- SEAMLESS TRANSITION: MEETING THE NEEDS OF SERVICEMEMBERS AND VETERANS

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

S. Hrg. 112-207

SEAMLESS TRANSITION: MEETING THE NEEDS OF SERVICEMEMBERS AND VETERANS

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HEARING

BEFORE THE

COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE

ONE HUNDRED TWELFTH CONGRESS

FIRST SESSION

__________

MAY 25, 2011

__________

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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

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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

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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.]