke and any resulting health conditions in 
our Servicemembers in order to determine the extent of any long-term 
health risks that may exist. DOD is working closely with VA to ensure 
care for those who are possibly affected.
    Additional monitoring of burn pit emissions in Afghanistan is 
planned for 2011. The Defense Health Board and the Institute of 
Medicine are reviewing the Armed Forces Health Surveillance Center's 
report, and we are looking forward to their suggestions on how we can 
improve our studies as well as the frequency that they should be 
repeated.

                               CONCLUSION

    We cannot overstate how far DOD has come with our VA partners in 
the past four years since the SOC and other governance processes were 
put in place. Each of the Services has stood up a very comprehensive 
and `stand alone' Wounded Warrior Care program. Yet we still have much 
progress to make. And as we close, we would like to be clear: One 
mistake, undue delay or any other aberration in the care or transition 
of our wounded ill or injured servicemembers is one too many. We will 
continue to work with our team-mates at the VA and throughout the 
interagency to do anything and everything we can to provide our 
Servicemembers with the absolute best care and treatment that they so 
rightfully deserve in return for their selfless service and sacrifice 
to our Nation. We continue to be awed and grateful for their service 
and that of their Families.
    While we are pleased with the quality of effort and progress made, 
we fully understand that there is much more to do. We have thus 
positioned ourselves to implement these provisions and continue our 
progress in providing world-class support to our warriors and veterans 
while allowing our two Departments to focus on our respective core 
missions. Our dedicated, selfless servicemembers, veterans and their 
families deserve the very best, and we pledge to give our very best 
during their recovery, rehabilitation, and return to the society they 
defend.

    Mr. Chairman, thank you again for your generous support of our 
wounded, ill, and injured servicemembers, veterans and their families. 
We look forward to your questions.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Patty Murray to 
                       U.S. Department of Defense

    Question 1. The Departments have numerous programs and projects to 
inform servicemembers of their rights and benefits upon separation from 
the military. Yet repeated reports from young men and women state that 
the transition assistance was not available or they were given too much 
information at a time when their focus was on returning to their 
family.
    a. What are the Departments doing to jointly manage the information 
flow related to separation?
    b. How do E-Benefits and the Veterans Relationship Management 
program fit into a joint VA/DOD plan to keep all separating 
servicemembers informed?

    Response. a. The three agencies are working together to update TAP. 
Each agency has revamped its curriculum, and DOD recently developed a 
new pre-separation counseling checklist. DOD's TurboTAP.org Web site 
was specifically developed to be a readily available resource to manage 
the information flow related to separation. Transitioning 
Servicemembers are referred to this Web site as one of the primary 
reference sources should they need further information in the future. 
The Web site provides retiring and separating Servicemembers, as well 
as veterans, access to pre-separation guides covering topics such as 
employment assistance, education and training, health care and life 
insurance, and veterans benefits; it also contains a Career Decision 
Toolkit covering every aspect of career transition, from exploring 
career options to negotiating the ideal compensation package for a new 
job.
    b. To keep all separating Servicemembers informed, the eBenefits 
portal is a collaborative effort between the Department of Veteran 
Affairs (VA) and the Department of Defense (DOD) to provide 
Servicemembers, veterans, and their families personalized access to 
benefit information, resources, and self-service capabilities. This 
Servicemember/veteran-centric portal focuses on the health, benefits, 
and support needs, consisting of both a public Web site and a secure 
portal that allows for multiple self-service capabilities along with 
personalization by the user and customizes benefits related information 
based on user profile. This enables Servicemembers, veterans, and their 
authorized designees to find benefits related information and services 
in one location.The eBenefits portal and Web site design is user-
friendly and helps Wounded Warriors to easily locate the information 
and services needed. Specifically, transitioning Servicemembers will be 
able to locate Transition Assistance Program (TAP) information and 
utilize the self service capabilities to know and apply for eligible 
benefits on a persona-based platform.
    The VA's Veterans Relationship Management (VRM) initiative is to be 
integrated with the eBenefits portal to aid proactive messaging for 
outreach to Servicemembers and veterans regarding their eligibility to 
benefits and entitlements, benefits assistance, and delivery. VRM is a 
broad multi-year initiative to improve veterans' secure access to 
health care and benefits information and assistance. VRM will provide 
VA employees with up-to-date tools to better serve veterans and their 
families, and will empower veterans through enhanced self-service 
capabilities such as those found within the eBenefits portal.

    Question 2. The Department's testimony stressed the importance of 
information technology to improve services and programs for all of our 
men and women in uniform. In the Department's view, what role will a 
single DOD/VA modernized electronic health record play in delivering 
services to these departing servicemembers?
    Response. In the Department's view, the role of a common electronic 
health record (EHR) in delivering services to departing Servicemembers 
is to better enable secure, seamless, cross-boundary sharing of health, 
benefits, and administrative information for Servicemembers and 
Veterans to those with the need to know.
    It is evident that efficient access to health, benefits, and 
administrative records of Servicemembers and Veterans can help reduce 
or eliminate delays in care due to unnecessary red tape and lack of 
access to needed records. To this end, the Department of Defense (DOD) 
partnered with the Department of Veterans' Affairs (VA) and other 
agencies to create an electronic capability to share a virtual record 
of health, benefits, and administrative information of Servicemembers 
and veterans, beginning the date of entry into military service and 
extending beyond their lifetime. Implementation and use of this Virtual 
Lifetime Electronic Record (VLER) will improve continuity of care, 
administration of benefits, and accessibility of service records for 
Servicemembers, veterans, and their authorized designees.
    DOD and VA are also collaborating on a common framework and 
approach to modernize the Departments' EHR applications. Secretary 
Gates and Secretary Shinseki met on May 2, 2011, and reaffirmed their 
commitment to pursue a joint, common platform enabled through 
appropriate governance for EHR. Synchronization of EHR planning 
activities will accommodate the rapid evolution of healthcare practices 
and data sharing needs, and speed fielding of new capabilities.

    Question 3. Over the years, VA and DOD have increased 
servicemembers' opportunities to file a ``pre-discharge'' disability 
claim, yet the Departments estimate that less than half of all 
servicemembers currently have access to file a claim. With the use of 
contractors and the potential of filing an electronic claim, it is 
reasonable that 100 percent of servicemembers would be able to 
participate in this process.
    a. Do both Departments intend to provide 100 percent of 
transitioning servicemembers with the opportunity to file a ``pre-
discharge'' disability claim, and if so, what is the timeline for 
completion of this goal?
    b. What obstacles, if any, stand in the way of providing 100 
percent of transitioning servicemembers with the opportunity to file a 
``pre-discharge'' disability claim?

    Response. a. Yes. DOD and VA intend to provide 100% of 
transitioning Servicemembers with the opportunity to file a pre-
discharge disability claim. The Benefits Delivery at Discharge (BDD) 
and Quick Start Programs are Department of Veterans Affairs (VA) 
programs that allow Servicemembers to apply for disability compensation 
benefits from VA prior to retirement or separation from military 
service.
    Servicemembers can apply for disability benefits through the BDD 
program at 131 military installations in the Continental United States 
(CONUS), Germany, Italy, Portugal, the Azores, and Korea. Additionally, 
Servicemembers can apply for disability benefits through the Quick 
Start program at all installations.
    b. At this time, we are not aware of any obstacles in the way of 
providing 100% of transitioning Servicemembers to file pre-discharge 
disability claims.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Richard Burr to 
                       U.S. Department of Defense

    Question 1. According to a memorandum signed by the Secretary of 
Defense and the Secretary of Veterans Affairs, the two Departments have 
agreed to move forward with a plan to revise the Integrated Disability 
Evaluation System (IDES) so that the entire process could be completed 
within 150 days, instead of the current target of 295 days. At the same 
time, the Departments have agreed to look at options for reducing that 
timeframe to 75 days.

    a. Does this suggest that the Departments consider the existing 
IDES process not to be an effective way to handle the transition for 
wounded servicemembers?
    b. How would the IDES process potentially be revised?
    c. Could these potential revisions be done administratively or will 
legislation be needed?
    d. What is the timeline for rolling out a revised IDES process in 
some fashion?
    e. In the meantime, please explain why the Departments plan to 
continue rolling out the existing IDES process to additional sites. Why 
not improve the process first?
    f. Does the decision to move forward with the IDES rollout take 
into account what impact the delays and uncertainties of the IDES 
process may be having on injured military personnel before they are 
discharged? Please explain.
    g. Does this suggest that the Departments consider the existing 
IDES process not to be an effective way to handle the transition for 
wounded servicemembers?
    Response. a-g. No, the Department considers the Integrated 
Disability Evaluation System (IDES) to be the most effective system 
currently available to handle transitioning Wounded Warriors. Although 
we are continuously looking for ways to improve, the IDES has proven to 
be faster, fairer and substantially reduced the DOD/VA benefits gap. 
This constitutes a major improvement over the legacy DES and we, along 
with the VA, are committed to the worldwide expansion.
    Although IDES has yet to meet performance goals, our continuous 
process improvement efforts are beginning to show signs that some of 
the stages/phases of the process are becoming more timely. Even as the 
worldwide IDES rollout is completed in the next few months, DOD 
continues to actively pursue greater efficiencies in process 
timeliness. The ultimate goal will always be to provide the best 
possible Disability Evaluation System for every wounded, Ill or injured 
Servicemember.
    h. How would the IDES process potentially be revised?
    The IDES process would potentially be revised processing current 
sequential steps that can be accomplished in parallel to each other. 
For example, the Servicemember being able to request a VA rating 
reconsideration while they are out-processing from the unit, allowing 
better handoffs between DOD and VA. By reorganizing elements of the 
process, streamlining elements like the Medical Evaluation Board, and 
testing other innovative disciplines such as information technology and 
paperless/electronic records transfers, we continue to improve 
timeliness and move closer to achieving performance goals. Using 
parallel processes and innovative technology will continue to reduce 
the transition time for Servicemembers.
    i. Could these potential revisions be done administratively or will 
legislation be needed?
    These potential revisions to the IDES under consideration can be 
accomplished within the existing laws.
    j. What is the timeline for rolling out a revised IDES process in 
some fashion?
    The timeline for rolling out a revised IDES process is January 
through September 2012. This revised IDES process is entitled IDES 
Remodel Proof-of-Concept and will be conducted at designated sites for 
each Military Department. This will allow the Departments to determine 
its effectiveness toward improving the timeliness of the IDES process.
    k. In the meantime, please explain why the Departments plan to 
continue rolling out the existing IDES process to additional sites. Why 
not improve the process first?
    The Departments plan to continue rolling out the existing IDES 
because the Departments would not want to unduly delay benefits of our 
Servicemembers. Unlike the ``Legacy DES,'' the IDES provides a 
Servicemember with their military and VA compensation shortly after 
separation or retirement from active service. DOD and VA are fully 
committed to IDES as an improvement over the Legacy DES. The benefits 
achieved thus far outweigh the alternative of not continuing with the 
plan to expand the IDES to all locations. The Departments are committed 
to looking at every alternative to continue improving the delivery of 
benefits to our valued Servicemembers and their families.
    l. Does the decision to move forward with the IDES rollout take 
into account what impact the delays and uncertainties of the IDES 
process may be having on injured military personnel before they are 
discharged? Please explain.
    Yes, the focus is making sure that every plan is Servicemember 
centric. The Departments are committed to continually improving IDES to 
make it more efficient. While the current process continues to be 
improved, it is important to note that the Servicemember receives their 
full pay and allowances throughout the entire IDES transition process. 
Once a date of separation from service is established, the 
Servicemember and/or their family are able to receive their military 
and VA compensation much sooner than with the Legacy DES.
    The Departments are committed to getting the system to a more 
reasonable timeframe, and to complete every step in the process as 
quickly as is fair to Servicemembers. As new delays are discovered, 
solutions are developed. The Departments are also exploring ways to 
further reduce that process time.

    Question 2. In a September 2010 report, the Department of Veterans 
Affairs and the Department of Defense identified timeliness and 
customer satisfaction as key indicators of performance for the IDES and 
found that it was, at that time, a ``success'' with ``proven 
performance.'' Now, IDES sites are collectively missing the 295-day 
timeliness goal by over 100 days and some sites--like Camp Lejeune--are 
missing that goal by well over 200 days. In fact, only 15% of 
servicemembers are completing the process within the target timeframe. 
Also, customer satisfaction goals are not being met. At Lejeune, 
satisfaction is only 60%--20% lower than the target.

    a. In light of these statistics, how would the Department of 
Defense rate the performance of the Integrated Disability Evaluation 
System now?
    b. What impact do these delays have on the military in terms of 
readiness and resources for each branch of the military?
    c. Please explain the root causes of these delays and what steps 
are being taken in the near term, while the IDES process is being 
revised, to improve timeliness and customer satisfaction.
    d. Until those revisions are complete, please provide the Committee 
with weekly updates on the average time it is taking military-wide to 
complete the IDES process and the percent of servicemembers who are 
completing the process within the 295-day goal.

    Response. a. In light of these statistics, how would the Department 
of Defense rate the performance of the Integrated Disability Evaluation 
System now?
    The Department would rate the performance of IDES as improving. The 
Departments set ambitious goals and are striving to meet them. IDES 
still outperforms Legacy DES processing in efficiency, time, and 
satisfaction while eliminating the benefits gap. These measures suggest 
a successful program that is continuing to improve. Surveys collected 
during April, 2011, show overall improvement with IDES from previous 
months. Air Force and Navy Servicemembers reported satisfaction at or 
above the 80% DOD goal. For the same period, Soldiers reported 72% 
satisfaction and Marines reported 65%. Guard and Reserve Servicemembers 
reported 78% satisfaction with the IDES process in April 2011.
    b. What impact do these delays have on the military in terms of 
readiness and resources for each branch of the military?
    While in the IDES, Servicemembers are not available, which has an 
impact on readiness. These are real challenges, and our efforts to 
decrease time in system will assist the Services better manage their 
available end strength.
    The Army found that consistent growth in the Physical Disability 
Evaluation System (PDES) population, does pose a risk to Army readiness 
over the coming fiscal years. The Navy population concerned is not 
large enough to have a significant effect on overall readiness. For the 
Air Force, individuals processing through IDES are not deployable 
assets, and though they may remain in deployable positions, they may 
not be able to be utilized for deployment tasking by their unit 
Commander.
    c. Please explain the root causes of these delays and what steps 
are being taken in the near term, while the IDES process is being 
revised, to improve timeliness and customer satisfaction.
    The root causes of the delays were found to be Medical Evaluation 
Board (MEB) processes and the processing and development of initial 
ratings. We have studied the IDES process and know where delays are 
occurring. We have put together a team from the Services to address 
those Servicemembers dealing with delays at various stages in the IDES 
process. They have reported and customer satisfaction is now trending 
in the right direction.
    DOD solutions include the Army and Navy implementing streamlined 
Medical Evaluation Board (MEB) processes to reduce time required for 
that stage of the process. VA has also added an additional rating site 
in Rhode Island to speed up the processing and development of initial 
ratings by augmenting the existing work being done in Baltimore and 
Seattle.
    d. Until those revisions are complete, please provide the Committee 
with weekly updates on the average time it is taking military-wide to 
complete the IDES process and the percent of servicemembers who are 
completing the process within the 295-day goal.
    As DOD continues to expand IDES worldwide to 139 sites we will 
provide the Committee with the requested status reports.

    Question 3. Information recently obtained by the Committee reflects 
that at least 280 servicemembers going through the IDES process have 
received an Administrative Discharge and 40 others have been court-
martialed. Worse, at least 17 servicemembers going through the IDES 
process have died from non-natural causes, including suicide, 
overdoses, a motorcycle accident, and gunshot wounds.
    a. Has the Department of Defense made any attempts to figure out 
what went wrong for these particular servicemembers? If so, please 
explain.
    b. Are any efforts being made to gauge the personal toll the delays 
and uncertainties of the IDES process may be taking on wounded 
servicemembers?
    c. What is the Department of Defense doing to identify and provide 
help for IDES participants having suicidal thoughts, having problems 
with drugs, or engaging in risky behavior?
    d. What more can be done to make sure wounded servicemembers going 
through the IDES process have the supports and services they need to 
cope with the transition process and go on to successful civilian 
lives?
    e. Until the IDES process has been revised, please provide the 
Committee with monthly updates on the number of servicemembers going 
through the IDES process who have received Administrative Discharges, 
been court-martialed, or died from non-natural causes.

    Response. a. Has the Department of Defense made any attempts to 
figure out what went wrong for these particular servicemembers? If so, 
please explain.
    The Department as a whole is doing everything it can to address 
these issues. As Servicemembers are transitioning they remain subject 
to disciplinary actions and the Uniformed Code of Military Justice. As 
such, there are a myriad of behaviors or varied actions that require 
Administrative Discharges, non-judicial punishment or court-martials. 
All deaths are reviewed to ensure standards of medical care are met. 
The Armed Forces Medical Examiner is notified of all Active Duty deaths 
that occur outside DOD and makes a determination of whether to accept 
the findings of local officials or whether further investigation is 
required and warranted.
    b. Are any efforts being made to gauge the personal toll the delays 
and uncertainties of the IDES process may be taking on wounded 
servicemembers?
    Soldiers are surveyed at various points throughout the disability 
evaluation process to determine their satisfaction with the IDES 
process, the results of which are reviewed at all levels of leadership. 
Currently, the Army has the one of the highest satisfaction rates 
within the DOD.
    The Department of the Navy is also committed to supporting all 
Servicemembers throughout the IDES process. Servicemember satisfaction 
surveys are requested throughout the process to formally evaluate their 
experience. Additionally, Healthcare Providers, Physical Evaluation 
Board Liaison Officers, Recovery Care Coordinators and Medical Case 
Managers work with patients to assist them and to reduce burdens. As 
problems are identified, local commands work quickly to address these 
issues to reduce the burden to the Servicemember.
    c. What is the Department of Defense doing to identify and provide 
help for IDES participants having suicidal thoughts, having problems 
with drugs, or engaging in risky behavior?
    To help identify and provide help for IDES participants, every 
Recovery Care Coordinator has received training on suicide prevention. 
Servicemembers dealing with suicidal thoughts have multiple programs 
and intervention/treatment avenues, to include the National Suicide 
Prevention Lifeline, Military OneSource, and the ability to seek 
immediate care without the need for referral. Each Service also has an 
active suicide prevention program, designed to minimize suicide 
behavior.
    d. What more can be done to make sure wounded servicemembers going 
through the IDES process have the supports and services they need to 
cope with the transition process and go on to successful civilian 
lives?
    In addition to the DOD-wide efforts of Disabled Transition 
Assistance Program, Operation Warfighter internship program, and the 
Education & Employment Initiative, each Service has specific programs 
for Servicemembers as they go through the transition process.
    The Army has multiple programs in place to ensure that Soldiers 
have the support and resources they need to prepare for their 
transition out of the military. The most seriously wounded, ill, and 
injured Soldiers are assigned to Warrior Transition Units, where 
soldiers are afforded a triad of leadership focused on ensuring they 
are connected with the programs and support systems needed based upon 
their individualized needs. Navy Safe Harbor seeks to focus upon the 
transition process for seriously wounded, ill and injured Sailors and 
Coast Guardsmen. To enhance community reintegration, the Marine Corps 
Wounded Warrior Regiment's Transition Support Cell, manned by Marines 
and representatives from the Departments of Labor and Veterans Affairs, 
proactively reaches out to identify employers and job training programs 
that help WII Marines obtain positions in which they are most likely to 
succeed and enjoy promising and fulfilling careers. The Air Force 
Airman and Family Readiness Center (A&FRC) is the initial point of 
contact for all separating Airmen and their families, and its staff 
provides services, counseling, training, workshops, employment 
assistance, and educational information throughout the transition 
process.
    e. Until the IDES process has been revised, please provide the 
Committee with monthly updates on the number of servicemembers going 
through the IDES process who have received Administrative Discharges, 
been court-martialed, or died from non-natural causes.
    As of June 21, 2011, the Veterans Tracking Application indicates 
the following IDES cumulative dispositions: a total of 324 
Administrative Discharges, plus 51 court-martials, plus 41 deaths. The 
Office of Wounded Warrior Care and Transition Policy (WWCTP) will work 
with the Services to compile the data and provide a monthly report.

    Question 4. The Government Accountability Office (GAO) has reported 
that some servicemembers going through the IDES process are not given 
meaningful employment and, if left idle, are more likely to engage in 
behavior that could result in a discharge for misconduct. Recently, the 
Department of Defense informed the Committee that it plans to publish a 
guide that will direct commanders to make sure servicemembers going 
through the IDES process have meaningful work.
    a. Do the large number of court-martials and Administrative 
Discharges for those going through the IDES process suggest that there 
is a real problem with some wounded servicemembers being left idle? 
Please explain.
    b. Has the new guide been published and distributed yet? If not, 
when will it be?
    c. How will the Department of Defense track whether military bases 
are complying with the requirement to provide meaningful work for IDES 
participants?
    d. Has the Department of Defense considered whether the surveys 
given to IDES participants should include questions to gauge whether 
idleness or lack of meaningful work is seen as a problem?

    Response. a. Do the large number of court-martials and 
Administrative Discharges for those going through the IDES process 
suggest that there is a real problem with some wounded servicemembers 
being left idle? Please explain.
    No, from our records, the rates do not suggest a problem. IDES 
cumulative rate for these categories is less than 1.5%. Through 
leadership from squad leaders and commanders, the Services work to keep 
Servicemembers active and engaged throughout the transition process.
    Soldiers who are on active duty during the course of their 
disability evaluation process are, under the direction of their unit 
commander and assigned work that is appropriate based upon their 
physical limitations. Of those Soldiers found ``fit'' over the past 
three fiscal years, only 3% went on to be administratively separated 
but none were separated for the same reason that they were originally 
boarded. The reasons for the administrative separations were varied, 
and represent instances that would have resulted in the separation of 
the Soldier regardless of the physical condition that prompted the 
referral to the disability evaluation process.
    b. Has the new guide been published and distributed yet? If not, 
when will it be?
    No, the new guide has not been published and distributed yet. At 
this time, the forthcoming IDES Directive Type Memorandum (DTM) is in 
final review and we anticipate publication soon.
    c. How will the Department of Defense track whether military bases 
are complying with the requirement to provide meaningful work for IDES 
participants?
    The Department will be alerted as appropriate by unit Commanders. 
DOD believes that the unit Commander is responsible for ensuring that 
each Servicemember is assigned appropriate and meaningful work at all 
times.
    d. Has the Department of Defense considered whether the surveys 
given to IDES participants should include questions to gauge whether 
idleness or lack of meaningful work is seen as a problem?
    Yes, the IDES Satisfaction surveys included questions on Idleness 
beginning in May 2011. As of May 18, 2011, all IDES and Legacy DES 
survey respondents are asked specific questions about opportunities to 
engage in meaningful work or activities, whether they participated or 
not, and, if not, why. Although it will be several months before 
sufficient data can be compiled to provide an analysis on this subject, 
early results show that Servicemembers are engaged and satisfied with 
their work or activities.

    Question 5. According to written testimony provided by the 
Department of Defense in connection with a November 2010 Committee 
hearing, ``The Services face challenges adequately staffing the IDES 
process, ensuring transportation to and from and timely disability 
examinations, and the impacts of the extra time on active duty during 
the IDES on force structure and readiness, housing and billeting, and 
command and control.'' Despite these challenges, the Departments plan 
to rollout the IDES process worldwide by September 2011, a timeframe 
GAO described as ``ambitious in light of substantial management 
challenges and * * * deteriorating case processing times.''
    a. In light of these challenges, what factors initially led the 
Department of Defense to conclude that the number of IDES sites should 
be aggressively expanded?
    b. Will these challenges be tackled before either the existing IDES 
process or a revised IDES process is rolled out to any more sites?
    c. What impact do these challenges have on wounded servicemembers?

    Response. a. In light of these challenges, what factors initially 
led the Department of Defense to conclude that the number of IDES sites 
should be aggressively expanded?
    The Department concluded that sites should be expanded due to the 
fact that the IDES outperforms Legacy DES in processing efficiency, 
time, and satisfaction, and eliminates the benefits gap. Surveys and 
performance metrics, taken during evaluation of the Pilot and 
subsequent stages, suggest a successful program, which is expanding in 
careful sequence as potential improvements are explored.
    b. Will these challenges be tackled before either the existing IDES 
process or a revised IDES process is rolled out to any more sites?
    Yes. The Services and VA are actively engaged in hiring additional 
staff, determining solutions to transportation and other efforts to 
minimize impacts on force structure, which is why we are also actively 
pursuing faster processes.
    c. What impact do these challenges have on wounded servicemembers?
    The Services and VA provide an extensive support network and are 
aggressively pursuing several process improvements, which reduce the 
challenges that were alluded to in the November 2010 hearing.

    Question 6. Last month, the Senate Committee on Veterans' Affairs 
held a hearing on employment. The Committee heard several complaints 
from veterans regarding service records containing military training 
information that is difficult for potential private employers to 
understand. According to your testimony before the Committee on 
May 25th, the Department of Defense has undertaken a number of 
initiatives to translate military experience to jobs in the private 
sector, and has been doing so for some time. Yet, it appears these 
initiatives are still not working for many servicemembers transitioning 
to civilian jobs.
    Please explain what DOD is doing so that civilian employers 
understand the military skills and are able to transfer them into 
private sector jobs.
    Response. The Department's approach is to prepare our transitioning 
Servicemembers by providing them with the training, tools and 
information to be well prepared as they enter the civilian job market. 
During pre-separation counseling, Servicemembers are informed about 
several resources that can assist them in translating their military 
training and skills into civilian equivalent occupations and 
terminology.
    The first resource is the Verification of Military Experience and 
Training (VMET) document that translates military skills and 
occupations into civilian equivalents, and can be used as a source 
document to verify job skills, education, training, and experience 
acquired while on active duty that has application to employment in the 
civilian sector. Other resources include the Service's Credentialing on 
Line, or COOL Web sites, and the Occupational Information Network, or 
O*NET Web sites. These Web sites allow Servicemembers to crosswalk 
their Military Occupational Specialty code to its civilian equivalency 
through O*NET's Standard Occupational Classifications. An additional 
resource for Servicemembers is a skills translator to use to identify 
Federal jobs related to their military occupations. DOD, the 
Departments of Labor and Veterans Affairs collaborated with The State 
of Maryland to develop the Military to Federal Jobs Crosswalk. The web 
site can be found at: http://www.mil2fedjobs.com/.
    In August 2010, the Office of Wounded Warrior Care and Transition 
Policy also launched the Career Decision Tool kit, accessible via 
interactive CD and TurboTap.org Web site, which includes a tutorial on 
translating military skills and experience to civilian occupations. In 
March 2011, we also began a series of online webinars that includes two 
offerings, ``Building a Better Resume'' and ``Decoding Military Skills 
for Civilian Employers'' to specifically assist transitioning 
Servicemembers in this area.
    Additionally, Servicemembers receive instructions during the 
Department of Labor's TAP Employment Workshop on how to use the above 
resources to eliminate ``military jargon'' and develop resumes that 
translate their skills and experience into language that employers 
understand.

    Question 7. According to a report by GAO on the Federal Recovery 
Coordination Program, Federal Recovery Coordinators (FRC) ``cannot 
readily identify potential enrollees using existing data sources.'' The 
Senior Oversight Committee developed a categorization system to 
identify those servicemembers that would benefit from an FRC. However, 
these are purely administrative categories and do not line up with VA 
or DOD's medical and benefits systems.
    a. What steps have been taken to align the categories set out by 
the Senior Oversight Committee with the medical and benefits system of 
DOD?
    b. What steps has DOD taken to better identify potential 
servicemembers that can benefit from a Federal Recovery Coordinator?
    c. The Special Operations Command's Care Coalition has been 
recognized to be the ``gold standard'' by Admiral Mike Mullen, the 
Chairman of the Joint Chiefs of Staff, for helping wounded 
servicemembers. What is this program doing right and could this model 
be replicated?

    Response. a. What steps have been taken to align the categories set 
out by the Senior Oversight Committee with the medical and benefits 
system of DOD?
    DOD hosted a Wounded Warrior Care Coordination Summit in 
March 2011, bringing together representatives from care coordination 
programs throughout the Services, VA, and Department of Labor to 
participate in working groups.
    The direct result of the FRC/RCC Collaboration Working Group was 
the recommendation to eliminate care categories (1, 2, and 3) 
eligibility criteria and establish appropriate assessment criteria for 
care coordination.
    The DOD/VA Executive Committee also recommended refining the 
referral criteria to ensure appropriate referrals are made. As a result 
of this recommendation, the Case Management Workgroup will be 
reconvened to address the matter. These categories are administrative 
in nature and are primarily used to determine what type of care 
coordination is provided by DOD and the VA.
    In addition, the RCCs are currently serving those recovering 
Servicemembers within Category 2 and 3, and include FRCs within 
Category 3. Recovery Care Coordinators and Federal Recovery 
Coordinators (FRCs) are all highly trained and skilled in Federal, 
local, and private resources, benefits, and compensation, as well as 
the Disability Evaluation System process for our wounded, ill, and 
injured Servicemembers in both categories.
    b. What steps has DOD taken to better identify potential 
servicemembers that can benefit from a Federal Recovery Coordinator?
    First, if a wounded, ill, or injured Servicemember receives an 
acuity assessment score in the Category 3 level, there is an automatic 
referral to a Federal Recovery Coordinator (FRC). In addition, we are 
currently including the FRC Leadership and FRCs in the RCC orientation 
training to educate RCCs on the FRCs' function, where they are located, 
their contact information, and how to best utilize their talents. Some 
service programs have FRCs collocated with RCCs at major Military 
Treatment Facilities, which has enhanced the collaborative relationship 
and allowed for earlier identification and referral to an FRC.
    RCCs are trained to provide outreach briefs of the programs and 
what services they offer, how to access them, and key points of 
contacts. We are also working to improve marketing the FRC program and 
benefits to other Federal agencies and private sector agencies that 
serve our Servicemembers, families and veterans.
    c. The Special Operations Command's Care Coalition has been 
recognized to be the ``gold standard'' by Admiral Mike Mullen, the 
Chairman of the Joint Chiefs of Staff, for helping wounded 
servicemembers. What is this program doing right and could this model 
be replicated?
    USSOCOM's Care Coalition, like other Service Wounded Warrior 
Programs, is involved very early after incident or injury and acts as a 
``gatekeeper'' to the dozens of assisting services provided to the 
Servicemember while they are still hospitalized. USSOCOM also matches a 
Servicemember and family/caregiver with a mentor who has had the same 
injury or illness. It is a way for the wounded, ill, or injured to 
build a relationship with someone who understands, is happy to help and 
has gone through similar experiences. The recovering Servicemember and 
their family/caregiver respond very well in this environment of care.
    This USSOCOM model has been included in overall best practices for 
helping our Wounded Warriors. As a result of our Wounded Warrior Care 
Coordination Summit in March 2011, many of these strategies are now 
included in all Wounded Warrior Programs.

    Question 8. The GAO report points to challenges coordinating with 
other programs supporting the FRC program. Although, these programs are 
not just for the most severely injured servicemembers, they have 
similar case management functions and many recovering servicemembers 
are enrolled in more than one program. This has led to a duplication of 
efforts and could lead to confusion for the servicemember.
    What steps have been taken to better share information on 
servicemembers enrolled in the Federal Recovery Coordination Program to 
reduce confusion and redundancy in the recovery process?
    Response. In order to better share information on Servicemembers 
enrolled in the FRCP, Recovery Care Coordinators (RCCs) work 
collaboratively with the Soldier and Family Assistant Centers, Warrior 
and Family Assistance Centers, Warrior Transition Units, and Federal 
Recovery Coordinators to avoid duplication of efforts. They also 
educate recovering Servicemembers and their families/caregivers on the 
services available to assist in whatever issues may arise.
    To reduce confusion and redundancy, RCCs transition recovering 
Servicemembers, who then become Veterans, and begin to work with the 
Veteran Administration's Liaisons and OIF/OEF/OND case managers, as 
well as being tracked by VA Nurse Case Managers (NCMs) and the FRCs. 
All the Services and United States Special Operations Command (USSOCOM) 
work with the FRCs, VA Liaisons and OEF/OIF/OND Case Managers.. 
USSOCOM's Care Coalition has a VA Advisor and a FRC who are both co-
located with the RCCs in the Care Coalition office at their Tampa 
Headquarters.
    While it is a challenge when it comes to sharing information 
between DOD and the VA on Servicemembers, the Deputy Assistant 
Secretary of Defense for Wounded Warrior Care and Transition Policy co-
chairs the Information Sharing Initiative (ISI) to support the 
coordination of non- clinical care. The increased ability to share 
information electronically across DOD and VA will improve the process 
as we move forward.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Mark Begich to 
                       U.S. Department of Defense

    Question 1. Mr. Taylor, TRICARE Management Activity has worked with 
me over the last 2 and half years to make TRICARE serve its 
beneficiaries better in Alaska. Together, we have made a lot of 
progress. A critical component of making TRICARE--and all other Federal 
health care options--work for patients in Alaska is an appropriate 
reimbursement rate that reflects the higher cost of providing care in 
Alaska. Recognizing this, all Federal entities currently pay 
reimbursements higher than Medicare rates. However, since all the 
Federal agencies pay a higher but different rate, often times they end 
up creating competition amongst themselves for the primary care 
physicians and specialists. Keep in mind; many of our communities have 
one physician. For some specialties it may only be practiced by one 
person in the entire state. So having a single, appropriate Federal 
reimbursement rate is key to ensuring all Federal health care 
beneficiaries are served. A Federal task force I commissioned validated 
the need for a single rate.
    a. Will you look in to this issue? Will you work with your VA 
counter-parts?
    b. Do the VA witnesses have any comment?
    Response. Yes, in fact the Department of Defense representatives 
met with our Department of Veterans' Affairs (VA) counterparts on 
May 12, 2011. During this initial meeting, we committed to ongoing 
meetings with the VA on the issue and to work toward a solution.

    Question 2. Mr. Taylor, there is a lack of trauma care in Alaska. 
There is no Level 1 trauma center in the state--the nearest is in 
Seattle--4 hours away. There is only one Level 2 Trauma center in 
Anchorage. Trauma is the leading cause of death for Alaskans between 
the ages of 15-24. Military medics have to travel to the lower 48 to 
maintain skills. With the high deployment tempo for military medics 
from Alaska to combat zones and need for trauma care in Alaska, it 
seems a civilian-military partnership would be a mutually beneficial 
relationship, may even save the Department of Defense some training 
money. More importantly it will save lives. A military and civilian 
partnership for trauma care exists in Washington at the Tacoma Trauma 
Care Center.
    Has the Department of Defense explored a trauma center partnership 
in Alaska? Why or why not? Will you look in to this?
    Response. Yes, the DOD has explored a trauma center partnership in 
Alaska. Due to the need for military medics to maintain their trauma 
skills, military leadership has expressed interest in partnering with 
the Anchorage community to provide the level of care found in similarly 
sized cities in the 48 contiguous states. The Air Force hospital at 
Elmendorf has been working on an agreement for its surgeons to begin 
covering emergency trauma care in the civilian community in order to 
obtain trauma and other experience. A shortage of key specialists in 
the civilian community who are willing or able to provide trauma care 
continues to impede efforts to move forward and could be mitigated 
through collaboration. Governor Parnell of Alaska has included the 
military on the state trauma commission as of this year, and the 
Services are partnering as much as time and resources allow. The trauma 
partnership will be a topic of discussion at the State Healthcare 
Commission. We agree that more work remains to be done, but efforts are 
underway.

    Question 3. Mr. Burdette, establishing a seamless transition 
process for wounded warriors is critical.
    a. Can you explain why there isn't a seamless case manager that 
follows the warrior from DOD to VA system?
    b. What can be done to make the process more fluid and more user-
friendly to our veterans and their families?
    c. Can you explain why the Social Security determination unit does 
not accept the DOD and VA's disability determination? For example, if 
the vet is deemed unable to work by the VA, why does the rating not 
automatically carry over to the SSA?

    Response. a. Can you explain why there isn't a seamless case 
manager that follows the warrior from DOD to VA system?
    While not called seamless transition case managers, there are 
several people in the process who work with transitioning 
Servicemembers to ensure their transition is as smooth and seamless as 
possible, and RCCs are on the frontline in this area. The RCCs seek to 
develop a good rapport with the Servicemember and family/caregivers, 
and work to prepare them for transition by working with Physical 
Evaluation Board Liaison Officers (PEBLOs) to successfully move them 
through the Integrated Disability Evaluation System. They also work 
with the VA Military Service coordinators (MSCs) to explain VA 
benefits, ensure Servicemembers and families attend Transition 
Assistance Briefings, discussing options for education and employment 
for the entire family, housing and vehicle adaptations, State veteran's 
benefits, and other resources. The RCCs are trained in all these areas, 
not to be the expert, but to possess general knowledge and then reach 
out to the experts in each of these areas and ensure that contacts are 
made, followed up on, and Servicemembers and their families/caregivers 
understand the benefits and resources, know how to access them, and 
have the point of contacts who can assist if necessary.
    b. What can be done to make the process more fluid and more user-
friendly to our veterans and their families?
    To strive for excellence and to continue to use the resources 
listed above. Properly allocating resources, providing timely 
information and open lines of communication will improve the process.
    c. Can you explain why the Social Security determination unit does 
not accept the DOD and VA's disability determination? For example, if 
the vet is deemed unable to work by the VA, why does the rating not 
automatically carry over to the SSA?
    The VA defines someone as unemployable if they are unable to engage 
in a ``substantial gainful occupation.'' This term has been defined by 
the VA to ``that which is ordinarily followed by the nondisabled to 
earn their livelihood with earning common to the particular occupation 
in the community where the veteran resides.'' The VA does not consider 
marginal employment (defined as earned income that does not exceed the 
poverty level for one person as defined by the U.S. Department of 
Commerce and the Bureau of the Census) as substantial gainful 
employment. Thus, a veteran marginally employed may still be considered 
unemployable for VA purposes.
    The Social Security Administration uses different criteria for 
establishing who is unemployable. Under their regulations to be 
considered unemployable, a person cannot engage in any work activity 
for pay or profit. Thus, a Servicemember who is marginally employed 
would be considered unemployable for VA purposes but employable for SSA 
purposes.
    Since the criteria for what is considered unemployable varies 
between the two agencies, SSA cannot accept the finding of the VA as a 
binding decision. However, DOD will work with VA and SSA to determine 
if we can come to a better governmentwide approach to defining those 
who are considered ``unemployable.''

    Chairman Murray. Thank you very much, Dr. Zeiss, for your 
testimony.
    Before I get into my systemic issues, I just want to 
implore you, someone, to look into Mr. Bohn's situation and get 
him back on track. Obviously, it should not take a veteran 
coming here to testify before this Committee to be able to get 
the help and support they need. So, I want to ask each of you, 
how do you begin to explain what went wrong in his case?
    Senator Burr. Madam Chairman?
    Chairman Murray. Yes.
    Senator Burr. I have to leave for an engagement that I 
cannot change. I would ask unanimous consent that I have the 
ability to send my questions in writing, some of which I have 
not written yet because of today's testimony. And I would 
conclude with one thing, Dr. Taylor: you made a promise to 
check up on why the testimony did not get here in time. Is this 
your testimony or is this somebody else's?
    Dr. Taylor. This is our testimony, our combined testimony.
    Senator Burr. I am lost for the reason that you would have 
to check up to figure out why it did not get here on time.
    Dr. Taylor. Well, sir, there is a process when you write 
the testimony. There is a series of approvals through the 
Department and OMB before it is cleared to come here, and I 
need to figure out where the delay was.
    Senator Burr. Well, I would appreciate you sharing it with 
us.
    Dr. Taylor. Yes, sir. I will be happy to show you, in this 
particular case, what happened.
    Senator Burr. I think I know what we are going to find out, 
but I would reiterate what the Chairman said. This is not the 
first time.
    Dr. Taylor. Yes, sir.
    Senator Burr. I hope it is the last time.
    Dr. Taylor. Yes, sir.
    Senator Burr. Thank you, Madam Chairman.
    Chairman Murray. Thank you very much, and your questions 
will be submitted for the record.
    But let me go back and ask you again. How do we begin to 
explain what happened in Mr. Bohn's situation and why he was 
not cared for appropriately?
    Mr. Burdette. Madam Chair, I think a number of things from 
both of our heroes' stories today were immensely troubling. I 
think it is largely a function, and there is good news at the 
end of this story. A lot of the absolutely heartbreaking data 
points that they presented to us are really programs and 
actions that we are fixing across the board.
    For example, the Recovery Care Program, we mention 20 or 22 
Federal Recovery Coordinators on the VA side. We have almost 
150 care coordinators on the DOD side, and if you even look 
more expansively than that, the Army has 4,000 people in a 
support mode for their entire Warrior Transition Units. Those 
4,000 people are charged, from the minute that we know they are 
coming from the battlefields of Afghanistan, from the hospitals 
in Landstuhl, they have the manifests of the people that are 
coming, they know where the families are going to come from, 
and we connect with those servicemembers and their families to 
make it better than it was.
    Chairman Murray. Do we not have enough coordinators?
    Mr. Burdette. We are training more right now. There are 28 
more coordinators in class today and those coordinators are 
going to connect with those servicemembers and their families. 
The 4,000 people across the network are doing a better job than 
our heroes reported today.
    Chairman Murray. Do we have more soldiers coming home 
wounded than we are prepared for?
    Mr. Burdette. I think that the infrastructure is there. I 
think that the people who are trained are there. The stories 
they reported in 2007 and 2008 were really troubling. In 2011, 
in 2012, we are much better. When I toured the--he referenced 
the Warrior Transition Unit at Fort Meade. I was there last 
Wednesday.
    It is a radically different unit than when he went through. 
They are not just getting air show tickets today. We were there 
with an intern program where we signed up 13 servicemembers 
into Federal internships last Wednesday. They have squad 
leaders that know where they live, they know where their 
families live. They are concerned with housing issues for them 
and their families.
    That is also true across the board, whether you are at 
Randolph Air Force Base in Texas. We are particularly focused 
on the closing of Walter Reed on September 15th, and as I meet 
with Admiral Matson and get his briefs, and they can tell you 
exactly who is going to Belvoir, exactly who is going to New 
Bethesda.
    I have toured the facilities that are there. They are 
designed for family members to be in the rooms with these 
servicemembers. The housing, I just know off the top of my 
head, there are 12 exceptional families that are going to be 
housed at Belvoir. I have seen the facilities where those 
families will live.
    We asked the same tough questions that you would expect, 
and I hope that you ask today and continue to ask, and by name, 
these leaders at every level are prepared, they are trained, 
and they are providing for these servicemembers.
    Chairman Murray. Dr. Kemp, Dr. McNamee, do either of you 
have any comments or suggestions as to Mr. Bohn's and Mr. 
Horton's treatment?
    Dr. McNamee. You know, obviously those are very troubling 
stories that were told, and specifically on Mr. Bohn, I would 
like to defer to Debbie Amdur, who is behind us here from the 
Office of Social Work in the VA. I would like her to answer 
this question for us.
    Ms. Amdur. Thank you. First, I would like to start by 
thanking Specialist Bohn, Lance Corporal Horton, and Lieutenant 
Colonel Lorraine for coming today and sharing their experiences 
with us. I can tell you that as a clinical social worker with 
20-some years experience, most of it spent working directly 
with veterans, their families, and caregivers, I was extremely 
disturbed to hear about the experiences that they shared, and 
consider them absolutely unacceptable.
    They certainly fall short, very short of the service that 
we strive for. I do think that we have made progress since 
2007. Since 2007, we have implemented the Federal Recovery 
Coordination Program in collaboration with our colleagues in 
Department of Defense. They are designed to address the needs 
and provide that one-on-one care coordination for the most 
severely injured of our returning servicemembers.
    We have also put in place an OEF/OIF/OMD post-deployment 
team at each of our 152 medical centers around the country. 
Those teams are designed to welcome our returning 
servicemembers into the VA, to make sure that they are aware of 
the resources, that they do get linked appropriately to the 
services that they need.
    We also have put in place an additional 16 VA liaisons for 
health care. We have 33 of them total stationed at 18 military 
treatment facilities, and their role is to ensure that those 
leaving Department of Defense facilities and requiring ongoing 
medical care do leave with not only a name and contact 
information, but also an appointment in hand at a VA medical 
center.
    I can tell you that in 2010, the 7,000-plus individuals 
that these liaisons helped to transition, 85 percent of them--
our goal, of course, is 100 percent--but 85 percent of them did 
leave with an appointment at a VA medical center in hand.
    This being said, we clearly still have a very long way to 
go. I think that it is clearly now a time that we need to 
revisit, to streamline, to make sure that we are addressing the 
issue of too many case managers. I can tell you that on the VA 
side, our teams at the VA medical centers, we have 400-plus 
case managers, and they currently provide case management 
services to 54,000 of our returning servicemembers and 
veterans.
    Chairman Murray. Are we unprepared for the number of 
soldiers coming home wounded today?
    Ms. Amdur. I think that we do have adequate resources. I 
think that we have an opportunity to streamline the services so 
that we do not have as much redundancy. Now, a certain level of 
redundancy, I feel, is beneficial because it is one of the 
things that does keep people from falling through the cracks.
    We also have a lot of experience, that there is benefit to 
having that continued DOD involvement after someone moves to 
veteran's status. On a regular basis, our teams in the field 
call on the Recovery Care Coordinators to work with them, 
because sometimes you have an individual who is very resistant 
to coming in for VA care, but they need it, and it is not 
uncommon to have our case manager pick up the phone and call 
the Marine liaison and have the Marine liaison send someone in 
uniform out to that veteran's home to get them into treatment. 
That kind of collaboration we need to really expand upon.
    As our Deputy Secretary, Deputy Secretary Gould said, there 
has been an executive committee which has been put together by 
the SOC, and it is reviewing the care management system. I am 
serving on that committee which is under the leadership of Dr. 
Karen Geiss and Robert Carrington, and I think we all recognize 
in that group the importance of us continuing to improve and 
enhance our collaborative efforts. Clearly there is work ahead 
to be done which we take very, very seriously.
    Chairman Murray. Who is going to intervene on Mr. Bohn's 
situation?
    Ms. Amdur. I will take responsibility for that. Absolutely.
    Chairman Murray. OK. And I want to follow up with you on 
what happens. Again, there are good people out there working 
everywhere. You see them every single day. But when soldiers 
are falling through the cracks, either we do not know enough 
about the injuries that the are coming home with and do not 
have the resources because we have not been told that we need 
more resources.
    If this Committee is not told that we need more resources 
or that there are people falling through the cracks, we do not 
know enough to ask for it. So we have got to have honest 
answers back from all of you. If we need additional resources, 
if we need more trained people, whether the facilities are 
ready to take our soldiers--we need honest answers from all of 
you, and I expect that.
    I also wanted to follow up on Mr. Horton's testimony. He 
talked about his waiting for VA care for his prosthetic, the 
pain that he went through. Dr. McNamee how do you say it--
McNamee?
    Dr. McNamee. McNamee.
    Chairman Murray. McNamee.--if you could please respond to 
that, because it is extremely painful when they need service 
for that. Waiting 2 months is intolerable. It is like, as I 
think Mr. Horton explained to us, walking around on a broken 
bone. Can you talk to me a little bit about that?
    Dr. McNamee. Yeah, absolutely, and I want to thank Lance 
Corporal Horton for those illuminating comments. Specifically, 
coming from the perspective of a physician who manages 
individuals with amputations and prosthetic limbs, I know that 
these individuals really rely on us to literally give them 
their legs and the ability to interact with the world and to 
move through the world. The pain associated with this, the 
potential skin breakdown, the time that individuals have to 
spend off of their limbs because of these issues are very, very 
real, and I have seen them throughout my career.
    I am terribly disappointed in the fact that there is 
potentially a clinic out there where this gentleman did not 
have the access and does not have the access that he needs. 
That is not acceptable. I do not think anybody would disagree 
with that.
    I can look at our own system in Richmond where I have 
worked and run the amputee clinics there for years and when we 
have had government contractors, we will always have them 
actually in the clinics with us to be able to hand the 
prescription over to them and to coordinate with them directly.
    Knowing that I am here to discuss the amputation system of 
care in the rollout and we are not quite complete with the 
rollout, we will be looking into these issues and we will be 
making sure that the access is there, because as I say, it is 
not acceptable. This gentleman relies on us to give him his 
legs, period, and if we cannot do that in a timely fashion, we 
need to figure that out and we will.
    Chairman Murray. I appreciate that. I am encouraged by your 
work. I know you are doing some really good work there, and one 
of the outcomes of the review that you are doing was the 
creation of the Amputee and Polytrauma Transitional Care Unit 
being piloted at the Richmond clinic. Will more of that 
transitional units be created?
    Dr. McNamee. So we now have four of them in the polytrauma 
field specifically dedicated to individuals with Traumatic 
Brain Injuries. The way that the amputee transitional program 
is set up right now is as a pilot program. So it is a singular 
pilot program at this time. We recognize that we had extra, in 
a sense, bed space in Richmond. We had met with the folks at 
the Military Advanced Training Center in Walter Reed and they 
requested something along these lines, and we are working very, 
very quickly to get it up and running.
    You know, our goal is to admit the first patient October 
1st of this year. The need was just identified just this past 
October on our task force, and to prove to both systems, the 
Defense--the Veterans Affairs and DOD that this really is 
effective in getting people through the dual eligibles quickly 
and back to work very quickly. So it is our hope that we can 
prove benefit with this program through the servicemembers that 
come through and that this pilot program is taken out to the 
system.
    Chairman Murray. I know my staff was there visiting 
earlier. Is there anything missing that you need?
    Dr. McNamee. At this point, no. We have got good 
connections with--from a resource standpoint, we have been very 
well resourced both by VACO as well by our local facility. From 
a flow perspective, we are on target, I said, October 1, 
potentially also help with the transition, the BRAC transition, 
from Walter Reed over to Bethesda. Have worked very closely 
with Colonel Pasquina and Dr. Scoville at Walter Reed, as well.
    There are some issues as we begin to kind of unpack this 
and understand how we get the vocational rehab resources to our 
active duty servicemembers prior to transitioning out of the 
military. The one thing that predicts return to work after 
significant injury is early return to work. The quicker you go 
back to work, the more likely you are to work over time.
    So with this program, we are really going to be trying to 
push the needle back and get people into active vocational 
settings while they are on active duty still. The ultimate 
goal, honestly, is that a servicemember becomes a veteran on 
Friday. On Monday morning, they report to a full-time paying 
job in which they have had an unpaid internship in that 
facility for months up to that period of time. So there are 
some issues that we are beginning to unpack and trying to 
understand to make that as smooth as possible.
    Chairman Murray. We want to work closely with you and 
please let us know if there is anything else you need. I 
appreciate that.
    Dr. McNamee. Very much appreciate that.
    Chairman Murray. I want to turn to an issue that I am 
deeply concerned about and that is the issue of suicide. The 
number of servicemembers and new veterans we have lost to 
suicide is now on par with the number of those who have been 
killed in combat. That should be disturbing to everyone in this 
room.
    Last week at this hearing, we talked about the very high 
rate of suicide among those participating in the joint 
disability evaluation process. Those servicemembers are 
actually under constant supervision of the department and that 
occurred.
    We do know that there is progress being made in suicide 
prevention and mental health treatment. Dr. Kemp, your program 
has been outstanding. I have heard good reviews of that, but 
there is a lot of work that remains to be done, and I want to 
ask on behalf of this Committee, what do we need to do to 
address this problem?
    Ms. Kemp. Yeah. First, Chairman Murray, I want to say the 
numbers are appalling and we know that and recognize that, and 
no one who serves their country and comes back alive should die 
by suicide, ever, and I think that we have worked very hard in 
the past few years to put programs into place.
    One of the things that you mentioned earlier was the crisis 
line which we have opened up now to servicemembers and families 
and friends of servicemembers and continue to get calls from 
that population. But we need to continue to communicate its 
availability. We need to make sure that people know that there 
is someone there 24 hours a day, 7 days a week.
    We need to work more closely with our DOD partners and we 
are in the process of doing this, to be able to communicate to 
our suicide prevention coordinators in the VA sooner and 
earlier that someone may be released and someone needs 
services, and we need to start that care ahead of time.
    We also need to do more work, and this is also in progress, 
in the area of training all providers and all people who do 
these disability exams to do screening, to ask the right 
questions; that just because someone is being evaluated for a 
physical injury, we have to ask the emotional need questions, 
also.
    Chairman Murray. How long will it take to train all the 
providers?
    Ms. Kemp. We have started the process with the providers 
who do the exams in the VA, and we will start the contracting--
--
    Chairman Murray. At every facility across the country?
    Ms. Kemp. Yes, yes. And we have also started training all 
of our primary care providers across the country to really work 
with emotional issues as well as regular mental issues. So I 
anticipate that this is something we can do rather quickly, and 
I will make a promise to you to move that process along.
    Chairman Murray. OK. And we will be following that and I 
want to know when those people have been trained.
    Ms. Kemp. Exactly.
    Chairman Murray. The data released at the end of April show 
that the number of Iraq and Afghanistan veterans who are now 
utilizing VA care for mental health needs is now more than half 
of all Iraq and Afghanistan veterans who are using the VA. In a 
way, that is a positive sign that more veterans are willing to 
come forward and ask for care, but I want to know if the system 
is adequately equipped now to handle those rising numbers and 
meet the criteria that we have set out.
    Ms. Zeiss. We are resourced to be able to provide that care 
in mental health, but certainly I can defer to other staff 
members here for some of the other physical health concerns 
that are also very much a part of what they bring to us. But in 
terms of mental health, in 2004, VA recognized that there were 
gaps in staffing and in services, developed the Comprehensive 
Mental Health Strategic Plan, began to implement that in 2005, 
and really with a stronger pace in 2006.
    And since then, we have increased our staffing for mental 
health services to over 21,000. It is an increase of over 40 
percent in our core mental health staff. As we track the number 
of veterans who are receiving mental health services, those 
also have increased greatly during that time period, but have 
not increased to the same proportion as the percent of staff 
that we have added.
    We think that is the right balance, because as I said, we 
had gaps when we started. So we have been able to fill gaps for 
those patients who were seeking VA care and intensive VA care 
earlier in this decade, and to enhance our staff such that 
currently we can continue in a proactive way to meet the needs 
of returning servicemembers who come to us as veterans while 
sustaining care for those veterans who are with us for their 
lifetimes.
    We will continue to track that very carefully, of course, 
because we do not know when there may be significant additional 
numbers of servicemembers returning. We look forward to working 
with you and keeping pace in terms of the data on whether we 
are adequately resourced to provide care.
    Chairman Murray. OK. We have been notified by the floor 
that there is going to be an objection to any Committee 
hearings going past noon. I have a number of questions that I 
want to get through, so I am going to go really fast here. I am 
concerned about the veterans who do not come in to the VA. The 
statistics that I just talked about are for those who come in.
    We heard about reaching out and the concerns about that, so 
what about those veterans who are not seeking care? I am going 
to ask you to respond to that in writing because I do have one 
other question I want to ask before we hit noon.
    Because we have discussed some of the problems with the 
gaps in the amputee system of care last week when I raised this 
issue about the Centers of Excellence with the Deputy 
Secretaries, and as I mentioned again then and this morning, we 
need those Centers online to improve the quality of care. So, 
Dr. Taylor, or anyone else, can you or any of you help me 
identify, what is the problem with getting this going?
    Dr. Taylor. Senator Murray--and Dr. McNamee can probably 
help out--last summer, the two departments signed a Memorandum 
of Understanding on standing up the Center. There has been an 
ongoing Center of Excellence work group between the VA, the 
DOD, and the services to make sure that we are doing the core 
aspects of the Center of Excellence.
    You are not going to find a Center of Excellence with a 
sign and a receptionist. It is operating virtually right now 
until we finish the transition this summer in the national 
capital area, and then we can have a permanent location for a 
Center of Excellence.
    In the meantime, I am sure Dr. McNamee has participated in 
some of these activities where the DOD, VA, and the services 
are assuring that they are bringing the most advanced 
technologies and the most advanced rehabilitative processes in 
the standardization of care across the DOD and the VA.
    Chairman Murray. Dr. McNamee.
    Dr. McNamee. Thank you for the question, Chairman. There is 
no question that there is a need here for us to help tie the 
departments together from a research, education, and clinical 
care perspective, as well as the traumatic registry. I know 
that the VA has been at the table in terms of developing the 
concept of operations, and we look forward to being full 
partners with the DOD in this in terms of pulling this 
together.
    The amputation system of care is ready to jump fully into 
this once that concept of our operations comes out and this 
becomes a reality past from what Dr. Taylor said, it is a 
virtual center into a bricks and mortar center.
    Chairman Murray. OK. I would like you to give me a timeline 
in writing on when this is going to occur.
    Dr. Taylor. Yes, ma'am; be glad to do that.
    Chairman Murray. OK. I have a number of questions. I am 
really disappointed that somebody has objected to Committee 
hearings going because this is really important. None of you 
are off the hook. I am going to give these questions to you. I 
want answers back. I know Senator Burr has as well. I want to 
know about the Federal Recovery Coordinators. You heard the 
concerns about that.
    I want to hear about the compensation, that we know that 
Mr. Bohn had to receive $700 less. That is a serious issue for 
families. The ratings issue are questions that I have about as 
well, and a number of others. But this hearing is going to have 
to shut down.
    I just want to say, as we do that, that Deputy Secretary 
Lynn and Deputy Secretary Gould last week highlighted the 
challenges and successes as well that DOD and VA have 
encountered on this path toward a seamless transition. I want 
to thank all of our witnesses today for sharing first-hand 
their accounts with the perils of this path.
    I especially want to thank Mr. Bohn, Mr. Horton, Mr. 
Lorraine for sharing with us their views and stories. And I 
want to thank our Government witnesses who, at the program 
level, are working very hard to deal with both the visible and 
invisible wounds of war.
    In particular I want to mention Tom Pamperin, who is VA's 
Deputy Secretary for Disability Assistance who has given us 
nearly 40 years of Government service, and wish him well on his 
retirement. I look forward to working with all of you.
    I know there are a lot of good people out there working, 
but as you know, we still have some challenges. This Committee 
needs to know what those challenges are. We do not have the 
capability of talking to every single person going through this 
or not going through this that is lost, and we need to get this 
right.
    But before I close, I do want to mention again the wounded 
warrior that I talked about in my opening statement. I told you 
I am keeping him in mind as he goes through his very difficult 
transition, knowing how important it is that we do not forget a 
single warrior as we provide them services.
    His girlfriend is actually in the audience today. I am not 
going to single her out. But I want her to know that our 
thoughts and our prayers and our support are with her, and I 
thank her for her courage and to pass on to her servicemember 
who is in surgery today our very best wishes.
    With that, we are required to shut this hearing down, but I 
will be submitting our questions and I want responses back from 
all of you. Thank you very much.
    [Whereupon, at 11:59 a.m., the Committee was adjourned.]