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



 
       DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2012

                              ----------                              


                        WEDNESDAY, APRIL 6, 2011

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

                         DEPARTMENT OF DEFENSE

                        Medical Health Programs

STATEMENT OF LIEUTENANT GENERAL ERIC B. SCHOOMAKER, 
            SURGEON GENERAL, DEPARTMENT OF THE ARMY

             OPENING STATEMENT OF CHAIRMAN DANIEL K. INOUYE

    Chairman Inouye. I would like to welcome all of you to this 
special hearing.
    There will be two panels this morning. First, we will hear 
from the Surgeons General, Lieutenant General Eric B. 
Schoomaker, Vice Admiral Adam Robinson, Jr., and Lieutenant 
General Charles Green. Then we will hear from our Chiefs of the 
Nurse Corps, Major General Patricia Horoho, Rear Admiral 
Elizabeth Niemyer, and Major General Kimberly Siniscalchi.
    I understand that this will be the last hearing for General 
Schoomaker and Admiral Robinson, and I would like to thank both 
of you for your dedicated service and wish you well in your 
future endeavors.
    General Green, I look forward to continuing our work to 
ensure the future of our military medical programs and 
personnel.
    Every year, the subcommittee holds this hearing to discuss 
the critically important issues related to the care and well-
being of our service members and their families. As such, the 
Surgeons General and nurses have been called upon to share 
their insight on medical issues that need improvement and areas 
that are seeing continued success and progress.
    The healthcare benefits we provide to our service members 
and their families are one of the most basic benefits we can 
provide to the men and women serving our Nation. It is also one 
of the most important effective recruiting and retention tools 
we have at our disposal.
    The advancements military medicine has made over the last 
several decades has not only dramatically improved medical care 
on the battlefield, but also enhanced healthcare delivery and 
scientific achievements throughout the aspects of medicine. The 
result impacts millions of Americans who likely have no idea 
that these improvements were initiated by the military.
    While there has been significant success and momentum 
advanced in modern medicine and the care we provide, there is 
much more to be done. The Department of Defense must stay ahead 
of the curve and remain vigilant to the ever-changing 
healthcare needs of our forces and their families. Even in this 
challenging fiscal environment, we must continue to provide the 
resources required to maintain and grow the expertise needed to 
stay at the forefront of military medicine.
    Times have certainly changed since I was a soldier. For 
instance, when I was injured in World War II, it took 9 hours 
to evacuate me. Now the military's goal is to evacuate within 
the so-called Golden Hour. In my regiment, for example, there 
were no double amputee or traumatic brain injury survivors 
because they died en route. Today, thanks to military medicine 
advancements and helicopter and other transport devices, our 
men and women in uniform survive these grave injuries.
    Despite the great progress made by the military medical 
community, more and more of our troops are suffering from 
medical conditions that are much harder to identify and treat, 
such as traumatic brain injury (TBI), post-traumatic stress, 
and depression. I know that all of you here today are striving 
to address these issues, and I applaud your efforts to place 
more mental health providers throughout the medical facilities, 
and especially within primary care offices. In addition, you 
employ more of these specialists in theater to provide early 
intervention and prevent further escalation.
    Due to the prolific number of medical assistance efforts 
being offered, there can be confusion on where to seek help. I 
have heard many stories of service members who have six 
different magnets on their refrigerators identifying a website 
or a phone number for where to seek help. I believe it is 
essential that we offer these services, both anonymously and 
officially, but it can also be very difficult to navigate 
through this maze of options that are available. It is my hope 
that in your efforts to provide increased and advanced 
services, that you work to consolidate these services and make 
it easier for service members and their families to find the 
help they need.
    These are some of the issues we hope to discuss today. I 
look forward to your testimony and note that your full 
statements will be included in the record.
    I wish to now call upon the vice chairman of this 
subcommittee, Senator Cochran, for his opening statement.

                   STATEMENT OF SENATOR THAD COCHRAN

    Senator Cochran. Mr. Chairman, thank you very much.
    I am pleased to join you in welcoming this distinguished 
panel of witnesses to our subcommittee today, the Surgeons 
General of our military forces. We appreciate your 
distinguished service, and thank you for your cooperation with 
our subcommittee to assess and review the budget request for 
the next fiscal year.
    Thank you.
    Chairman Inouye. All right. Thank you very much.
    Our witnesses on the first panel are Lieutenant General 
Eric B. Schoomaker, Surgeon General of the Army, Vice Admiral 
Adam Robinson, Jr., Surgeon General of the Navy, and Lieutenant 
General Charles B. Green, Surgeon General of the Air Force.
    Surgeon General of the Army.
    General Schoomaker. Thank you, sir.
    Chairman Inouye, Vice Chairman Cochran, and distinguished 
members of the subcommittee, thank you for providing me this 
opportunity to talk with you about the dedicated men and women 
of the United States Army Medical Department, who bring value 
and inspire trust in Army medicine.
    As you noted, Mr. Chairman, I am joined today by my Deputy 
Surgeon General and our Chief of the Army Nurse Corps, Major 
General Patty Horoho. Some of my staff have characterized this 
as an awful Broadway production of ``Beauty and the Beast''.
    Despite over 9 years of continuous armed conflict, every 
day our soldiers and their families are kept from injuries, 
illnesses, and combat wounds through our health promotion and 
prevention measures, are treated in state-of-the-art fashion 
when prevention fails, and supported by a talented medical 
force, including those with a warrior on the battlefield.
    Army medicine partners with our soldiers, their families, 
our veterans, our fellow service members, and the interagency 
to provide innovations in trauma care and preventive medicine. 
We save lives and we improve the well-being of our warriors, 
delivering the very best care at the right time and place.
    Let me discuss our work through the lens of five Es: 
Enduring, early, effective, efficient, and in an enterprise 
fashion.
    We have an enduring commitment through initiatives, such as 
our Warrior Care and Transition Program and the soldier medical 
readiness campaign plan. We have an enduring responsibility as 
part of the military health system and with the Department of 
Veterans Affairs to provide care and rehabilitation for our 
wounded, ill, and injured for many, many years to come.
    The United States Army's Warrior Transition Command, under 
the leadership of Brigadier General Darryl Williams, is a key 
part of the enduring provision of care and provides oversight 
of the Army's Warrior Care and Transition Program. Since the 
inception of these Warrior Transition Units in June 2007, more 
than 40,000 wounded, ill, and injured soldiers and their 
families have either progressed through or are now being cared 
for by these dedicated caregivers. Over 16,000 of these 
soldiers have rejoined the force, and the remainder remain--
have been returned to the community with dignity and respect.
    The Soldier Medical Readiness Campaign helps to maintain a 
healthy and resilient force. Major General Richard Stone, our 
Deputy Surgeon General for Mobilization, Readiness, and Reserve 
Affairs, leads that campaign. Among the campaign's tasks are 
the--are to provide commanders with a tool to manage their 
soldiers' medical requirements, identify those medically non-
ready soldiers, and reduce this population so that we can have 
a fully fit and capable, ready Army. The end state is healthy 
soldiers and increased medical readiness.
    Those soldiers who no longer meet retention standards must 
navigate the Physical Disability and Evaluation System. 
Assigning disability has long been a contentious issue. The 
Department of Defense and VA have jointly designed a new 
Disability Evaluation System that integrates DOD and the 
Veterans Administration (VA) processes with a goal of 
expediting the delivery of VA benefits to service members. The 
pilot of the new Integrated Disability Evaluation System, or 
the IDES, began in November 2007 at Walter Reed. It is now in 
16 medical treatment facilities, and it will be the DOD and VA 
replacement for this Legacy Disability Evaluation System that 
we have had for upwards of 60 years.
    But even with this improvement, disability evaluation 
remains complex and adversarial. Our soldiers still undergo 
dual adjudication with the military rates only for unfitting 
conditions and the VA rates for all service-connected 
conditions. Dual adjudication is confusing to soldiers. It 
leads to serious misperceptions about the Army's appreciation 
of the wounded, ill, and injured soldiers' complete medical and 
emotional situation. The IDES has not changed the fundamental 
nature of the dual adjudication process. Under the leadership 
of our Army Chief of Staff General George Casey and the Army G-
1, we continue to forge the consensus necessary for a 
comprehensive reform of the Physical Disability and Evaluation 
System, which the Army and DOD only determines fitness for duty 
and the VA determines disability compensation.
    Our second strategic aim is to reduce suffering, illness, 
and injury through early prevention. Army Public Health 
protects and improves the health of Army communities through 
education, the promotion of healthy lifestyles, and disease and 
injury prevention.
    The health of the total Army is essential for readiness, 
and prevention is the key to health. Examples of our practices 
include the implementation of the Patient-Centered Medical Home 
for Primary Care Delivery, something that we are doing in 
concert with our fellow service members, led by the Air Force, 
frankly, the Army's development and use of vaccines, and the 
early advocation of management of battlefield concussion.
    We lead in the recognition and treatment of mild traumatic 
brain injury, or concussion, through what's called the educate, 
train, treat, track strategy. Under the personal leadership of 
the Vice Chief of the Army, General Pete Chiarelli, and refined 
by Brigadier General Richard Thomas, our Assistant Surgeon 
General for Force Projection, we have fielded a program that 
has led to increased awareness and screening for traumatic 
brain injury and decreased the stigma associated with seeking 
early diagnosis and treatment.
    This leads into the use of evidence-based practices aimed 
at the most effective care. As an example, Army medicine now 
strengthens our soldiers' and families' behavioral health and 
emotional resiliency through a campaign to align the various 
behavioral health programs with the deployment and reset cycle, 
a process we call the Comprehensive Behavioral Health System of 
Care. Under the leadership of the Deputy Surgeon General, Major 
General Patty Horoho, this program uses multiple touch points 
to assess both the health and behavioral health for a soldier 
and the family. Coupled with the advances in battlefield care 
under the Joint Theater Trauma System, we have made great 
strides in managing the physical and emotional wounds of war.
    Additionally, we have developed a comprehensive pain 
management strategy to address chronic and acute pain that many 
of our soldiers face. This strategy uses state-of-the-art 
modalities and technologies. It focuses on the use of non-
medication pain management modalities, incorporating 
complementary and alternative or integrative approaches, such 
as acupuncture and massage therapy, yoga, and other tools. We 
were recently recognized by the American Academy of Pain 
Medicine with a Presidential commendation for the impact on 
pain management in the United States.
    Our fourth strategic aim is optimizing efficiencies through 
leading-edge business practices, partnerships with our other 
services and veterans organizations, to support the DOD and VA 
collaboration on treating post-traumatic stress disorder, and 
pain, and other healthcare issues, and electronic health 
records should seamlessly transfer patient data between 
partners to improve efficiencies, effectiveness, and the 
continuity of care.
    No two health organizations in the Nation share more non-
billable health information than the Department of Defense and 
the Veterans Administration. The Departments continue to 
standardize sharing activities and deliver information 
technologies to improve the secure sharing of information.
    Finally, our fifth aim is the Army enterprise approach. We 
have reengineered Army medicine, such as the creation of a 
provisional Public Health Command, to optimally serve the 
soldier. We have aligned our regional medical commands with the 
TRICARE regions, resulting in improved readiness and support 
from the managed care support contractor to our regions. Three 
standardized continental United States-based regional medical 
commands are now aligned with the three TRICARE regions in the 
continental United States.
    We also have regional readiness cells now that can reach 
out to our Reserve components within their areas of 
responsibility, ensuring that all medical services required are 
identified and provided at all times. Part of this 
reorganization has been the standup of a public health command 
under the command of Brigadier General Tim Adams. This 
consolidation has already resulted in an increased focus on 
prevention, health promotion, and wellness.
    As you have noticed here, this is my last congressional 
hearing cycle as the Army Surgeon General and the Commanding 
General of the United States Army Medical Command. I thank the 
subcommittee for allowing me to highlight the accomplishments 
we have made, the challenges we continue to face, to hear your 
perspectives regarding health of our extended military family 
and the healthcare we provide. I have appreciated your 
questions, your insights, and your commitment to our Army 
soldiers and their families.

                           PREPARED STATEMENT

    On behalf of the over 140,000 soldiers, civilians, and 
contractors that make up my command in Army medicine, I also 
thank Congress for your continued support and for providing the 
resources that we have needed to deliver leading edge health 
services and build healthy and resilient communities.
    I welcome your questions.
    Chairman Inouye. All right. Thank you very much, General 
Schoomaker.
     [The statement follows:]
      Prepared Statement of Lieutenant General Eric B. Schoomaker
    Chairman Inouye, Vice Chairman Cochran and distinguished members of 
the committee. Thank you for providing me this opportunity to talk with 
you today about some of the very important work being performed by the 
dedicated men and women--military and civilian--of the U.S. Army 
Medical Department (AMEDD) who bring value and inspire trust in Army 
Medicine.
    Now in my last congressional hearing cycle as the Army Surgeon 
General and Commanding General, U.S. Army Medical Command (MEDCOM), I 
would like to thank the committee for the opportunities provided over 
the past 4 years that have allowed me to share what Army Medicine is, 
to highlight the accomplishments we have made, to detail the challenges 
we have faced, and to hear your collective perspectives regarding the 
health of our extended Military Family and the military healthcare we 
provide. On behalf of the over 70,000 dedicated Soldiers, civilians, 
and contractors that make up Army Medicine, I also thank Congress for 
your continued support of Army Medicine and the Military Health System, 
providing the resources we need to deliver leading edge health services 
to our Warriors, Families and Retirees.
    Despite over 9 years of continuous armed conflict for which Army 
Medicine bears a heavy load, every day our Soldiers and their Families 
are kept from injuries, illnesses, and combat wounds through our health 
promotion and prevention efforts; are treated in state-of-the-art 
fashion when prevention fails; and are supported by an extraordinarily 
talented medical force including those who serve at the side of the 
Warrior on the battlefield.
    Army Medicine is a dedicated member of the Military Health System 
and is equally committed to partnering with our Soldiers, their 
Families, and our Veterans to achieve the highest level of fitness and 
health for each of our beneficiaries. Army Medicine historically is a 
leader in developing innovations for trauma care and preventive 
medicine that save lives and improve well-being for our uniformed 
personnel, improvements which have also favorably influenced civilian 
care. We are focused on delivering the best care at the right time and 
place. Army Medicine operates using the following strategic aims--The 
Five E's: Enduring, Early, Effective, Efficient, and Enterprise to 
reflect our commitment to selfless service.
  --To provide Enduring care through initiatives such as the Warrior 
        Care and Transition Program and the Soldier Medical Readiness 
        Campaign Plan.
  --To reduce the need for subsequent care through Early prevention; 
        for example, Army Medicine identifies medical issues early with 
        its concussive protocols and behavioral health practices, and 
        promotes healthy lifestyles with the patient-centered medical 
        home model of primary care delivery.
  --To use evidence-based practices which provide the most Effective 
        treatment for medical issues such as pain management and post-
        traumatic stress (PTS).
  --To optimize Efficiencies through leading edge business processes 
        and partnerships with other services and veterans 
        organizations.
  --To be an integral part of the Army Enterprise approach through re-
        engineering Army Medicine such as the provisional Public Health 
        Command (PHC) to keep the Army strong and with other Army 
        commands and agencies to optimally serve the Soldier and 
        Family.
    We must continue to provide the very best ongoing care for wounded, 
ill, or injured Soldiers. We have an enduring responsibility--alongside 
our sister services and the Department of Veterans Affairs (VA)--to 
provide care and rehabilitation of our wounded, ill, and injured for 
many years to come. The U.S. Army Warrior Transition Command (WTC) is a 
Major Subordinate Command under the MEDCOM and a key part of the 
enduring provision of care. The WTC Commander, Brigadier General Darryl 
Williams is also the Assistant Surgeon General for Warrior Care and 
Transition. The WTC's mission is to provide centralized oversight of 
the Army's Warrior Care and Transition Program. This includes providing 
the necessary guidance and advocacy to empower wounded, ill, and 
injured Soldiers and Families with dignity, respect, and the self-
determination to successfully reintegrate either back into the force or 
into the community. The WTC supports Army Force Generation (ARFORGEN) 
by supporting those who have returned from combat and require 
coordinated, complex care management to help them cope with and 
overcome the cumulative effects of war and multiple deployments.
    At the heart of the Warrior Care and Transition Program are 29 
Warrior Transition Units (WTUs) located at major Army installations 
worldwide, and nine Community Based Warrior Transition Units (CBWTUs) 
located regionally around the United States and Puerto Rico. Today, 
4,280 highly trained cadre and staff oversee a current population of 
10,011 wounded, ill and injured Soldiers. Since their inception in June 
2007, more than 40,000 wounded, ill, or injured Soldiers and their 
Families have either progressed through or are being currently cared 
for by these dedicated caregivers and support personnel. Over 16,000 of 
those Soldiers have been returned to the force.
    The Army, with great support of Congress, has spent or obligated 
more than $1.2 billion in military construction projects to improve the 
accessibility and quality of Wounded Warrior barracks, including the 
development of Warrior Transition complexes that will serve both 
Warriors in Transition and their Families. Construction of complexes 
continues through fiscal year 2012 at which time 20 state-of-the-art 
complexes will be in operation.
    Since 2004, the Army Wounded Warrior Program (AW2) has supported 
the most severely wounded, ill, and injured Soldiers. Soldiers are 
assigned an AW2 Advocate who provides personalized assistance with day-
to-day issues that confront healing Warriors and their Families, 
including benefits counseling, educational opportunities, and financial 
and career counseling. AW2 Advocates serve as life coaches to help 
these wounded Warriors and their Families regain their independence. 
Since its inception, AW2 has provided support to nearly 8,000 Soldiers 
and Veterans.
    The WTC is refining a policy change to enhance the Army's ability 
to ensure Reserve Component Soldiers recovering at home from wounds, 
illnesses, or injuries incurred while on Active Duty benefit from the 
same system of care management and command and control experienced by 
Soldiers who are recovering in WTUs. The revised policy makes it easier 
for Reserve Component Soldiers who do not require complex medical care 
management to heal and transition closer to home.
    To support each wounded, ill, or injured Soldier in their efforts 
to either return to the force or transition to Veteran status, the Army 
has created a systematic approach called the Comprehensive Transition 
Plan (CTP). The CTP is a six-part multidisciplinary and automated 
process which enables every Warrior in Transition to develop an 
individualized plan that will enable them to set and reach their 
personal goals. These end goals shape the Warrior in Transition's day-
to-day work plan while healing.
    Additionally to help Warriors in Transition achieve their physical 
fitness goals, WTUs offer several adaptive sports options to supplement 
the Warrior in Transition's therapy, often in coordination with the 
U.S. Olympic Committee's Paralympic Military Program. The WTC is also 
coordinating the Army's participation in the 2011 Warrior Games to be 
held at the U.S. Olympic Training Center in Colorado Springs, Colorado 
May 16-21, 2011.
    We created a Soldier Medical Readiness Campaign to ensure we 
maintain a healthy and resilient force. Major General Richard Stone, 
Deputy Surgeon General, Mobilization, Readiness, and Reserve Affairs, 
is the campaign lead. The deployment of healthy, resilient, and fit 
Soldiers and increasing the medical readiness of the Army is the 
desired end state of this campaign.
    The campaign's key tasks are to provide Commanders the tools to 
manage their Soldiers' medical requirements; coordinate, synchronize 
and integrate wellness, injury prevention and human performance 
optimization programs across the Army; identify the medically not ready 
(MNR) Soldier population; implement medical management programs to 
reduce the MNR Soldier population, assess the performance of the 
campaign; and educate the force.
    Those Soldiers who no longer meet retention standards must navigate 
the Physical Disability Evaluation System (PDES). Assigning disability 
has long been a contentious issue. The present disability system dates 
back to the Career Compensation Act of 1949. Since its creation 
problems have been identified include long delays, duplication in DOD 
and VA processes, confusion among Service members, and distrust of 
systems regarded as overly complex and adversarial. In response to 
these concerns, DOD and VA jointly designed a new disability evaluation 
system to streamline DOD processes, with the goal of also expediting 
the delivery of VA benefits to service members following discharge from 
service. The Army began pilot testing the Disability Evaluation System 
(DES) in November 2007 at Walter Reed Army Medical Center and has since 
expanded the program, now known as the Integrated Disability Evaluation 
System (IDES), to 16 military treatment facilities. DOD is now planning 
on replacing the military's legacy disability evaluation system with 
the IDES.
    The key features of the of the IDES are a single physical 
disability examination conducted according to VA examination protocols, 
a single disability rating evaluation prepared by the VA for use by 
both Departments for their respective decisions, and delivery of 
compensation and benefits upon transition to veteran status for members 
of the Armed Forces being separated for medical reasons. The DOD PDES 
working group continues to reform this process by identifying steps 
that can be reduced or eliminated, ensuring the service members receive 
all benefits and entitlements throughout the process.
    The WTC is also working with U.S. Army Medical Command staff to 
develop the concept of ``Medical Management Centers.'' Medical 
Management Centers utilize the case management approaches developed for 
the WTUs to assist Soldiers who remain in their units but require a 
PDES determination. The WTC is also working closely with Army Reserve 
and Army National Guard leadership to develop and provide necessary 
support to the Reserve Component Soldier Medical Support Center 
(RCSMSC) being established in Pinellas Park, Florida. The RCSMSC is 
intended to ensure the PDES process also runs smoothly and efficiently 
for Reserve Component Soldiers not on Active Duty or in WTUs.
    Army Medicine strives to reduce the need for subsequent care 
through early prevention and the emphasis on health promotion. Over the 
past year Army medicine has initiated multiple programs in support of 
this aim and I would like to highlight a few of those starting with the 
new U.S. Army Public Health Command (Provisional) (PHC).
    As part of the overall U.S. Army Medical Command reorganization 
initiative, all major public health functions within the Army, 
especially those of the former Veterinary Command and the Center for 
Health Promotion and Preventive Medicine have been combined into a new 
PHC, located at Aberdeen Proving Ground in Maryland, under the command 
of Brigadier General Timothy K. Adams. The consolidation has already 
resulted in an increased focus on health promotion and has created a 
single accountable agent for public health and veterinary issues that 
is proactive and focused on prevention, health promotion and wellness. 
The PHC reached initial operational capability in October 2010 and full 
operational capability is targeted for October 2011.
    Army public health protects and improves the health of Army 
communities through education, promotion of healthy lifestyles, and 
disease and injury prevention. Public health efforts include 
controlling infectious diseases, reducing injury rates, identifying 
risk factors and interventions for behavioral health issues, and 
ensuring safe food and drinking water on Army installations and in 
deployed environments. The long-term value of public health efforts 
cannot be overstated: public health advances in the past century have 
been largely responsible for increasing human life spans by 25 years, 
and the PHC will play a central role in the health of our Soldiers, 
deployed or at home.
    The health of the total Army is essential for readiness, and 
prevention is the best way to health. Protecting Soldiers, retirees, 
Family members and Department of Army civilians from conditions that 
threaten their health is operationally sound, cost effective and better 
for individual well-being. Though primary care of our sick and injured 
will always be necessary, the demands will be reduced. Prevention--the 
early identification and mitigation of health risks through 
surveillance, education, training, and standardization of best public 
health practices--is crucial to military success. Army Medicine is on 
the pathway to realizing this proactive, preventive vision.
    While the PHC itself is relatively new, a number of significant 
public health accomplishments already have been achieved. Some 
examples:
  --Partnering with Army installations to standardize existing Army 
        Wellness Centers to preserve or improve health in our 
        beneficiary population. The centers focus on health assessment, 
        physical fitness, healthy nutrition, stress management, general 
        wellness education and tobacco education. They partner with 
        providers in our Military Treatment Facilities (MTFs) through a 
        referral system. I hold each MTF Commander responsible for the 
        health of the extended military community as the installation 
        Director of Health Services (DHS).
  --Hiring installation Health Promotion Coordinators (HPCs) to assist 
        the MTF Commander/DHS and to facilitate health promotion 
        efforts on Army installations. HPCs are the ``air traffic 
        controllers'' or coordinators of services and identifiers of 
        service needs; they work with senior mission commanders and 
        installation Community Health Promotion Councils to synchronize 
        all of the installation health and wellness resources.
  --Providing behavioral health epidemiological consultations to advise 
        Army leaders and program developers on the factors that 
        contribute to behavioral health issues including high-risk 
        behaviors, domestic violence and suicide.
  --Identifying Soldier physical training programs that optimize 
        fitness while minimizing injuries and resultant lost-duty days 
        and improve Soldier medical readiness.
  --Decreasing the rate of overweight and obese Family members and 
        retirees by adopting the Healthy Population 2010 goals for 
        weight and obesity and implementing a standardized weight-
        management program developed by the VA.
  --Integrating human and animal disease surveillance to better assess 
        health risks.
    The Army recognizes that traumatic brain injury or TBI is a serious 
concern, and we will continue to dedicate resources to research, 
diagnose, treat and prevent mild, moderate, severe, and penetrating 
TBI. The Army is leading the way in early recognition and treatment of 
mild TBI or concussive injuries with our ``Educate, Train, Treat, and 
Track'' strategy. Under the personal leadership of the Vice Chief of 
Staff of the Army, General Peter Chiarelli and refined by Brigadier 
General Richard Thomas, Assistant Surgeon General for Force Projection, 
we are fielding a program which some have called ``CPR for the brain''. 
Our education and training efforts have led to increased awareness and 
screening for TBI and have contributed to decreasing the stigma 
associated with seeking diagnosis or treatment for TBI. TBI training 
has been integrated into education and training initiatives of all 
deploying units to increase awareness and education regarding 
recognition of symptoms as well as emphasize commanders and leaders' 
responsibilities for ensuring their Soldiers receive prompt medical 
attention as soon as possible after an injury.
    DOD policy changes in June 2010 implemented mandatory event-driven 
protocols following exposure to potentially concussive events in 
deployed environments. Events mandating an evaluation include any 
Service Member in a vehicle associated with a blast event, collision, 
or rollover; all personnel within close proximity to a blast; or anyone 
who sustains a direct blow to the head. Additionally, the command may 
direct a medical evaluation for any suspected concussion under other 
conditions. All new medics and Physician Assistants at the Army Medical 
Department Center and School are being trained on their roles in 
supporting this policy. During my recent visit to Afghanistan with my 
fellow Surgeons General in February 2011, discussions with Warriors and 
medical personnel at a number of sites lead me to conclude that these 
protocols are aggressively endorsed by commanders and are being 
complied with.
    The Army along with the DOD is implementing computerized tracking 
of these events for the purposes of providing healthcare providers with 
awareness of an individuals' history of proximity to blast events, 
allowing for greater visibility of at risk Soldiers during post-
deployment health assessment, informing Commanders, and to provide 
documentation to support Line of Duty investigations for Reserve and 
Guard members. The program from August to December 2010 has documented 
1,472 Soldiers. We are working hard to overcome the technical barriers 
for complete data input. My fellow Surgeons General and I saw this 
first hand in our trip to Afghanistan last month. We saw, as well, the 
complete commitment of all field commanders, small unit leaders, and 
medical professionals to the implementation of these protocols.
    To further the science of brain injury recovery, the Army relies on 
the U.S. Army Medical Research and Materiel Command's TBI Research 
Program. The overwhelming generosity of Congress and the DOD's 
commitment to brain injury research has significantly improved our 
knowledge of TBI in a rigorous scientific fashion. Currently, there are 
almost 350 studies funded by DOD to look at all aspects of TBI. The 
purpose of this program is to coordinate and manage relevant DOD 
research efforts and programs for the prevention, detection, mitigation 
and treatment of TBI. Some examples of the current research include 
medical standards for protective equipment, measures of head impact/
blast exposure, a portable diagnostic tool for TBI that can be used in 
the field, blood tests to detect TBI, medications for TBI treatment, 
and the evaluation of rehabilitation outcomes. The TBI Research Program 
leverages both DOD and civilian expertise by encouraging partnerships 
to solve problems related to TBI. The DOD partners with key 
organizations and national/international leaders, including the VA, the 
Defense Centers of Excellence for Psychological Health and TBI, the 
Defense and Veterans Brain Injury Center, academia, civilian hospitals 
and the National Football League, to improve our ability to diagnose, 
treat and care for those affected by TBI.
    Similar to our approach to concussive injuries, Army Medicine 
harvested the lessons of almost a decade of war and has approached the 
strengthening of our Soldiers and Families' behavioral health and 
emotional resiliency through a campaign plan to align the various 
Behavioral Health programs with the human dimension of the ARFORGEN 
cycle, a process we call the Comprehensive Behavioral Health System of 
Care (CBHSOC). This program is based on outcome studies that 
demonstrate the profound value of using the system of multiple 
touchpoints in assessing and coordinating health and behavioral health 
for a Soldier and Family. The CBHSOC creates an integrated, 
coordinated, and synchronized behavioral health service delivery system 
that will support the total force through all ARFORGEN phases by 
providing full spectrum behavioral healthcare. We leveraged experiences 
and outcome studies on deploying, caring for Soldiers in combat, and 
redeploying these Soldiers in large unit movements to build the CBHSOC. 
Some have been published, such as the landmark studies on concussive 
brain injury and PTSD by Charles Hoge, Carl Castro and colleagues or 
the recent publication of a forerunner program to the CBHSOC in the 3rd 
Infantry Division by Chris Warner, Ned Appenzeller and their co-
workers. These studies will be discussed further later.
    The CBHSOC is a system of systems built around the need to support 
an Army engaged in repeated deployments--often into intense combat--
which then returns to home station to restore, reset the formation, and 
re-establish family and community bonds. The intent is to optimize care 
and maximize limited behavioral health resources to ensure the highest 
quality of care to Soldiers and Families, through a multi-year campaign 
plan.
    Under the leadership of Major General Patricia Horoho, the Deputy 
Surgeon General, the CBHSOC campaign plan has five lines of effort: 
Standardize Behavioral Health Support Requirements; Synchronize 
Behavioral Health Programs; Standardize & Resource AMEDD Behavioral 
Health Support; Access the Effectiveness of the CBHSOC; and Strategic 
Communications. The CBHSOC campaign plan was published in September 
2010, marking the official beginning of incremental expansion across 
Army installations and the Medical Command. Expansion will be phased, 
based on the redeployment of Army units, evaluation of programs, and 
determining the most appropriate programs for our Soldiers and their 
Families.
    Near-term goals of the CBHSOC are implementation of routine 
behavioral health screening points across ARFORGEN and standardization 
of screening instruments. Goals also include increased coordination 
with both internal Army programs like Comprehensive Soldier Fitness, 
Army Substance Abuse Program, and Military Family Life Consultants. 
External resources include VA, local and state agencies, and the 
Defense Centers of Excellence for Psychological Health.
    Long-term goals of the CBHSOC are the protection and restoration of 
the psychological health of our Soldiers and Families and the 
prevention of adverse psychological and social outcomes like Family 
violence, DUIs, drug and alcohol addiction, and suicide. This is 
through the development of a common behavioral health data system; 
development and implementation of surveillance and data tracking 
capabilities to coordinate behavioral health clinical efforts; full 
synchronization of Tele-behavioral health activities; complete 
integration of the Reserve Components; and the inclusion of other Army 
Medicine efforts including TBI, patient centered medical home, and pain 
management. Integral to the success of the CBHSOC is the continuous 
evaluation of programs, to be conducted by the PHC.
    For those who do suffer from PTSD, Army Medicine has made 
significant gains in the treatment and management of PTSD as well. The 
DOD and VA jointly developed the three evidenced based Clinical 
Practice Guidelines for the treatment of PTSD, on which nearly 2,000 
behavioral health providers have received training. This training is 
synchronized with the re-deployment cycles of U.S. Army Brigade Combat 
Teams, ensuring that providers operating from MTFs that support the 
Brigade Combat Teams are trained and certified to deliver quality 
behavioral healthcare to Soldiers exposed to the most intense combat 
levels. In addition, the U.S. Army Medical Department Center & School, 
under the leadership of Major General David Rubenstein, collaborates 
closely with civilian experts in PTSD treatment to validate the content 
of these training products to ensure the information incorporates 
emerging scientific discoveries about PTSD and the most effective 
treatments.
    Work by the Army Medical Department and the Military Health System 
over the past 8 years has taught us to link information gathering and 
care coordination for any one Soldier or Family across the continuum of 
this cycle. Our Behavioral Health specialists tell us that the best 
predictor of future behavior is past behavior, and through the CBHSOC 
we strive to link the management of issues which Soldiers carry into 
their deployment with care providers and a plan down-range and the same 
in reverse.
    As mentioned previously, the results of a recent Army study 
published in January in the American Journal of Psychiatry by Major 
Chris Warner, Colonel Ned Appenzeller and colleagues report on the 
success of pre-deployment mental health support and coordination of 
care that dramatically reduced adverse behavioral health outcomes for 
over 10,000 Soldiers who received pre-deployment support prior to 
deployment compared to a like group of over 10,000 Soldiers who were 
deployed to the same battle space but were unable to receive the pre-
deployment behavioral health assessment and care coordination. These 
results show the Army, as part of its Comprehensive Behavioral Health 
System of Care Campaign Plan, is moving in the right direction 
implementing new policies and programs to enhance pre- and post-
deployment care coordination for Soldiers. This study demonstrates the 
ability to bridge the gap between identification through pre-deployment 
screening, as required by the National Defense Authorization Act for 
Fiscal Year 2010, Sec. 708 and actively managing and coordinating care 
for Soldiers with existing behavior health concerns to insure a 
successful deployment that benefits the Army and continued support to 
Soldiers and Families.
    The results are significant and provide the first direct evidence 
that a program that combines pre-deployment support and coordination of 
care that includes primary care managers, unit surgeons and behavioral 
health providers is effective in preventing adverse behavioral health 
outcomes for Soldiers. The study results move away from a perception of 
use of mental health screenings by Army and DOD as a tool to ``weed 
out'' Soldiers and service members deemed mentally unfit, to one of use 
and integration of behavioral health screenings as a routine part of 
Soldiers' and service members primary care during deployment. Coupled 
with insights provided by Walter Reed Army Institute of Research 
(WRAIR) researchers, such as Dr. Charles Hoge and COL Carl Castro about 
the relationship between concussive injury and PTSD as well as 7 years 
of annual surveys of BH problems and care in the deployed force through 
the WRAIR Mental Health Advisory Teams, we are making giants steps 
forward in prevention, early recognition, and mitigation of the 
neuropsychological effects of prolonged war on our Soldiers and 
Families.
    Much of the future of Army Medicine will be practiced at the 
Patient-Centered Medical Home (PCMH). The PCMH is a model of primary 
care-based health improvement and healthcare services being adopted 
throughout the Military Health System and in many venues in civilian 
practice. I commend the Air Force for taking the lead on some PCMH 
practices. The PCMH will be the principal enabler to improve readiness 
of the force and continuity of access to tailored patient services. It 
is a design that the Army will apply to all primary care settings.
    Dr. Paul Grundy, Director of Healthcare Transformation at IBM, 
pointed out that ``a smarter health system forges partnerships in order 
to deliver better care, predict and prevent disease and empower 
individuals to make smarter choices.'' In his estimation, the PCMH is 
``advanced primary care.'' According to Dr. Grundy the PCMH can build 
trust between patient and physician, improve the patient experience of 
care, reduce staff burnout, and hold the line on expenditures.
    The Medical Home philosophy concentrates on what a patient requires 
to remain healthy, to restore optimal health, and when needed, to 
receive tailored healthcare services. It relies upon building enduring 
relationships between patient and their provider--doctor, nurse 
practitioner, physician assistant and others--and a comprehensive and 
coordinated approach to care between providers and community services. 
This means much greater continuity of care, with patients seeing the 
same physician or professional partner 95 percent of the time. The 
result is more effective healthcare for both the provider and the 
patient that is based on trust and rapport.
    The PCMH integrates the patient into the healthcare team, offering 
aggressive prevention and personalized intervention. Physicians will 
not just evaluate their patients for disease to provide treatment, but 
also to identify risk of disease, including genetic, behavioral, 
environmental, or occupational risk. The healthcare team encourages 
healthy lifestyle behaviors, and success will be measured by how 
healthy they keep their patients, rather than by how many treatments 
they provide. The goal is that people will live longer lives with less 
morbidity, disability and suffering.
    Community Based Medical Homes (CBMHs) are part of the Army's 
implementation of the Patient Centered Medical Home. CBMHs are Army 
operated primary care clinics located in leased space in the off-post 
communities in which many of our active duty Families live. These 
clinics are extensions of the Army Hospital and staffed by government 
civilians. Active duty Family members receive enrollment priority. This 
initiative was undertaken to improve access and continuity to 
healthcare services, including behavioral health, for active duty 
Family members by expanding capacity and extending MTF services off-
post. The Army has grown and consumption of healthcare services is on 
the rise as a result of the war. These clinics will help Army Medicine 
improve quality of care and the patient experience; improve value 
through standardization and optimization of resources enabling 
operations at an economic advantage to the DOD; and improve the 
readiness of our Army and our Army Families. Clinics are placed where 
Families lacked access to Army primary care services and currently 17 
clinics are being developed in 13 markets. Recently clinics supporting 
Fort Campbell, Fort Sill, Fort Stewart and Fort Bragg have opened and 
initial feedback has been outstanding.
    The CBMHs build upon and are in many ways the culmination of a 
MEDCOM--wide campaign to closely monitor and reduce barriers to access 
and continuity; improve clinic productivity through standardization of 
administrative operations and support; to leverage improved health 
information management tools like AHLTA; and to incentivize commanders 
and providers to provide the right kind of care so as to improve 
individual and community health and outcomes of healthcare delivery in 
accordance with evidenced-based practices for chronic illness.
    We are adopting other methods as well to ensure better outcomes for 
patient care. At the MEDCOM, we have implemented a performance-based 
adjustment model (PBAM) to increase hospital and department 
responsibilities for how our funding is spent in health improvement and 
the delivery of healthcare services. PBAM creates a justifiable budget 
by a business planning process that links to outputs, such as volume or 
complexity of procedures. With the need for greater accountability and 
transparency, the MEDCOM has used PBAM to create performance measures 
that are consistent and can be compared across our facilities. We have 
experienced gains in total output, gains in provider efficiency, and 
increases in coding accuracy all aimed at improved outcomes of care--a 
more effective system for our beneficiaries and the Army. Incentives 
which are built into the program have measurably improved health and 
compliance with science--or--evidence-based care for chronic disease 
like diabetes and asthma.
    Army Medicine is committed to using evidence-based practices which 
provide the most effective treatment for the variety of medical issues 
confronting our patient population and especially those issues caused 
by the almost 10 years of war such as pain management. An Army at war 
for almost a decade recognizes it has accumulated significant issues 
with acute and chronic pain amongst its Soldiers. In August 2009, I 
chartered the Army Pain Management Task Force to make recommendations 
for a MEDCOM comprehensive pain management strategy. I appointed 
Brigadier General Richard Thomasas the Task Force Chairperson. Task 
Force membership included a variety of medical specialties and 
disciplines from the Army, as well as representatives from the Navy, 
Air Force, TRICARE Management Activity, and VA.
    The Pain Management Task Force developed 109 recommendations that 
lead to a comprehensive pain management strategy that is holistic, 
multidisciplinary, and multimodal in its approach, utilizes state of 
the art/science modalities and technologies, and provides optimal 
quality of life for Soldiers and other patients with acute and chronic 
pain. The Army Medical Command is operationalizing recommendations 
through the Pain Management Campaign Plan. I am proud to say that Army 
Medicine was recognized by the American Academy of Pain Medicine with 
the Presidential Commendation for its impact on pain medicine in the 
United States.
    An important objective of the Pain Management Task Force calls for 
building a full spectrum of best practices for the continuum of pain 
care, from acute to chronic, which is based on a foundation of the best 
available evidence based medicine. This can be accomplished through the 
adoption of an integrative and interdisciplinary approach to managing 
pain. Pain management should be handled by integrated care teams that 
use a biopsychosocial model of care. The standard of care should 
decrease overreliance on medication driven solutions and create an 
interdisciplinary approach that encourages collaboration among 
providers from differing specialties.
    The DOD should continue to responsibly explore safe and effective 
use of advanced and non-traditional approaches to pain management and 
support efforts to make these modalities covered benefits once they 
prove safe, effective and cost efficient. One way to achieve an 
interdisciplinary, multimodal and holistic approach to pain management 
is by incorporating complementary and alternative therapies--
integrative approaches--into an individualized pain management plan of 
care to include acupuncture, massage therapy, movement therapy, yoga, 
and other tools in mind-body medicine. To best address the goal of 
patient-centered care, providers must work in partnership with patients 
and Families in providing health promotion options while maintaining 
efficacy and safety standards. This integration needs to be methodical, 
appropriate, and evaluated throughout the process to ensure the best 
potential outcomes.
    While the Pain Management Task Force has worked to expand the use 
of non-medication pain management modalities, as combat operations 
continue, more Soldiers are presenting with physical or psychological 
conditions, or both, which require clinical care, including medication 
therapy. Consequently, some of them may be treated for multiple 
conditions with a variety of medications prescribed by several 
healthcare providers. While the resulting ``polypharmacy''--the use of 
multiple prescription or other medications--can be therapeutic in the 
treatment of some conditions, in other cases it can unwittingly lead to 
increased risk to patients. New Army policies and procedures to 
identify and mitigate polypharmacy have reduced the risk of these 
factors in garrison and deployed environments.
    Polypharmacy is not unique to military medical practice and is also 
a patient safety issue in the civilian medical community. The risks of 
polypharmacy include overdose (intentional or accidental); toxic 
interactions with other medications or alcohol; increased risk of 
adverse effects of medications; unintended impairment of alertness or 
functioning that may result in accident and injury; and the development 
of tolerance, withdrawal, and addiction to potentially habit-forming 
medications.
    U.S. Army Medical Command has issued guidance for enhancing patient 
safety and reducing risk via the prevention and management of 
polypharmacy. For example, Soldiers and Commanders are educated to take 
responsibility for, and active roles in, ensuring effective 
communication between patients and primary care managers to formulate 
treatment plans and address potential issues of polypharmacy. Annual 
training on managing polypharmacy patients is required for clinicians 
who prescribe psychotropic agents or central nervous system 
depressants. And through the electronic health record, patient health 
information, including prescriptions, is shared among providers to 
increase awareness of those patients with multiple medications.
    Evidence-based science makes strong Soldiers and we rely heavily on 
the U.S. Army Medical Research and Material Command (MRMC). Under the 
leadership of Major General James Gilman, MRMC manages and executes a 
robust, ongoing medical research program for the MEDCOM to support the 
development of new healthcare strategies. I would like to highlight a 
few research programs that are impacting health and care of our 
Soldiers today.
    The Combat Casualty Care Research Program (CCCRP) reduces the 
mortality and morbidity resulting from injuries on the battlefield 
through the development of new life-saving strategies, new surgical 
techniques, biological and mechanical products, and the timely use of 
remote physiological monitoring. The CCCRP focuses on leveraging 
cutting-edge research and knowledge from government and civilian 
research programs to fill existing and emerging gaps in combat casualty 
care. This focus provides requirements-driven combat casualty care 
medical solutions and products for injured Soldiers from self-aid 
through definitive care, across the full spectrum of military 
operations.
    The mission of the Military Operational Medicine Research Program 
(MOMRP) is to develop effective countermeasures against stressors and 
to maximize health, performance, and fitness, protecting the Soldier at 
home and on the battlefield. MOMRP research helps prevent physical 
injuries through development of injury prediction models, equipment 
design specifications and guidelines, health hazard assessment 
criteria, and strategies to reduce musculoskeletal injuries.
    MOMRP researchers develop strategies and advise policy makers to 
enhance and sustain mental fitness throughout a service member's 
career. Psychological health problems are the second leading cause of 
evacuation during prolonged or repeated deployments. MOMRP 
psychological health and resilience research focuses on prevention, 
treatment, and recovery of Soldiers and Families behavioral health 
problems, which are critical to force health and readiness. Current 
psychological health research topic areas include behavioral health, 
resiliency building, substance use and related problems, and risk-
taking behaviors.
    The Clinical and Rehabilitative Medicine Research Program (CRMRP) 
focuses on definitive and rehabilitative care innovations required to 
reset our wounded warriors, both in terms of duty performance and 
quality of life. The Armed Forces Institute of Regenerative Medicine 
(AFIRM) is an integral part of this program. The AFIRM was designed to 
speed the delivery of regenerative medicine therapies to treat the most 
severely injured U.S. service members from around the world but in 
particular those coming from the theaters of operation in Iraq and 
Afghanistan. The AFIRM is expected to make major advances in the 
ability to understand and control cellular responses in wound repair 
and organ/tissue regeneration and has major research programs in Limb 
Repair and Salvage, Craniofacial Reconstruction, Burn Repair, Scarless 
Wound Healing, and Compartment Syndrome.
    The AFIRM's success to date is at least in part the result of the 
program's emphasis on establishing partnerships and collaborations. The 
AFIRM is a partnership among the U.S. Army, Navy, and Air Force, the 
Department of Defense, the VA, and the National Institutes of Health. 
The AFIRM is composed of two independent research consortia working 
with the U.S. Army Institute of Surgical Research. One consortium is 
led by the Wake Forest Institute for Regenerative Medicine and the 
McGowan Institute for Regenerative Medicine in Pittsburgh while the 
other is led by Rutgers--the State University of New Jersey and the 
Cleveland Clinic. Each consortium contains approximately 15 member 
organizations, which are mostly academic institutions.
    MRMC is also the coordinating office for the DOD Blast Injury 
Research Program. The Blast Injury Research Program is addressing 
critical medical research gaps for blast-related injuries and is 
developing partnerships with other DOD and external medical research 
laboratories to achieve a cutting-edge approach to solving blast injury 
problems. One of the program's major areas of focus is the improvement 
of battlefield medical treatment capabilities to mitigate neurotrauma 
and hemorrhage. Additionally, the program is modernizing military 
medical research by bringing technology advances and new research 
concepts into DOD programs.
    We created a systematic and integrated approach to better organize 
and coordinate battlefield care to minimize morbidity and mortality, 
and optimize the ability to provide essential care required for 
casualty injuries--the Joint Theater Trauma System (JTTS). JTTS focuses 
on improving battlefield trauma care through enabling the right 
patient, at the right place, at the right time, to receive the right 
care. The components of the JTTS include prevention, pre-hospital 
integration, education, leadership and communication, quality 
improvement/performance improvement, research and information systems. 
The JTTS was modeled after the civilian trauma system principles 
outlined in the American College of Surgeons Committee on Trauma 
Resources for Optimal Care.
    Effectiveness and efficiency are also enhanced by electronic tools. 
To support DOD and VA collaboration on treating PTSD, pain, and other 
healthcare issues, the Electronic Health Record (EHR) should seamlessly 
transfer patient data between and among partners to improve 
efficiencies and continuity of care. The DOD and the VA share a 
significant amount of health information today and no two health 
organizations in the nation share more non-billable health information 
than the DOD and VA. The Departments continue to standardize sharing 
activities and are delivering information technology solutions that 
significantly improve the secure sharing of appropriate electronic 
health information. We need to include electronic health information 
exchange with our civilian partners as well--a health information 
systems which brings together three intersecting domains--DOD, VA, 
civilian--for optimal sharing of beneficiary health information and to 
provide a common operating picture of healthcare delivery. These 
initiatives enhance healthcare delivery to beneficiaries and improve 
the continuity of care for those who have served our country. 
Previously, the burden was on service members to facilitate information 
sharing; today, we are making the transition between DOD and VA easier 
for our service members.
    The Office of the Surgeon General (OTSG) works closely with Defense 
Health Information Management System of Health Affairs/TRICARE 
Management Activity in pursuing additional enhancements and fixes to 
AHLTA. The OTSG Information Management Division also continues to 
implement the MEDCOM AHLTA Provider Satisfaction Program, which now 
provides dictation and data entry software applications, tablet 
computing hardware, business process management, clinical business 
intelligence, and clinical systems training and integration to the 
providers and users of AHLTA. OTSG is taking the EHR lead in designing 
and pursuing the next generation of the EHR by participating in DOD and 
Inter-agency projects such as the EHR Way Ahead, the Virtual Lifetime 
Electronic Record Pilot Project, Nationwide Health Information Network, 
In-Depth EHR Training, and VA/DOD Sharing Initiatives. We are aligned 
with the Air Force's COMPASS program in ensuring that our providers and 
our clinics have the best and most user-friendly EHR.
    The Medical Command was reorganized in October 2010, to align 
regional medical commands (RMCs) with TRICARE regions with the 
resulting effect of improved readiness and support for the Army's 
iterative process of providing expeditionary, modular fighting units 
under the ARFORGEN cycle. We are well on the way to standardizing 
structure and staffing for RMC headquarters to provide efficiencies and 
ensure standardized best practices across Army Medicine. Three CONUS-
based regional medical commands, down from four, are now aligned with 
the TRICARE regions to provide healthcare in a seamless way with our 
TRICARE partners.
    In addition to TRICARE alignment, each region will contain an Army 
Corps headquarters, and health-care assets will be better aligned with 
beneficiary population of the regions. Each RMC has a deputy commander 
who is responsible for a readiness cell to coordinate and collaborate 
with the ARFORGEN cycle. This regional readiness cell will reach out to 
Reserve Component elements within their areas of responsibility to 
ensure that all medical and dental services required during the 
ARFORGEN cycle of the Reserve units are also identified and provided.
    In recent years, the Army has transformed how it provides 
healthcare to its Soldiers, with improvements impacting every aspect of 
the continuum of care. The Patient Centered Medical Home and the 
Warrior Transition Command are examples of the Army's strong commitment 
to adapt and improve its ability to provide the best care possible for 
our Soldiers and their Families. We have a duty and responsibility to 
our Soldiers, Families, and retirees. The level of care required does 
not end when the deployed Soldier returns home; there will be 
considerable ongoing healthcare costs for many years to support for our 
wounded, ill, or injured Service members. They need to trust we will be 
there to manage the health related consequences of over 9 years of war, 
including behavioral healthcare, post-traumatic stress, burn or 
disfiguring injuries, chronic pain or loss of limb. We will require 
ongoing research to establish more effective methodologies for 
treatment. Army Medicine remains focused on developing partnerships to 
achieve the aims of the MHS as we work together to provide cost 
effective care to improve the health of our Soldiers. The goal is to 
provide the best care and access possible for Army Families and 
retirees and to ensure optimal readiness for America's fighting forces 
and their Families.
    Last, I would like to join General Casey in expressing support for 
the military healthcare program changes included in the fiscal year 
2012 budget. The changes include modest enrollment fee increases for 
working-age retirees, pharmacy co-pay adjustments, aligning Defense 
reimbursements to sole community hospitals to Medicare consistent with 
current statute, and shifting future Uniformed Services Family Health 
Plan enrollees into the TRICARE-for-Life/Medicare program established 
by Congress in the fiscal year 2001 National Defense Authorization Act.
    In closing, over the past 40 months as the Army Surgeon General I 
have had numerous occasions to appear before this subcommittee, meet 
individually with you and your fellow members and interact with your 
staff. I have appreciated your tough questions, valuable insight, sage 
advice and deep commitment to your Army's Soldiers and their Families. 
Thank you for this opportunity to share Army Medicine with you. I am 
proud to serve with the Officers, Non-commissioned Officers, the 
enlisted Soldiers and civilian workforce of Army Medicine. Their 
dedication makes our Nation strong and our Soldiers and Families 
healthy and resilient.
    Thank you for your continued support of Army Medicine and to our 
Nation's men and women in uniform.
    Army Medicine: Building Value . . . Inspiring Trust

    Chairman Inouye. And now may I call upon Admiral Robinson.

STATEMENT OF VICE ADMIRAL ADAM M. ROBINSON, JR., 
            SURGEON GENERAL, DEPARTMENT OF THE NAVY
    Admiral Robinson. Good morning.
    Chairman Inouye, Vice Chairman Cochran, I am pleased to be 
with you today, and I want to thank the subcommittee for the 
tremendous confidence and unwavering support of Navy medicine, 
particularly as we continue to care for those who go in harm's 
way, their families, and all beneficiaries.
    Force health protection is the bedrock of Navy medicine. It 
is our duty, our obligation, and our privilege to promote, 
protect, and restore the health of our sailors and marines. The 
mission spans the full spectrum of healthcare from optimizing 
the health and fitness of the force, to maintaining robust 
disease surveillance and prevention programs, to saving lives 
on the battlefield. It also involves providing humanitarian 
assistance and disaster response around the world, and this is 
no more evident than in our efforts currently underway in Japan 
following the devastating earthquake and tsunami last month. I, 
along with my fellow surgeons general, traveled to Afghanistan 
in February and again witnessed the stellar performance of our 
dedicated men and women, both Active and Reserve, delivering 
expeditionary combat casualty care. At the NATO Role 3 
Multinational Medical Unit, Navy medicine is currently leading 
the joint and combined staff to provide the largest medical 
support in Kandahar. We are working side by side with Army and 
Air Force medical personnel, rapidly implementing best 
practices and employing unique skill sets in support of their 
demanding mission, leaving no doubt that the historically 
unprecedented survival rate from the battlefield is the direct 
result of better trained and equipped personnel, in conjunction 
with improved systems of treatment and casualty evacuation.
    We spend a lot of time discussing what constitutes world 
class healthcare. There is no doubt in my mind that the trauma 
care being provided in theater today is truly world class, as 
are the men and women delivering it. I am pleased to report to 
you that their morale is high and professionalism is unmatched.
    We also had the opportunity to visit our Concussion 
Restoration Care Center at Camp Leatherneck in Helmand 
Province. The center, which opened last August, assesses and 
treats service members with concussion, or mild traumatic brain 
injury, and musculoskeletal injuries. The goal is safely 
returning them to duty--to full duty following recovery. The 
Restoration Center, along with the initiatives like OSCAR, our 
Operational Stress Control and Readiness Program, where we 
embed full-time mental health personnel with deployed marines, 
continues to reflect our priority of positioning our medical 
personnel with deploying marines--our medical personnel and 
resources where they are most needed.
    Navy medicine has no greater responsibility than caring for 
our service members, wherever and whenever they need us. We 
understand that preserving the psychological health of service 
members and their families is one of the greatest challenges we 
face today. We also know that nearly a decade of continuous 
combat operations has resulted in a growing population of 
service members suffering with traumatic brain injury. We are 
forging ahead with improved screening, surveillance, treatment, 
education, and research; however, there is still much we do not 
yet know about these injuries and their long-term impact on the 
lives of our service members.
    I would specifically highlight the issuance of the 
directive-type memorandum in June 2010, which has increased 
line leaders' awareness of potential traumatic brain injury 
exposure, and, importantly, it mandates post-blast evaluations 
and removal of blast-exposed warfighters to promote recovery.
    We also recognize the importance of collaboration and 
partnership. Our collective efforts include those coordinated 
jointly with the other services, the Department of Veterans 
Affairs, the Centers of Excellence, as well as leading academic 
and research institutions.
    Let me now turn to patient and family centered care. 
Medical Home Port is Navy medicine's patient-centered medical 
home model, an important initiative that will significantly 
impact how we provide care to our beneficiaries. Medical Home 
Port emphasizes team-based, comprehensive care and focuses on 
the relationship between the patient, their provider, and the 
healthcare team. We continue to move forward with the phased 
implementation of Medical Home Port at our medical centers and 
family medicine teaching hospitals. An initial response from 
our patients and our providers is very encouraging.
    Finally, I would like to address the proposed Defense 
Health Program cost efficiencies. Rising healthcare costs 
within the military health system continue to present 
challenges. The Secretary of Defense has articulated that the 
rate at which healthcare costs are increasing and the relative 
proportion of the Department's resources devoted to healthcare 
cannot be sustained. The Department of the Navy fully supports 
the Secretary's plan to better manage costs moving forward and 
ensure our beneficiaries have access to the quality care that 
is the hallmark of military medicine.
    In summary, I am proud of the progress we are making, but 
not satisfied. We continue to see groundbreaking innovations in 
combat casualty care and remarkable heroics in saving lives. 
But all of us remain concerned about the cumulative effects of 
worry, stress, and anxiety on our service members and their 
families brought about by a decade of conflict. Each day 
resonates with the sacrifices that our sailors, marines, and 
their families make quietly and without bravado. It is this 
commitment, this selfless service, that helps inspire us in 
Navy medicine. Regardless of the challenges ahead, I am 
confident that we are well positioned for the future.
    As my last cycle of hearings is now coming to a close, as 
is my Navy career, I would like to thank this subcommittee and 
the entire Congress for their support of Navy medicine and 
everything that you have done to make sure that our men and 
women have the best in every possibility, both on the 
battlefield, in their recovery, and after they are out of the 
service.

                           PREPARED STATEMENT

    I appreciate the opportunity to be here today, and I look 
forward to your questions. Thank you very much.
    Chairman Inouye. Thank you very much, Admiral.
     [The statement follows:]

        Prepared Statement of Vice Admiral Adam M. Robinson, Jr.

                              INTRODUCTION

    Chairman Inouye, Vice Chairman Cochran, distinguished Members of 
the Subcommittee, I am pleased to be with you today to provide an 
update on Navy Medicine, including some of our accomplishments, 
challenges and strategic priorities. I want to thank the Committee 
Members for the tremendous confidence and unwavering support of Navy 
Medicine, particularly as we continue to care for those who go in 
harm's way, their families and all beneficiaries.
    Navy Medicine delivers world class care, anytime, anywhere. We are 
forward-deployed and engaged around the world every day, no matter what 
the environment and regardless of the challenge. The operational tempo 
of this past year continues to demonstrate that we must be flexible, 
adaptable and ready to respond globally. We will be tested in our 
ability to meet our operational and humanitarian assistance 
requirements, as well as maintain our commitment to provide patient and 
family centered care to a growing number of beneficiaries. However, I 
am proud to say that Navy Medicine is responding to these challenges 
with skill, commitment and compassion.

           STRATEGIC ALIGNMENT, INTEGRATION AND EFFICIENCIES

    Strategic alignment with the priorities of the Secretary of the 
Navy, Chief of Naval Operations and Commandant of the Marine Corps is 
critical to our ability to meet our mission. As a world-wide healthcare 
system, Navy Medicine is fully engaged in carrying out the core 
capabilities of the Maritime Strategy and the Cooperative Strategy for 
the 21st Century Seapower around the globe. Our ongoing efforts, 
including maintaining warfighter health readiness, conducting 
humanitarian assistance and disaster relief missions, protecting the 
health of our beneficiaries, as well as training our future force are 
critical to our future success.
    We also recognize the importance of alignment within the Military 
Health System (MHS) as evidenced by the adoption of the Quadruple Aim 
initiative as a primary focus of the MHS Strategic Plan. The Quadruple 
Aim applies the framework from the Institute for Healthcare Improvement 
(IHI) and customizes it for the unique demands of military medicine. It 
targets the MHS and Services' efforts on integral outcomes in the areas 
of readiness, population health and quality, patient experience and 
cost. The goal is to develop better outcomes and implement balanced 
incentives across the MHS.
    Within Navy Medicine, we continue to maintain a rigorous strategic 
planning process. Deliberative planning, constructive self-assessment 
and alignment at all levels of our organization, have helped create 
momentum and establish a solid foundation of measurable progress that 
drives change. It's paying dividends as we are seeing improved and 
sustained performance in our strategic objectives.
    This approach is particularly evident in our approach to managing 
resources. We are leveraging analytics to target resource decisions. An 
integral component of our Strategic Plan is providing performance 
incentives that promote quality and directly link back to workload, 
readiness and resources. We continue to evolve to a system which 
integrates requirements, resources and performance goals and promotes 
patient and family centered care. This transformation properly aligns 
authority, accountability and financial responsibility with the 
delivery of quality, cost-effective healthcare that remains patient and 
family centered.
    Aligning incentives helps foster process improvement particularly 
in the area of quality. Our Lean Six Sigma (LSS) program continues to 
be highly successful in identifying projects that synchronize with our 
strategic goals and have system-wide implications for improvement. 
Examples include reduced cycle time for credentialing providers and 
decreased waiting times for diagnostic mammography and ultrasound. I am 
also encouraged by our collaboration with the Johns Hopkins' Applied 
Physics Laboratory to employ industrial engineering practices to 
improve clinical processes and help recapture private sector workload.
    Navy Medicine continues to work within the MHS to realize cost 
savings through several other initiatives. We believe that robust 
promotion of TRICARE Home Delivery Pharmacy Program, implementation of 
supply chain management standardization for medical/surgical supplies 
and the full implementation of Patient-Centered Medical Home (PCMH) 
will be key initiatives that are expected to successfully reduce costs 
without compromising access and quality of care.
    Rising healthcare costs within the MHS continue to present 
challenges. The Secretary of Defense has articulated that the rate at 
which healthcare costs are increasing and relative proportion of the 
Department's resources devoted to healthcare, cannot be sustained. He 
has been resolute in his commitment to implement systemic efficiencies 
and specific initiatives which will improve quality and satisfaction 
while more responsibly managing cost.
    The Secretary of the Navy, Chief of Naval Operations and Commandant 
of the Marine Corps recognize that the MHS is not immune to the 
pressure of inflation and market forces evident in the healthcare 
sector. In conjunction with a growing number of eligible beneficiaries, 
expanded benefits and increased utilization throughout our system, it 
is incumbent upon us to ensure that we streamline our operations in 
order to get the best value for our expenditures. We have made 
progress, but there is more to do. We support the efforts to 
incentivize TRICARE Home Delivery Pharmacy Program and also to 
implement modest fee increases, where appropriate, to ensure equity in 
benefits for our retirees.
    The Department of the Navy (DON) fully supports the Secretary's 
plan to better manage costs moving forward and ensure our beneficiaries 
have access to the quality care that is the hallmark of military 
medicine. As the Navy Surgeon General, I appreciate the tremendous 
commitment of our senior leaders in this critical area and share the 
imperative in developing a more affordable and sustainable healthcare 
benefit.
    Navy Medicine has worked hard to get best value of every dollar 
Congress has provided and we will continue to do so. The President's 
budget for fiscal year 2012 adequately funds Navy Medicine to meet its 
medical mission for the Navy and Marine Corps. We are, however, facing 
challenges associated with operating under a potential continuing 
resolution for the remainder of the year, particularly in the areas of 
provider contracts and funding for facility special projects.

                        FORCE HEALTH PROTECTION

    Force Health Protection is the bedrock of Navy Medicine. It is what 
we do and why we exist. It is our duty--our obligation and our 
privilege--to promote, protect and restore the health of our Sailors 
and Marines. This mission spans the full spectrum of healthcare, from 
optimizing the health and fitness of the force, to maintaining robust 
disease surveillance and prevention programs, to saving lives on the 
battlefield. When Marines and Sailors go into harm's way, Navy Medicine 
is with them. On any given day, Navy Medicine is underway and forward 
deployed with the Fleet and Marine Forces, as well as serving as 
Individual Augmentees (IAs) in support of our global healthcare 
mission.
    Clearly, our focus continues to be combat casualty care in support 
of Operation Enduring Freedom (OEF). I, along with my fellow Surgeons 
General, recently returned from the Central Command (CENTCOM) Area of 
Responsibility (AOR) and again witnessed the stellar performance of our 
men and women delivering expeditionary combat casualty care. At the 
NATO Role 3 Multinational Medical Unit, Navy Medicine is currently 
leading the joint and combined staff to provide the largest medical 
support in Kandahar with full trauma care to include 3 operating rooms, 
12 intensive care beds and 35 ward beds. This state-of-the-art facility 
is staffed with dedicated and compassionate active and reserve 
personnel who are truly delivering world-class care. Receiving 70 
percent of their patients directly from the point of injury on the 
battlefield, our doctors, nurses and corpsmen apply the medical lessons 
learned from 10 years of war to achieve a remarkable 97 percent 
survival rate for coalition casualties.
    The Navy Medicine team is working side-by-side with Army and Air 
Force medical personnel and coalition forces to deliver outstanding 
healthcare to U.S. military, coalition forces, contractors, Afghan 
national army, police and civilians, as well as detainees. The team is 
rapidly implementing best practices and employing unique skill sets 
with specialists such as an interventional radiologist, pediatric 
intensivist, hospitalist and others in support of their demanding 
mission. I am proud of the manner in which our men and women are 
responding--leaving no doubt that the historically unprecedented 
survival rate from battlefield injuries is the direct result of better 
trained and equipped personnel, in conjunction with improved systems of 
treatment and casualty evacuation.
    Combat casualty care is a continuum which begins with corpsmen in 
the field with the Marines. We are learning much about battlefield 
medicine and continue to quickly put practices in place that will save 
lives. All deploying corpsmen must now complete the Tactical Combat 
Casualty Care (TCCC) training. TCCC guidelines for burns, hypothermia 
and fluid resuscitation for first responders have also been updated. 
This training is based on performing those interventions on the 
battlefield that address preventable causes of death. In addition, we 
have expanded the use of Combat Application Tourniquets (CATs) and 
hemostatic impregnated bandages as well as improving both intravenous 
therapy and individual first aid kits (IFAKs) and vehicle medical kits 
(VMKs).
    We continue to see success with our Forward Resuscitative Surgical 
System (FRSS) which allows for stabilization within the ``golden 
hour''. The FRSS can perform 18 major operations over the course of 72 
hours without being re-supplied. Our ability to send medical teams 
further forward has improved survivability rates. To this end, we are 
clearly making tremendous gains in battlefield medicine throughout the 
continuum of care. Work being conducted by the Joint Theatre Trauma 
Registry and Joint Combat Casualty Research Teams are enabling us to 
capture, evaluate and implement clinical practice guidelines and best 
practices quickly.

              HUMANITARIAN ASSISTANCE AND DISASTER RELIEF

    Navy Medicine continues its commitment to providing responsive and 
comprehensive support for Humanitarian Assistance/Disaster Relief (HA/
DR) missions around the world. We are often the first responder for HA/
DR missions due to the presence of organic medical capabilities with 
forward deployed Navy assets. Our hospital ships, USNS Mercy (T-AH 19) 
and USNS Comfort (T-AH 20) are optimally configured to deploy in 
support of HCA activities in South America, the Pacific Rim and East 
Asia.
    Navy Medicine not only responds to disasters around the world and 
at home, we also conduct proactive humanitarian missions in places as 
far reaching as Africa through Africa Partnership Station to the 
Pacific Rim through Pacific Partnership and South America through 
Continuing Promise. Mercy's recent deployment in support of Pacific 
Partnership 2010, the fifth annual Pacific Fleet proactive humanitarian 
mission, is strengthening ongoing relationships with host and partner 
nations in Southeast Asia and Oceania. During the 144-day, six nation 
mission, we treated 109,754 patients, performed 859 surgeries and 
engaged in thousands of hours of medical subject matter expert 
exchanges.
    Our hospital ships are executing our Global Maritime Strategy by 
building the trust and cooperation we need to strengthen our regional 
alliances and empower partners around the world. With each successful 
deployment, we increase our interoperability with host and partner 
nations, non-governmental organizations and the interagency partners. 
Today's security missions must include humanitarian assistance and 
disaster response,
    Enduring HA missions such as Pacific Partnership and Continuing 
Promise, as well other Medical Readiness Education Training Exercises 
(MEDRETEs) provide valuable training of personnel to conduct future 
humanitarian support and foreign disaster relief missions. Our 
readiness was clearly evident by the success of Operation Unified 
Response (OUR) following the devastating earthquake in Haiti last year. 
Our personnel were trained and prepared to accomplish this challenging 
mission.

                            CONCEPT OF CARE

    Patient and family centered care is our core philosophy--the 
epicenter of everything we do. We are providing comprehensive, 
compassionate healthcare for all our beneficiaries wherever they may be 
and whenever they may need it. Patient and family centered care helps 
ensure patient satisfaction, increased access, coordination of services 
and quality of care, while recognizing the vital importance of the 
family. Navy Medicine serves personnel throughout their treatment 
cycle, and for our Wounded Warriors, we manage every aspect of medicine 
in their continuum of care to provide a seamless transition from 
battlefield to bedside to leading productive lives.
    Medical Home Port is Navy Medicine's Patient-Centered Medical Home 
(PCMH) model, an important initiative that will significantly impact 
how we provide care to our beneficiaries. In alignment with my 
strategic goal for patient and family centered care, Medical Home Port 
emphasizes team-based, comprehensive care and focuses on the 
relationship between the patient, their provider and the healthcare 
team. The Medical Home Port team is responsible for managing all 
healthcare for empanelled patients, including specialist referrals when 
needed. Patients see familiar faces with every visit, assuring 
continuity of care. Appointments and tests get scheduled promptly and 
care is delivered face-to-face or when appropriate, using secure 
electronic communication. PCMH is being implemented by all Services and 
it is expected to improve population health, patient satisfaction, 
readiness, and is likely to impact cost in very meaningful ways.
    It is important to realize that Medical Home Port is not brick and 
mortar; but rather a philosophy and commitment as to how you deliver 
the highest quality care. A critical success factor is leveraging all 
our providers, and supporting information technology systems, into a 
cohesive team that will not only provide primary care, but integrate 
specialty care as well. We continue to move forward with the phased 
implementation of Medical Home Port at our medical centers and family 
medicine teaching hospitals, and initial response from our patients is 
very encouraging.

          CARING FOR OUR HEROES, THEIR FAMILIES AND CAREGIVERS

    We have no greater responsibility than caring for our service 
members, wherever and whenever they need us. This responsibility spans 
from the deckplates and battlefield to our clinics, hospitals and 
beyond. This commitment to provide healing in body, mind and spirit has 
never been more important. Our case management programs, both medical 
and non-medical, play a vital role in the development of Comprehensive 
Recovery Plans to provide our war-injured service members' optimal 
outcomes. Case management is the link that connects resources and 
services for our Wounded Warriors and their families.
    Associated with this commitment, we must understand that preserving 
the psychological health of service members and their families is one 
of the greatest challenges we face today. We recognize that service 
members and their families are resilient at baseline, but the long 
conflict and related deployments challenge this resilience. DON is 
committed to providing programs that support service members and their 
families.
    The Navy Operational Stress Control program and Marine Corps Combat 
Operational Stress Control programs are the cornerstones of our 
approach to early detection of stress injuries in Sailors and Marines 
and are comprised of line-led programs which focus on leadership's role 
in monitoring the health of their people; tools leaders may employ when 
Sailors and Marines are experiencing mild to moderate symptoms; and 
multidisciplinary expertise (medical, chaplains and other support 
services) for more affected members.
    Navy Medicine's Psychological Health (PH) program supports the 
prevention, diagnosis, mitigation, treatment and rehabilitation of 
post-traumatic stress disorder (PTSD) and other mental health 
conditions, including planning for the seamless transition of service 
members throughout the recovery and reintegration process. We have 
increased the size of the mental health workforce to support the 
readiness and health needs of the Fleet and Marine Corps throughout the 
deployment cycle and, during fiscal year 2010, funded 221 clinical and 
support staff positions at 14 Navy military treatment facilities (MTFs) 
to help ensure timely access to care.
    Stigma remains a barrier; however, Navy and Marine Corps' efforts 
to decrease stigma have had preliminary success--with increased active 
leadership support and Operational Stress Control (OSC) training 
established throughout the Fleet and Marine Forces.
    Within the Marine Corps, we continue to see success with the 
Operational Stress Control and Readiness (OSCAR) program as well as the 
OSCAR Extender program. OSCAR embeds full-time mental health personnel 
with deploying Marines and uses existing medical and chaplain personnel 
as OSCAR Extenders and trained senior and junior Marines as mentors to 
provide support at all levels to reduce stigma and break down barriers 
to seeking help. Our priority remains ensuring we have the service and 
support capabilities for prevention and early intervention available 
where and when it is needed. OSCAR is allowing us to move forward in 
this important area.
    We recently deployed our third Navy Mobile Mental Health Care Team 
for a 6-month mission in Afghanistan. The team consists of three mental 
health clinicians, a research psychologist and an enlisted psychiatry 
technician. Their primary tool is the Behavioral Health Needs 
Assessment Survey (BHNAS). The results give an overall assessment of 
real time force mental health and well-being every 6 months, and can 
identify potential areas or sub-groups of concern for leaders. It 
assesses a wide variety of content areas, including mental health 
outcomes, as well as the risk and protective factors for those outcomes 
such as combat exposures, deployment-related stressors, positive 
effects of deployment, morale and unit cohesion. The Mobile Care Team 
also has a mental health education role and provides training in 
Psychological First Aid to Sailors in groups and individually. 
Ultimately, Psychological First Aid gives Sailors a framework to 
promote resilience in one another.
    Our Naval Center for Combat & Operational Stress Control (NCCOSC) 
is one way we are developing an environment that supports 
psychologically fit, ready and resilient Navy and Marine Corps forces. 
The goal is to demystify stress and help Sailors and Marines take care 
of themselves and their shipmates. NCCOSC continues to make progress in 
advancing research for the prevention, diagnosis and treatment of 
combat and operational stress injuries to include PTSD. They are 
involved in over 64 ongoing scientific projects with 3,525 participants 
enrolled. NCCOSC has recently developed a pilot program, Psychological 
Health Pathways, which is designed to ensure that clinical practice 
guidelines are followed and evidence-based care is practiced and 
tracked. To date, 1,554 patients have been enrolled into the program 
with 600,062 points of clinical data gathered. The program involves 
intensive mental health case management, use of standardized measures, 
provider training and comprehensive data tracking.
    In November 2010, we launched a pilot program, Overcoming Adversity 
and Stress Injury Support (OASIS) at the Naval Medical Center, San 
Diego. Developed by Navy Medicine personnel and located onboard the 
Naval Base Point Loma, California, OASIS is a 10-week residential 
program designed to provide intensive mental healthcare for service 
members with combat related mental health symptoms from post-traumatic 
stress disorder, as well as major depressive disorders, anxiety 
disorders and substance abuse problems. The program offers a 
comprehensive approach, focusing on mind and body through various 
methods including yoga, meditation, spirituality classes, recreation 
therapy, art therapy, intensive sleep training, daily group therapy, 
individual psychotherapy, family skills training, medication management 
and vocational rehabilitation. We will be carefully assessing the 
efficacy of this pilot program throughout this year.
    Associated with our Operational Stress Control efforts, suicide 
prevention remains a key component. Suicide destroys families and 
impacts our commands. We are working hard at all levels to build the 
resilience of our Sailors and Marines and their families, as well as 
foster a culture of awareness and intervention by the command and 
shipmates. Our programs are focused on leadership engagement, 
intervention skills, community building and access to quality 
treatment. All of us in uniform have a responsibility to care for our 
shipmates and remain vigilant for signs of stress. A-C-T (Ask--Care--
Treat) remains an important framework of response. In 2010, both the 
Navy and Marine Corps saw reductions in the number of suicides from the 
prior year, with the Navy seeing a reduction of 17 percent while the 
Marine Corps realized a 29 percent drop.
    We are also committed to improving the psychological health, 
resiliency and well-being of our family members. When our Sailors and 
Marines deploy, our families are their foothold. Family readiness is 
force readiness and the physical, mental, emotional, spiritual health 
and fitness of each individual is critical to maintaining an effective 
fighting force. A vital aspect of caring for our Warriors is also 
caring for their families and we continue to look for innovative ways 
to do so.
    To meet this growing challenge, Navy Medicine began an unparalleled 
approach in 2007 called Project FOCUS (Families OverComing Under 
Stress) to help our families. FOCUS is a family centered resiliency 
training program based on evidenced-based interventions that enhances 
understanding, psychological health and developmental outcomes for 
highly stressed children and families. FOCUS has been adapted for 
military families facing multiple deployments, combat operational 
stress, and physical injuries in a family member. It is an 8-week, 
skill-based, trainer-led intervention that addresses difficulties that 
families may have when facing the challenges of multiple deployments 
and parental combat related psychological and physical health problems. 
It has demonstrated that a strength-based approach to building child 
and family resiliency skills is well received by service members and 
their family members. Notably, program participation has resulted in 
statistically significant increases in family and child positive coping 
and significant reductions in parent and child distress over time, 
suggesting longer-term benefits for military family wellness.
    Project FOCUS has been highlighted by the Interagency Policy 
Committee on Military Families Report to the President (October 2010) 
and has been recognized by the Department of Defense (DOD) as a best 
practice. Given the success FOCUS has demonstrated thus far, we will 
continue to devote our efforts to ensuring our service members and 
their families have access to this program. To date, over 160,000 
Service members, families and community support providers have received 
FOCUS services, across 23 locations CONUS and OCONUS.
    Our programs must address the needs of all of our Sailors, Marines 
and families, including those specifically targeted to the unique needs 
of reservists and our caregivers. The Reserve Psychological Health 
Outreach Program (RPHOP) identifies Navy and Marine Corps Reservists 
and their families who may be at risk for stress injuries and provides 
outreach, support and resources to assist with issue resolution and 
psychological resilience. An effective tool at the RPHOP Coordinator's 
disposal is the Returning Warrior Workshop (RWW), a 2-day weekend 
program designed specifically to support the reintegration of returning 
Reservists and their families following mobilization. Some 54 RWWs have 
been held since 2008 with over 6,000 military personnel, family members 
and guests attending.
    Navy Medicine is also working to enhance the resilience of 
caregivers to the psychological demands of exposure to trauma, wear and 
tear, loss, and inner conflict associated with providing clinical care 
and counseling through the Caregiver Occupational Stress Control 
(CgOSC) Program. The core objectives are early recognition of distress, 
breaking the code of silence related to stress reactions and injuries, 
and engaging caregivers in early help as needed to maintain both 
mission and personal readiness.
    In addition, the Naval Health Research Center (NHRC) produced ``The 
Docs'', a 200-page graphic novel, as a communication tool to help our 
corpsmen with the stresses of combat deployments. ``The Docs'' is the 
story of four corpsmen deployed to Iraq. While some events in the novel 
are specific to Operation Iraqi Freedom (OIF), it is not intended to 
depict any specific time period or conflict but rather highlight 
general challenges faced by corpsmen who serve as the ``Docs'' in a 
combat zone. It was developed with the intent to instill realistic 
expectations of possible deployment stressors and to provide examples 
for corpsmen on helpful techniques for in-theater care of stress 
injuries. This format was chosen for its value in providing thought-
provoking content for discussion in training scenarios and to appeal to 
the targeted age group.
    Nearly a decade of continuous combat operations has resulted in a 
growing population of service members suffering with Traumatic Brain 
Injury (TBI), the very common injury of OEF and OIF. The majority of 
TBI injuries are categorized as mild, or in other words, a concussion. 
We know more about TBI and are forging ahead with improved 
surveillance, treatment and research. However, we must recognize that 
there is still much we do not yet know about these injuries and their 
long-term impacts on the lives of our service members.
    Navy Medicine is committed to ensuring thorough screening for all 
Sailors and Marines prior to expeditionary deployment, enhancing the 
delivery of care in theater, and the identification and testing of all 
at-risk individuals returning from deployment. We are committed to 
enhancing training initiatives, developing better tools to detect 
changes related to TBI and sustaining research into better treatment 
options.
    Pre-deployment screening is prescribed using the Automated 
Neuropsychological Assessment Metrics (ANAM). Testing has expanded to 
Navy and Marine Corps worldwide, enhancing the ability to establish 
baseline neurocognitive testing for expeditionary deployers. This 
baseline test has provided useful comparative data for medical 
providers in their evaluation, treatment and counseling of individuals 
who have been concussed in theater.
    In-theater screening and treatment has also improved over time. The 
issuance of the Directive-Type Memorandum (DTM) 09-033 in June 2010 has 
increased leaders' awareness of potential TBI exposure and mandates 
post-blast evaluations and removal of blast-exposed warfighters from 
high risk situations to promote recovery. Deploying medical personnel 
are trained in administering the Military Acute Concussion Evaluation 
(MACE), a rapid field assessment to help corpsmen identify possible 
concussions. Additionally, deploying medical providers receive training 
on the DTM requirements and in-theater Clinical Practice Guidelines 
(CPGs) for managing concussions.
    In August 2010, the Marine Corps, supported by Navy Medicine, 
opened the Concussion Restoration Care Center (CRCC) at Camp 
Leatherneck in Helmand Province to assess and treat service members 
with concussion or musculoskeletal injuries, with the goal of safely 
returning as many service members as possible to full duty following 
recovery of cognitive and physical functioning. The CRCC is supported 
by an interdisciplinary team including sports medicine, family 
medicine, mental health, physical therapy and occupational therapy. I 
am encouraged by the early impact the CRCC is having in theatre by 
providing treatment to our service members close to the point of injury 
and returning them to duty upon recovery. We will continue to focus our 
attention on positioning our personnel and resources where they are 
most needed.
    Post-deployment surveillance for TBI is accomplished through the 
Post-Deployment Health Assessment (PDHA) and Post-Deployment Health 
Reassessment (PDHRA), which are required for returning deplorers. 
Further evaluation, treatment and referrals are provided based on 
responses to certain TBI-specific questions on the assessments.
    TBI research efforts are focused on continuing to refine tools for 
medical staff to use to detect and treat TBI. Two specific examples are 
a study of cognitive and physical symptoms in USMC Breacher instructors 
(who have a high lifetime exposure rate to explosive blasts) and an 
ongoing surveillance effort with USMC units with the highest identified 
concussion numbers to determine the best method for identifying service 
members requiring clinical care. These efforts are coupled with post-
deployment ANAM testing for those who were identified as sustaining at 
least one concussion in theater. Other efforts are underway to identify 
physical indicators and biomarkers for TBI, such as blood tests, to 
help in diagnosis and detection. We are also conducting evaluations of 
various neurocognitive assessment tools to determine if there is a 
``best'' tool for detecting concussion effects in the deployed 
environment. Our efforts also include those coordinated jointly with 
the other Services, the Defense and Veterans Brain Injury Center 
(DVBIC), and the Defense Centers of Excellence for Psychological Health 
and Traumatic Brain Injury (DCoE).
    I am committed to ensuring that we build on the vision advanced by 
the Members of Congress and the hard work of the dedicated 
professionals at all the Centers of Excellence, MTFs, research centers 
and our partners in both the public and private sectors. These Centers 
of Excellence have become important components of the Military Health 
System and their work in support of clinical best practices, research, 
outreach and treatment must continue with unity of effort and our 
strong support.
    Our service members must have access to the best treatment, 
research and education available for PH and TBI. We continue to see 
progress as evidenced by the opening of the National Intrepid Center of 
Excellence (NICoE) onboard the National Naval Medical Center campus. As 
a leader in advancing state-of-the-art treatment, research, education 
and training, NICoE serves as an important referral center primarily 
for service members and their families with complex care needs, as well 
as a hub for best practices and consultation. NICoE also conducts 
research, tests new protocols and provides comprehensive training and 
education to patients, providers and families--all vital to advancing 
medical science in PH and TBI.
    Navy Medicine is also working with the DCoE, its component centers 
including DVBIC, the Department of Veterans Affairs, research centers, 
and our partners in both the public and private sectors to support best 
clinical practices, research and outreach. We continue to see gains in 
both the treatment and development of support systems for our Wounded 
Warriors suffering with these injuries; however, we must recognize the 
challenging and extensive work that remains. Our commitment will be 
measured in decades and generations and must be undertaken with urgency 
and compassion.

                         THE NAVY MEDICINE TEAM

    Our people are our most important assets, and their dignity and 
worth are maintained through an atmosphere of service, professionalism, 
trust and respect. Navy Medicine is fortunate to have over 63,000 
dedicated professionals working to improve and protect the health of 
Sailors, Marines and their families. Our team includes officers, 
enlisted personnel, government civilians and contractors working 
together in support of our demanding mission. I have been privileged to 
meet many of them in all environments--forward-deployed with the 
operating forces, in our labs and training facilities, at the bedside 
in our medical centers and hospitals--and I'm always inspired by their 
commitment.
    We are working diligently to attract, recruit and retain our Navy 
Medicine personnel. Overall, I remain encouraged with the progress we 
are making in recruiting and overall manning and we are seeing the 
successes associated with our incentive programs. In fiscal year 2010, 
we met our Active Medical Department recruiting goal and attained 90 
percent of Reserve Medical Department goal, but there was a notable 
shortfall in Reserve Medical Corps recruiting at 70 percent. Given the 
relatively long training pipeline for many of our specialties, we 
clearly recognize the impact that recruiting shortfalls in prior years, 
particularly in the Health Professions Scholarship Program (HPSP), can 
have in meeting specialty requirements today and moving forward. 
Recruiting direct accession physicians and dentists remains 
challenging, requiring our scholarship programs to continue recent 
recruiting successes to meet inventory needs. Retention has improved 
for most critical wartime specialties, supported by special pay 
initiatives; however, some remain below our requirements and continue 
to be closely monitored.
    Within the active component Medical Corps, general surgery, family 
medicine and psychiatry have shortfalls, as does the Dental Corps with 
general dentistry and oral maxillofacial surgery specialties. We are 
also experiencing shortfalls for nurse anesthetists, perioperative and 
critical care nurses, family nurse practitioners, clinical 
psychologists, social workers and physician assistants.
    The reserve component shortages also exist within anesthesiology, 
neurosurgery, orthopedic surgery, internal medicine, psychiatry, 
diagnostic radiology, comprehensive dentistry and oral maxillofacial 
surgery as well as perioperative nursing, anesthesia and mental health 
nurse practitioners.
    We appreciate your outstanding support for special pays and bonus 
programs to address these shortages. These incentives will continue to 
be needed for future success in both recruiting and retention. We are 
working closely with the Chief of Naval Personnel and Commander, Naval 
Recruiting Command to assess recruiting incentive initiatives and 
explore opportunities for improvement.
    For our civilian personnel within Navy Medicine, we are also 
coordinating the National Security Personnel System (NSPS) replacement 
for 32 healthcare occupations to ensure pay parity among healthcare 
professions. We have been successful in hiring required civilians to 
support our Sailors and Marines and their families--many of whom 
directly support our Wounded Warriors. Our success in hiring is in 
large part due to the hiring and compensation flexibilities that have 
been granted to the DOD's civilian healthcare community over the past 
several years.
    Our priority remains to maintain the right workforce to deliver the 
required medical capabilities across the enterprise, while using the 
appropriate mix of accession, retention, education and training 
incentives.
    I want to also reemphasize the priority we place on diversity. Navy 
Medicine has continued to emerge as a role model of diversity as we 
focus on inclusiveness while aligning ethnic and gender representation 
throughout the ranks to reflect our Nation's population. Not only are 
we setting examples of a diverse, robust and dedicated healthcare 
force, but this diversity also reflects the people for whom we provide 
care. We take great pride in promoting our message that we are the 
employer of choice for individuals committed to a culturally competent 
work-life environment; one where our members proudly see themselves 
represented at all levels of leadership.
    For all of us in Navy Medicine, an excerpt from the Navy Ethos 
articulates well what we do: ``We are a team, disciplined and well-
prepared, committed to mission accomplishment. We do not waiver in our 
dedication and accountability to our Shipmates and families.''

      EXCELLENCE IN RESEARCH AND DEVELOPMENT AND HEALTH EDUCATION

    World-class research and development capabilities, in conjunction 
with outstanding medical education programs, represent the future of 
our system. Each is a force-multiplier and, along with clinical care, 
is vital to supporting our health protection mission. The work that our 
researchers and educators do is having a direct impact on the treatment 
we are able to provide our Wounded Warriors, from the battlefield to 
the bedside. We will shape the future of military medicine through 
research, education and training.
    The overarching mission of our Research and Development program is 
to conduct health and medical research, development, testing, and 
evaluation (RDT&E), and surveillance to enhance the operational 
readiness and performance of DOD personnel worldwide. In parallel, our 
Clinical Investigation Program activity, located at our teaching MTFs 
is, to an increasing degree, participating in the translation of 
appropriate knowledge and products from our RDT&E activity into proof 
of concept and cutting edge interventions to benefit our Wounded 
Warriors and our beneficiaries. We are also committed to connecting our 
Wounded Warriors to approved emerging and advanced diagnostic and 
therapeutic options within and outside of military medicine while 
ensuring full compliance with applicable patient safety policies and 
practices.
    Towards this end, we have developed our top five strategic research 
goals and needs to meet the Chief of Naval Operations and Commandant of 
the Marine Corps warfighting requirements. These include:
  --Traumatic brain injury (TBI) and psychological health treatment and 
        fitness for both operational forces and home-based families.
  --Medical systems support for maritime and expeditionary operations 
        to include patient medical support and movement through care 
        levels I and II with emphasis on the United States Marine Corps 
        (USMC) casualty evacuation (CASEVAC) and En Route Care systems 
        to include modeling and simulation for casualty prediction, 
        patient handling, medical logistics, readiness, and command, 
        control, communications and intelligence (C\3\I).
  --Wound management throughout the continuum of care, to include 
        chemical, molecular, and cellular indicators of optimum time 
        for surgical wound closure, comprehensive rehabilitation; and 
        reset to operational fitness.
  --Hearing restoration and protection for operational maritime surface 
        and air support personnel.
  --Undersea medicine, diving and submarine medicine, including 
        catastrophe intervention, rescue and survival as well as 
        monitoring and evaluation of environmental challenges and 
        opportunities.
    During my travel overseas this past year, including Vietnam, 
current partnerships and future partnerships possibilities between Navy 
Medicine and host nation countries were evident. Increasing military 
medical partnerships are strengthening overall military to military 
relationships which are the cornerstone of overarching bilateral 
relations between allies. These engagements are mutually beneficial--
not only for the armed forces of both countries, but for world health 
efforts with emerging allies in support of global health diplomacy.
    Graduate Medical Education (GME) is vital to our ability to train 
our physicians and meet our force health protection mission. Vibrant 
and successful GME programs continue to be the hallmark of Navy 
Medicine and I am pleased that despite the challenges presented by a 
very high operational tempo and past year recruiting shortfalls, our 
programs remain strong. All of our GME programs eligible for 
accreditation are accredited and most have the maximum or near maximum 
accreditation cycle lengths. In addition, our graduates perform very 
well on their Specialty Boards--significantly exceeding the national 
pass rate in almost every specialty year after year. The overall pass 
rate for 2009 was 97 percent. Most importantly, our Navy-trained 
physicians continue to prove themselves to be exceptionally well 
prepared to provide care in austere settings from the battlefield to 
disaster relief missions.
    In addition to GME, we are leveraging our inter-service education 
and training capabilities with the new state-of-the-art Medical 
Education and Training Campus (METC) in San Antonio, Texas. Now 
operational, METC represents the largest consolidation of Service 
training in the history of DOD, and is the world's largest medical 
training campus. Offering 30 programs and producing 24,000 graduates 
annually, METC will enable us to train our Sailors, Soldiers and Airmen 
to meet both unique Service-specific and joint missions. Our corpsmen 
are vital to saving lives on the battlefield and the training they 
receive must prepare them for the rigors of this commitment. I am 
committed to an inter-service education and training system that 
optimizes the assets and capabilities of all DOD healthcare 
practitioners yet maintains the unique skills and capabilities that our 
corpsmen bring to the Navy and Marine Corps--in hospitals, at sea and 
on the battlefield.

                        COLLABORATION ENGAGEMENT

    Navy Medicine recognizes the importance of leveraging collaborative 
relationships with the Army and Air Force, as well as the Department of 
Veterans Affairs (VA), and other Federal and civilian partners. These 
engagements are essential to improving operational efficiencies, 
education and training, research and sharing of technology. Our 
partnerships also help create a culture in which the sharing of best 
practices is fundamental to how we do business and ultimately helps us 
provide better care and seamless services and support to our 
beneficiaries.
    The progress we are making with the VA was clearly evident as we 
officially activated the Captain James A. Lovell Federal Health Care 
Center in Great Lakes, Illinois--a first-of-its-kind fully integrated 
partnership that links Naval Health Clinic Great Lakes and the North 
Chicago VA Medical Center into one healthcare system. We are grateful 
for all your support in helping us achieve this partnership between the 
Department of Veterans Affairs, DOD and DON. We are proud to able to 
provide a full spectrum of healthcare services to recruits, active 
duty, family members, retirees and veterans in the Nation's first fully 
integrated VA/Navy facility. We look forward to continuing to work with 
you as we improve efficiencies, realize successes and implement lessons 
learned.
    Navy Medicine has 52 DOD/VA sharing agreements in place for medical 
and ancillary services throughout the enterprise as well as 10 Joint 
Incentive Fund (JIF) projects. When earlier JIF projects ended, they 
were superseded by sharing agreements. Naval Health Clinic Charleston 
and the Ralph H. Johnson VA Medical Center celebrated the opening of 
the new Captain John G. Feder Joint Ambulatory Care Clinic. This newly 
constructed outpatient clinic located on Joint Base Charleston Weapons 
Station is a state-of-the-art 188,000 square foot facility that is 
shared by the VA and the Navy Health Clinic Charleston. This project is 
another joint initiative such as the Joint Ambulatory Care Center in 
Pensacola that replaced the former Corry Station Clinic; and another in 
Key West where the VA's Community Based Outpatient Clinic (CBOC) and 
the Navy Clinic are co-located, continuing collaboration and providing 
service at the site of our first VA/DOD Joint Venture.
    We are also continuing to work to implement the Integrated 
Disability Evaluation System (IDES) at our facilities in conjunction 
with VA. To date, this program has been implemented at 15 of our MTFs. 
This world-wide expansion, to be completed in fiscal year 2011, follows 
the DES Pilot program and the decision of the Wounded, Ill and Injured 
Senior Oversight Council (SOC) Co-chairs (Deputy Secretary of Defense 
and Deputy Secretary of Veterans Affairs) to move forward to streamline 
the DOD DES process.
    One of our most important projects continues to be the successful 
transition of the new Walter Reed National Military Medical Center 
(WRNMMC) onboard the campus of the National Naval Medical Center, 
Bethesda. This realignment is significant and the Services are working 
diligently with DOD's lead activity, Joint Task Force Medical--National 
Capital Region to ensure we remain on track to meet the Base 
Realignment and Closure (BRAC) deadline of September 15, 2011. Our 
priority continues to be properly executing this project on schedule 
without any disruption of services. We also understand the importance 
of providing a smooth transition for our dedicated personnel--both 
military and civilian--to the success of WRNMMC. We recognize that 
these dedicated men and women are critical to our ability to deliver 
world class care to our Sailors, Marines, their families and all our 
beneficiaries for whom we are privileged to serve.

                            THE WAY FORWARD

    I am proud of the progress we are making, but not satisfied. We 
continue to see ground-breaking innovations in combat casualty care and 
remarkable heroics in saving lives. But all of us remain concerned 
about the cumulative effects of worry, stress and anxiety on our 
service members and their families brought about by a decade of 
conflict. Each day during my tenure as the Navy Surgeon General, we 
have been a Nation at war. Each day resonates with the sacrifices that 
our Sailors, Marines and their families make, quietly and without 
bravado. They go about their business with professionalism, skill, and 
frankly, ask very little in return. It is this commitment, this 
selfless service, that helps inspire us in Navy Medicine. Regardless of 
the challenges ahead, I am confident that we are well-positioned for 
the future.
    I will be retiring from Naval Service later this year and I want to 
express my thanks for all the support you provide to Navy Medicine and 
to me throughout my tenure as the Navy Surgeon General.

    Chairman Inouye. And now, may I call upon General Green.

STATEMENT OF LIEUTENANT GENERAL CHARLES B. GREEN, 
            SURGEON GENERAL, DEPARTMENT OF THE AIR 
            FORCE
    General Green. Good morning.
    Chairman Inouye, Senator Cochran, distinguished members of 
the subcommittee, I truly appreciate the opportunity to meet 
with you today and represent the men and women of the Air Force 
Medical Service. We could not achieve our goals of better 
readiness, better health, better care, and best value for our 
heroes and their families without your support. And we thank 
you.

                  MILITARY HEALTH SYSTEM ACHIEVEMENTS

    Military Health System achievements have changed the face 
of war. We deploy and set up hospitals within 12 hours of 
arrival anywhere in the world. We move wounded warriors from 
the battlefield to operating rooms within minutes and have 
achieved and sustained the less than 10 percent died of wounds 
rate.
    We move our sickest patients in less than 24 hours of 
injury and get them home to loved ones within 3 days to hasten 
their recovery.
    We have safely evacuated more than 85,000 patients since 
October 2001, 11,300 just this last year, many of them 
critically injured.
    The Air Force Medical Service has a simple mantra: 
``Trusted Care Anywhere.'' This fits what we do today and will 
continue to do in years ahead. It means creating a system that 
can be taken anywhere in the world and be equally effective, 
whether it is for war or for humanitarian assistance.
    Air Combat Command's new Expeditionary Medical System, the 
Health Response Team, is capable of seeing the first patient 
within 1 hour of arrival anywhere in the world, and performing 
surgery within 3 to 5 hours. Our Radiological Assessment Team 
was in place quickly to assist Japan in measuring the levels of 
radiation, food and water safety, overall impact on health, and 
to distribute personal dosimeters for protection of our 
personnel. Our deployed systems are linked back to American 
quality care and refuse to compromise on patient safety.
    Providing trusted care anywhere requires the Air Force 
Medical Service to focus on patients and populations. By the 
end of 2012, the Air Force Patient-Centered Medical Home will 
provide 1 million of our beneficiaries new continuity of care 
via single provider-led teams at all Air Force facilities.
    Patient-Centered Care builds new possibilities in 
prevention by linking the patient to a provider team, and both 
the patient and the provider team to decision support from 
informatics networks dedicated to improving care. Efficient and 
effective health teams allow recapture of care in our medical 
treatment facilities to sustain our currency and offer best 
value. We will do all in our power to improve the health of our 
population while working to control the rising costs of 
healthcare.
    The Air Force Medical Service treasures our partnership 
with OSD, the Army, Navy, VA, civilian and academic partners. 
We leverage all the tools that you have given us to improve 
retention and generate new medical knowledge. We will continue 
to deliver nothing less than world class care to military 
members and their families, wherever they may serve around the 
world.

                           PREPARED STATEMENT

    And I stand ready to answer your questions. Thank you.
    Chairman Inouye. All right. Thank you very much.
     [The statement follows:]

    Prepared Statement of Lieutenant General (Dr.) Charles B. Green
    Military Health System achievements have changed the face of war. 
We deploy and set up hospitals in 12 hours of arrival almost anywhere 
in the world. We move wounded warriors from the battlefield to an 
operating room within minutes and have achieved and sustained less than 
10 percent died-of-wounds rate. We move our sickest patients in less 
than 24 hours of injury and get them home to loved ones within 3 days 
to hasten recovery. We have safely evacuated more than 86,000 patients 
since October 2001, 11,300 in 2010 alone, many of them critically 
injured. This is all pretty amazing.
    The Air Force Medical Service (AFMS) has a simple mantra: ``Trusted 
Care Anywhere.'' This fits what we do today and will continue to do in 
the years ahead. It means creating a system that can be taken anywhere 
in the world and be equally as effective whether in war or for 
humanitarian assistance. This system is linked back to American quality 
care and refuses to compromise on patient safety. These are formidable 
challenges, but we have the foundation we need and the best creative 
minds working with us to achieve this end.
    Providing Trusted Care Anywhere requires the AFMS to focus on 
patients and populations. Patient-centered care builds new 
possibilities in prevention by linking the patient to a provider team 
and both patient and provider team to an informatics network dedicated 
to improving care. Efficient and effective health teams allow recapture 
of care in our medical treatment facilities (MTFs) to sustain currency. 
Continually improving our readiness ensures patients and warfighters 
always benefit from the latest medical technologies and advancements.

                     PATIENT-CENTERED MEDICAL HOME

    To improve Air Force primary care and achieve better health 
outcomes for our patients, we implemented our Family Health Initiative 
(FHI) in 2009, which is a team-based, patient-centered approach 
building on the Patient-Centered Medical Home (PCMH) concept 
established by the American Academy of Family Physicians. We aligned 
existing resources and now have PCMH at 32 of our MTFs caring for 
340,000 enrolled patients. By the end of 2012, 1 million of our 
beneficiaries will have a single provider and small team of 
professionals providing their care at all AFMS facilities. This means 
much greater continuity of care, with our patients seeing the same 
physician or their professional partner 95 percent of the time. The 
result is more effective healthcare based on trust and rapport for both 
the patient and the provider.
    Air Force Medical Home integrates the patient into the healthcare 
team, offering aggressive prevention and personalized intervention. 
Physicians will not just evaluate their patients for disease to provide 
treatment, but also to identify risk of disease, including genetic, 
behavioral, environmental and occupational risks. The healthcare team 
will encourage healthy lifestyle behavior, and success will be measured 
by how healthy they keep their patients, rather than by how many 
treatments they provide. Our goal is that people will live longer lives 
with less morbidity. We are already seeing how PCMH is bringing that 
goal to fruition. For example, diabetes management at Hill AFB, Utah, 
showed an improvement in glycemic control in 77 percent of the diabetic 
population, slowing progression of the disease and saving over $300,000 
per year.
    Patient feedback through our Service Delivery Assessment survey 
shows an overall improvement in patient satisfaction for patients 
enrolled in PCMH, with the greatest improvement noted in the ability to 
see a personal provider when needed. As relationships develop, our 
providers will increase their availability to patients after hours and 
through secure patient messaging. This will further enhance patient 
satisfaction and reduce costs by minimizing emergency department 
visits.
    Our next step is to embark on an innovative personalized medicine 
project called Patient Centered Precision Care, or PC\2\, that will 
draw and build on technological and genetic based advances in academia 
and industry. Effective, customized care will be guided by patient-
specific actionable information and risk estimation derived from robust 
Health Information Technology applications. We're excited about our 
collaboration opportunities with renowned partners, such as the Duke 
Institute for Genome Sciences and Policy, IBM, and others.
    Patient-centered care includes caring for Air Force special needs 
families, and we are working closely with our personnel community to 
ensure these families receive the specialized medical or educational 
support they require. The Air Force Exceptional Family Member Program 
(EFMP) is a collaborative and integrated program that involves medical, 
family support, and assignment functions to provide seamless care to 
these families. Enhanced communication of the program will be 
facilitated by an annual Caring for People Forum at each installation, 
giving families an opportunity to discuss concerns and receive advice. 
Starting in fiscal year 2012, the Air Force will begin adding 36 full-
time Special Needs Coordinators at 35 medical treatment facilities 
(MTFs) to address medical concerns and assignment clearance processes.
    An important aspect of patient-centered preventive care includes 
safeguarding the mental health and well-being of our people and 
improving their resilience, because no one is immune to the stresses 
and strains of life. While Air Force suicide rates have trended upward 
since 2007, our rate remains below what we experienced before the 
inception of our suicide prevention program in 1997. The most common 
identified stressors and risk factors have remained the same over the 
last 10 years: relationship, financial and legal problems. Although 
deployment can stress Airmen and their families, it does not seem to be 
an individual risk factor for Airmen, and most Airmen who complete 
suicide have never deployed. We are redoubling our efforts to prevent 
suicide and specifically target those identified at greatest risk.
    We use the Air Force Post-deployment Health Assessment (PDHA) and 
Post-deployment Health Reassessment (PDHRA) to identify higher risk 
career groups for post-traumatic stress disorder (PTSD). While most Air 
Force career fields have a very low rate of PTSD, others such as EOD, 
security forces, medical, and transportation have higher rates of post 
traumatic stress symptoms.
    Advances in treatment, such as the Virtual Reality Exposure Therapy 
(VRET) system we call ``Virtual Iraq,'' have been fielded to treat 
service members returning from theater with PTSD and other related 
mental health disorders. This system is founded on two well established 
forms of psychotherapy: Cognitive-Behavioral Therapy and Prolonged 
Exposure Therapy. VRET is now deployed at 10 Air Force mental health 
clinics and is lauded by patients.
    The Air Force provides additional support to our most at-risk 
Airmen with frontline supervisor's suicide prevention training given to 
all supervisors in career fields with elevated suicide rates. Mental 
health providers are seeing patients in our primary care clinics across 
the Air Force. They see patients who may not otherwise seek care in a 
mental health clinic because of perceived stigma. We have significantly 
expanded counseling services beyond those available through the 
chaplains and mental health clinic. Other helping programs include 
Military Family Life Consultants, who see individuals or couples; and 
Military OneSource, which provides counseling to active duty members 
off-base for up to 12 sessions.
    A recent example of how suicide prevention skills saved a life is 
the story of how Senior Airman Jourdan Gunterman helped save a friend 
from halfway around the world in Afghanistan. His training first helped 
him recognize the warning signs of a friend in trouble: drinking 
heavily, violent outbursts, disciplinary actions, and recent discharge 
from the Air Force following a challenging deployment. A cryptic 
emotional message on Facebook from the friend led Airman Gunterman to 
question his friend's disturbing behavior. He discovered his friend had 
ingested a bottle of pills.
    When his troubled friend no longer responded, Airman Gunterman 
obtained the friend's phone number on-line from another friend, Senior 
Airman Phillip Sneed, in Japan. Airman Sneed promised to keep calling 
the friend until he picked up. Meanwhile Airman Gunterman enlisted the 
help of his chaplain to locate the suicidal friend. Finally, locating a 
hometown news release about his friend, Airman Gunterman was able to 
learn his friend's parents' names and then used a search engine to find 
their address. He contacted the local police, who rushed to the 
friend's house and saved him. Airman Gunterman is an expert with social 
media--but more important--he is an incredible wingman who saved his 
buddy's life.
    Resiliency is a broad term that describes the set of skills and 
qualities that enable Airmen to overcome adversity and to learn and 
grow from experiences. It requires a preventive focus based on what we 
have learned from individuals who've been through adversity and 
developed skills to succeed. Distilling those skills and teaching them 
will lead to a healthier force.
    The Air Force uses a targeted resiliency training approach, 
recognizing different Airmen will be in different risk groups. For 
those who have higher exposure to battle, we have developed initiatives 
such as the Deployment Transition Center (DTC) at Ramstein Air Base, 
Germany, which opened in July. The DTC provides a 2-day reintegration 
program en route from the war zone, involving chaplain, mental health, 
and peer facilitators. The DTC provides training, not treatment--the 
focus is on reintegration into work and family. Feedback from deployers 
has been overwhelmingly positive.
    We teach our Airmen that seeking help is not a sign of weakness, 
but a sign of strength. Lieutenant Colonel Mary Carlisle is an Air 
Force nurse who struggled with PTSD following her deployment. She 
shares her story of how she was able to overcome PTSD by seeking help 
and treatment. She realized that she would be affected forever, but is 
now more resilient from her experience and treatment. She shared her 
story with over 700 of my senior medics at a recent leadership 
conference. Lt. Col. Carlisle's openness and leadership are an 
invitation to others to tell their stories, and in so doing change our 
culture and shatter the stigma associated with mental healthcare.
    In addition to the Air Force-wide approach, some Air Force 
communities are pursuing other targeted initiatives. The highly 
structured program used by Mortuary Affairs at Dover AFB, Delaware, 
where casualties from OIF and OEF are readied for burial, is now being 
used as a model for medics at our hospitals in Bagram, Afghanistan, and 
Balad, Iraq, where the level of mortality and morbidity are much higher 
than most medics see at home station MTFs. The Air Force continually 
seeks to leverage existing ``best practice'' programs such as Dover's 
for Air Force-wide use. If we can help our Airmen develop greater 
resiliency, they will recover more quickly from stresses associated 
with exposure to traumatic events.

               RECAPTURING CARE AND MAINTAINING CURRENCY

    Trusted Care means good stewardship of our resources. In an era of 
competing fiscal demands and highly sought efficiencies, recapturing 
patients back into our MTFs is critical. Where we have capability, we 
can provide their care more cost-effectively by managing care in our 
facilities. Equally important is building the case load and complexity 
needed to keep our providers' skills current to provide care wherever 
the Air Force needs them. We have expanded our hospitals and formed 
partnerships with local universities and hospital systems to best 
utilize our skilled professionals.
    We value our strong academic partnerships with St. Louis 
University; Wright State University (Ohio); the Universities of 
Maryland, Mississippi, Nebraska, Nevada, California and Texas, among 
others. They greatly enrich our knowledge base and training 
opportunities as well as provide excellent venues for potential 
resource sharing.
    Since the early 1970s, many Air Force Graduate Medical Education 
(GME) programs have been affiliated with civilian universities. Our 
affiliations for physician and dental education at partnership sites 
have evolved to include partnership sponsoring institutions for 
residencies. In addition, our stand-alone residency programs have 
agreements for rotations at civilian sites. Our Nurse Education 
Transition Program (NETP) and Nurse Enlisted Commissioning Program 
(NECP) have greatly benefited from academic partnerships. The NETP is 
available at 11 sites with enrollment steadily increasing, while the 
NECP enrolls a total of 50 nursing students per year at the nursing 
school of their choice. A nursing program partnering with Wright State 
University and Miami Valley College of Nursing in Ohio, and the 
National Center for Medical Readiness Tactical Laboratory has produced 
a master's degree in Flight Nursing with Adult Clinical Nurse 
Specialist in disaster preparedness, a first of its kind in the 
country.
    Our GME programs are second to none. Our first-time pass rates on 
specialty board exams exceed national rates in 26 of 31 specialty 
areas. Over the past 4 years, we've had a 92 percent overall first time 
board pass rate. I am very proud of this level of quality in our medics 
and grateful to our civilian partners who help make Air Force GME a 
success.
    Partnerships leveraging our skilled work force prepare us for the 
future. Our Centers for the Sustainment of Trauma and Readiness (C-
STARS) in Baltimore, Cincinnati and St. Louis continue to provide our 
medics the state-of-the-art training required to treat combat 
casualties. In 2009 we complemented C-STARS with our Sustainment of 
Trauma and Resuscitation Program (STARS-P) program, rotating our 
providers through Level 1 trauma centers to hone their war readiness 
skills. Partnerships between Travis AFB and University of California at 
Davis; Nellis AFB, and University Medical Center, Nevada; Wright-
Patterson AFB and Miami Valley Hospital; Luke AFB and the Scottsdale 
Health System; MacDill AFB and Tampa General Hospital; and others, are 
vital to sustaining currency.
    Our hospitals, C-STARS and STARS-P locations are enhanced by the 
Air Force medical modeling and simulation Distributed High-Fidelity 
Human Patient Simulator (DHPS) program. There are currently 80 programs 
worldwide and the AFMS is the Department of Defense lead for medical 
simulation in healthcare education and training. Over the next year, we 
will link the entire AFMS using Defense Connect Online and our new Web 
tele-simulation tool. This will enable all Air Force MTFs to play real 
time medical war games that simulate patient management and movement 
from point of injury to a Level 3 facility and back to the States.
    Our partnership with the Department of Veterans Affairs (VA) has 
provided multiple avenues for acquiring service, case mix, and staffing 
required for enhancing provider currency. Direct sharing agreements, 
joint ventures and the Joint Incentive Fund (JIF) have all proved to be 
outstanding venues for currency and collaboration.
    A great example is the JIF project between Wright-Patterson Medical 
Center and the Dayton VA. The expansion of their radiation-oncology 
program includes a new and promising treatment called stereotactic 
radio surgery. This surgery, really a specialized technique, allows a 
very precise delivery of a single high dose of radiation to the tumor 
without potentially destructive effects to the surrounding tissues. 
Without a single drop of blood, the tumor and its surrounding blood 
supply are destroyed, offering the patient the hope of a cure and 
treatment that has fewer side effects.
    In another Air Force/VA success story, Keesler AFB, MS and VA Gulf 
Coast Veterans Health Care System Centers of Excellence Joint Venture 
is receiving acclaim. Ongoing clinical integration efforts have shown 
an increase in specialty clinic referrals. Plans for continued 
integration are on track, with many departments sharing space and staff 
by fiscal year 2012 and the joint clinic Centers of Excellence in place 
by fiscal year 2013.
    Providing a more seamless transition for Airmen from active duty to 
the VA system remains a priority. This process has been greatly 
enhanced with the Integrated Disability Evaluation System (IDES). 
Expansion of the initial pilot program is occurring by region in four 
stages, moving west to east, and centered around the VA's Veteran 
Integrated Service Networks (VISN). Phase 3 of the expansion has added 
an additional 18 Air Force MTFs for a total of 24. The Services and the 
VA continue to conduct IDES redesign workshops to further streamline 
the process to be more timely and efficient for all transitioning 
Service members. The goal is to provide coverage for all Service 
members in the IDES by September 2011.
    We continue to look for innovative ways and new partnerships to 
meet our currency needs and provide cutting-edge care to our military 
family. We will expand partnerships with academic institutions and the 
VA wherever feasible to build new capabilities in healthcare and 
prevent disease.

                CONTINUOUSLY IMPROVING READINESS ASSETS

    We have made incredible inroads in our efforts to be light, lean 
and mobile. Not only have we vastly decreased the time needed to move 
our wounded patients, we have expanded our capabilities. Based on 
lessons learned from our humanitarian operations in Indonesia, Haiti 
and Chile, we developed obstetrics, pediatrics and geriatrics modules 
that can be added to our Expeditionary Medical System (EMEDS). We 
simply insert any of these modules without necessarily changing the 
weight or cube for planning purposes. Medics at Air Combat Command are 
striving to develop an EMEDS Health Response Team (HRT) capable of 
seeing the first patient within 1 hour of arrival and performing the 
first surgery within 3-5 hours. We will conduct functional tests on the 
new EMEDS in early 2011.
    On the battlefield, Air Force vascular surgeons pioneered new 
methods of hemorrhage control and blood vessel reconstruction based on 
years of combat casualty experience at the Air Force Theater Hospitals 
in Iraq and Afghanistan. The new techniques include less invasive 
endovascular methods to control and treat vascular injury as well as 
refinement of the use of temporary shunts. Their progress has saved 
limbs and lives and has set new standards, not only for military 
surgeons, but also for civilian trauma.
    A team of medical researchers from the 59th Medical Wing Clinical 
Research division has developed a subject model that simulates leg 
injuries seen in Iraq and Afghanistan to enable them to try 
interventions that save limbs. The team is also studying how severe 
blood loss affects the ability to save limbs. Their findings show blood 
flow should be restored within the first hour to avoid muscle and nerve 
damage vs. traditional protocol that allowed for 6 hours. Team member 
and general surgery resident Captain (Dr.) Heather Hancock, stated, 
``You cannot participate in research designed to help our wounded 
soldiers and not be changed by the experience.''
    We are also advancing the science and art of aeromedical evacuation 
(AE). We recently fielded a device to improve spinal immobilization for 
AE patients and are working as part of a joint Army and Air Force team 
to test equipment packages designed to improve ventilation, oxygen, 
fluid resuscitation, physiological monitoring, hemodynamic monitoring 
and intervention in critical care air support.
    We are finding new ways to use specialized medical equipment for 
our wounded warriors. In October, we moved a wounded Army soldier with 
injured lungs from Afghanistan to Germany using Extracorporeal Membrane 
Oxygenation (ECMO) support through the AE system--the first time we 
have used AE ECMO for an adult. The ECMO machine provides cardiac and 
respiratory support for patients with hearts and/or lungs so severely 
diseased or damaged they no longer function. We have many years of 
experience with moving newborns via the 59th Medical Wing (Wilford 
Hall) ECMO at Lackland AFB, Texas, but the October mission opened new 
doors for wounded care.
    Another new tool in battlefield medicine is acupuncture. The Air 
Force acupuncture program, the first of its kind in DOD, has expanded 
beyond clinic care to provide two formal training programs. Over 40 
military physicians have been trained. We recognize the success of 
acupuncture for patients who are not responding well to traditional 
pain management. This is one more tool to help our wounded Soldiers and 
Airmen return to duty more rapidly and reduce pain medication usage.
    We've made progress with electronic health records in the Theater 
Medical Information Program Air Force (TMIP-AF), now used by AE and Air 
Force Special Operations. TMIP-AF automates and integrates clinical 
care documentation, medical supplies, equipment and patient movement 
with in-transit visibility. Critical information is gathered on every 
patient and entered into our deployed system. Within 24 hours, records 
are moved and safely stored in our databases stateside.
    Established in May 2010 with the Air Force as lead component, the 
Hearing Center of Excellence (HCE) is located at Wilford Hall in San 
Antonio, TX. This center continues to work closely with Joint DOD/VA 
subject matter experts to fine-tune concepts of operation. Together we 
are moving forward to achieve our goals in the areas of outreach, 
prevention, care, information management and research to preserve and 
restore hearing.
    DOD otologists have worked internally and with NATO allies to 
investigate emerging implant technologies and have developed plans to 
test a central institutional review board (IRB) in a multi-site, 
international study to overcome mixed hearing loss. The HCE is also 
pursuing standardization of minimal baseline audiometric testing and 
point of entry hearing health education within DOD. They are working 
with the Defense Center of Excellence for Psychological Health and 
Traumatic Brain Injury (DCoE) to establish evidence-based clinical 
practice guidelines for management of the post-traumatic patient who 
suffers from dizziness. The HCE has worked with analysts within the 
Joint Theater Trauma System to develop the Auditory Injury Module (AIM) 
to collect auditory injury data within the Joint Theater Trauma 
Registry (JTTR). These, among others, are critical ways the HCE 
supports the warfighter in concert with our partners at DCoE and the 
VA.
    All of these advances I've addressed are critical to improving 
medical readiness, but the most important medical readiness assets are 
our people. Recruiting and retaining top-notch personnel is 
challenging. We continue to work closely with our personnel and 
recruiting partners to achieve mission success. Optimizing monetary 
incentives, providing specialty training opportunities, and maintaining 
a good quality of life for our members are all essential facets to 
maintaining a quality workforce.
    The AFMS continues to optimize the use of monetary incentives to 
improve recruiting and retention. We are working with the Air Force 
personnel and recruiting communities to develop a sustainment model 
specific for each of the AFMS Corps. Specifically, we are targeting the 
use of special pays, bonuses, and the Health Professions Scholarship 
Program (HPSP) to get the greatest return on investment. Congress' 
support of these programs has helped to maintain a steady state of 
military trained physicians, dentists, nurses, and mental health 
professionals.
    The new consolidated pay authority for healthcare professionals 
allows greater flexibility of special pays to enhance recruitment and 
retention of selected career fields. While we use accession bonuses to 
attract fully qualified surgeons, nurses, mental health specialists, 
and other health professionals to the AFMS, HPSP remains the number one 
AFMS pipeline for growing our own multiple healthcare professionals.
    We were able to execute 100 percent of HPSP in fiscal year 2009 and 
fiscal year 2010 and were able to graduate 219 and 211 new physicians, 
respectively, in these years. In fiscal year 2010, 49 medical school 
graduates from the Uniformed Services University of the Health Sciences 
also joined the Air Force Medical Service. These service-ready 
graduates hit the ground running. Specialized military training and 
familiarity with the DOD healthcare system ensures more immediate 
success when they enter the workforce. Once we have recruited and 
trained these personnel, it is essential that we are able to keep them. 
We are programming multiyear contractual retention bonuses at 
selectively targeted healthcare fields such as our physician and dental 
surgeons, operating room nurses, mental health providers, and other 
skilled healthcare professions to retain these highly skilled 
practitioners with years of military and medical expertise.
    For our enlisted personnel, targeted Selective Reenlistment 
Bonuses, combined with continued emphasis on quality of life, generous 
benefits, and job satisfaction, positively impact enlisted recruiting 
and retention efforts. Pay is a major component of recruiting and 
retention success, but we have much more to offer. Opportunities for 
education, training, and career advancement, coupled with state-of-the-
art equipment and modern facilities, serve together to provide an 
excellent quality of life for Air Force medics. Successful and 
challenging practices remain the best recruiting and retention tool 
available.
    We look 20 to 30 years into the future to understand evolving 
technologies, changing weapon systems, and changes in doctrine and 
tactics to protect warfighters from future threats. This ensures we 
provide our medics with the tools they need to fulfill the mission.
    We continue to build state-of-the-art informatics and telemedicine 
capabilities. Care Point now allows individual providers to leverage 
our vast information databases to learn new associations and provide 
better care to patients. These same linkages allow our Applied Clinical 
Epidemiology Center to link healthcare teams and patients with best 
practices. VTCs are now deployed to 85 of our mental health clinics 
broadening the reach of mental health services, and our teleradiology 
program provides digital radiology systems interconnecting all Air 
Force MTFs, enabling diagnosis 24/7/365.
    We are engaged in exciting research with the University of 
Cincinnati to enhance aeromedical evacuation, focusing on the 
challenges of providing medical care in the darkened, noisy, moving 
environments of military aircraft. We are studying how the flight 
environment affects the body, and developing possible treatments to 
offset those effects. Clinical studies are examining the amount of 
oxygen required when using an oxygen-concentrating device at higher 
altitudes. Simulators recreate the aircraft medical environments and 
are used extensively to train our medical crews. This new research 
expands our knowledge and training opportunities, and offers the 
possibility of future partnering efforts.
    We are also developing directed energy detection and laser assisted 
wound healing; advancing diabetes prevention and education; and 
deploying radio frequency identification technology in health 
facilities. We partner with multiple academic institutions to advance 
knowledge and apply evidence based medicine and preventive strategies 
with precision. These are some of the critical ways we seek to improve 
readiness, advance medical knowledge and keep the AFMS on the cutting 
edge for decades to come.

                             THE WAY AHEAD

    While at war, we are successfully meeting the challenges of Base 
Realignment and Closure as we draw near to the 2011 deadline. We have 
successfully converted three inpatient military treatment facilities to 
ambulatory surgery centers at MacDill AFB, Florida; Scott AFB, 
Illinois; and the USAF Academy, Colorado. By September of this year, 
the medical centers at Lackland AFB, Texas; and Joint Base Andrews, 
Maryland are on track to convert to ambulatory surgery centers. The 
medical center at Keesler AFB, Mississippi, is poised to convert to a 
community hospital. Medical Groups at Joint Base Lewis-McChord, 
Washington and Pope AFB, North Carolina have been effectively realigned 
as Medical Squadrons. Military treatment facilities at Shaw AFB, South 
Carolina; Eglin AFB, Florida; Joint Base McGuire, New Jersey; and Joint 
Base Elmendorf, Alaska; have been resourced to support the migration of 
beneficiaries into their catchment areas as a result of BRAC 
realignments.
    At Wright-Patterson AFB, Ohio, we have relocated cutting-edge 
aerospace technology research, innovation, and training from Brooks 
AFB. In tandem with our sister Services, we have also relocated basic 
and specialty enlisted medical training to create the new Medical 
Education and Training Campus (METC), the largest consolidation of 
training in DOD history.
    Our strategy to control DOD healthcare costs is the right approach 
to manage the benefit while improving quality and satisfaction. 
Adjustments to the benefit such as minimally raising TRICARE enrollment 
fees for working retirees, requiring future enrollees to the U.S. 
Family Health Plan to transition into TRICARE-for-Life upon turning 65 
years of age, paying sole-source community hospitals Medicare rates, 
and incentivizing the use of the most effective outlets for 
prescriptions are prudent. There will be limited impact (prescription 
only) on active duty family members. By implementing these important 
measures we will be able to positively affect the rising costs of 
healthcare and improve the health of our population.
    The AFMS is firmly committed to MHS goals of readiness, better 
health, better care and best value. We understand the value of teaming 
and treasure our partnerships with the Army, Navy, VA, academic 
institutions, and healthcare innovators. We will continue to deliver 
nothing less than world-class care to military members and their 
families, wherever they serve around the globe. They deserve, and can 
expect, Trusted Care Anywhere. We thank this Subcommittee for your 
support in helping us to achieve our mission.

                    RECRUITING MEDICAL PROFESSIONALS

    Chairman Inouye. General Green, let us start with you.
    The subcommittee has been advised that an important aspect 
of your work is the recruiting of medical professionals, and 
you need them to carry out the services. But I have been told 
that it is a challenge because, for example, the Government 
Accountability Office (GAO) reported that hiring civil servants 
at the Defense Centers of Excellence for Traumatic Brain Injury 
took an average of about 4 months. And the nomination of 
medical officers can take just as long. What are you doing to 
streamline this effort?
    General Green. Sir, your information is correct. It can 
take significant time to bring a fully qualified individual on 
board. Our major effort in terms of what we as medics have been 
doing is to shift some of our recruiting for fully qualified 
and the dollars associated into our scholarship programs. And 
over the last 3 to 4 years, we have expanded our scholarships 
through the Health Professional Scholarship Program by nearly 
400, from about 1,266 to 1,666. This is not just used for 
physicians, but also for pharmacists and for psychologists, 
trying to bring in the right expertise. And although there is a 
longer trail to get these folks, we now have a more reliable 
understanding of what is in the pipeline and when we will we 
have solutions.
    With regard to the specific questions regarding hiring 
civilians, we find frequently that we have to go after 
contractors rather than using general schedule (GS). It takes a 
little longer to get GS positions on our books, and so, when we 
have a more immediate need, we will substitute a contractor 
until we can get those positions into our books where we can 
use them. There has been a lot of effort in our A-1 community 
to try and streamline civilian hiring, and we are making 
progress. If you would have asked me this same question really 
within the last 1\1/2\ or 2 years, you would not have been 
talking to me about 4 months; you might have been talking about 
6 months and longer. And so, we are making progress in terms of 
our civilian hiring.
    When you talk to the military side and the scroll process 
in terms of how we get our officers, we continue to work with 
our A-1 personnel community to try and shorten that process. 
And when needed for specific expertise, we have been able to 
come through the process more rapidly. But it remains a 
process, as defined in law, that is fairly lengthy to ensure we 
bring the right people when we are bringing them on our books 
as Federal employees.

                           MEDICAL PAY SCALES

    Chairman Inouye. Do you find that the pay scale provided is 
competitive?
    General Green. I think that we have many special pays 
available, not just to the military, but also to our GS that 
does make them competitive. It is on the Active duty side, we 
certainly have a dynamic ability to move dollars to the 
specialties that we need and make ourselves competitive. On the 
civilian side, it is sometimes more difficult, but there are 
pays associated that do drive for the non-super specialist 
competitive pay. If you are asking me if I can get in the GS 
world a competitive salary for a neurosurgeon, the answer is 
no, and it has to do with what the civilian world is driving in 
terms of salaries for these folks. But that is not true 
necessarily for some of the areas where we are the shortest in 
terms of our flight surgeons and our family practitioners. When 
you start talking to trauma surgeons, particularly to try and 
hire them into a GS position, that is more difficult.
    And so, from a military perspective, the answer is, we have 
the authorities we need to offer pay that will retain and 
recruit new members on the GS side. I think that we are 
competitive in the primary care specialties, but not as 
competitive in the sub-specialties.
    Chairman Inouye. All right. Thank you very much. I will be 
submitting questions, if I may.
    General Green. Yes, sir, of course.
    Chairman Inouye. Admiral Robinson, when I first visited 
Afghanistan, I was impressed and surprised to note that the 
Navy was running the hospital, and it was landlocked.

                  MEDICAL SERVICES TO DEPLOYED MARINES

    Admiral Robinson. It still is.
    Unidentified Speaker. We are under the bridge now.
    Admiral Robinson. We tried to move it to the water, but it 
did not work.
    Chairman Inouye. How do you provide services to, say, the 
marines that are usually deployed to forward operating bases? I 
notice that some of the reports coming in indicate the 
difficulty involved in evacuating them. Do you have any special 
techniques?
    Admiral Robinson. No, sir. I am not sure I understand your 
question. How do we provide support to forward deployed medical 
personnel or forward deployed naval personnel?
    Chairman Inouye. Forward deployed marines.
    Admiral Robinson. Marines, I am sorry. Forward deployed 
marines have--we have a methodology that includes having with 
them FRSs, forward resuscitative surgical teams, and also 
surgical trauma platoons that usually operate with the marines 
in their forward areas.
    The first line of medical defense or the first line of 
medical operations would be the corpsmen. The corpsmen are 
there and are going to provide the type of emergency care with 
tourniquets and with the ABCs, airway, breathing, and 
circulation control. That is going to be followed by the 
corpsmen teaching buddy care to the other marines that are in 
the units that are there. This is very important because very 
often my corpsmen are also injured and injured in very grave 
ways. So often, the immediate care that they need has to come 
from a buddy who has in fact been instructed in the proper 
utilization and the use of tourniquets.
    As the injuries occur and as the word gets out that we have 
injuries, we then have the FRSs, the forward resuscitative 
surgical teams, that are forward deployed and can do 
resuscitative surgery in a very timely fashion. The 
resuscitative surgery is meant to be lifesaving only--to 
staunch the bleeding, to meet the immediate needs of the 
patient to restore circulation, to restore volume, and then to 
evacuate the patient to a higher level of care, which is 
usually at a Role 3 facility, such as Kandahar.
    Chairman Inouye. All right. Thank you very much. And I will 
be submitting more questions, if I may.
    Admiral Robinson. Yes, sir.
    Chairman Inouye. General, I am constantly amazed at the 
advancements we have made in medicine, plus other things like 
body armor and greater armor on our trucks and vehicles. And, 
for example, I was pleased with some of the advancements made 
in protecting hearing because of the explosions in the cars. 
But I am well aware that you are currently working on many 
other advancements. I will give you an opportunity to brag 
about it now. What are we doing?
    General Schoomaker. Well, sir, I think you have heard my 
colleagues describe--and you yourself described--some of the 
things that you have seen improvements in since you were a 
soldier in the Second World War. And those advances are 
really--have taken place, as you point out, all the way from 
protecting soldiers--changing combat tactics on the 
battlefield--to further protect soldiers and reduce risks, to 
the development of improved body armor, vehicles, combat 
goggles, ballistic goggles, hearing protection, better helmets, 
and the like. In fact, we have a program that is done in a 
joint environment. In fact, most of what is being described 
here and what you have alluded to is actually a joint effort, 
meaning all services are involved in either--even other 
agencies.
    The program to improve body armor, personal protective 
equipment for the soldier or their vehicles, and aviation 
equipment is known as the Joint Theater Analysis for Protection 
of Injury in Combat, the JTAPIC program. And this tracks 
injuries, both survivable and non-survivable injuries, and then 
looks at the vehicle, the personal protective equipment, and 
goes to the next level to develop a better protection, a better 
vehicle for them. And that has been very successful.
    But we have done what Admiral Robinson talked about. We 
have better trained the individual combatant as to how they can 
do lifesaving on themselves. We have issued better bandages to 
the individual soldier, a tourniquet for every soldier, and we 
train young soldiers to be almost medics, combat lifesavers. 
So, it is frequent that a combatant who is injured in combat 
would be first treated by himself or a colleague, and then a 
medic would appear on the scene, or a corpsmen in the case of 
the Navy. That corpsman is better trained and that medic is 
better trained than in past wars.
    And then evacuation has improved. We have seen recently in 
Afghanistan when we visited that the footprint of air 
evacuation, which is largely through the Army, is very robust. 
In fact, every casualty in which a aircraft is not launched 
within 15 minutes of having a request or does not complete the 
mission within 60 minutes, is briefed all the way up to the top 
of the Department of Defense really, and they have to explain 
why they could not meet that Golden Hour. And that is generally 
because of weather or operational, or someone makes a 
decision--an appropriate clinical decision--to overfly the most 
immediate, you know, surgical site to go to a better and more 
definitive care site. That has been very successful.
    We have also placed critical care nurses now on the--
selected medivac flights and have seen improvements in 
survival.
    A consequence of all of this through the Joint Theater 
Trauma System is that incrementally we have improved every 
stage of care of the combatant from the point of injury through 
the evacuation chain to forward resuscitative care and how 
surgeons are doing. We are really directing even trauma care 
for the world at large in the civilian sector, who benefited 
greatly from and have contributed to our understanding of this.
    What we are currently seeing as a consequence of that--I 
will just make a note of this--is that the survivors of some of 
these really grievous wounds now are not they themselves very 
grievously wounded. And we are working in concert with the 
other services and the VA to better care for a much more 
complex injury than we have seen in previous conflicts, or even 
earlier in this conflict.
    I hope that addresses your question, sir.
    Chairman Inouye. Yes. I have just one other.
    A couple of years ago, I learned at one of these hearings 
that the man who is deployed out on the front lines has on his 
body something like 100 pounds of armor and equipment. And so, 
I took a special effort to weigh what I had to carry, and mine 
was less than 25 pounds. That included a medical kit and 
ammunition boots, helmet, my gun. Can we lighten the load?
    General Schoomaker. Yes, sir. There is a very active 
program in the Army, and I think in all the services. The 
Soldier Program is intended to do exactly what you have talked 
about, but I think there are limitations to the weight and 
cube. Every item that goes into the basic load for a combat 
soldier, right down to the packaging of their meals or the 
material that goes into their uniforms, is evaluated for its 
relative contribution for cost and weight.
    But you heard Sergeant Giunta, who is our first living 
recipient of the Medal of Honor, when you honored him here in 
Congress, mentioned that he used to complain about those 
ceramic sappy plates and his body armor until he was shot twice 
and survived it. And he said, I'll never complain about 
carrying that load again. It is a very delicate balance, and I 
do not mean to trivialize or minimize what the soldier or the 
marine, any combatant is carrying. But I think it is an active 
process of looking at reducing that weight.
    Chairman Inouye. Thank you very much.
    Senator Cochran.
    Senator Cochran. Mr. Chairman, thank you.
    Thank you all for being here this morning and helping us 
with your assessment of the needs for funding of the programs 
and activities of the U.S. military. We appreciate your careers 
of service.
    I was especially taken with the comments about how in our 
medical assessment of fitness for duty--I think General 
Schoomaker made this point--after a person has fulfilled a 
requirement of service of tours of duty on a voluntary basis, 
and there is a question about fitness or physical impairment 
caused by service in the military, that there are two really 
distinct questions that have to be answered when there is a 
claim for disability. One is an assessment of fitness for duty, 
which is a military issue, and the other is a medical issue. 
How do you sort out the differences and what the impacts are in 
terms of individual claims under our current state of the law? 
Would you like to take a shot at that first, General 
Schoomaker?
    General Schoomaker. I will, then I would love to hear from 
General Green, who is actually one of the co-chairs of the 
Disability Evaluation System for the--a review for the 
Department of Defense. I do not mean to pass the buck here, but 
we have been sort of fighting this war for, literally and 
figuratively, for a very long time, Senator, so I appreciate 
that question.
    The current law and policy that governs the disability 
adjudication for an individual soldier--I am a solider, so I 
will use the term soldier, but it extends to sailors, airmen, 
and marines as well--is a dual system in which the military 
makes a judgment about any conditions which are unfitting for 
service, and then makes a decision about the unfitting 
condition that would lead to separation of that soldier.
    Ironically, the termination of the disability that derives 
from that condition is identical to what the Veterans 
Administration uses. We actually use the same tables; they were 
developed in concert. But then the Veterans Administration--the 
Veterans Benefits Administration--looks at the same soldier and 
the same constellation of problems, but adjudicates disability 
on the basis of the whole person concept, in which every 
individual illness or injury, current or past, can be put into 
the equation, and comes up with a whole person disability kind 
of equation.
    The two are high disparate. The difficulty we face is that 
soldiers get direct benefits from the military on the basis for 
that single unfitting condition. And as benefits have improved, 
especially--health benefits under the TRICARE program, if you 
can pass in the military side a critical threshold of 30 
percent disability, you are entitled then to the benefits of 
healthcare for yourself, which follow any military medical 
disability, but for your family as well. It has become a very, 
very desirable benefit to have. And soldiers are confused and 
their families are angered by the fact that we adjudicate for 
only that one unfitting condition and yet pass to the VA, and 
they see that, you know, had you been evaluated by a much 
more--a much larger, more composite system, it might have been, 
I would have been eligible for a higher degree of benefit from 
that.
    So we have eliminated some of the confusion and 
miscommunication, and we have accelerated the rate at which 
soldiers and their families can get VA benefits by this 
integrative process whereby a single physical exam is conducted 
by the VA in an adjudication of the total disability. But we 
still are required under the current state to adjudicate in the 
military system for the unfitting condition and in the VA 
system for the total person. We are advocating for the DOD--the 
Army--to adjudicate for--excuse me, determine unfitness, which 
is our title X authority and requirement, but then pass to the 
VA, which is--are the experts in disability adjudication, the 
responsibility for doing more comprehensive disability 
evaluation.
    With that, with your permission, sir, I will just pass to 
General Green.
    Senator Cochran. Sure.
    General Green.

                     ASSESSING PHYSICAL DISABILITY

    General Green. Yes, sir. I am the co-chairman with Dr. 
Karen Guice from the VA on the Recovering Warrior Task Force, 
which has now had three meetings and basically three site 
visits. We are still in our discovery phase, if you will, in 
terms of the differences in approach between the services.
    Within the current constraints, we do see--or current laws, 
basically--we do see some differences as--in terms of each 
service's approach. But there are similarities, and that is the 
area where Dr. Schoomaker is talking. Basically, we now are all 
using a single physical for the assessment of disability. 
Because we all use the same tables, it makes sense for everyone 
to use the same physical assessment.
    The place where there is some variance is in the service's 
assessment of ability to continue on active duty. Today once 
the average soldier, sailor, or airman go through the DES 
process, the current return to duty, even having gone all the 
way through the DES, is about--I will use the Air Force's 
numbers--17 to 20 percent in terms of being a little high. And 
so, you would think that once the physical is done that we 
could assess whether that person could stay on Active duty or 
not and that it would not necessarily go through the remainder 
of the disability system evaluation. But the way it is 
currently being run, there are slight differences in terms of 
each service.
    The other thing that happens, as Dr. Schoomaker was 
outlining, is that the VA looks at a total person for their 
disability rating. So, whereas--I will use something non-combat 
related. Whereas your cardiovascular disease may be significant 
enough to prevent you from being able to stay on Active duty, 
some of the other things that are rated in terms of the total 
disability are not necessarily disabling for DOD service, 
things like flat feet, or a recurrent rash, or mild hearing 
loss, things that could actually--you could stay on Active duty 
if you did not have the cardiovascular disease. And so, if we 
were to move to a system wherein the DOD simply paid for the 
total disability, there is a significant cost to the 
Government, whereas the current system basically has DOD paying 
for that ailment, if you will, that is disabling from further 
service.
    I think that as the task force continues, we will have some 
recommendations. You folks have been kind enough to give the 
task force some time to look at this as we kind of check out 
whether the systems that have been put in place are providing 
the best service to our recovering warriors. I do not want to 
speak for the committee because we really are still in 
discovery phase, but just to reaffirm the things we are seeing 
confirmed, some of the things that Dr. Schoomaker is talking 
about.

                          DISABILITY SERVICES

    Senator Cochran. Admiral Robinson, do you have any comments 
you would like to share with the subcommittee on that subject?
    Admiral Robinson. Sir, I think it has been covered very 
well. I just would make one comment. Usually General Schoomaker 
makes a note about the fact that the disability system that we 
use needs an overhaul since it is about 40 or 50 years old. And 
I think that actually General Green's committee and a lot of 
the input that we have given as SGs through the last 3 or 4 
years--is getting us there. We are working hard on this.
    Senator Cochran. Thank you very much.
    Thanks, Mr. Chairman.
    Chairman Inouye. Thank you.
    Senator Mikulski.
    Senator Mikulski. Mr. Chairman, and the Surgeon Generals.
    First of all, we in Maryland feel very close to military 
medicine. We are the home of Naval Bethesda, and in a short 
time, sir, will be the home to Walter Reed Naval Bethesda, and 
I hope this later this summer, perhaps the subcommittee could 
go out and take a tour of what is being done there. And I think 
we would be very proud of it.
    We are proud of USU, which is the Military Medical School 
in Nursing and Public Health, and Battleship Comfort--or, I 
should say, not battleship. It fights other battles, but 
Hospital Ship Comfort and Fort Detrick. So, we feel very close 
to you.
    In terms of our work here today, I am going to pick up on 
the Dole-Shalala report. And I would like, General, to talk to 
you because we went through a lot. And I want to just use that 
as kind of the grid to see progress made and where we are 
heading, okay?
    So, in Dole-Shalala, first of all, remember what happened--
the terrible national scandal at Walter Reed. Secretary Gates 
immediately responded. There was a change in personnel and I 
think a real commitment to upgrade. And then, our own 
colleague, Senator Dole, and Secretary Shalala issued this 
great report.
    Now, I am going to focus on issues related to preventing 
and treating post-traumatic stress disorder and brain injury, 
strengthening support for the families, and their 
recommendations to transfer the work with VA-DOD, and the 
workforce issues at Walter Reed.
    The workforce issues, though, I think go well beyond acute 
care medicine, and I will be raising that with our nurses in a 
short time.
    But, General, let us go to what Dole-Shalala recommended, 
and I know you might not have the report before you. But it 
said that we should aggressively treat post-traumatic stress 
and traumatic brain injury, and yet now we are seeing in that--
so, could you tell me where we are in the progress made, how 
you see it improving, and then tell me why we have such 
increased rates of suicides and such increased rates of 
addictions to the very drugs that are supposed to treat post-
traumatic stress?
    General Schoomaker. Well, ma'am, a complex question with 
several parts.
    I think the last----
    Senator Mikulski. But it goes to the heart of kind of where 
we are in this.
    General Schoomaker. Yes, ma'am. I do not deny that.
    Let me try to address, first, suicides. I think the suicide 
question is--remains a challenge and is perplexing for all of 
the services. The Army saw a very disturbing doubling or more 
of the suicide rate from where it was 6 or 7 years ago in which 
it was age and employment adjusted and gender adjusted 
comparison to the public at large, kept by the Centers for 
Disease Control and Preventive medicine in Atlanta. We went 
from roughly one-half of a comparable population in the United 
States to being on par, if not exceeding that.
    This is a problem that was tackled by the Vice Chief of 
Staff of the Army himself, stood up a task force, which has 
been in operation for almost 2 years now looking very carefully 
at all the factors. And as it recently----
    Senator Mikulski. But what are we doing where we are?
    General Schoomaker. We have made this a commanders' and a 
leaders' issue and problem. The factors that go into reducing 
risks and identifying soldiers and families at risk, and the 
many factors that lead to our soldiers turning to suicide in 
desperation--as we have said, a permanent solution to temporary 
problems that they may suffer----
    Senator Mikulski. But do you feel that you are on track to 
cracking this?
    General Schoomaker. I think we are making progress, ma'am. 
We are beginning to see--let me give you a----
    Senator Mikulski. And this is not meant to be aggressive to 
you. We have been down this road now for over 4 years.
    General Schoomaker. Yes, ma'am, and it is--frankly, it has 
involved bringing in national leaders in this--the National 
Institutes for Mental Health for the $50 million Stars Program.
    But as a real quick example of this, we got a notice the 
other day from one of our posts that one of our warriors in 
transition--that is, one of the soldiers going through an 
injury and illness recovery--in interacting with the small unit 
leader, dropped clues that she was in distress, wanted a 
chronic pain problem solved permanently for her. And when she 
could not be reached, the NCO leadership reached out to her, 
actually drove to her home off post. When they could not get in 
the door or she would not respond, they called the police. The 
police broke down the door and found her hung in the home, but 
still alive, got her to the hospital in time. So, I think that 
is a small example of what we see as----
    Senator Mikulski. Yes, but, General, that is indeed a 
poignant problem. And, I mean, that is a very poignant story. I 
have very limited time here.
    General Schoomaker. Yes.
    Senator Mikulski. So, here are my questions. Let us go at 
this way. I love hearing stories. Remember me, I am the social 
worker at the table.
    General Schoomaker. Yes, ma'am, I know.
    Senator Mikulski. So, and I am going to approach it as a 
social worker. Do you feel you have adequate mental health 
personnel? And do you feel that they are adequately trained in 
the warrior culture? As you know, there is a great gap growing 
between civilian culture and military culture. Also, from what 
I understand from other data, that often in the first hour of 
the first treatment, the military facing this problem walks out 
and tells the counselor essentially to go to hell because they 
do not feel they get it, and they are so upset. So, my question 
is, let us go to adequacy of capacity and adequacy of training. 
And then we will go to new techniques and approaches, because 
obviously standard talk therapy and meds, as we know it, are 
not working. Can you----
    General Schoomaker. We are working very actively in finding 
evidence-based approaches to the treatment of post-traumatic 
stress disorder, which I think in the main is--can be treated 
successfully. And we are seeing that.
    Suicide, I think, is far more complex. It is not a medical 
problem. I think this is one of the things that vice has said, 
it is a larger command problem. Frankly, one-half or more of 
people who commit suicide have never seen a mental health 
provider or been identified as having a problem.
    We are working very hard----
    Senator Mikulski. Do you have adequacy of mental health 
professionals?
    General Schoomaker. I think the Nation is facing a problem 
with mental health professionals----
    Senator Mikulski. No, do you have it? I am not talking 
about the Nation.
    General Schoomaker. As a microcosm of the Nation, we have 
problems, especially as----
    Senator Mikulski. Again, I am not being--I really----
    General Schoomaker. We have problems, ma'am.
    Senator Mikulski. I so admire what you have done and the 
leadership you have provided. I want to be very clear about 
that. But do you see my level of frustration? They are calling 
my office because they need help accessing services, not 
knowing where to go. So----
    General Schoomaker. I think the two things that we face----
    Senator Mikulski. And what about the tying in the warrior 
culture?
    General Schoomaker. The things that we face most--and, 
frankly, I think is a subordinate element of this warrior 
culture issue might be present in some cases, but not 
universally. Our people do a good job with that. We are working 
hard to prevent post-traumatic stress by rapid identification 
of concussion on the battlefield and reducing that. We have got 
a comprehensive behavioral health system of care now that ties 
every phase of soldier deployment to each other phase and 
passes information. That has resulted in remarkable reductions 
in stress problems.
    And what we have residual problems with in the Reserve 
component who go home to communities where access to care is a 
problem for all care, but especially behavioral health, and in 
remote size within the Army where it is tough to compete for 
civilian employees of any kind. But in some of our places where 
we have camps, posts, and stations, in the desert in 
California, for example, it is hard to recruit and retain high-
quality people.
    Senator Mikulski. All right. So, here is what I would like 
in my limited time. I appreciate that and the challenges. But I 
would really like to hear, based on the Dole-Shalala 
recommendations, what, from your--and I mean the group--
perspective--on what is the progress made. But the Army assumed 
primary responsibility for implementing Dole-Shalala. And then 
also on the adequacy of training.
    The other question I have is, we have to--and, Mr. 
Chairman, with your indulgences--support for the families. You 
know, when a warrior bears this either permanent wound or 
permanent impact, it is the spouse or the mother or the family, 
and it is also the children who bear this often--well, there is 
a saying in both the civilian and military world, post-
traumatic stress is contagious. In other words, if one person 
has it, the family has it. So, it is not like isolated like 
cardiovascular disease where you have got it. Maybe the spouse 
is helping with a better diet and lifestyle. Can you tell me--
again, going to Dole-Shalala--where we are in the support for 
the family?
    General Schoomaker. Yes, ma'am. We are working very 
actively on programs to support families, especially children, 
but spouses as well. We are reaching out into communities, 
engaging schools, churches, other community members, to extend 
the reach of insulation-based services into the communities to 
highlight that these are families of the military that face 
great stresses in their lives and identify children who are at 
risk and spouses who are at risk.
    Ma'am, in an earlier meeting several years ago, you 
challenged me, without any data at the time, to rank order 
three elements of deployment in terms of their impact on 
soldiers and families: the frequency of deployment, the length 
of a deployment----
    Senator Mikulski. Right.
    General Schoomaker [continuing]. The time between 
deployments we call dwell. And what I told you was we suspect 
that probably of the three, the most important is the dwell 
between deployments, and then after that, the length of the 
deployment, and then the frequency of deployment. We have 
special operations units that have deployed and individuals 
that have deployed a dozen times or more. But they are shorter 
deployments and they have adequate dwell between.
    One thing we cannot--we now have good science to document, 
through surveys on the battlefield and from returning soldiers, 
that not allowing a soldier and a family to have a minimum of 
24 months of dwell between deployments does not allow them to 
restore their psychological state.
    Senator Mikulski. That is a good point.
    General Schoomaker. And one of the things that I think we 
need real support from the Congress in is to not--is to allow 
us to resume a, we call boots on the ground to dwell rate of 
one to two; that is, 2 years back home for every year that you 
are in combat. That, I think, will make a significant--have a 
significant impact on the mental state and the psychological 
state of both families and soldiers.
    Senator Mikulski. Well, General Schoomaker, thank you.
    Mr. Chairman, you have been indulgent. I could talk all day 
with this panel. Perhaps you and I could meet and talk over 
this in more detail, and then take some ideas to the chairman.
    Thank you very much.
    Chairman Inouye. Thank you.
    Senator Mikulski. But, you know, this deployment is a big 
issue. If we are going to cut the military, then we got to 
cut--like, we are going to shrink the Marine Corps, you know, 
the old budget? But if we are going to shrink the Marine Corps, 
then we should shrink what we ask the Marine Corps to do. And 
that would go for every military service, so I think we have 
got to keep this in mind.
    Chairman Inouye. It is a major challenge to all of us here.
    Senator Mikulski. For every year you are deployed, you need 
2 years at home to stay connected to your family to deal with 
exactly some of these really horrific situations you and I have 
just discussed.
    General Schoomaker. Yes, ma'am. And the Army, in 10 years 
of war, has never been able to achieve a 2-year dwell. In fact, 
on average it has been at 1.3 years----
    Senator Mikulski. Well----
    General Schoomaker [continuing]. Of dwell for every year of 
deployment.
    Senator Mikulski. Thank you.
    Chairman Inouye. Thank you very much.
    Senator Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman.
    And I want to recognize the comments of my colleague from 
Maryland, talking about not only the impact to the individual, 
to the soldier, to those that are actively serving, but to the 
health and well-being of the families that are at home and 
supporting them. So I appreciate, General, your comments and 
recognition that it is the health of the whole family, not just 
the soldier, that we need to address here. It is a considerable 
challenge, but I think when we think about our effectiveness, 
our ability to recruit, our preparedness, it all has to come 
together. And I appreciate the discussion here this morning.
    Gentlemen, welcome, and thank you all for your service, 
greatly appreciate it in so many ways.
    General Green, it was a pleasure to have the opportunity to 
meet with you when you were in Alaska to attend the retirement 
ceremony for a friend of ours, Colonel Powell. At that time, we 
discussed the efforts to bring Fisher House to Alaska, and that 
is now a reality. We greatly appreciate that--your efforts and 
then your support for what Colonel Powell was trying to do, 
which was to focus on the hometown healing, has been remarkably 
successful. So we have got some good news to report up north.
    My question today, and this is for you, General Green, is 
regarding the Elmendorf Hospital facility. As you know, it is a 
joint venture facility with the Air Force and the VA. And 
recognizing that it truly is joint venture in the sense that we 
have got the other services involved--Air Force, Army, and also 
serving our Coast Guard families. So, it clearly is a benefit 
to the region.
    What I want to ask you today is whether or not the Air 
Force and the VA are in alignment when it comes to meeting the 
staffing needs there at Elmendorf Hospital.
    We have got a situation where within the VA, far too many 
of our veterans are being sent outside--being sent to Seattle 
and parts outside the State simply because the services cannot 
be obtained there, or because the VA says we are going to do it 
outside, even when the services are available. I had an 
opportunity to discuss this with Secretary Shinseki at an 
Approps meeting last week, and he has pledged to me we are 
going to work to do better in purchasing care for our veterans 
there.
    But what I am trying to determine is whether or not within 
this joint venture hospital we are truly able to meet the 
needs, given the strains that we have on capacity within the 
community, given the issues that we have in meeting the needs 
for certain specialties. And what I am looking for this morning 
is an assurance that we can be working to ensure that the joint 
venture hospital has what it needs--the people--to serve both 
the active military populations as well as our veteran 
population.

              ELMENDORF HOSPITAL--A JOINT VENTURE FACILITY

    General Green. Yes, ma'am. Thank you, and I appreciate our 
luncheon with Eli Powell, too, who is a good friend of mine.
    Senator Murkowski. Yeah.
    General Green. In answer to your question, I think that you 
will kind of get a sense of the commitment we have to this 
venture.
    The joint venture with the VA at Elmendorf is one of six 
that the Air Force is now doing with the VA. We have now 
invested about $7 million in JIF funds just at Elmendorf. We 
have about $100 million in all of our joint ventures across the 
world where we are partnered with the VA. My commitment up 
there has been to basically increase the manpower by about just 
under 200 positions to try and augment the staffing at 
Elmendorf to pick up on some of the workload, strongly 
encouraging further joint ventures with the Indian Health 
Service, which, as you know, is one of the larger hospitals in 
the Federal system there. And we have had people working in the 
Indian health hospital as well as we try to--they are a level 2 
trauma hospital now--as we try to maintain skills.
    We have also increased the budget up at Elmendorf by about 
$4 million annually in addition to just adding manpower, and we 
have seen an output from that of nearly 40 percent increase in 
surgeries that can be now in Alaska instead of people being 
sent elsewhere.
    My commitment to the joint venture is very solid. I would 
love to see Elmendorf thrive. We have talked about whether or 
not we can bring graduate medical education up there. I have 
worked with some of your community physicians as they look to 
bring a pediatric residency to see if we can join them in that 
effort. And we have also talked with the family practice 
residency up there to see how we can basically partner.
    Some of this has to do with how the hospital grows and how 
long it takes for construction in your State sometimes. The new 
VA clinic up there has been very successful, and my hope is we 
can do even more. And my hope is we can do even more. So, you 
have my commitment, and I won't speak for the VA, but when I 
talk with them, they are very committed also to expanding 
services.
    Senator Murkowski. Well, what we would like to do is to be 
able to identify those areas or perhaps those gaps within the 
VA system, whether it is in orthopedics, ENT, neurology, 
wherever that is, and see if in fact there is a--there is the 
ability within the Air Force to kind of reach in and fill those 
gaps as we look to how we staff and truly meet the needs of, 
again, our Active service men and women and our veterans up 
there. But I appreciate your commitment, and I look forward to 
working with you on that.
    General Green. Yes, ma'am. We send you very talented people 
that I----
    Senator Murkowski. Yes, you do.
    General Green [continuing]. Expect to help me grow that 
particular area.
    Senator Murkowski. We appreciate that as well.
    General Schoomaker, this is probably for you as the Army is 
the one that administers the congressionally directed Medical 
Research Program. And my question to you this morning is about 
the research program as it pertains to ALS, or Lou Gehrig's 
disease, a horrible disease for all--those of us that know of 
it, but a concern for us in the military as we look to the 
exceptionally high incidence--incident rate of those who 
contract ALS, who are our military heroes. It strikes those in 
the military at approximately twice the rate as the general 
public.
    Back in 2008, ALS, as I understand, was determined to be a 
presumptive disability by the VA, a service-related disease. 
And again, those of us who have been in a situation where we 
know someone with ALS know that this is a condition that moves 
quickly--5- to 6-year life expectancy from diagnosis, and a 
terribly, terribly horrific and debilitating disease that cost 
incredible amounts of money as we provide for that level of 
care and that level of treatment.
    And so, when we look to the statistics, it causes one to 
wonder, well, what will the impact to our military systems be 
as we pick up the costs for those that are afflicted with ALS? 
We are all very cognizant that we are in times of greatly 
reduced budgets, and some would look at these programs--these 
congressionally directed medical research programs--as being 
something that are perhaps nice, but not necessary. So, I would 
like to hear from you this morning kind of where you are coming 
from on these congressionally directed medical research 
programs, more specifically, ALS, whether you think that it is 
something that should be continued to be funded in terms of the 
research, and whether or not you think that that research is 
making a difference in the lives of our service members who 
have been afflicted.
    General Schoomaker. Yes, ma'am. Thanks for that question. 
And I think you have made exactly the case I would make for 
these programs.
    Congress has been remarkably enlightened and forthcoming 
with funds for congressionally directed research dollars and 
for programs which are, as you point out, ma'am, administered 
through the Medical Research and Materiel Command at Fort 
Detrick under the congressionally directed medical research 
program and other congressional special interest programs.
    They currently--we have got a very effective, I think, and 
efficient process by which research dollars and programs are 
targeted for our review for both scientific credibility and for 
programmatic integrity; that is, that they will be successfully 
executed. We have a very good program of soliciting the best 
investigators from across the country, both inside and outside 
the military, but largely outside the military, to conduct 
this. And the programs that they--that are addressed in these 
include amyotrophic lateral sclerosis that you have talked 
about, ALS, but also prostate cancer, breast cancer, and a 
variety of other problems that afflict not only the population 
at large, but military members and families as soldiers, 
sailors, airmen, and marines.
    We try to make these as appropriate as possible to the 
military population, but we admit that a lot of these 
breakthroughs have overflow or application to other neurologic 
problems. I mean, insights into ALS will give us insights into 
other problems from an injury or illnesses that afflict 
soldiers.
    Currently, the limit on earmarks is going to threaten about 
50 percent of the total research that is done within the 
Medical Research and Materiel Command.
    Senator Murkowski. What do you think that will do to the 
status of research?
    General Schoomaker. Well, I mean, it is going to take down 
my structure. It is very hard to rebuild the structure that is 
the people and the programs that administer these programs for 
the military. You cannot snap your fingers and rebuild them, 
and so we are going to have to take those down over the next 
few months and have already started that process.
    I am very eager to see the Congress come up with a solution 
that allows us to keep some of the critical programs because 
they have been very innovative and been very successful in 
delivering, you know, insights into new products to improve the 
lives of people who are suffering from these problems.
    Senator Murkowski. Well, it is difficult to hear that we 
would go backward on our research--go backward on the progress 
that we have made. And I hate to try to put a dollar on, you 
know, what it costs to deal with somebody that is afflicted, 
again, with a disease where, again, you are looking at 
incidence rates within our military that are twice the number 
within the general population out there. You would hate to 
think that somebody would hesitate to join up and become a 
member of our military because they are concerned that somehow 
or other they may be afflicted with a disease that they really 
want to steer clear of.
    I recognize that these are difficult budget times, but I 
also recognize that the advancements that we have made, the 
investments that we have made in our research and technology, 
are not something that we want to dial back on. So, I would 
hope that we could work with you as we try to make more forward 
progress in this area.
    Mr. Chairman, I have yet another question, but I have taken 
plenty of time this morning. But I will defer to Senator Leahy.
    Chairman Inouye. Thank you very much.
    Senator Leahy.
    Senator Leahy. Thank you, Mr. Chairman.
    I have found the questions here and answers interesting. 
You have a panel of three very, very well qualified people to 
answer them, and I appreciate that.
    General Schoomaker, recently 42 Members of Congress joined 
me in sending a letter to the Army and the Guard Bureau asking 
them to fund eight States' National Guard outreach programs. 
The programs are going to expire soon. Now, in full disclosure, 
one of them is in my own State of Vermont.
    But I think when we have heard the questions, especially 
those of the last two Senators, I would add to their points by 
saying these programs fill a serious gap in the Guard 
behavioral health. These programs are kind of like the MRAP, 
although it was an entirely different thing, but the program 
seemed like an idea where the Army and the Congress can work 
together to do the right thing. We did, getting the troops that 
equipment. Now we are talking about our soldiers and how we 
take care of them.
    You have made great strides, and I listened to what you and 
Senator Mikulski were saying about suicide prevention in recent 
years. But last year's doubling of Army Guard suicides shows 
that the Army falls short when it comes to the needs of the 
Army Guard and Reserve. They do not have a base. They are not 
going back to a port or a base where you can have the services 
within a limited geographical area. A State like Vermont, which 
has no active duty installations, the Guard uses its outreach 
programs to reach out to personnel where they live in home 
towns across the State. That may be a town like the one I live 
in with 1,500 people; it may be in one with 100 people, or it 
may be a community like Burlington that has a larger 
population. And our own adjutant general, Mike Dubie, whom I 
believe you know, told me that there had been many potential 
suicides that had been averted by this outreach program.
    Now, the funds needed to preserve these programs are less 
than $10 million for the remainder of the fiscal year. Are 
these programs going to be funded for this year and for the 
future?
    General Schoomaker. Well, sir, first of all, I want to 
thank you for the advocacy you showed for the 86th Infantry 
Brigade Combat Team that did deploy and then redeployed through 
Fort Drum, and I think illustrated the progress we have made in 
trying to bring back, redeploy, and then demobilize our Guard 
and Reserve.
    What you have highlighted, and other members of the 
subcommittee have highlighted, are the problems that are 
inherent within the operationalization of the Reserves. The--
our Guard and Reserve, which was within the Army, conceived of 
in past times as a strategic reserve ready to get launched one 
time for a major Nation-threatening, you know, war or conflict 
has now been, for the last 10 years, integrated fully into the 
deployment of the Army through an operational Reserve. And in 
doing that, what we have identified are shortcomings and 
challenges in providing care for National Guard and Reserve 
soldiers and families when they get back to their communities.
    Senator Leahy. And providing that care is a little bit 
different than going back to a base, going back to----
    General Schoomaker. Sure. No question.
    Senator Leahy [continuing]. Fort Hood or somewhere else.
    General Schoomaker. And the rules that govern access to 
that care are quite different. I mean, while the soldier is on 
Active duty, if the soldier incurs an injury or an ailment as a 
consequence of that deployment or that training to go to 
deployment, there is no question we have ready access to 
military units and military healthcare, and our TRICARE 
network, for that matter. But it does become a challenge when 
soldiers are redeployed and demobilized and then sent back home 
where they may face environments. And you are not alone in 
Vermont in facing this problem.
    I am working very closely with the Guard and Reserve. I 
think one of the major efforts that Major General Rich Stone, 
who is a mobilized reservist in the South out of Michigan, and 
a physician in practice, but has left his practice to work with 
us and orchestrate a program to look at how we can better 
support the Guard and Reserve. We have been looking for the 
last couple of years at exactly how we can better care for and 
reach out to the Guard and Reserve through TRICARE and our 
other efforts. So, we are looking at the programs that are 
threatened by the loss of funding, sir.
    Senator Leahy. Well, please look carefully and work with my 
office. We have had, you know, a redeployment. We talked about 
the Warrior Transition Program. And I know that there is a 
pilot program established at Fort Drum which still has some 
issues to work out. It is far superior than what the 86th 
Brigade had before, though. And I just would like to see these 
things around the country because when you have been in Iraq 
and you have been in Afghanistan, as I have, and you see these 
people out in the field, you cannot look at the soldiers going 
in and say, well, that one is a Guard member and--you cannot 
tell, nor are their duties any different.
    And I have one other question, and actually I pass this on 
to all of you, General, to you, and Admiral Robinson, and 
General Green. I have long supported improvements in military 
medical care through information technology and increased use 
of it. I have supported a military medical decisionmaking tool 
called CHART. The Office of the Secretary of Defense plans to 
mandate it for use by the services in pre- and post-deployment 
healthcare screening. A recent study by an Army doctor in the 
American Journal of Psychiatry linked deployment screenings to 
improved mental health outcomes. Are your services going to be 
using CHART and interface with your readiness systems?
    Admiral Robinson, would you like to----
    Admiral Robinson. Sir, I----
    Senator Leahy [continuing]. Take a swing at that one?
    Admiral Robinson. I will take a swing at it. I am not 
familiar with CHART, so I do not know whether we will be using 
it or not. But I can certainly take this for the record and get 
back to you.
    Senator Leahy. Would you please?
    Admiral Robinson. I certainly will do that.
    Senator Leahy. Thank you.
    [The information follows:]

    An electronic tool to integrate multiple health assessment 
questionnaires and display results in the DOD electronic health 
record system would he beneficial. In its current Conn, CHART 
has multiple shortcomings, and requires major enhancement 
before it can be considered as an acceptable solution for the 
Services.
    Each of the Services currently possesses operational 
readiness information systems with an integrated health 
assessment questionnaire capability. These systems manage each 
Service's unique readiness requirements and operate in their 
unique fielding environments. CHART as a health assessment 
questionnaire tool would duplicate and fragment our ability to 
assess and monitor readiness of Soldiers, Airmen, Sailors, and 
Marines. For these reasons, CHART is currently ranked very low 
in the overall funding priority.

    General Schoomaker. Sir, and for the Army, I am not 
familiar with that as well, but I will--this is a good point 
for me to make a pitch for this behavioral health system of 
care that Major General Horoho is taking personal leadership 
in. It allows us to look at programs like CHART, or any other 
program, in an objective way and do a head-to-head comparison 
with our existing systems, and see if it delivers a better 
outcome. So, I think----
    Senator Leahy. I mean, we all want the same thing. We want 
the best outcome. And I am just pushing to make sure we have 
it.
    And, General Green? And certainly all three of you please 
do give me something for the record on this.
    General Green.

                       ELECTRONIC HEALTH RECORDS

    General Green. Yes, sir. And I will take the question for 
record on the CHART, specific question.
    I would add that we now have almost 5 years of data from 
our electronic health record. And so, leveraging the data that 
is in AHLTA and basically linking that with the pharmacy 
transaction databases as well as the M-2, we are now leveraging 
informatics to try and get to new levels of decision support 
that will really change medicine over time. I strongly believe 
that if we can get better information to the patient so that 
they make sound decisions, that we can then also get them to 
the healthcare team which can augment and give them even 
further information, we will see tremendous change in medicine 
because we will be able to pinpoint prevention back to the--
what is necessary for patient care.
    Senator Leahy. Well, take a look at this one and take a 
look at any of the DOD directives on it, because there has to 
be follow-up to make it work, and that is what I am most 
concerned about. I worry very, very much that some of these 
brave men and women we have deployed fall off the screen 
because they are not treated properly. I do not pretend to be 
knowledgeable on this, but I know when my wife was working as a 
registered nurse, she saw a lot of these people that should 
have been helped--that was a different time--should have been 
helped, could have been helped. And I go to some places where 
the care is superb, and the person might have committed suicide 
somewhere else, or might have dropped off the screen somewhere 
else, or had debilitating illness that could have been 
corrected and was not. We ask them to put their lives on the 
line, then--I mean, you know that, and you believe as I do. I 
think we owe them something when they come back. So, let us see 
what this is going, let us see what the directives are, and let 
us see what the implementation might be.
    Thank you.
    Mr. Chairman, thank you for this hearing.
    Chairman Inouye. All right. Thank you very much.
    And, General Schoomaker, Admiral Robinson, General Green, I 
thank you very much on behalf of the subcommittee. And I wish 
you well also.
    And now we will have the second panel: Major General 
Patricia Horoho, Chief, Army Nurse Corps, Rear Admiral 
Elizabeth S. Niemyer, Director of the Navy Nurse Corps, Major 
General Kimberly Siniscalchi, Assistant Air Force Surgeon 
General for Nursing Services.

STATEMENT OF MAJOR GENERAL PATRICIA HOROHO, CHIEF, ARMY 
            NURSE CORPS, DEPARTMENT OF THE ARMY
    General Horoho. Good morning, sir.
    Chairman Inouye, Vice Chairman Cochran, and distinguished 
members of the subcommittee, it is an honor to speak before you 
today on behalf of the nearly 40,000 officer, civilian, and 
enlisted team members that represent Army nursing. Your 
continued support has enabled Army nursing in support of Army 
medicine to provide exceptional care to those who bravely 
defend and protect our Nation.
    It is a privilege to share with you today what is happening 
across Army nursing.
    Our strategic priority, the Patient CareTouch System, was 
implemented in February of this year at three medical treatment 
facilities, Madigan, Brooke, and Womack Army Medical Centers, 
and then this month we began the roll out of the remaining 
facilities. Army-wide implementation of Patient CareTouch will 
be complete by December 2011. This system is fully embraced by 
all medical leaders and is successfully being implemented 
across Army medicine.
    The Patient CareTouch System is comprised of five elements, 
which we truly believe guide, gauge, and ground patient-
centered care delivery. The elements are patient advocacy, 
enhanced care team communication, clinical capability building, 
evidence-based practices, and healthy work environments. There 
are 10 supporting components that enhance these elements.
    A key element of the Patient CareTouch System is evidence-
based practice, and nursing researchers, embedded in newly 
formed centers for nursing science and clinical inquiry, 
translating research into practice to optimize the quality of 
care provided to our patients.
    Army nursing is continuing to answer the call of the 
combatant commander for critical care nurses who are prepared 
and dedicated to care delivery in the back of medical 
evacuation helicopters.
    In December 2007, nurses assigned to the Medical Task Force 
in Iraq leveraged the capabilities of our critical care and 
emergency nurses. We created and then codified a premier en 
route care transport program that ensured our wounded, ill, and 
injured receive the right care at the right time by the right 
provider. Since last year, we have performed nearly 450 en 
route care transport missions. This capability directly 
impacted the 98 percent survival rate for wounded service 
members in Iraq, and is now the standard across all theaters of 
operation.
    The demand for increased numbers of trauma nurses in both 
theaters of operation prompted me to make a decision this year 
to establish a separate area of concentration for trauma 
nurses. This required a consolidation of critical care and 
emergency nursing specialties from which this new specialty, 
the 66th Tango, was established. This consolidation will 
provide unparalleled level of trauma nursing capability for 
military medicine, and it will be the force multiplier in both 
our fixed and deployed hospitals.
    I would like to provide you with an update of several 
programs that I introduced to you last year.
    The Brigadier General Retired Anna May Hayes Clinical Nurse 
Transition Program continues to prepare our novice nurses to 
provide patient-centered care. Since 2009, over 520 novice 
nurses have completed this program, achieving a higher advanced 
beginner competency. This program continues to exceed the 
national standard.
    Since the inception of the Virtual Leader Academy, we have 
graduated over 500 officers, non-commissioned officers, and 
civilians from our courses. This Academy focuses on capability 
and facilitates lifelong learning.
    Army nursing is committed to the education of its advanced 
practice nurses. To that end, Uniformed Services University has 
once again proven to be the stalwart partner of Army nursing, 
as well as to our sister services to ensure the development of 
the curriculum to tackle the requirements for transition from 
Masters to DMP Program by 2015.
    An area that we have focused our effort pertains to 
behavioral health. We have refined the clinical capability for 
the Advanced Practice Army Behavioral Health Nurse 
Practitioners, a key member of the behavioral health team. We 
have leveraged their capability toward building resiliency in 
our deployed service members and their families.
    Over the past year, 424 Army nurses deployed with two 
medical brigades and four combat support hospitals in support 
of Operation New Dawn and Operation Enduring Freedom. We had 
the extreme honor of celebrating the successful command tour of 
two combat support hospital nurse commanders. These nurses were 
integral in leading healthcare delivery and facilitating 
medical diplomacy across Iraq.
    Army nurses are writing our history with each patient they 
touch, with each experience they have, and each story that they 
tell.
    On February 2, we celebrated 110 years of proud service to 
our Nation. We thank you, Mr. Chairman, and Senator Murkowski 
for introducing Senate Resolution 31 to commemorate this 
historic occasion.
    Mr. Chairman, we also thank you for the very touching, 
heartfelt video message for the many years of unwavering 
support of Army and Army nursing.
    I continue to envision an Army Nurse Corps of the future 
that we leave its mark on military nursing and will be a leader 
of nursing practice reform at the national level. We are 
committed to leveraging lessons learned from the past, engaging 
present innovation, and shaping the future of professional 
nursing. Our priority remains our patients and their families, 
and our common purpose is to support and maintain a system for 
health. In order to achieve this common purpose, we serve with 
the courage to care, the courage to connect, and the courage to 
change, so that we may provide the best possible healthcare to 
those that wear the cloth of our Nation.

                           PREPARED STATEMENT

    On behalf of the entire Army Nurse Corps, serving both home 
and abroad, I would like to thank each of you for your service 
to our Nation and your unwavering support.
    Thank you.
    Chairman Inouye. General Horoho, thank you very much for 
you testimony. We appreciate it very much.
    [The statement follows:]
         Prepared Statement of Major General Patricia D. Horoho

    Chairman Inouye, Vice Chairman Cochran and distinguished members of 
the committee, it is an honor and a great privilege to speak before you 
today on behalf of the nearly 40,000 Active component, Reserve 
component and National Guard officers, non-commissioned officers, 
enlisted and civilians that represent Army Nursing. It has been your 
continued tremendous support that has enabled Army Nursing, in support 
of Army Medicine, to provide exceptional care to those who bravely 
defend and protect our Nation.

                        PATIENT CARETOUCH SYSTEM

    I am pleased to provide you with an update on Army Nursing and to 
share with you my strategic priority, the Patient CareTouch System. The 
Patient CareTouch System implementation began on February 7, 2011 at 
three medical treatment facilities: Madigan Army Medical Center, Brooke 
Army Medical Center, and Womack Army Medical Center. Seven facilities 
will begin their roll out this month: Walter Reed Army Medical Center, 
DeWitt Army Community Hospital, Tripler Army Medical Center, Landstuhl 
Regional Medical Center, William Beaumont Army Medical Center, Carl 
Darnall Army Medical Center, and Blanchfield Army Community Hospital. 
The remaining facilities will join the process in three implementation 
phases beginning in mid-May. Army-wide implementation at every patient 
touch point will be completed by December 2011. The Patient CareTouch 
System spans all care environments where nurses touch patients by 
ensuring quality care is delivered carefully, compassionately and in 
accordance with standards for best practice. The Patient CareTouch 
System is comprised of five elements, which we believe guide, gauge, 
and ground patient centered care. These elements include: Patient 
Advocacy, Enhanced Care Team Communication, Clinical Capability 
Building, Evidence-Based Practices, and Healthy Work Environments. The 
elements are supported by 10 components that include core values for 
patient care, care teams, peer feedback, standardized documentation, 
skill building, talent management, clinical leader development, 
optimized clinical performance, Centers for Nursing Science and 
Clinical Inquiry (CNSCI), and shared accountability for quality of 
patient care delivery.
    The Patient CareTouch System provides a sustainable framework for 
our transition from a healthcare system to a system for health. It 
cultivates trust by providing a standard by which care can be measured 
across Army Medicine, and it allows us to look critically at what we 
do, how we do it, and how we can improve. The Patient CareTouch System 
ensures that our patients know that we have their best interest at the 
forefront of all care decisions and it promotes standards, not 
standardization, for nursing care Army-wide. We found, when we piloted 
the Patient CareTouch System at Fort Campbell, Kentucky, that we had a 
positive impact on patient outcomes, patient satisfaction, clinical 
communication, provider-nursing staff collaboration, and provider 
satisfaction. We believe these results will be reproducible across Army 
Medicine and we are using evidence based metrics to benchmark nurse 
sensitive indicators against national standards. This will validate our 
firm belief that our patients are receiving world class, high quality 
nursing care.

                    OPTIMIZING PATIENT CARE DELIVERY

    Evidence based practice is a key element in the Patient CareTouch 
System and nursing researchers, embedded within newly formed CNSCIs are 
translating research into practice to optimize the quality of care 
provided to our patients. The CNSCIs are promoting enhanced nursing 
decision support, evidence-based practice and research. Nurse 
scientists, Clinical Nurse Specialists, and Nurse Methods Analysts 
comprise the CNSCI. These experts working together are affecting the 
transition from a ``question-to-answer model'' to the more valuable 
``question-to-translation-to-evaluation model.'' Consolidating nursing 
support assets who are working on a common sense research priority 
agenda increases the capacity for evidence-based management and 
evidence-based practice Army Nursing wide.
    Research and evidence-based practice are overarching and core 
constructs in the Army Nursing Campaign Plan. Army Nursing is 
transforming from an expert-based practice model to a systems-based 
care model in order to leverage nursing assets and realize the benefits 
of knowledge management and research translation. This is critical to 
improve patient outcomes, safety, healthcare value, and quality. Tenets 
of a systems-based care model includes system resourcing, healthcare 
economics, teamwork, cost-benefit considerations, and practice 
management. Key to success is uniting various types of nursing support 
experts to better meet the needs of bedside nurses and the nurse 
leaders who provide and direct the delivery of patient care.
    Army Nurse scientists are collaborating in joint, multinational and 
academic settings to infuse nursing practice with evidence based 
science. The premier Army Nursing Practice Council (ANPC), established 
in the fall 2010, is providing the critical connection between nursing 
science and nursing practice. The ANPC meets monthly to review 
evidence, data, and science to develop evidence-based nursing tactics, 
techniques and procedures (TTP) that then become the standards across 
Army Medicine. Recently published standards include an innovative falls 
prevention program, structured nursing hourly rounding, and bedside 
shift reporting. TriService Nurse Research Program (TSNRP) funded 
studies support several evidence-based nursing TTPs. For example, in 
the Emergency Room at Bayne Jones Army Community Hospital, Fort Polk, 
Louisiana, white boards in the patient rooms facilitate real time 
status updates on medications, procedures, and tests completed to 
enhance communication between emergency room staff and the patient and 
family members.
    The TSNRP funded an evidence-based practice project titled: 
``Evaluating Evidence-Based Interventions to Prevent Falls and Pressure 
Ulcers.'' This study was the basis for revising clinical practice 
guidelines for prevention of falls and skin breakdown within the 
Madigan Army Medical Center. It was also the means by which their CNSCI 
team introduced patient-centered rounds and monitoring of nurse-
sensitive outcomes such as nurse satisfaction, patient satisfaction, 
and rates of falls and pressure ulcers.

                              WARRIOR CARE

    Enroute care transport is not a new mission for Army Nursing; we 
have been providing this type of care for over 60 years. In 1943 the 
first Army nurses formally trained in air evacuation procedures were 
assigned to secret missions in North Africa, New Guinea, and India. 
Army nurses cared for patients on helicopter ambulances, transporting 
over 17,700 U.S. casualties of the Korean War. During the Vietnam war, 
Army Nurses were aboard helicopters moving almost 900,000 United States 
and allied sick and wounded Soldiers.
    Army Nursing is continuing to answer the call of the combatant 
commander for critical care nurses who are prepared and dedicated to 
care delivery in the back of a medical evacuation helicopter. In 
December 2007, nurses assigned to the medical task force in Iraq 
leveraged the capabilities of our critical care and emergency nurses 
and created, then codified, a premier enroute care transport program 
that ensured our wounded, ill and injured service members received the 
right care, at the right time, by the right provider. This program 
directly impacted and sustained the 98 percent survival rate for 
wounded service members in Iraq.
    The Army Nursing Enroute Care Transport Program was so successful 
in Iraq in decreasing the incidence of hypothermia, accidental 
endotracheal tube extubation, and prevention of hypovolemic shock in 
our Wounded Warriors that the program is currently in place in 
Afghanistan. Army nurses continue to refine and improve the program, 
maintaining a focus on nursing TTPs for critical care patients 
transports. I am so proud of our Army nurses who, at the beginning of 
the war in Iraq, saw a gap in rotor wing critical care patient 
transport and identified processes to fill the gap. As a result, our 
enroute care transport program is unparalleled in terms of the quality 
of nursing care that our combat veteran critical care nurses provide to 
Wounded Warriors. The quality of care during the strategic evacuation 
care continuum does not end in the theater of operation. Landstuhl 
Regional Medical Center's (LRMC) unique TriService Air Evacuation 
mission processes all casualties through the Deployed Warrior Medical 
Management Center. The nursing care provided to wounded, ill and 
injured Warriors and coalition armed forces air evacuated from 
Operation Iraqi Freedom, Operation Enduring Freedom, Operation New Dawn 
and other Overseas Contingency Operations to LRMC significantly 
contributed to LRMC being awarded the Association of Military Surgeons 
of the United States (AMSUS) 2010 Facility-based Healthcare (Hospital) 
Top Federal Hospital for fiscal year 2010. Continuing their high 
operational tempo, the LRMC's triservice nursing team cared for 11,185 
casualties (4,284 inpatient casualties and 6,901 outpatients) in fiscal 
year 2010.
    Nursing staff augmented the Contingency Aeromedical Staging 
Facility on Ramstein Air Base, enabling continuous casualty flow from 
LRMC to CONUS medical centers. Receiving casualties from over 500 Air 
Evacuation flights, LRMC nurses have significantly supported the 
aeromedical evacuation process. On any given day at LRMC, nursing staff 
on the medical-surgical units will discharge 10 inpatients and admit 11 
new patients, illustrative of the high operational tempo that is 
commonplace at LRMC.
    Nurse researchers like Lieutenant Colonel Betty Garner, are 
augmenting warrior care efforts by conducting studies designed to 
produce evidence for new nursing care modalities. Lieutenant Colonel 
Garner and her team are determining the impact nursing care has on 
injured Soldiers and their families after a traumatic brain injury 
(TBI). Understanding the needs of the Wounded Warrior and their 
families are imperative to improve the quality of life among those 
affected by TBI.
    These examples of Army Nursing's clinical initiatives illustrate an 
amazing flexibility and agility to ensure that we are responsive to the 
needs of our wounded, ill, and injured service members. I would like to 
provide you with an update of several programs that I introduced to you 
last year, and are key enablers of Army Nursing's strategic 
initiatives.

                          CAPABILITY BUILDING

Talent Management
    Inherent in clinical capability building is leadership, and in 
order to best leverage the capabilities of our nursing team, we 
examined the methods by which we identified, managed, and developed 
clinical leader talent. The Army Nurse Corps' (ANC) talent management 
strategy is a mission critical process that ensures the Corps has the 
right quantity and quality of leaders in place to meet the current and 
future Army Medical Department missions and priorities. Our strategy 
covers all aspects of the ANC life cycle, to include aligning the Corps 
strategic goals with capability requirements and distributing the right 
talent for the right position at the right time and rank.
    We partnered with U.S. Army Accessions Command and implemented 
precision recruiting to ensure we are recruiting the right capability 
in order to develop clinical leader talent. In spring 2010, for the 
first time, our Human Resources Command, Army Nurse Corps Branch 
executed a formalized capability-based assignment process, placing 
senior officers in key positions based on their skills, knowledge, and 
behaviors instead of on availability. In addition, we defined and 
established a sustained succession plan for key leadership positions in 
the ANC. Our talent management strategy enables us to assign full 
spectrum leaders across all care environments in support of the Army 
Medicine mission.

Leader Academy
    Since the inception of our virtual Leader Academy, we have 
graduated over 500 officers, non-commissioned officers and civilians 
from our courses. Over the past year we analyzed ways to optimize the 
Leader Academy to ensure agility in meeting evolving requirements. We 
have sequenced learning and redesigned a ``building block'' curriculum 
to facilitate lifelong learning at all professional development phases. 
The five core elements of the Patient CareTouch System serve as the 
foundational framework for the Leader Academy and the key components 
are threaded throughout the curriculum of all courses offered.
    The BG(R) Anna Mae Hays Clinical Nurse Transition Program (CNTP) 
continues to prepare our novices with good results. Preliminary program 
evaluation results presented at the 2010 Phyllis J. Verhonick Nursing 
Research conference indicate that of the four cohorts evaluated, all 
participants achieved advanced beginner competency at the end of the 
program. In order to stabilize the program, all director positions are 
now being filled by competitively selected non-rotating civilians, two 
of which are Doctoral prepared and the remaining are Master's prepared. 
A review of current studies revealed that standardized preceptorship 
programs (preceptor training and tracking) increases nurse transition 
from academia to practice. As a result of this evidence, the CNTP 
directors adopted a Preceptor Development Program and established 
guidelines now being implemented at all transition sites. The Patient 
CareTouch System provides a framework for the program and the evidence 
and science inform the standards by which nurses deliver care across 
the age spectrum. Patient responses have been favorable, specifically 
complimenting nurse transition program participants in hospital 
satisfaction surveys. As we interview new lieutenants in the program, 
we have found that many, who were planning to leave at the end of their 
initial service commitment, are instead continuing their careers in the 
ANC as a result of the enculturation process that is inherent in the 
CNTP. Retaining new graduate nurses preserves the knowledge, experience 
and confidence gained during the first year of professional practice 
and has a positive impact on the quality of patient care.
    There has been an array of secondary benefits resulting from the 
creativity of the nurses participating in the CNTP. At Madigan Army 
Medical Center, novice nurses developed and implemented a program to 
track chart audits and produced a training video on ``Preventing 
Patient Falls.'' At Womack Army Medical Center, novice nurses presented 
an abstract entitled ``Response to Enhance the Quality and Consistency 
of Shift Reports'' at the Karen A. Reider Federal Nursing Research 
poster session during the AMSUS conference.

                         PORTFOLIO OF EXPERTISE

    We are constantly refining our clinical capabilities to meet the 
ever-changing complexity of providing care in challenging care 
environments. As a result of increasing demands for trauma nurses and 
the complexity of care required in both theaters of operation we made 
the decision to establish a separate area of concentration 
consolidating intensive care unit (ICU) and emergency nursing with the 
educational and clinical focus on combat trauma care. This new area of 
concentration will provide us a flexible and agile economy of force, 
while providing an economy of effort for training.
    We are re-shaping our ICU and emergency nursing courses into one 
curriculum focused on acquisition of trauma nursing and critical care 
competencies. The Army trauma nurse area of concentration will result 
in assignment flexibility in both our hospitals and deployed combat 
support hospitals (CSH) and provide an unprecedented level of trauma 
nursing capability for military medicine. We are also analyzing ways to 
leverage potent Army medicine force multipliers such as our psychiatric 
nurse practitioners and psychiatric nurses.
    This year, in response to increasing requirements for trauma 
trained nurse, we expanded our emergency nursing course by adding a 
second training site at Madigan Army Medical Center and graduated our 
first class at this location in December 2010. This additional program 
doubles the number of emergency nurses trained annually and enhances 
our ability to provide world class care at home and abroad.
    Through the efforts of our Perioperative Nurse Consultant, in 
collaboration with the national perioperative nursing organization, we 
have added additional sterilization procedures to the curriculum for 
both our Perioperative Nurse and Operating Room Technician programs. 
This proactive initiative addresses a national health concern regarding 
potential infectious disease transmission resulting from improper 
sterilization processing of surgical scopes. Currently, we are 
developing a pilot program for the utilization of graduate prepared 
Perioperative Clinical Nurse Specialists as Perioperative Nurse Case 
Managers responsible for the coordination of clinical care across the 
perioperative continuum from preoperative preparation to post-
anesthesia care. We are closely examining operating room processes, 
with a focus on the perioperative nurse.
    The operating room can be one of the busiest touch points in a 
facility, and as a result an area that we want to ensure quality and 
safe care delivery. We believe that a critical examination of an 
expanded role of the perioperative clinical nurse specialist is needed. 
This role will concentrate on quality assurance with a focus on patient 
safety and perioperative arena efficiency to include the operating room 
and the centralized sterile processing department. This role is unique 
in that it cannot be replaced by a non-perioperative advanced practice 
nurse.
    Last year I discussed our initiative related to critical care 
skills for our enlisted licensed practical nurses (LPN). In October, we 
conducted our first pre-deployment critical care course for enlisted 
practical nurses from one of our deploying CSH. The Soldiers received 
didactic instruction and clinical rotations in critical care and burn 
care at Brooke Army Medical Center and the Institute of Surgical 
Research. Three enlisted practical nurses from the deploying 115th CSH 
attended a ``critical care skills during deployment'' pilot. On 
average, students demonstrated a 42 percent increase in self-reported 
skills related to chest tube drainage system set up, cardiac strip 
interpretations, and patient report/handoff. With the success of this 
pilot, we are currently developing a pre-deployment LPN course that 
will prepare deploying LPN's for the complex trauma missions they will 
support. Every Army Nurse is a trauma nurse.
    During calendar year 2010, Army nurses deployed with two Medical 
Brigades and four CSHs in support of Operation New Dawn and Operation 
Enduring Freedom to provide force health protection and combat health 
support to United States and coalition forces. Two CSHs were commanded 
by Army nurses--Colonel Barbara Holcomb, Commander of 21st CSH, Iraq 
and Colonel Judy Lee, Commander of 14th CSH, Iraq--who facilitated 
healthcare delivery and medical diplomacy.
    Major Pamela Atchison, an Army nurse, deployed with Task Force MED 
East in support of Operation Enduring Freedom, developed the 
Afghanistan Trauma Mentorship Program for the Afghanistan Theater of 
Operation. Major Atchison implemented the Afghanistan Trauma Mentorship 
Program at two Afghanistan civilian hospitals and trained over 500 
medical personnel (Physicians, Medics and Nurses) assigned to the 
Afghanistan National Security Force and Afghanistan National Army. Her 
contribution to Health Sector Development for Afghanistan, will have a 
lasting effect for both the civilian and military medical communities 
throughout the Afghanistan Theater of Operation.
    Major Michael Barton developed the United States Forces Afghanistan 
policies for Infectious Diseases, Needle Stick Injuries, and 
Surveillance. Major Barton's efforts had a significant impact on the 
quality of care that U.S. Service Members and Coalition Forces received 
throughout the Afghanistan Theater of Operation. Major Barton also 
compiled monthly reports for Task Force Medical commanders throughout 
the theater, which consisted of information regarding epidemiological 
investigations and disease non-battle injuries. The report enabled the 
Task Force Medical commanders to focus on medical readiness issues for 
both U.S. and Coalition Soldiers.
    Colonel William Moran deployed with Task Force (TF) 62 MED as the 
Patient Safety Officer for the Afghanistan Theater of Operation. He 
implemented the first ever formal Patient Safety Program in that 
theater that positively impacted over 1,900 service members, 3 Level 
III hospitals, and 12 Level II Forward Surgical Teams/Elements. In 
order to decrease variance in patient safety management, Colonel Moran 
travelled to each TF 62 MED subordinate units to train 28 Patient 
Safety Officers and establish unit based patient safety programs. 
Colonel Moran significantly improved patient safety and the overall 
delivery of healthcare in theater by establishing an environment of 
trust, teamwork, and communication based on standards that improved 
patient safety and prevented adverse events.
    Army nurses are contributing significantly to the success of 
multinational operations and working collaboratively with coalition and 
Afghan healthcare professionals. I'm very proud of the medical 
diplomacy efforts, displayed by the nursing leaders in command of the 
Forward Surgical Teams (FST) in Afghanistan.
    Lieutenant Colonel Ruth Timms commanded the 160th FST in support of 
Operation Enduring Freedom. Her team was embedded within a German NATO 
Role III hospital and provided direct support to over 11,000 U.S. and 
Coalition Soldiers that comprised 15 nations. Lieutenant Colonel Timms 
was an integral proponent for initiating mentorship programs between 
United States, German, and Afghan providers which is enabling an Afghan 
Healthcare system fully capable of providing comprehensive healthcare 
services to the people of Afghanistan.
    Captain Roger Beaulieu commanded the 934th FST in support of 
Operation Enduring Freedom. He and his team cared for over 460 wounded 
service members, performed over 160 surgeries and improved the medical 
capabilities of the local national hospital by training four Afghan 
Surgeons and nearly 100 Afghan medical support personnel.
    These Army nurses are writing Army nursing history, and on February 
2 of this year, we celebrated 110 years of proud service to our country 
as a recognized Corps of the United States Army. We thank you, Mr. 
Chairman, Vice Chairman Cochran and Senator Murkowski for introducing 
Senate Resolution 31 to commemorate this historic occasion. Chairman 
Inouye, we also thank you for the very touching, heartfelt video 
message and for your many years of unwavering support of Army nursing. 
We marked this day and its meaning by laying a wreath at the Nurse 
Memorial located in Arlington Cemetery to pay respect to all Army 
nurses who came before us. We honor them for their service, dedication, 
and vision.
    In the National Capital Area over 500 nurses, active, retired, 
reserve, and civilian, family and friends of nursing gathered on 
February 5, 2011 to commemorate this monumental milestone in our rich 
history. Together, we celebrated ``Touching Lives for 110 Years,'' 
which really resonated with me and illustrated what I believe is the 
true essence of Army Nursing. We have been on the battlefield, serving 
with our fellow Soldiers, throughout our remarkable history and we 
continue to do so today. Our collective success has been the result of 
compassion, commitment, and dedication. I am inspired by the pride, 
enthusiasm, and openness to change that I see across the ANC in support 
of Army Medicine and our Nation's missions. My number one priority is 
the Patient CareTouch System that will serve as the cornerstone to 
improving the healthcare that provides patient care to our Soldiers and 
the Families that support them.
    I continue to envision an ANC of the future that will leave its 
mark on military nursing, and will be a leader of nursing practice 
reform at the national level. Our priority remains our patients and 
their families, and our common purpose is to support and maintain a 
system for health. In order to achieve this common purpose, we serve 
with the courage to care, the courage to connect, and the courage to 
change so that we may provide the best possible care to those who wear 
the cloth of our Nation. The ANC is committed to leveraging lessons 
learned from the past, engaging present innovations, and shaping the 
future of professional nursing.
    On behalf of the entire Army Nurse Corps, serving both at home and 
abroad, I would like to thank each of you for your unwavering support, 
and I look forward to continuing to work with you. Thank you.

    Chairman Inouye. Admiral Niemyer.

STATEMENT OF REAR ADMIRAL ELIZABETH S. NIEMYER, 
            DIRECTOR, NAVY NURSE CORPS, DEPARTMENT OF 
            THE NAVY
    Admiral Niemyer. Good morning.
    Chairman Inouye, Vice Chairman Cochran, and distinguished 
members of the subcommittee, thank you for the opportunity to 
speak today on the state and future vision of the Navy Nurse 
Corps.
    Nowhere is Navy nursing's commitment to the operational 
forces more evident than in our active engagement in military 
operations in Southwest Asia, at the Expeditionary Medical 
Facilities in Kuwait and Kandahar, and with the 1st Marine 
Logistics Group in Afghanistan. We are clearly essential to our 
military's medical successes on the front lines of Operation 
Enduring Freedom.
    Nurse practitioners manage the clinical operations at NATO 
Role 3 in the urgent care clinic and participate in the 
Shoulder-to-Shoulder Project at Kandahar Regional Military 
Hospital. In this role, they mentor Afghan nurses in the 
classroom and in the clinical setting. The promise of enhanced 
clinical care in the Afghan healthcare system is a vision 
shared by all those stationed at NATO Role 3.
    Navy nurses are also members of embedded training teams and 
provincial reconstruction teams, collaborating with Coalition 
partners and offering assistance to military and civilian 
healthcare providers in Afghanistan.
    We played a key role in humanitarian assistance and 
disaster relief operations in support of Operation Unified 
Response in Haiti, Pacific Partnership 2010, and Continuing 
Promise 2010. These operations present a unique opportunity to 
test our education and clinical skills in rudimentary 
healthcare environments while strengthening our capability to 
partner with host nations, U.S. Government agencies, non-
governmental agencies, and academic institutions.
    Navy nurses continue to support the fleet and expand the 
services they provide to our sailors and marines at sea. Nurses 
assigned to aircraft carriers and fleet surgical teams are 
actively involved in operational missions around the globe and 
are essential members of shipboard medical teams.
    The role of Navy nurses assigned to the Marine Corps 
continues to expand and diversify. Currently, 18 nurses are 
directly attached to the Marine Corps serving in clinics and 
advanced leadership roles. For the first time in our history, 
the 2d Marine Expeditionary Fleet surgeon is a nurse.
    Today Navy Nurse Corps' active component is manned at 92 
percent, and for the fifth consecutive year, we have achieved 
Navy nursing's active component recruiting goal. The Reserve 
component is 85.9 percent manned and has reached 48 percent of 
their fiscal year 2011 recruiting goal. I attribute our 
recruiting successes to the continued funding and support for 
our accession and incentive programs, the local recruiting 
efforts of Navy recruiters, direct involvement of Navy nurses, 
and the continued positive public perception of service to our 
country.
    Mr. Chairman, I am privileged to provide an update to you 
and your subcommittee on the progress of our initiative for 
doctoral preparation of nurse practitioners and nurse 
anesthetists.
    For the past 2 years, we have selected nurses to transition 
their education programs to a doctorate of nursing practice, 
either to transition from a master's program to the Doctorate 
of Nursing practice, or transition from a bachelors program 
directly to doctoral level work.
    Staff members from my office are diligently working on a 
promotion and schooling plan to maximize opportunities to send 
newly trained nurse practitioners and nurse anesthetists to 
study directly for their doctoral education. I am committed to 
making this education transition the standard for our advanced 
practice nurses.
    We have numerous Navy nursing and joint research and 
evidence-based projects in progress, and continue to be 
extremely grateful for your ongoing support of the Tri-Service 
Nursing Research Program. One study of interest is a 
collaborative project the Navy is leading that will gather 
first-person accounts of nurses caring for wounded service 
members and the memories of the experience from the service 
members themselves. The knowledge gained about their wounded 
care journey is essential in order to develop and sustain 
nursing competencies, and to examine the factors affecting 
reintegration of the wounded warrior.
    Coordination of seamless care is a top priority for the 
ongoing care of our wounded warriors. This year, we will staff 
a Navy Nurse Corps officer directly to a newly created position 
at the VA headquarters. This nurse will work directly with the 
Federal Recovery Coordinator Program to uncover process issues 
and craft solutions to streamlined care.
    In September 2010, I met with a core group of leaders to 
formulate my 2011 Navy Nurse Corps Strategic Plan. We 
identified objectives within five areas of focus: workforce, 
nursing knowledge, nursing research, strategic partnerships, 
and information management. I look forward to updating you on 
Nurse Corps accomplishments on these initiatives in support of 
Navy medicine.
    Being in the military has its challenges, yet it is these 
challenges that allow Navy nurses to excel both personally and 
professionally. Our Navy medicine concept of care is patient 
and family focused, never losing perspective in the care for 
those wounded, ill, or injured, their families, our retirees 
and their families, and each other.

                           PREPARED STATEMENT

    Chairman Inouye, thank you for your unwavering support of 
the commitment to the Navy Nurse Corps, and thank you for 
providing me this opportunity to speak today. I am honored to 
represent the total force, Navy Nursing Team, and look forward 
to continued service as the 23d Director of the Navy Nurse 
Corps.
    Thank you.
    Chairman Inouye. I thank you very much, Admiral.
    [The statement follows:]

        Prepared Statement of Rear Admiral Elizabeth S. Niemyer

                              INTRODUCTION

    Good Morning. Chairman Inouye, Vice Chairman Cochran, and 
distinguished members of the subcommittee, I am Rear Admiral Elizabeth 
Niemyer, the 23d Director of the Navy Nurse Corps. Thank you for the 
opportunity to speak today on the state and future vision of the Navy 
Nurse Corps. I first want to recognize Rear Admiral Karen Flaherty, the 
22d Director of the Navy Nurse Corps, who turned over the helm to me 
this past August, and now serves as the Deputy Surgeon General. I 
sincerely thank her for her hard work and dedication which provided for 
a smooth transition for the Nurse Corps.
    Dr. Jonathan Woodson, our new Assistant Secretary of Defense for 
Health Affairs, recently spoke about the well-being of service members 
at the 2011 Warrior Resiliency Conference. The 2-day conference focused 
on Total Force Fitness, an initiative by the Joint Chiefs of Staff. 
Attendees delved into a more holistic approach to the health of service 
members and their families. Woodson said; ``Resiliency is key to the 
welfare of the modern troop, as extended warfare is now commonplace.'' 
He echoed Admiral Michael Mullen, Chairman of the Joint Chiefs of 
Staff, by saying; ``Resiliency training must be incorporated into all 
levels of leadership and stages of a service member's military 
career.'' Navy nurses understand the importance of fostering resiliency 
in our patients, their families, our staff, and ourselves as we adapt, 
overcome, and grow stronger in the enormous challenge of supporting 
healthcare in a variety of contingencies.
    Today, I will highlight the accomplishments of the Navy Nurse Corps 
over the past year and discuss issues facing the Navy Nurse Corps in 
2011, as we care for the health of the Force. The total Navy Nurse 
Corps is comprised of 3,987 Active and Reserve component nurses and 
almost 2,000 government service civilian nurses. Working together, we 
are a collegial team of clinicians, patient advocates, mentors, and 
leaders, who are a caring and compassionate face to those affected by 
armed conflict, natural disasters and the day-to-day challenges of 
work, life and family.
    I will also tell you about the successes and accomplishments 
achieved by our Corps since we last presented to you, concluding with a 
discussion of the future of the Navy Nurse Corps as we forge ahead to 
advance nursing care, integrate evidence into practice, and elevate 
nursing at all levels. My strategic focus is on five key areas: Our 
Workforce, Nursing Knowledge, Research, Strategic Partnerships, and 
Information Management. It is within these five areas that I will talk 
about our successes and address our future efforts. However, before 
discussing these areas of focus, I want to share the many incredible 
accomplishments of Navy nurses in operational settings with the Fleet 
and Fleet Marine Forces, as well as review the increasingly important 
role that Navy nurses play in humanitarian and disaster relief 
missions.

                          OPERATIONAL SUPPORT

    Nowhere is Navy nursing's commitment to the operational forces more 
evident than in our active engagement in military operations in 
southwest Asia at the Expeditionary Medical Facilities in Kuwait and 
Kandahar, and with the 1st Marine Logistics Group in Afghanistan. 
Currently there are over 70 Active and 60 Reserve component nurses 
deployed in a variety of missions in the Central Command Area of 
Responsibility. At the NATO Role 3 Multinational Medical Unit in 
Kandahar, Afghanistan, Navy nurses have taken unprecedented leadership 
positions both in the hospital and in the battle space of southern 
Afghanistan. We are clearly essential to our military's medical 
successes on the front lines of Operation Enduring Freedom. For 
example, nurse practitioners manage the clinical operations of the NATO 
Role 3 Urgent Care Clinic, responsible for providing urgent, emergent, 
and non-emergent healthcare services to 30,000 NATO, coalition, and 
civilian Afghan personnel residing on the Kandahar Air Field. Navy 
nurses have taken a lead role in the highly successful enroute care 
program where specially trained flight nurses are being stationed with 
outlying Forward Surgical Teams, providing critical care in the air 
during patient transfers from distant locations to the NATO Role 3. 
Having flown over 100 flights in 2010, this program has recorded a 
remarkable 100 percent survival rate. An initiative undertaken by Navy 
nurses at the NATO Role 3, and one which contributes greatly to our 
efforts to improve conditions in Afghanistan is their participation in 
the Afghan National Army Nurse Corps' Shana baShana (Shoulder-to-
Shoulder) Project at the Kandahar Regional Military Hospital. In this 
project, Navy nurses work in concert with a U.S. Air Force mentoring 
team in a recurring 2-week curriculum where Navy nurses enhance and 
update the nursing skills of Afghan military nurses in both a classroom 
and clinical setting. The promise of enhanced clinical care in the 
Afghan healthcare system is a vision all those stationed at the NATO 
Role 3 share.
    Navy nurses are also members of Embedded Training Teams and 
Provincial Reconstruction Teams, collaborating with coalition partners 
and offering assistance to military and civilian healthcare providers 
in Afghanistan. Let me share with you the experience of one of our 
nurses, LCDR Zaradhe Yach, who served with the Provincial 
Reconstruction Team (PRT) at the Forward Operation Base (FOB) Ghazni. 
This base is located in one of the largest and most dangerous provinces 
in the Regional Command East. During the first 90 days in country, FOB 
Ghazni was rocketed by enemy forces over 40 times. During this same 
timeframe the PRT experienced more than 15 significant activities while 
conducting mounted combat patrols throughout the province and LCDR Yach 
was present each time, providing medical assessments and emergency 
treatments to wounded service members. Patrols were engaged in complex 
attacks of multiple improvised explosive devices (IEDs), rocket 
propelled grenades (RPGs), indirect fire, and small arms fires. One IED 
struck her vehicle, causing catastrophic damage and injuries. The 
convoy was able to suppress fire and return, while LCDR Yach and her 
team, along with the Air Force Forward Surgical Team (FST) staff, 
ensured all injuries were thoroughly evaluated and treated.
    During her deployment LCDR Yach facilitated health sector 
development between coalition partners, meeting multiple times with 
Afghan leaders. Additionally, she served as a mentor while leading the 
daily operations of the PRT aid station which provided care for 
coalition forces, contractors and local interpreters. Under her 
leadership and guidance, her clinic was able to help over 3,000 
patients and distribute over $150,000 in humanitarian aid and medical 
supplies, greatly enhancing the quality of life of the Afghan people. 
Her selfless performance of duties in a combat zone resulted in 
awarding of the Bronze Star Medal by the Secretary of the Army.
    Navy nurses played a key role in humanitarian assistance and 
disaster relief operations in support of Operation Unified Response in 
Haiti. On January 16, 2010 USNS Comfort (T-AH 20) deployed to Haiti 
within 72 hours notice to provide disaster relief following a magnitude 
7.0 earthquake that devastated the Haitian capital and surrounding 
countryside. The first patient was received on January 19, just 7 days 
after the disaster. Nearly 200 patients were admitted within the first 
40 hours on station, and the inpatient census peaked at 411 patients on 
January 28. There were a total of 1,002 admissions and 931 surgical 
procedures conducted during this mission. Seven operating rooms ran 12 
hours per day and three ran ``around the clock'' to accommodate 
surgical emergencies. For three weeks, Comfort was the most advanced 
and busiest orthopedic trauma center in the world.
    Nurses aboard USS Bataan (LHD 5) and USS Carl Vinson (CVN 70) also 
made significant contributions to Operation Unified Response. Fleet 
Surgical Team EIGHT nurses aboard the Bataan participated in the care 
of 97 patients who were evacuated to the ship and assisted in the 
delivery of a healthy newborn. The sole Ship's Nurse on Carl Vinson 
worked with a small group of medical augmentees in caring for 60 
patients admitted to the ship for medical, surgical and post-partum 
care. The magnitude of the mission brought an unprecedented number and 
complexity of casualties. Once again, Navy nursing demonstrated its 
flexibility, commitment, and professionalism in responding to a 
humanitarian crisis. Mr. Chairman, I am exceedingly proud of this 
amazing demonstration of how nurses from joint and international 
military services and non-governmental organizations united together as 
a global force to support the population of Haiti in their time of 
need.
    Other significant humanitarian operations included the deployments 
of USNS Mercy (T-AH 19) during Pacific Partnership 2010, and USS Iwo 
Jima (LHD 7) for Continuing Promise 2010. In support of these missions, 
Navy nurses traveled to Vietnam, Cambodia, Indonesia and Timor-Leste, 
as well as Haiti, Colombia, Guatemala, Nicaragua, Costa Rica, Panama, 
Suriname and Guyana. These operations presented a unique opportunity to 
test our education and clinical skills in rudimentary healthcare 
environments, while strengthening our capability to partner with host 
nations, U.S. government agencies and academic institutions, 
international military medical personnel, regional health ministries, 
and nongovernmental agencies through medical, dental, and engineering 
outreach projects
    Navy nurses continue to support the Fleet and expand the services 
they provide to our Sailors and Marines at sea. Nurses assigned to 
aircraft carriers and Fleet Surgical Teams are actively involved in 
operational missions around the globe and are essential members of 
shipboard medical teams. The nurse aboard USS Harry S. Truman (CVN 75) 
deployed with Strike Group 10 and Carrier Air Wing 3 in support of the 
wars in Afghanistan and Iraq. During this deployment, our nurse 
provided training to over 5,000 personnel, to include instruction in 
basic wounds, First Aid, and Basic Cardiac Life Support. Aboard Iwo 
Jima, a certified registered nurse anesthetist (CRNA) from Fleet 
Surgical Team FOUR assisted in a research study conducted by the Navy 
Environmental and Preventive Medicine Unit to evaluate occupational 
exposure to anesthetic gases among operating room personnel at sea. 
Furthermore, Fleet Surgical Team nurses flew 20 medical evacuation 
missions from large deck amphibious ships to USNS Comfort or various 
shore-based facilities, configuring rotary wing aircraft to accommodate 
critically ill or injured patients, and providing life sustaining 
enroute nursing care under dangerous and austere conditions.
    The role of Navy nurses assigned to the Marine Corps continues to 
expand and diversify. Currently, 18 nurses are directly attached to the 
Marine Corps, serving in clinics and in advanced leadership roles. For 
the first time in the history of the Navy Nurse Corps, the Second 
Marine Expeditionary Fleet Surgeon is a nurse. Battalion nurses provide 
operational nursing support to the Forward Resuscitative Surgical 
Systems (FRSS), the Shock Trauma Platoons (STPs), and to enroute care 
missions. The nurse at the Marine Corps Training and Education Command 
oversees the training plans and the Readiness Manual for Marine Corps 
Health Services, while nurses at the Field Medical Training Battalions 
provide training for all corpsman and officers attached to Marine units 
in support of operational missions.
    Navy nurses remain inherently flexible and capable of supporting 
multiple missions in many settings and various platforms. I am 
continually awed by the men and women in the Navy Nurse Corps. They 
demonstrate daily that they are uniquely suited to answer the call when 
a medical response is required.
    Mr. Chairman, the remainder of my testimony is organized around my 
five key areas of strategic focus: Our Workforce, Nursing Knowledge, 
Research, Strategic Partnerships and Information Management.

                             OUR WORKFORCE

    Today's Navy Nurse Corps active component (AC) is manned at 92.0 
percent with 2,852 nurses currently serving around the world. For the 
fifth consecutive year, we have achieved Navy nursing's AC recruiting 
goal. This is quite an accomplishment only 7 months into the current 
fiscal year. The reserve component (RC) is 85.9 percent manned with 
1,135 nurses in inventory, and has reached 48 percent of their fiscal 
year 2011 recruiting goal with 5 months remaining this fiscal year. I 
attribute our recruiting successes to the continued funding support for 
our accession and incentive programs, the local recruiting activities 
of Navy Recruiters, direct involvement of Navy nurses, and the 
continued positive public perception of service to our country.
    The top two direct accession programs that favorably impact our 
recruiting efforts in the Active component include the Nurse Accession 
Bonus and the Nurse Candidate Program. The Nurse Accession Bonus 
continues to offer a $20,000 sign-on bonus for a 3-year commitment and 
$30,000 for a 4-year commitment; and the Nurse Candidate Program, 
tailored for students who need financial assistance while attending 
school, provides a $10,000 sign-on bonus and $1,000 monthly stipend. I 
would like to thank you Mr. Chairman, Vice Chairman Cochran, and all 
committee members for this ongoing and vital support.
    For the RC, a vigorous recruiting plan requires flexible tools to 
ensure we target high quality officers with appropriate skill sets. 
Incentive programs have proven to be key to recruiting the correct 
number of officers with the right skills. It is essential that our 
critical shortage of registered nurses in the specialties of CRNAs, 
critical care, medical-surgical, perioperative, and psychiatric nursing 
as well as mental health nurse practitioners are offered competitive 
incentives. The new officer affiliation and incentive program available 
to registered nurses in our critical shortage specialties is favorably 
impacting our reserve component recruiting efforts this fiscal year. 
The new incentives offer $10,000-$25,000 per year depending on the 
specialty area of practice and service obligation incurred. Loan 
repayment programs have also proven to be of great value in attracting 
critical shortage specialties, such as, advanced practice CRNAs and 
mental health nurse practitioners.
    We know that as the economy improves and civilian nursing 
opportunities expand through the Affordable Care Act we might once 
again be faced with recruiting and retention challenges. In 
anticipation of these challenges, we are inviting nursing students and 
new graduate nurses to participate as American Red Cross volunteers at 
our hospitals and clinics to enhance exposure to the military. 
Additionally, we assigned a Nurse Corps fellow to my staff to monitor 
recruitment and retention, and to ensure that both remain a priority.
    The education and training department at Naval Medical Center 
Portsmouth assists with a monthly recruitment seminar in which Corps 
representatives speak to prospective nurses and physicians about Navy 
Medicine. These sessions allow for arranging tours and one-on-one 
meetings with junior nurses to answer questions about military 
healthcare. Additionally, nurses aboard aircraft carriers, hospital 
ships and on Fleet Surgical Teams contribute to the recruiting effort 
by providing shipboard tours to prospective nurses, dentists, 
physicians and other healthcare professionals, ultimately enhancing 
their knowledge of and exposure to operational medicine and shipboard 
life.
    With the ongoing war, we are keenly aware of the need to grow and 
retain nurses in our critical war-time subspecialties. Though loss 
rates have improved overall, there remains a gap in the inventory to 
authorized billets for junior nurses with 5 to 10 years of commissioned 
service. Key efforts which have positively impacted retention continue 
to include Registered Nurse Incentive Special Pay (RN-ISP), which 
targets bonuses to undermanned clinical nursing specialties, and the 
Health Professional Loan Repayment Program (HPLRP), which offers 
educational loan repayment up to $40,000 per year. Full-time Duty Under 
Instruction (DUINS) further supports Navy recruitment and retention 
objectives by encouraging higher levels of professional knowledge and 
technical competence. Training requirements are selected on Navy 
nursing needs for advanced skills in war-time critical subspecialties. 
Seventy-six applicants were selected for DUINS through the fiscal year 
2011 board.
    We remain diligent in our efforts to grow and sustain our community 
of mental health nurses. The Navy Nurse Corps is entering its fourth 
year of officially recognizing the psychiatric mental health nurse 
practitioner specialty. Restructuring this manpower shift has not been 
without its challenges, but we are actively involved in building and 
expanding the close network of advanced practice psychiatric mental 
health nurses with their peers outside the mental health arena. We 
currently have two mental health nurse practitioners assigned to the 
U.S. Marine Corps at the 1st and 2d Marine Divisions, and a majority of 
our mental health nurse deployments have been in support of Joint 
Medical Task Force, Guantanamo Bay, Cuba. Many of our Navy psychiatric 
mental health nurses remain fully integrated in one collaborative 
mental healthcare approach and are active members of Wounded, Ill and 
Injured programs.

                           NURSING KNOWLEDGE

    Care for both service members and their families is the top 
priority for Navy Nursing, Navy Medicine and the Department of Defense. 
Nurses are a key component of Family and Patient Centered Care 
initiatives, and I would like to share with you a few success stories 
where Navy nurses are leading the charge.
    Nurse Case Managers provide services to the Wounded Warrior that 
span the entire care continuum from point of injury to either return to 
active duty or medical separation from service. The journey from 
theatre to stateside care is only the beginning of a long road of 
recovery for returning Wounded, Ill and Injured warriors who are often 
facing extensive care and rehabilitation for life-changing physical, 
psychological and cognitive injuries. The complexity of medical 
healthcare and military systems is often overwhelming to the Wounded, 
Ill and Injured service members, thus driving a critical need for 
someone to coordinate care and support services. Nurse case managers 
are the ``SOS or 1-800'' contact for the patient and family throughout 
the continuum of care. The nurse case managers, along with Navy Safe 
Harbor and the U.S. Marine Corps Wounded Warrior Regiment, bring a more 
holistic approach to transition of the Wounded, Ill and Injured into 
the Veterans Affairs (VA) or civilian care by addressing the medical 
and the non-medical needs concurrently. This collaboration is important 
to reducing stress and confusion during transition. I am proud to 
report that our Clinical Case Management Program has been recognized 
nationally by being awarded the 2010 Platinum Award for the Best 
Military Case Management Program. This award was presented by the Case 
Management Society of America and was featured in their journal, Case 
In Point in May 2010. Case management is at the heart of ensuring the 
development of comprehensive plans of care and ensuring smooth 
transitions for all Wounded, Ill and Injured service members and their 
families.
    In support of the Navy's efforts to develop resilience in Sailors, 
Marines, families and commands, we have detailed a senior mental health 
nurse to the Chief of Naval Personnel to implement the Navy's 
Operational Stress Control (OSC) program. This comprehensive effort is 
line-owned and led, integrating policies and initiatives under one 
overarching umbrella. The program is designed to build resilience and 
to increase the acceptance of seeking help for stress-related injuries 
through education, training and communication. Twenty-three modules of 
formal curriculum have been developed and are being taught at key nodes 
in a Sailor's career--from boot camp to the Naval War College, with 
more than 206,000 receiving training to date. We are working hard to 
develop a culture that rewards preventive actions and recognizes that 
seeking help is a sign of strength. Navy nurses are uniquely qualified 
to function in this non-traditional role where the focus is on building 
resilience and prevention vice treating injury or illness.
    During the past year we completed a nurse led Navy Medicine 
assessment of caregiver occupational stress. Not surprisingly, the 
study found evidence of caregiver occupational stress. The study also 
identified that meaningful work, good training, and engaged clinical 
leaders all contribute to building caregiver resilience. Our future 
efforts will continue to invest in strategies that enhance resilience 
and performance while identifying and mitigating expected caregiver 
demands.
    Clinical excellence is the cornerstone of Navy Nursing. An 
innovative program titled ``The Immersion in Critical Care and 
Emergency Nursing'' (ICE) program at Naval Medical Center Portsmouth 
has been designed to train and sustain skills essential to our critical 
wartime specialties. This three-part program, consists first of 
prerequisite training with introductory courses and modules available 
to and within the Military treatment facility (MTF). The second phase 
is the Simulation/Skills Lab which targets skills review and specific 
patient scenarios for high risk situations encountered by the nurse. 
The final phase involves a practicum with time spent delivering hands-
on patient care, focused on specific areas of the specialty. The first 
nurses to attend this program are just weeks into their deployment 
rotation at the Expeditionary Medical Facility in Kuwait, so feedback 
has not been obtained post-deployment. However, we anticipate that ICE 
will be of great value in introducing nurses to critical care and 
emergency nursing situations prior to future deployments.
    To promote clinical excellence for families of Sailors and Marines 
we are preparing nurses for unexpected emergencies both stateside and 
overseas. This year our nurses participated in Mobile Obstetric 
Emergencies Simulator training at Madigan Army Medical Center, Fort 
Lewis, along with health providers from all branches of the armed 
forces. Additionally, we joined in community outreach by partnering 
with Baby Connections, a care-giver and infant learning/play group 
facilitated by the local county health department, providing 
information to caregivers regarding development, infant care, 
breastfeeding, and dental care for newborns to 3 year olds. Navy nurses 
serve as members of breastfeeding coalitions and have established 
lactation consultant presence in hospitals, clinics, and at fleet 
commands, all in support of initiatives to meet the Healthy People 2020 
goals. Nurses are involved in numerous programs which support family 
centered care, including the Happiest Baby on the Block and parent-
infant bonding programs. Family centered care is the foundation of our 
care delivery model in all treatment facilities.
    Nurse Corps officers are actively involved in mentoring 
baccalaureate and master's students at universities throughout Navy 
Medicine. Naval Medical Center Portsmouth identified the need for a 
Nurse Education Coordinator who has the responsibility of coordinating 
the activities for over 30 local and distance learning schools of 
nursing from the licensed practical nurse-level to the facilitation of 
graduate-level clinical experiences. We realize that community 
involvement with the future nursing workforce is key to both our 
recruiting and retention efforts as well as to creating a multi-
talented, diverse workforce. We are committed to providing high quality 
clinical experiences to students whenever possible.
    For the third year, I am pleased to tell you that funding has 
allowed us to continue support of the Graduate Program for Federal 
Civilian Registered Nurses (GPFCRN). We recognize the challenges 
associated with recruitment and retention of civilian nurses for 
Federal service positions, and continue to see this program as a way to 
cultivate clinical expertise and future nursing leaders from our 
civilian workforce by offering graduate nursing education. In the fall 
we will select another five nurses to attend programs across the 
country to develop skills as a clinical nurse specialist. After 
graduation, they will continue their Federal service, directing expert 
clinical nursing practice across the enterprise.
    Navy nurses are at the forefront of Navy Medicine leadership. There 
are currently eight Nurse Corps Officers serving as commanding 
officers. In addition, nurses are encouraged to assume leadership 
positions as associate directors and directors, sometimes in non-
traditional nursing roles. Our operational nurses also serve in key 
leadership roles while underway. This year, the first Nurse Corps 
Officer held the position of Deputy Commander for the Joint Medical 
Group with the Joint Task Force Guantanamo, Guantanamo Bay, Cuba. 
Leaders in executive medicine positions showcase the versatility of our 
Corps and pave the path for an expanded role for future Nurse Corps 
leaders.
    This year, 22 nurses aboard aircraft carriers and amphibious ships 
earned the Surface Warfare Medical Department Officer qualification. 
This qualification is earned by Medical Department officers who attain 
extensive shipboard knowledge and experience outside of the medical 
professions. This includes knowledge of engineering systems, navigation 
methods, communication and weapon systems and offensive and defensive 
capabilities. The qualification requires knowledge of watch standing 
responsibilities on the Bridge and in the Combat Information Center and 
culminates with a final qualifying oral board. Nurses also earn and 
wear the Fleet Marine Force (FMF) Qualified Officer Insignia. The FMF 
insignia is earned by Navy officers assigned to the Fleet Marine Force, 
and it clearly makes a statement that the wearer is a key member of the 
Marine Corps team. Earning this designation requires serving for 1 year 
in a Marine Corps command, passing an arduous written test, completing 
the Marine physical fitness test, and passing an oral board conducted 
by FMF qualified officers. To date, we have 56 nurses holding this 
qualification, from our junior lieutenant junior grades officers, to 
officers holding the rank of captain.
    Nurses are not just caregivers, but are a vital part of our 
organizational structure as mentors to junior officers and our enlisted 
personnel. Navy-wide, nurses are seen leading Junior Officer Career 
Development seminars, speaking at local high schools, health fairs, and 
community colleges. We are actively involved with Navy Nurse Corps 
students at our Reserve Officer Training Corps (NROTC) programs, 
frequently attending activities to support and mentor students during 
their time in school. These experiences are mutually beneficial, 
providing opportunities for junior nurses to be involved within our 
community by establishing and maintaining professional relationships, 
and allowing junior nurses and nurse candidates to seek guidance from 
senior nurses.
    Deployed nurses also serve as mentors and educators for other 
officers and enlisted personnel. One Navy Nurse recently returned from 
a 6-month deployment as an individual augmentee in Camp Bastion, 
Helmand Province, Afghanistan. He was an integral part of the 
Emergency/Trauma Department where they provided direct patient care to 
4,000 combat and non-combat injured patients, delivering over 3,600 
units of blood products. During his deployment, this officer conducted 
TeamSTEPPS Essential training to the Emergency Department. The 
Department of Defense, in collaboration with the Agency for Healthcare 
Research and Quality (AHRQ), developed the TeamSTEPPS program to serve 
as a powerful, evidence-based teamwork system to improve communication 
and teamwork skills. I am proud this energetic Navy Nurse took this 
training to the deck plate, recognizing that we demand excellence in 
healthcare quality even at our most remote locations. It is this type 
of engaged leadership that is the hallmark of Navy Nursing.
    Mr. Chairman, I am privileged to provide an update to you and your 
Committee on the progress of the Navy Nurse Corps initiative for 
doctoral preparation of our nurse practitioners and nurse anesthetists. 
As you recall, the 2009 National Defense Authorization Act (Senate 
Report 111-74, page 275) provided direction from this committee, 
describing your support of graduate nursing education through our Duty 
Under Instruction (DUINS) program for training nurse practitioners. The 
Committee directed the Service Surgeons General, in coordination with 
the Nurse Corps Chiefs, to provide a report outlining a critical 
analysis of emerging trends in graduate nurse practitioner education, 
with an emphasis on the consideration of replacing Master's in Nursing 
preparation with a Doctorate of Nursing Practice degree program. We 
submitted that Report to Congress in March 2009, and I am pleased to 
tell you we immediately identified top performers who were completing 
their Masters degrees, selecting them to add additional time onto their 
schooling to complete their Doctorate of Nursing Practice. This past 
November, we selected seven additional nurses to either transition 
their Master's program to a Doctorate of Nursing Practice, or to pursue 
education which will take them from their Bachelor's nursing degree 
directly into doctoral level work, bypassing the Masters degree. Staff 
members from my office are diligently working on a promotion and 
schooling plan to send newly trained nurse practitioners and nurse 
anesthetists to study directly for their doctoral education.

                            NURSING RESEARCH

    The National Institute of Health (NIH), through The National 
Institute of Nursing Research (NINR), defines nursing research as the 
development of knowledge to build a scientific foundation for clinical 
nursing practice, prevent disease and disability, manage and eliminate 
symptoms caused by illness, and enhance end-of-life and palliative 
care. We have numerous Navy Nursing and joint research and evidence-
based projects in process, and continue to be extremely grateful for 
your ongoing support of the TriService Nursing Research Program. 
Research projects are currently being conducted by active and reserve 
component nurses on clinical topics such as; heat illness, hemorrhagic 
shock, development of Navy-wide evidence-based guidelines for wound 
care management and pressure ulcers, ultrasound guided and peripheral 
nerve stimulation techniques, catheter removal and motor function 
recovery, the role of nursing in implementation of a Patient Centered 
Medical Home (PCMH) in MTFs, virtual reality for stress inoculation, 
clinical knowledge development and continuity of care for injured 
service members, competency and work environments of perioperative 
nurses, moral distress, and nurse-managed clinics.
    One study of interest is a collaborative project Navy is leading 
which includes nurse researchers from the Army, Air Force and the VA. 
The purpose of this study is to gather first person experience-near 
accounts of experiential learning of military and civilian nurses 
caring for wounded service members, along with first person accounts of 
service members' memories of all levels of care and transitions from 
the combat zone to rehabilitation. The knowledge gained about their 
wounded care journey is essential in order to develop and sustain 
nursing competencies, and to examine the acute and rehabilitative 
factors affecting reintegration of the wounded warrior. This study also 
has critical utility for optimal functioning of service members 
returning to the United States, transitioning into the military and 
Veterans Affairs healthcare systems, and for developing training 
programs with military healthcare personnel who work with service 
members in acute and rehabilitation healthcare settings. Preliminary 
data analysis is underway. Nurses have shared their expertise and 
knowledge, and lessons learned are being formulated to improve patient 
care throughout the Department of Defense and VA healthcare systems.
    Nurse researchers are also actively conducting research to explore 
retention of recalled reservists, psychometric evaluation of a triage 
decisionmaking, and construction of learning experiences using clinical 
simulations. Without your initial support of the TriService Nursing 
Research Program in the early 1990's this would have been a very 
difficult task to achieve. Ongoing support of military nursing research 
as a unique and distinct entity is vital to the advancement of this 
important niche of science to our Nation.

                         STRATEGIC PARTNERSHIPS

    A collaborative approach between Services and Federal agencies has 
never been more important than it is today. Navy nurses, find 
themselves serving as individual augmentees (IAs) with sister Services, 
working in Federal healthcare facilities such as the James Lovell 
Federal Health Care Center in Great Lakes, supporting academia in 
facilities such as the Uniformed Services University Graduate School of 
Nursing and serving in Joint Commands.
    The Captain James A. Lovell Federal Health Care Center (FHCC) is 
the Nation's first fully integrated medical facility between the VA and 
DOD. Established on October 1, 2010, the facility integrates all 
medical care into a Federal healthcare center with a single combined VA 
and Navy mission, serving military members, Veterans, military family 
members and retirees. Integrating many ``types'' of nurses has been 
rewarding, and had very few challenges. Combining the strengths of 
active duty, DOD, VA nurses and contract nurses, we have formed one 
orientation nursing program, increased the venues for active duty 
nurses to obtain their clinical sustainment hours, and combined forces 
for one Executive Committee of the Nursing staff, with Navy and VA 
Nursing Executives as equal co-chairs.
    Coordination of seamless care is a top priority for the ongoing 
care of our Wounded Warriors. I am pleased to tell you about a joint 
initiative between the Deputy Secretary of Veterans Affairs and the 
Deputy Secretary of Defense to staff a Navy Nurse Corps officer 
directly to a newly created position at the VA Headquarters in 
Washington, DC. This nurse will work directly with the Federal Recovery 
Coordinator Program to uncover process issues and craft solutions to 
streamline care. The nurse will serve as a vital link between the 
Veterans Affairs Federal Recovery Coordination Program and the MTFs to 
assist severely Wounded, Ill and Injured patients and their family 
members in the complex coordination of their care throughout the 
rehabilitation continuum. I look forward to providing additional 
information to you next year on this important role.
    Our nurses in Guam have joined their civilian counterparts from 
Guam Memorial Hospital and Air Force nurses from Anderson Air Force 
Base to share their skills and experiences. Navy nurses provide the 
Trauma Nursing Core Course both for providers and instructors. This 
course has been instrumental in building the confidence and honing 
assessment skills of nurses who normally do not work in an Emergency 
Department setting. Naval Hospital Guam also included Joint Medical 
Attendant Transport Team (JMATT) members in their Emergency Department, 
allowing them to receive this training at no-cost.
    The nurses in the Primary Care Clinic at Naval Health Clinic Corpus 
Christi (NHCCC) collaborated with our Air Force Nursing counterparts at 
Wilford Hall Medical Center Diabetes Center of Excellence in San 
Antonio regarding Diabetes Education. The staff at Wilford Hall Medical 
Center routinely travels to Naval Health Clinic Corpus Christi to 
provide monthly diabetic education classes to our patients. In 
addition, they provide ``train the trainer'' sessions so our staff can 
assume the role as the trainer. Naval Health Clinic Corpus Christi also 
established a collaborative relationship with Brooke Army Medical 
Center for supplementary clinical experiences.
    Naval Hospital Pensacola maintains a Memorandum of Understanding 
with the local trauma center, allowing collaboration for training and 
clinical sustainment in critical care, pediatrics, neonatal, and high 
risk obstetrics. Additionally, the civilian community nurses provide 
trainers for our specialty neonatal course that prepares staff in the 
care of high acuity newborns needing transfer to a higher level of 
care. Recognizing that our nurses must be operationally prepared for 
deployment, but may have limited inpatient nursing care exposure while 
working in the clinic environment similar arrangements with inpatient 
facilities have been made in Hawaii at Tripler Army Medical Center and 
Newport, Rhode Island with the Providence Veteran's Hospital. We remain 
grateful to the Army, Air Force, Veterans Affairs and civilian 
facilities for these partnerships.
    Our RC nurses routinely participate in joint initiatives. Through 
their reserve commands, Nurse Corps Officers take part in joint 
training exercises with the Coast Guard, Seabee forces through Naval 
Mobile Construction Battalions, and Air Force and Army medical teams. 
Our Operational Hospital Support Units have agreements with Veterans 
Affairs Medical Centers in several States to provide real time patient 
treatment both for nurses and hospital corpsmen during drill weekends. 
This not only supports their continued training and clinical 
sustainment requirements, but provides additional resources for the VA 
facility.
    I am excited to tell you about our annual ``Host Nation Symposium'' 
event at Naval Hospital Rota, Spain, where healthcare providers in the 
community and military gather to share education and best practices 
between the two unique healthcare systems. It also provides an 
opportunity for members of Navy Medicine to meet their counterparts and 
build camaraderie. We are also partnering with the head of the Spanish 
Nurse Corps in Rota to allow newly graduated Spanish military nurses to 
work in our facility. Their graduates spend approximately 2 weeks at 
our hospital shadowing fellow American nurses. In turn, select military 
nurses then travel to a trauma course hosted in Madrid. Both the 
Commanding Officer and Surgeon General from Spain are very optimistic, 
seeing this exchange as an opportunity to provide diverse experiences 
and better understand the diverse cultures and healthcare needs of our 
allies.

                         INFORMATION MANAGEMENT

    The sharing and quick dissemination of news, resources and 
announcements is a top priority of the Navy Nurse Corps. From a needs 
assessment, we know that nurses want rapid and easy online access to 
information which can be accessed at work whether in a traditional or 
deployed environment. Navy Knowledge Online serves as one platform for 
that capability and we are working to maximize its utility while we 
leverage other means of communication.
    Last year we reported the launch of the active duty Nurse Corps 
Career Planning Guide, a web-based mentoring tool for nurses at each 
stage of their career. Informally the feedback received has been 
overwhelmingly positive. Within the past several months we deployed 
similar Career Planning Guides for Reserve Nurse Corps Officers and 
Government Service Civilian nurses on Navy Knowledge Online. Both 
groups play a critical role in contributing to the Nurse Corps and Navy 
Medicine as we meet our peace and wartime missions. As ``One Team,'' 
our civilian nurses work with our military staff, providing continuity, 
experience, and enabling our military nurses to deploy in support of 
our warriors in the field. Navy Nursing is committed to providing all 
of our nurses the opportunities to enhance their understanding of 
operational medicine, grow professionally, and give them the tools to 
be leaders in Navy Medicine. The web-based Career Planning Guides 
(active, reserve and government service) provide a ``point and click'' 
list of resources to maximize career opportunities and knowledge for 
all nurses commensurate with rank and time in service. For example, 
under ``Operational Support,'' information on Navy War College Distant 
Learning Courses are provided, plus numerous links, and articles to 
enhance their operational skills & knowledge. To help nurses grow 
professionally, all the Bureau of Medicine and Surgery training and 
reimbursement opportunities are placed in a ``one stop'' shop. Finally, 
civilian nurses serve in leadership positions as directors, department 
heads and division officers. Our Civilian Career Planning Guide gives 
them comprehensive information and links to help them manage their 
military and civilian workforce, and grow as a leader in Navy Medicine. 
We are able to meet our mission requirements because of our dedicated 
civilian nurses, and it is an honor to work with them side-by-side in 
today's Navy Medicine. We will formally evaluate all three Career 
Planning guides and will to continue to adjust information based on 
feedback from the end users.

                            FUTURE DIRECTION

    In September 2010, I met with a core group of leaders to formulate 
my 2011 Navy Nurse Corps Strategic Plan. Included in the discussions 
were Specialty Leaders representing over 70 percent of all Nurse Corps 
officers; headquarters staff; junior officers from Navy Medicine East, 
West, and the National Capital Region; and the Army Deputy Commander 
for Nursing Services from the National Naval Medical Center. During 
this 2-day offsite meeting, five key goals were identified and Team 
Champions named. Since then, the Strategic Goal teams--comprised of 
nurses from around the world--have collaborated on projects to meet 
identified objectives within the five areas of focus: Workforce 
(maximizing human capital), Nursing Knowledge, Nursing Research, 
Strategic Partnerships, and Information Management. I recently had my 
first quarterly update, and I am confident the teams are on track to 
make solid recommendations for action. I look forward to my next report 
when I can share with you the accomplishments of Navy nurses throughout 
2011 and update you on their initiatives in support of Navy Medicine.

                               CONCLUSION

    Navy Nurse Corps officers are healers of mind, body and spirit; 
ambassadors of hope; respected nursing professionals and commissioned 
officers. Being in the military has its challenges, yet it is these 
challenges that allow Navy nurses to excel both personally and 
professionally. Mr. Chairman, Vice Chairman Cochran, and distinguished 
members of the subcommittee, thank you for providing me this 
opportunity to share the state and future direction of the Navy Nurse 
Corps and our continuing efforts to meet Navy Medicine's mission. Our 
Navy Medicine concept of care will remain patient and family focused; 
never losing perspective in the care for those wounded, ill, or 
injured, their families, our retirees and their families, and each 
other. I am honored to be here today to represent the Navy nursing 
team, and I look forward to continuing to serve as the 23d Director of 
the Navy Nurse Corps.

    Chairman Inouye. And now may I call upon General 
Siniscalchi. General.

STATEMENT OF KIMBERLY SINISCALCHI, ASSISTANT SURGEON 
            GENERAL FOR NURSING SERVICES, DEPARTMENT OF 
            THE AIR FORCE
    General Siniscalchi. Mr. Chairman, Mr. Vice Chairman, and 
esteemed members of this subcommittee, it is my distinct honor 
and privilege to once again represent over 18,000 men and women 
of the Air Force Nurse Corps and share our successes and 
challenges as we execute our strategic plan for global 
operations, force development, force management, and patient-
centered care.

                      AEROMEDICAL CREWS SAVE LIVES

    Across the globe, our Aeromedical Evacuation and Critical 
Care Air Transport Teams continue to be a vital link in saving 
lives.
    In 2010, our Aeromedical Evacuation crews accomplished 
26,000 patient movements on over 1,800 missions. David Brown, 
from the Washington Post, reported on an Army sergeant from 
California who was critically injured in Afghanistan in October 
2010. In his article, Brown stated, ``In any U.S. hospital, 
Sergeant Solorzano would be considered too sick to put on an 
elevator and take to the CT-scan suite. Now, he's about to fly 
across half of Asia and most of Europe. The U.S. military's 
ability to take a critically ill soldier on the equivalent of a 
7-hour elevator ride epitomizes an essential feature of the 
doctrine for treating war wounds in the 21st century: Keep the 
patient moving.''
    Members of Congress, thank you for passing Resolution 1605 
recognizing airmen who perform our aeromedical evacuation 
mission.
    Recently, I was afforded the opportunity to meet my nursing 
colleague, Brigadier General Rahimi Razia of the Afghanistan 
National Army. She expressed appreciation for the many 
contributions our senior mentors and training teams are making 
to advance nursing. They are helping her create a fundamental 
nursing education program and a scope of practice.

                       NURSE TRANSITION PROGRAMS

    Our outstanding success could not be possible without 
investing in our future. We completely transformed our nurse 
transition program for new graduates into four strategically 
located centers of excellence in an effort to broaden clinical 
training. Tampa General Hospital was recently approved as our 
newest site, and a training affiliation agreement was signed in 
February. This site will complement our other three sites at 
Scottsdale, Arizona, University of Cincinnati, Ohio, and San 
Antonio Military Health System, Texas. We also created a Phase 
2 component enabling us to advance the National Council of 
State Boards of Nursing Transition to Practice Model. Our pilot 
program at the 59th Medical Wing in San Antonio is leading the 
charge to deliberately develop our Nurse Transition Program 
graduates through a comprehensive, 9-month mentoring program.
    The American Association of Colleges of Nursing declared 
entry for advanced practice nurses to be at the doctorate level 
by 2015. Mr. Chairman, sir, your support of this initiative has 
been instrumental in our progression from masters to doctorate 
at the Uniformed Services University of the Health Sciences. We 
are preparing to send students to this program in 2012 and have 
three students starting the civilian programs in 2011.

                      ADVANCED IN MEDICAL TRAINING

    We continue to advance enlisted training. A ribbon-cutting 
was held in May 2010 at the new Medical Education and Training 
Campus in San Antonio, where all services will train their new 
enlisted medical personnel. This state-of-the-art training 
platform will graduate technicians in 15 different specialties 
to support the Department of Defense mission and optimize our 
interoperability across services.
    As we are developing our airmen, we are also developing our 
civilians. In January 2011, we conducted our first Nurse 
Civilian Developmental Board. This inaugural event served as a 
benchmark to create a civilian force development model that 
aligns with our officer and enlisted programs.
    Our goal of force management is to design and resource our 
nurse corps to sustain a world-class healthcare force. In 2010, 
we achieved 102 percent of our recruiting goal. Consistent with 
the line of the Air Force initiative to meet end strength 
requirements, our recruiting goals were reduced in 2011. 
However, we continue to work with the Office of Manpower 
Personnel and Services to ensure we maintain a robust 
recruiting program to preserve our quality force.
    Our Nurse Enlisted Commissioning Program creates a legacy 
career path in Air Force nursing. In 2010, 45 enlisted 
graduates were commissioned into the Nurse Corps. As we enter 
our third year of the Incentive Special Pay Program, we are 
seeing positive impacts on professional satisfaction and 
retention.
    We recognize the value of keeping clinical experts at the 
bedside, table side, and litter side. We developed a clinical 
track for master clinicians and researchers through the rank of 
colonel to foster a higher level of excellence within our 
nursing practice. One of our critical care master clinicians, 
Colonel McNeil, is currently deployed to Afghanistan and is 
making a significant difference in trauma and critical care 
outcomes.
    As we aim to provide better health, better care, best 
value, we are committed to the family health initiative, the 
Air Force's Pathway to Patient-Centered Medical Home. Our 
advanced practice nurses, clinical nurses, and technicians are 
positively impacting access, quality of care, patient outcomes, 
disease management, and case management. Within our patient-
centered care philosophy is the need to address resiliency and 
mental health of our airmen and families. Last year, I reported 
that a mental health nurse course was being developed at Travis 
Air Force Base in California. I am pleased to announce our 
first students started in February.
    The psychiatric Mental Health Nurse Practitioner Program at 
the Uniformed Services University of the Health Sciences is one 
of the few in the country that includes psychopharmacology and 
addresses behavioral techniques specific to the unique needs of 
our military population. We currently have four students 
enrolled in this program and four to start this summer.

                           PREPARED STATEMENT

    Mr. Chairman and distinguished members of the subcommittee, 
it is an honor to represent such a dedicated, strong nurse 
corps. Your continued support as we execute our priorities to 
advance military nursing is greatly appreciated. Our wounded 
and their families deserve nothing less than educated, skilled 
nurses and technicians who have mastered the art of caring. It 
is through the medic's touch, compassion, and professionalism 
that we answer our Nation's call to care for those who served 
yesterday, today, and will serve tomorrow.
    Thank you, and I welcome your questions.
    Chairman Inouye. All right. Thank you very much, General.
    [The statement follows:]

      Prepared Statement of Major General Kimberly A. Siniscalchi

    Mr. Chairman, and distinguished members of the committee, it is 
again my honor to represent the over 18,000 members of our Total 
Nursing Force (TNF). Together, with my senior advisors, Brigadier 
General Catherine Lutz of the Air National Guard (ANG), and Colonel 
Lisa Naftzger-Kang of the Air Force Reserve Command (AFRC), along with 
my Aerospace Medical Service Career Field Manager, Chief Master 
Sergeant Joseph Potts, we thank you for your continued support of our 
many endeavors to advance military nursing. It is a privilege to report 
on this year's achievements and future strategies.
    We are a total force nursing team delivering evidence-based, 
patient-centered care to meet global requirements. We have developed 
four strategic priorities in consonance with those of the Secretary and 
the Chief of Staff of the Air Force. They are: (1) Global Operations, 
(2) Force Development, (3) Force Management, and (4) Patient-Centered 
Care. These priorities are built on a foundation of education, training 
and research. This testimony will reflect our successes and challenges 
as we strive to execute our strategic priorities.

                           GLOBAL OPERATIONS

    For over two decades, our TNF has been supporting humanitarian 
missions and contingency operations that span the globe. We recognize 
that our mission effectiveness is contingent upon medics who are 
equipped, trained, and proficient at implementing Air Force 
capabilities across the full spectrum of operational environments. Air 
Force medics are truly expeditionary, and frequent deployments are a 
part of our culture. The nature of our current operating environment 
has reshaped the Air Force Medical Service (AFMS) and our Corps. 
Together we have experienced amazing success in the global environment.
    At a flight nurse and technician graduation ceremony at Brooks City 
Base in San Antonio, Texas on January 29, 2011, the guest speaker, Army 
Master Sergeant Todd Nelson, gave a poignant talk to our new flight 
crews. Sergeant Nelson was the personal recipient of aeromedical care 
after being injured by an Improvised Explosive Device blast during a 
convoy in Afghanistan. The explosion and shrapnel caused massive head 
and facial injuries; he was in grave status from the beginning. After 
receiving initial life-saving surgeries, Sergeant Nelson started his 
journey home, his condition still life-threatening. Despite the 
severity of his injuries, Sergeant Nelson remembers the aeromedical 
team as ``a phenomenal team of flight nurses and technicians who did 
not see me as a statistic, but as someone for whom they would do 
everything to ensure I survived and got home to my family. They didn't 
just see me as another patient, but as a person.'' In his closing 
comments to the class, he concluded, ``for those of you who are 
starting out and who will be caring for warriors such as myself, I 
thank you. It is because of you that I am standing here today. It is 
not only I who thank you, but my wife and my children for enabling me 
to continue to be a part of this family and their lives.''
    Aeromedical Evacuation (AE) Crews and Critical Care Air Transport 
Teams (CCATT) remain busy. In 2010, our Total Force Flight Nurses and 
Technicians accomplished 26,000 patient movements on over 1,800 
missions globally; approximately 11,500 of these patients originated in 
Central Command. Nearly 10 percent of these missions were for 
critically injured or ill patients who required a CCATT. While the 
number of patients has not drastically changed, there has been a shift 
of casualties from Iraq to Afghanistan. Battle injuries in Iraq have 
decreased but patients continue to require evacuation for medical 
illnesses and non-battle related injuries. We continue to see many 
polytrauma and critically injured patients originating in Afghanistan. 
Over 1,100 medics deploy each year supporting the AE mission.
    Validating this success, a major research study from the Tri-
Service Nursing Research Program was concluded this year. This study 
evaluated the care of over 2,500 critically ill and injured casualties 
as they moved through the continuum of care from the battlefield to 
home. As published in the July-September 2010 quarterly journal for the 
American Association of Critical-Care Nurses, Colonel Elizabeth 
Bridges, U.S. Air Force Reserves (USAFR), reported that despite having 
higher acuity than civilian trauma patients, and undergoing a 7,000 
mile transport in less than 7 days, the outcomes for critically injured 
combat casualties are equal to, or better than, outcomes for patients 
in the most sophisticated trauma systems in the United States. 
Additionally, the results of this study, along with research which has 
validated operational nursing competencies, has the potential to 
standardize and advance evidence-based practices for nurses in all 
Services, and to ensure training is focused on the highest priority 
areas including blast injuries, head trauma, shock, amputations, pain 
management, and patient transport.
    David Brown from The Washington Post reported in November 2010 on 
Army Sergeant Diego Solorzano, who was injured in Afghanistan, ``In any 
U.S. hospital, Solorzano would be considered too sick to put on an 
elevator and take to the CT-scan suite. Now he's about to fly across 
half of Asia and most of Europe . . . the U.S. military's ability--not 
to mention its willingness--to take a critically ill soldier on the 
equivalent of a 7-hour elevator ride epitomizes an essential feature of 
the doctrine for treating war wounds in the 21st century: Keep the 
patient moving.'' Despite the noise, vibration, temperature extremes, 
and pressure changes, AE and CCATT have truly been the critical link 
providing world-class care across the continuum from the battlefield to 
the United States.
    On September 28, 2010, members of the U.S. House of Representatives 
unanimously passed a resolution honoring the Airmen who support and 
perform AE. House Resolution 1605 recognizes the service of the medical 
crews and aircrews in helping our Wounded Warriors make an expeditious 
and safe trip home to the United States, commending the personnel of 
the Air Force for their commitment to the well-being of all our service 
men and women who help to guarantee wounded service men and women are 
quickly reunited with their families and given the best medical care. 
During a press release, Congressman Mike Thompson stated ``These men 
and women put their lives on the line on a regular basis to protect 
their fellow Americans.'' The ability to rapidly move patients from 
point of injury, to initial intervention, and then on through the 
system to the United States in 3 days or less for definitive care 
continues to sustain the lowest mortality rate of any war in United 
States history.
    While our AE crews and CCATT members are the most visible members 
of our AE system, it is the men and women in our Patient Movement 
Requirements Centers who work behind the scenes to coordinate all 
patient movements. Be it a tactical or strategic transport, patient 
movement requests are validated at the requirements center and then 
passed through an AE Control Team to match patients to AE crews, air 
crews, and aircraft. Personnel in these centers have knowledge in both 
the challenges of AE and an understanding of clinical pathologies. They 
use this combined knowledge to facilitate patient movement in the most 
timely and efficient manner possible. These individuals are integral to 
the extraordinary patient outcomes we are experiencing.
    Within the Pacific Theater, we constantly battle the tyranny of 
distance to meet patient movement requests. Our Theater Patient 
Movement Requirements--Pacific created a Joint-Medical Attendant 
Transport Team (JMATT) Training Program to augment our AE system. These 
multi-service medical attendants move critically ill or injured 
patients within and across the Pacific Command Theater of Operations. 
Since 2008, 98 Joint Department of Defense, Hawaii's Disaster Medical 
Assist Team, and international medics from Australia, India, Indonesia 
and Singapore have been trained to move high-acuity patients to augment 
our AE system. This permits us to optimize critical care resources for 
expedited patient movement.
    In addition to the over 100 AE flyers in the combat environment, 
over 1,300 nursing personnel support ground missions to include theater 
taskings such as trauma hospitals, provincial reconstruction and 
teaching teams, and forward-deployed and convoy medical missions. 
Working side-by-side with our sister Services and Coalition Partners 
enables us to integrate into the Joint environment and support our 
Secretary and the Chief of Staff's priorities to partner to win today's 
fight.
    Captain Denise Ross, who is currently deployed to Kandahar, 
Afghanistan, is a member of an Air Force multidisciplinary Medical 
Embedded Training Team (METT) which enables Afghan National Security 
Force nurses to train within their own hospitals using their own 
personnel and equipment resources. This program empowers the staff to 
problem solve using available resources. The development of this 
internal reliance is leading the creation of a self-sustaining program 
in order to ensure its continued success after North Atlantic Treaty 
Organization forces are no longer required.
    During a recent visit to Afghanistan, Brigadier General Rahimi 
Razia, Chief Nurse of the Afghanistan National Army, expressed her 
deepest appreciation for the contributions the METTs and our Senior 
Military Mentors have made to advance nursing for the Afghan National 
Army. These teams are assisting General Razia in developing a 
sustainable, 1 year basic nursing education program, and defining a 
fundamental scope of practice. This elemental program is essential to 
the evolution of nursing practice in Afghanistan. As we transition to 
an advisory role in Iraq and support ongoing operations in Afghanistan, 
we continue to educate and mentor the local national healthcare 
providers as they evolve their own healthcare system.
    Building partnerships is all about developing trust-based 
relationships in the global environment. Across the globe our medics 
collaborate with our Joint colleagues and National partners to advance 
the practice of nursing. Under the direction of Colonel Elizabeth 
Bridges, USAFR, the Defense Institute of Medical Operations initiated a 
new international trauma course. The course, which is the first of its 
kind, was developed to advance trauma nursing in developing nations. 
Additionally, the course focuses on the leadership role of nurses in 
developing trauma systems and in responding to disasters. Since May, 
the course has been presented to over 120 nurses from five nations, 
including Estonia, Latvia, Lithuania, Pakistan, and Nigeria, with a 
future course to be presented in Iraq. Feedback from the participants 
and the host nations has been positive, as exemplified by the feedback 
from Brigadier General Raiz, Commandant of the Pakistani Military 
Academy, who had glowing praise for the Trauma Nursing and First 
Responder courses. With regards to the nursing course, he stated that 
45 nurses have already returned to their home stations and are teaching 
other nurses using the course materials provided by the team.
    Another exciting area within this global spectrum is our 
International Health Specialist Program. This program is comprised of 
Total Force officers and enlisted members who focus on capacity 
building efforts and forging medical partnerships through humanitarian, 
civic assistance, and disaster response. One such example is Operation 
Pacific Angel in the Philippines, which is aimed at improving military-
civilian cooperation. During this operation in February 2010, the 
medical teams treated nearly 2,000 Filipino patients. This program 
assists Philippine officials to build capacity within their cities, 
focusing on basic life support, infectious disease prevention and 
treatments, disaster readiness, and public health.
    This year, officials from the United States and Republic of the 
Philippines co-hosted the 4th annual Asia-Pacific Military Nursing 
Symposium in Manila, Republic of the Philippines for more than 200 
nurses from 13 countries. This annual conference ignites the spirit of 
collaboration to focus on nursing education, career development, global 
pandemic preparedness, and disaster management. Through this unique 
symposium, participants learn about each other's healthcare systems, 
infection control practices, and nursing services. Colonel Narbada 
Thapa, the head delegate from the Nepalese Armed Forces, commented on 
the opportunity to build relationships and acquire knowledge on nursing 
from many armed forces from around the world, making the symposium a 
memorable event for all.

                           FORCE DEVELOPMENT

    Our outstanding success in mission support could not be possible 
without a solid investment in developing our nursing force. Grounded in 
education, training and research, we are generating new knowledge and 
advancing evidence-based care necessary to enhance interoperability in 
nursing operations. Stepping into the future, we are preparing our 
Total Nursing Force to meet emerging challenges as we develop globally 
minded medics capable of providing world-class healthcare on the 
strategic battlefields of today and tomorrow.
    Our Nurse Transition Program (NTP) continues to be an integral 
component in developing our new nurses. We graduated 212 nurses in 
fiscal year 2010 from eight military and two civilian locations. In 
December 2010, we graduated the third class from Scottsdale Healtcare 
System in Arizona. This outstanding civilian program has produced 56 
nurses since its inception. As a Magnet facility, Scottsdale Healthcare 
System is one of only 382 hospitals recognized world-wide for nursing 
excellence. This program provides complex clinical training under a 
preceptor-led transition model for new graduates. Under the supervision 
of Lieutenant Colonel Deedra Zabokrtsky, NTP Course Director--
Scottsdale, our new nurses are clinically prepared and gaining the 
confidence to take on their own clinical practice. Program excellence 
can be noted in a diary entry from one NTP student who had just begun 
her week in Obstetrics (OB). This student was assigned a patient who 
was failing to progress in labor and was informed that a cesarean 
section was believed inevitable. Based on current research, she decided 
to take an evidence-based approach as encouraged by her preceptor. 
Garnering support from her fellow nurses and agreement from her patient 
to try a new approach, a unique plan of care was initiated, to include 
rotation of the patient's position every 15-30 minutes. The final 
result: a vaginal birth of a beautiful baby boy. As the student stated, 
``This situation has affected the way I will educate my OB patients in 
the future . . . the best we can do as nurses is make sure our patients 
are well informed . . . this is true for all areas of nursing.'' This 
exemplar highlights the critical thinking and sound, evidence-based 
nursing practice needed from today's nurses.
    Due to the resounding success of this military-civilian 
collaboration, we decided to consolidate resources and create four NTP 
Centers of Excellence. A civilian Magnet facility, Tampa General 
Hospital, Florida, was recently approved as one of these sites and the 
training agreement was signed February 24, 2011. The remaining three 
Centers of Excellence will be in Scottsdale, Arizona; San Antonio, 
Texas; and Cincinnati, Ohio; and will provide our new nurses with the 
experiences so crucial to their professional development.
    Our Nurse Enlisted Commissioning Program (NECP) continues to be a 
balanced source of nurse accessions as we ``grow our own'' from our 
highly trained enlisted medics. In fiscal year 2010 we enrolled 46, 
students nearing our goal of 50 students per year. The graduates from 
this program are commissioned as Second Lieutenants and will continue 
their active duty service in the Nurse Corps.
    As we strive to create full-spectrum leaders and nursing 
professionals, our recently launched Project Lieutenant is designed to 
improve skills and reinforce training with increased oversight and 
mentoring during our new nurses' first year. Over the years, the 
National Council of State Boards of Nursing (NCSBN) has researched the 
issues of education, training, and retention of novice nurses and found 
that the inability of new nurses to properly transition from student 
into a new practice can have grave consequences. The NCSBN reported 
that approximately 25 percent of new nurses leave a position within 
their first year of practice. The increased turnover, consequently, has 
a potentially negative effect on patient safety and healthcare 
outcomes. The NCSBN's Transition to Practice Model provides a way to 
empower and formalize the journey of newly licensed nurses from 
education to practice. Project Lieutenant is our pilot program to 
support our nurses' successful completion of the nurse residency 
program and transition into new clinical practice areas. Established at 
the 59th Medical Wing, Joint Base San Antonio, Texas, Project 
Lieutenant is leading the charge to deliberately develop our newly 
graduated NTP nurses through a comprehensive 9 month mentoring program. 
The deliberate development of the novice nurse is in step with the 
NCBSN's model and will be replicated at several sites to ensure 
consistent quality of patient care and address the concerns of the new 
nurse, ultimately promoting public safety and positive patient 
outcomes.
    As we aim to improve upon positive patient outcomes, we are 
committed to serving our Wounded Warriors. As we enter our 10th year of 
intensive combat operations, we are not only faced with the challenge 
of caring for those with physiological wounds but also those with 
psychological wounds as well. As Secretary Gates stated, there is ``no 
higher priority in the Department of Defense, apart from the war 
itself, than taking care of our men and women in uniform who have been 
wounded, who have both visible and unseen wounds.'' The National 
Defense Authorization Act 2010, Section 714, directed an increase in 
the number of active duty mental health personnel and, to meet the 
Secretary's priority of taking care of our Airmen and families, we are 
launching a program to develop mental health nursing professionals from 
within our Corps. Our pilot class started at Travis Air Force Base, 
California, on February 14, 2011, and our next class is set to begin in 
June 2011, projecting eight graduates this year.
    The Uniformed Services University of Health Sciences (USUHS) 
Graduate School of Nursing recently stood up a Psychiatric Mental 
Health Nurse Practitioner Program (PMH-NP). This new program has 
graduated two Air Force advance-practice nurses, with two Air Force 
students currently enrolled and four more students planned for 2011. 
The PMH-NP is one of the few programs in the country that includes 
psycho-pharmacology and addresses behavioral techniques specifically 
designed for clinical care of the military population. The program also 
has specific training in the logistics of delivering healthcare in 
military populations and education in Compassion Fatigue/Resiliency to 
decrease the risk of mental health issues and burnout.
    We also recognize our unique role in supporting the AE System 
within the AFMS. In 2009, we developed an Air Force Institute of 
Technology Master's degree in Flight Nursing with a concentration in 
Disaster Preparedness. This program was developed in partnership with 
Wright State University, the Miami Valley College of Nursing, Dayton, 
Ohio, and the Health and National Center for Medical Readiness Tactical 
Laboratory. Additionally, a disaster training facility, called 
Calamityville, is being created and may be incorporated into civilian 
and military training programs. Our first student started the flight 
nurse graduate program in July of 2010 and another student is 
programmed to begin this summer. Upon graduation, these individuals 
will have been educated in emergency and disaster preparedness and they 
will be eligible to take the Adult Health Clinical Nurse Specialist and 
American Nurse Credentialing Center certification exams. This expertise 
will be invaluable to our current and future operational environment.
    A major movement in advanced practice nursing education was 
stimulated by the American Association of Colleges of Nursing (AACN) as 
they voted to move the current level of educational preparation from 
the master's level to the doctorate level by 2015. To maintain 
professional standards and remain competitive for high quality students 
amongst military advanced practice nurses, Senator Inouye addressed 
Congress in December to recognize the need to make this transition at 
USUHS. Along with our sister Service nursing colleagues, we are working 
with USUHS to develop the curriculum for a Doctorate of Nursing 
Practice (DNP) with a transition plan to meet this goal. By 2015, all 
students entering the nurse practitioner career path will graduate with 
a DNP. This entry level to advanced practice will apply also to direct 
advanced practice nurse accessions. The Health Professions Education 
Requirements Board (HPERB) allocated nine DNP positions for an August 
2011 start. Four of the candidates will go from a master's to doctorate 
level and five will progress from the baccalaureate level to the 
doctoral level to meet the new requirement.
    In addition to our DNP programs, we continue to bolster our 
evidence-based care through investment in nurse researchers. We 
recently developed a nursing research fellowship and the first 
candidate began in August 2010. This 1 year pre-doctoral research 
fellowship focuses on clinical and operational sustainment platforms. 
The intent of this program is for the fellow to develop a foundation in 
nursing research and ultimately pursue a Ph.D. Following the 
fellowship, they will be assigned to work in Plans and Programs within 
the Human Performance Wing of the Air Force Research Laboratory. This 
direction also reflects the National Research Council of the National 
Academies recommendation that those planning for careers with a heavy 
concentration in research have doctoral preparation.
    Major Candy Wilson and Major Jennifer Hatzfeld both received their 
Ph.D.s in Nursing Science through the Air Force Institute of Technology 
civilian institution program. The Air Force's investment in doctorally 
prepared researchers equipped these nurses to deploy as integral 
members of the Joint Combat Care Research Team with the clinical and 
scientific expertise needed to make a difference for our Wounded 
Warriors. The research and statistic expertise of these nurses in 
conjunction with their clinical expertise was pivotal in projecting the 
medical resources needed for casualties during the surge in combat 
operations and assisting the Afghan government in evaluating the effect 
of a Strong Food program supported by the U.S. Agency for International 
Development. The investment in military nurse education is critical for 
improving the lives of deployed U.S. military members, coalition 
partners, and host nationals.
    With a goal to advance cutting-edge, evidence-based nursing 
practice, we have further developed the clinical career track for 
Master Clinicians and Master Researchers through the rank of Colonel. 
Master Clinicians are board certified nursing experts with a minimum 
preparation of a master's degree and at least 10 years of clinical 
experience in their professional specialty. They serve as the 
functional expert and mentor to junior nurses. Our Master Researchers 
are Ph.D. prepared and have demonstrated sustained excellence in the 
research arena. Both of these highly respected positions facilitate 
critical thinking and research skills, and foster the highest level of 
excellence in care across our healthcare system. We currently have 
eight Master Clinicians and three Master Researchers within designated 
medical and research facilities.
    In addition to training our newest nurses, we have realized the 
efficiencies in Joint training for our enlisted medical technicians as 
well. Teaming with our Joint partners, a ribbon cutting ceremony was 
held in May 2010 at the new Joint Service Medical Education and 
Training Campus (METC). This training campus will grow to be home to 
nearly 8,000 students with an operating staff and faculty of over 1,400 
civilian and Joint military personnel. In March 2011 a Memorandum of 
Agreement and Board of Governers Charter was signed by all three 
service Surgeon Generals. Creating this state-of-the-art training 
platform will produce technicians in 15 different specialties to 
support the DOD mission and optimize our interoperability amongst the 
next generation of medics in the ever-growing Joint environment.
    An ongoing effort in the development of our enlisted members is the 
transition of our Independent Medical Technicians (IDMTs) and Aerospace 
Medical Technicians (4NOs) to certified paramedics. This advancement 
will continue to decrease our reliance on contract emergency response 
systems and with an end goal of 700 paramedics. In 2010 we certified 46 
paramedics, bringing our total over 200. To enhance the tremendous 
capability of our IDMTs, our goal is to reach 100 percent within this 
constrained career field over the next 5 years.
    We believe this advancement in the development of our medics will 
eliminate the stove pipe that has limited career opportunities within 
the IDMT specialty field and over the long run enhance career 
progression for these highly qualified medics. Additionally, our IDMTs 
are eligible for the selective reenlistment bonus which has aided in 
the recruitment and retention of these highly valuable assets. Our 
IDMTs are enlisted professionals who serve as physician extenders and 
force multipliers and who are capable of providing medical care, often 
in isolated locations. Senior Master Sergeant Patrick McEneany, who is 
just one of these valued medics, deployed for 7 months as an IDMT to 
Iraq with a Joint Special Operations task force. As a provider in a 
remote location, he supervised an urgent care medical clinic, serving a 
camp of 1,200 individuals. His accomplishments during this deployment 
included the resuscitation and stabilization of combat traumas and 
emergencies and the treatment of 1,500 ill and injured patients. 
Additionally, he evaluated multiple Combat Search and Rescue exercises 
at forward operating bases to validate the care for Special Operations 
Pararescuemen. For his efforts, Sergeant McEneany was awarded the 
Bronze Star.
    Further opportunities to maximize the potential of our Airman and 
grow the next generation of Noncommissioned Officers are available 
through the Air Force Institute of Technology (AFIT) for certain key 
enlisted specialties. To date, we have three such positions identified; 
one in education and training at the Air Force Medical Operations 
Agency, another within our Modeling and Simulation program at Air 
Education and Training Command, and the third within the research cell 
at Wilford Hall Medical Center. Our most recent addition to the 
research cell is Senior Master Sergeant Robert Corrigan, who just 
arrived to Wilford Hall Medical Center.
    Just as we are developing our Airmen, the development of our 
civilians is critical to our overall mission success. We are 
establishing a career path from novice to expert and offering 
deliberate, balanced, and responsive career opportunities for our 
civilians. Just as the career path for our military nurses and medics, 
this career path will focus on the right experience, training, and 
education, at the right time. In January 2011, we conducted our first 
Civilian Developmental Board at the Air Force Personnel Center. The 
goal of this board is to present the opportunity to our civilian nurses 
for deliberate development and vectoring from the Force Development 
team, similar to the feedback given to their military counterparts. 
During this inaugural event, Level I and Level II Civilian Nurse 
Supervisors volunteered their records for this formal review and career 
counseling opportunity. This program will be a benchmark for the AFMS 
as we continue to expand this vectoring process across all of our 
Corps.

                            FORCE MANAGEMENT

    The goal of Force Management is to design, develop, and resource 
the Air Force Nurse Corps to sustain a world-class healthcare force in 
support of our National Security Strategy and align our inventory and 
requirements by specialty and grade. We must have the right number of 
people to accomplish the mission. In fiscal year 2010, we recruited 170 
fully qualified nurses and selected 126 new nursing graduates exceeding 
our recruiting goal of 290. In line with initiatives to decrease Air 
Force end-strength, Nurse Corps recruiting service goals were reduced 
in 2011. As we face force shaping initiatives, it is critical that we 
continue to develop programs that provide the clinical ability 
essential to the sustainment of our nursing force.
    In fiscal year 2008, the long-needed increase in colonel 
authorizations for the Nurse Corps created a deficit to the grade 
ceiling. With current personnel and year-group sizes, filling the 
authorized grades at the senior level remains challenging. In an effort 
to resolve the persistent grade level imbalances, nursing leadership 
has been working closely with the Office of Deputy Chief of Staff, 
Manpower, Personnel and Services to develop options, to include the 
possibility of the Defense Officer Personnel Management Act relief. 
This scenario would allow the colonel grade ceiling to reach allowable 
guidelines by 2016. The Nurse Corps is continuing to pursue the optimal 
solution in keeping with the Chief of Staff of the Air Force's 
direction. These critical Nurse Corps positions are not affected by 
current Air Force efforts to reduce its endstrength to authorized 
levels.
    In light of the significant limitations placed on direct 
accessions, it is imperative that we focus on the retention of our 
experienced nurses. As we enter our third year of the Incentive Special 
Pay (ISP) program, we continue to see the positive impact this program 
has on enhancing the professional satisfaction and retention of our 
experienced clinical experts. This program, which incentivizes clinical 
excellence at the bedside, tableside and litter-side, is crucial in 
maintaining the needed staffing in career fields that are critically 
manned.
    Another incentive for our nursing force is the Health Professions 
Loan Repayment Program targeted at those specialties with identified 
shortages. Health professionals who qualify for the program are 
eligible for up to $40,000 of school loan repayment in exchange for an 
extended service agreement. In 2010, 53 nurses elected to use this 
opportunity for financial relief in paying back school loans.
    With Chief Master Sergeant Joseph Potts leading our enlisted force, 
he is pleased to report success in securing a Selective Reenlistment 
Bonus (SRB) for the 4N enlisted career field fiscal year 2010. As 
mentioned, our IDMTs, along with medical technicians in several other 
critically manned career fields such as the surgical sub-specialties, 
Ear Nose and Throat, urology and orthopedics, are eligible for this 
bonus. The SRB allows us to focus our resources in areas where we can 
best retain medics in our critically needed specialties.
    The Graduate School of Nursing (GSN) at USUHS continues to provide 
cutting-edge academic programs to prepare nurses with military unique 
clinical and research skills in support of delivery of patient care 
during peace, war, disaster, and other contingencies. The GSN helps to 
ensure the Services meet essential mission requirements and has a 
history of rapidly responding to Service needs that is not possible in 
civilian institutions. For example, the GSN established the 
Perioperative Clinical Nurse Specialist and Psychiatric Mental Health 
Nurse Practitioner Program; as well as focusing research and evidence-
based practice initiatives on pain management, traumatic brain injury, 
and the care of deployed and Wounded Warriors.

                         PATIENT CENTERED CARE

    As we mold our nursing force today, we are shaping our capabilities 
for tomorrow's fight. Our success will be measured continuously through 
conscious and deliberate planning and development. We strive to 
establish leadership and professional development opportunities to meet 
current and future Joint and Air Force requirements while building 
trust through continuity and patient centered care. ``Trusted Care 
Anywhere'' is the mantra of the Air Force Medical Service. 
Understanding the value of patient-centered care, the AFMS is focusing 
on ``Better Health, Better Care, Best Value'' through the Family Health 
Initiative.
    Across the globe, our healthcare teams are focused on building 
patient-centered platforms able to perform the full scope of medical 
and preventive care to our patients at home and abroad. We are 
committed to the execution of the Family Health Initiative (FHI), the 
Air Force's pathway to Patient-Centered Medical Home, which provides 
continuity of care, team work and fosters improved communication; all 
maximizing patient outcomes. Our Disease Managers and Clinical Case 
Managers (CCMs) play an integral part in this process. At several 
locations, our telephone consults have decreased by 21 percent from 
2009, and our network referrals to an Urgent Care Clinic have decreased 
by 50 percent since the FHI was started. This decrease in urgent care 
referrals has saved over $174,000 for Joint Base Elmendorf Richardson 
in Alaska. As well, a set of performance measures developed by the 
National Committee for Quality Assurance, Healthcare Effectiveness Data 
and Information Set (HEDIS), is used to measure clinical outcomes since 
FHI inception. The HEDIS results demonstrated an overall improvement in 
diabetic screening results and reporting. F.E. Warren Air Force Base, 
Wyoming reports patient satisfaction is at an all time high of 96 
percent for 2010. Additionally, many other sites are reporting similar 
experiences as a result of this modification in how we care for our DOD 
beneficiaries.
    Alongside our Disease Managers, our CCMs are helping patients 
receive safe, timely, cost-effective healthcare. The Air Force has 113 
CCMs and in fiscal year 2010 there were 47,000 CCM encounters, a 50 
percent increase over fiscal year 2009. Additionally, 4,000 of these 
encounters were with Wounded Warriors, a 100 percent increase over 
fiscal year 2009. Based on Air Force Audit projections, CCMs have 
generated over $300,000 in savings compared to fiscal year 2009. The 
CCM is integral to patient care coordination and the FHI, ensuring our 
patients see the right provider, at the right time, and at the right 
place. The goal of the Medical Home Model is to strengthen the 
partnership between the patient and the healthcare team, and continue 
to look at ways to provide timely, cost-effective care while focusing 
on patient safety, and decreasing variance at every point of healthcare 
delivery.
    Patient safety remains paramount. For AE, the rate of patient 
safety incident reports was less than 5 percent of patient moves. Of 
note, most of these events were near-miss, meaning the event was 
prevented and never reached the patient. To strengthen our Patient 
Safety Program, Air Mobility Command has created an Aeromedical 
Evacuation Patient Safety Course modeled on the principles of the 
Department of Defense's Patient Safety Program. Ms. Lyn Bell, a retired 
Lieutenant Colonel flight nurse and Chief, Aeromedical Evacuation 
Patient Safety, taught the first class in December 2010. She trained 17 
safety monitors from 10 total force agencies including AE Squadrons, 
the Patient Movement Requirements Center and Staging Facilities. This 
new program focuses on accurately capturing and documenting actual and 
potential patient safety concerns. It teaches units how to incorporate 
patient safety into their training scenarios and prepare the units for 
the high operations tempo in the combat theater. With these continued 
efforts, we hope to further enhance our culture that protects patients 
and advances process improvements.
    Beginning November 2010 through June 2011, the Air Force Medical 
Operations Agency (AFMOA), in conjunction with the DOD, is implementing 
the Patient Safety Reporting (PSR) System in Air Force military 
treatment facilities worldwide. The PSR provides staff with a simple 
process for reporting patient safety events using DOD standard 
taxonomies, which enhance consistency and timely event reviews. The PSR 
event data will be analyzed for trends and assist in identifying 
targets for process improvement, both at Air Force and DOD levels.
    A final note on patient safety: We have initiated a 1 year 
fellowship in Patient Safety incorporating all areas within the AFMS, 
to include the clinical, logistical, financial, and environment aspects 
of care. This fellowship includes education on patient safety event 
reporting, sentinel and adverse events, root cause analysis, proactive 
risk assessment, and risk management. The fellow will also become 
knowledgeable in patient safety database systems and strategic 
communication to allow them to engage with Air Force and DOD 
leadership.
    We also recognize our responsibility in caring for victims of 
sexual assault within our military healthcare system. Medical treatment 
facilities team with installation Sexual Assault Response Coordinators 
to deliver care to victims via coordination with Victim Advocates and 
Medical Specialists. To ensure the integrity of forensic evidence and 
guarantee access to care, most sexual assault exams are done off-base 
via a memorandum of understanding with local treatment facilities. In 
the deployed environment, seven of eight medical treatment facilities 
perform exams on-site while one location uses a co-located Army 
hospital. Upgraded First Responder training has been implemented to 
increase training efficiency; over 6,000 medics completed First 
Responder Training in fiscal year 2010.
    At the root of patient care is nursing research yielding evidence 
based practices. In fiscal year 2010, the Tri-Service Nursing Research 
Program (TSNRP) awarded 18 research grants, including five awards 
totaling $1,015,045 to Air Force nurse scientists. These investigators 
are now studying military unique and military relevant topics such as 
positive emotion gratitude, the resilience of active duty Air Force 
enlisted personnel, and military medics' insight into providing women's 
health services in a deployed setting.
    Under Colonel Marla De Jong's leadership, and for the first time in 
its history, TSNRP offered research grant awards to nurses at all 
stages of their careers--from novice nurse clinician to expert nurse 
scientist. The Military Clinician-Initiated Research Award is targeted 
to nurse clinicians who are well-positioned to identify clinically 
important research questions and conduct research to answer these 
questions under the guidance of a mentor. The Graduate Evidence-Based 
Practice Award is intended for DNP students who will implement the 
principles of evidence-based practice and translate research evidence 
into clinical practice, policy, and/or military doctrine. It is 
critical that funded researchers disseminate the results of their 
studies so that leaders, educators, and clinicians can apply findings 
to practice, policy, education, and military doctrine as appropriate. 
This grant will enhance this dissemination and uptake of evidence.
    This year, Air Force nurses authored more than 10 peer-reviewed 
publications and delivered numerous presentations at nursing and 
medical conferences. Also in 2010, the TSNRP's Battlefield and Disaster 
Nursing Pocket Guide and clinical practice guidelines were established 
as the primary performance criteria for the Air Force Nurse Corps 
readiness skills verification program. The integration of these 
evidence-based recommendations will ensure that all nurses are prepared 
and provide the highest quality, state-of-the-art care under 
operational conditions.
    We are also leveraging data gained from the Joint Theater Trauma 
Registry to create innovative solutions for the battlefields of 
tomorrow, today. In summer of 2011, in collaboration with our Joint and 
Coalition Partners, we are establishing an enroute critical care 
patient movement system to augment our existing tactical transport. 
Once wounded, a patient is transferred as quickly as possible to a 
forward surgical team, normally within 1 hour. These patients may 
undergo life-saving damage control resuscitation and surgery.
    Most often these patients are then transferred via helicopter to a 
trauma center where their wounds can be treated more extensively by 
medical specialists. These seriously and critically injured patients 
receive en-route care by an Emergency Medical Technician with basic or 
intermediate clinical skills or a facility must provide an attendant to 
accompany the patient. This latter option limits the availability of 
these skilled clinicians who may be needed for other incoming patients.
    Neither solution was considered optimal in terms of ensuring 
clinicians with the right skill sets are available while not reducing 
the availability of care providers. As a result, of these challenges, 
the Air Force developed Tactical Critical Care Evacuation Team, or 
TCCET, to augment these inter-hospital transfers. The current TCCET 
composition consists of two certified registered nurse anesthetists and 
an emergency room physician. This team possesses advanced clinical 
skills to support ventilated patients as well as patients who are 
hemodynamically unstable. The team can function as a whole or each 
provider can perform separately to meet the patient or mission needs. 
The TCCET will augment the Army flight medic, or Air Force 
pararescuemen on missions, and will also be able to support AE missions 
or augment the CCATT, if needed.
    Prior to deployment, these providers will hone their critical care 
skills by attending our Centers for Sustainment of Trauma and Readiness 
Skills (CSTARS) program at University of Cincinnati, Ohio. They will 
attend the Joint Enroute Care Course at Fort Rucker, Alabama to become 
familiar with rotary wing operations. The team will carry backpack 
sized equipment packs to support most critical care patients, to 
include pediatric patients. By inserting this higher level of 
specialized care at the earliest juncture in the injury spectrum, we 
hope to improve overall outcomes for the Wounded Warrior.
    In the area of skills sustainment, our partnerships with high 
volume civilian trauma centers continue to thrive. Our CSTARS platforms 
provide invaluable opportunities to hone war-readiness skills. In 2010, 
907 doctors, nurses, and medical technicians completed vital training 
at one of these three centers located in Baltimore, Maryland; 
Cincinnati, Ohio; and St. Louis, Missouri. Another example of our 
skills sustainment initiatives lies within the 88th Medical Group at 
Wright Patterson AFB, Ohio. The Medical Group stood up a state-of-the-
art Human Patient Simulation Center for providing realistic training 
opportunities for healthcare personnel in 2009 with completion of the 
center in 2010.
    The Center has incorporated simulation into various training 
courses including Advanced Cardiac Life Support, Pediatric Advanced 
Life Support, and the Neonatal Resuscitation Programs as well as the 
Aerospace Medical Service Apprentice Phase II and III program, and the 
Nurse Transition Program. The Simulation Center also initiated monthly 
Mock Code drills using human patient simulators and implemented Team 
Strategies and Tools to Enhance Performance and Patient Safety 
(TEAMSTEPPS) into simulation training scenarios. This center is also 
the primary pediatric simulation site for military and civilian medical 
students attending the region's Dayton Area Graduate Medical Education 
Consortium.
    Because of their efforts, the 88th Medical Group won the Air Force 
Modeling and Simulation Annual Innovative Program Team Award for their 
live training via a remote presence robot on the care of burn 
casualties. The team connects via laptop with a robot at Brooke Army 
Medical Center's burn unit during interventional patient care, and an 
on-site facilitator describes the treatment procedure in real time. The 
program was coordinated through the Army Institute of Surgical 
Research.
    Within our patient-centered care philosophy is the recognition of 
the need to address the resiliency of our Airmen and families as well 
as to care for the caregiver. As an experienced critical care nurse, 
Lieutenant Colonel Mary Carlisle thought she could handle anything on 
deployment to Iraq. But the casualties she saw daily took a toll on her 
psychological health. When Colonel Carlisle returned home, her war 
wounds were invisible. She became increasingly lost in sorrow, becoming 
absorbed and distracted by thinking ``What if?'' and ``Why?'' She 
sought solace at the National Mall in Washington, DC, studying the 
faces of the Vietnam Women's Memorial monument, identifying with each 
of the women depicted in the monument. During her 2010 Memorial Day 
speech at the Vietnam War Memorial she reflected how she was, during 
different times of her deployment, each one of those women. She states 
``I was the woman kneeling, looking down, defeated, holding the helmet 
that will never be worn again. I was the woman cradling the Wounded 
Warrior, fighting with everything I had to save his life. And, I was 
the woman gazing skyward; grasping the arm of my colleague, 
anticipating whatever was to come.''
    Colonel Carlisle found the courage to seek help for her wounds and 
hidden trauma. She further states ``now I am at peace knowing I--we--
did the best we could, and the fallen angels were not lost in vain, and 
America's freedom still reigns.'' Colonel Carlisle became a spokeswoman 
for nurses and other medical personnel with post-traumatic stress or 
other war-related adjustment issues. Instead of being rebuked by her 
upper command for openly talking about her experiences, Colonel 
Carlisle is praised for her efforts to encourage other troubled nurses 
and medical technicians to see help. Colonel Carlisle helps to show our 
Airmen that she is a senior officer who has experienced the same 
feelings they may be having and they should feel comfortable talking 
about their experiences and feelings. We are changing our culture to 
promote the building of resilience, facilitate recovery, and support 
reintegration of returning Service members.

                               WAY AHEAD

    The United States Air Force Nurse Corps consistently achieves 
excellence in all that we do. The use of professional clinical judgment 
in delivering evidence-based care is essential in enabling our Airman 
and their families to improve, maintain, or recover health, and achieve 
the best possible quality of life. By partnering with our civilian 
institutions, Joint, and Coalition partners we are building the next 
generation of care and capability. As we step into the 21st century, we 
are forging our future by addressing our stressors, embracing our 
professional diversity, and fortifying our Total Nursing Force with 
education, training and research.
    Mr. Chairman, and distinguished members of the Subcommittee, it is 
an honor to be here with you today and represent a dedicated, strong 
Total Nursing Force. Our Wounded Warriors and their families deserve 
nothing less than educated and skilled nurses and technicians who have 
mastered the art of caring. It is through the medic's character, 
compassion and touch that we answer our nations call to care for those 
who served yesterday, today and tomorrow.

    Chairman Inouye. And now, if I may, I was in the Army about 
69 years ago. That is a long time ago. And at that time, the 
highest-ranking nurse, I believe, was a colonel--one colonel. 
And in the hospital that I spent 2 months in Italy, the 
highest-ranking nurse was a major. The theater commander of the 
nurse corps was a lieutenant colonel. In the hospital in 
Atlantic City and Michigan, the highest-ranking nurse was a 
lieutenant colonel.
    As we all know, in 2003, we made nurses two stars. Now I 
have been told that the Secretary of Defense has come up with 
efficiencies, and he recommends a reduction from two stars to 
one star.
    I would just like to have your views, General Horoho.
    General Horoho. Yes, sir.
    First, sir, I would like to thank you very much for the 
support because I would not be sitting here as a two-star 
general without your support. So, thank you.
    We used the launching of the rank of two star to actually 
leader develop across all of our corps across Army medicine. We 
have right now nurses that are commanding at the level 2 
command within the theaters of operation. We also have them 
commanding across Army medicine. We have nurses that have 
strategic input into decisionmaking at the strategic level, and 
so we now have I think a very competitive field for our nurses 
to be able to be competitive for branch materiel one star and 
then also at the two-star level.
    Chairman Inouye. So, you are not in favor of the 
Department's recommendation?
    General Horoho. Sir, I will support the Secretary of 
Defense and his efficiencies, and I----
    Chairman Inouye. You are a good soldier.
    General Horoho [continuing]. Am very, very grateful for the 
rank of two star. Thank you.
    Chairman Inouye. Well, I will make certain you keep your 
two stars. I think it is about time we recognize the value of 
nurses. When I was in the hospital, other than the time spent 
on the operating table, in the wards I saw the doctor about 
once a week, nurses 24 hours per day. She is the one who 
provided minor surgery, all the medicine, all the care. But she 
was a second lieutenant. I think it is about time we recognize 
their value, and I think if a man gets two stars for commanding 
10,000 troops, I think a nurse should get two stars for 
commanding 18,000 troops.
    Senator Mikulski. Hear hear.
    Chairman Inouye. That is how I get my votes.
    Does the Navy support----
    Admiral Niemyer. Well, sir, I want to extend our grateful 
appreciation for the support you have provided to military 
nurses. It has enabled us to achieve both civilian nursing and 
military medicine respect commensurate with the rank of a two 
star, and the scope of responsibility of a two star as well.
    I have had the unique opportunity of being able to be 
selected as a one star and work in a very challenging joint 
position, which I believe enabled me to better lead the Nurse 
Corps today. We are extremely grateful, and I, too, would not 
be sitting here as a two star without your support and this 
subcommittee's support.
    Thank you.
    Chairman Inouye. General, does the Air Force support two 
stars or one star?

                      MILITARY NURSING LEADERSHIP

    General Siniscalchi. Sir, military nurses will continue to 
provide the best patient care possible and will continue to 
lead at whatever rank we are asked to lead at. But having 
served as a two star, and I thank you for your continued 
advocacy for military nursing and for the support that military 
nursing received in 2003, to have the leadership position 
raised to a two star. And when you look at our scope of 
leadership and our scope of responsibility and for the Air 
Force having to include our total force Active, Guard, Reserve, 
officer, enlisted, and civilian, we are close to 19,000. And to 
provide policy and directives for a total nursing force of that 
size, the two star rank has served us very well. And it is 
commensurate given our total nursing force engagement in global 
operations. But we will continue to support whatever decision 
is made, sir. Thank you.
    Chairman Inouye. Today's war has much trauma, brain 
injuries, multiple amputations, and it is a bloody war, much 
more severe than World War II. Are the nurses getting 
specialized training for this type of service?
    General Horoho. Mr. Chairman, we are looking at the Joint 
Trauma Tracking Registry System to get lessons learned, and we 
have changed, over these last several years, our training 
platform in the area of trauma nursing. We also made a decision 
with--over the last couple of years that every single nurse 
needs to be a trauma nurse. It is at our core competency. So, 
we have the combat trauma tactical course that our medics focus 
on. Everyone who deploys gets trauma training prior to their 
deployment, whether that is in San Antonio or it is in Florida 
at the University of Miami. And then we are constantly refining 
and looking out at what is occurring in the civilian sector, 
which is part of what develops our Virtual Leader Academy, is 
that we looked at competencies and capabilities, and we 
redesigned all of our training programs to better support the 
complexity of the wounds that we are seeing in this war.
    Chairman Inouye. Before I call upon Senator Cochran, 
listening to our two ladies, I could not help but think about 
the trauma that families have to go through. For example, today 
a spouse can call her husband in Afghanistan every day----
    General Horoho. Yes, sir.
    Chairman Inouye [continuing]. On a telephone that is not 
censored. Every evening she can watch CNN or whatever it is and 
see her husband's unit in action, and she has to sweat it out 
until the next day, and she does not hear from him. And you 
wonder why someone gets stress disorders. In my time, I made a 
telephone call before I left Hawaii. The next telephone call I 
made to Hawaii was 3 years later on my way home. The letters 
that I wrote to my family were all censored. All I could say 
was the food is terrific, Italy is a wonderful place, I love 
France and Paris--nothing about action or injuries.
    I can understand why there are more suicides today. I can 
imagine coming back, getting together with your family and 6 
months later have to ship off again. That is not the way to 
serve. We will have to do something about this.
    What are the nurses thinking about stress disorder and 
suicides?

                          MENTAL HEALTH ISSUES

    General Horoho. I will let you, and then we will just kind 
of go down the line.
    Admiral Niemyer. Thank you, Senator.
    The issue of families and our service members with post-
traumatic stress and mental health is a concern for all of us. 
We have tried to build resilience programs, not just for the 
service members themselves, but for our families as well. I 
know we have FOCUS, which is Families Overcoming Under Stress 
for our Navy personnel and Marine Corps personnel, and use that 
as a training platform to discuss those issues proactively. The 
goal currently is to build resilience and strengthen our 
soldiers, sailors, airmen, and marines, as well as each other. 
And that is just one type of program that we are using to 
address the families.
    We have also looked at building stigma reducing portals for 
our service members and their families to access mental health. 
An area where mental health psychiatric nurse practitioners are 
making a difference, as well as all of our mental health 
personnel, is to embed them in primary care areas where they 
are accessible to those that need them in an attempt to ward 
off and address those issues before they become problematic. 
Any one suicide is one too many, so building that resilience 
and looking proactively is one of the ways that we are trying 
to address that.
    General Horoho. Mr. Chairman and the subcommittee, part of 
what we learned over the last 10 years of supporting a Nation 
at war is that we cannot just treat the warrior, that we 
absolutely have to treat the family. And where social 
networking came in, which you mentioned, is that because of 
that, it connects the home to the battlefield, and all of the 
stressors that are at home are felt by the soldiers, and 
sailors, airmen, and marines, and Coast Guards that are 
deployed, as well as what is going on in theater is also known 
by the families.
    A couple of things that we have done: We have implemented 
in nursing as part of all of this--we have implemented the 
Comprehensive Behavioral System of Care, which has five touch 
points. And we evaluate 100 percent, so to try to reduce the 
stigma, it is mandatory from our privates to our general 
officers to be evaluated by either a psychologist, a 
psychiatrist, a psych nurse practitioner, or a social worker, 
and then primary care that are trained in behavior health. That 
evaluation then allows us to get them help as soon as possible 
if it is needed. We have also embedded our behavior health into 
primary care because what we found is a lot of our patients 
come in for healthcare, and it is a low back pain or maybe a 
headache when it really is something that has to do with stress 
or anxiety. Then when they are in the deployed theater and we 
have our nurses as part of the combat support teams, 100 
percent are evaluated prior to them redeploying back. That 
information of whether they are high risk, moderate, or a low 
risk is then sent back to the installation that is going to 
receive them. And we have behavior health and nursing as part 
of that team. When we talk behavior health, it is the entire 
complement from our medics, our nurses, psychiatrists, 
psychologists, and social workers, so when I use that, that is 
the team that I am talking about. They evaluate at each one of 
those touch points.
    We also found that we needed to leverage virtual behavior 
health when we talked about how difficult it is to be able to 
get a--national shortage of resources--how do we get that? So 
we leveraged virtual behavioral health, and we have over hired, 
and we have platforms in Europe as well as at Fort Louis, 
Washington, Walter Reed, and Brooke Army Medical Center, and 
then Eisenhower. And we use those electrons to be able to get 
healthcare to those that are needed. And when we marry the 
family up, what we are testing right now is using virtual 
behavior health and counseling of a family of children and the 
wife with a service member that is deployed to be able to keep 
continuity of care and look at trying to reduce the stressors 
of healthcare if we can deal with those issues now instead of 
delaying that till they redeploy back.
    And then on the children's side, we are also working, and 
actually all of our services are working with us and Department 
of Defense, to embed behavior health into the school system so 
that we can help with the young children that are stressed 
because of either multiple deployments of their parents. And so 
that is part of our school-based programs that we are using as 
pilots across, and we are starting to see whether or not that 
impacts by being proactive.
    Thank you, sir.
    Chairman Inouye. Thank you very much.
    General.

                    TIERED-BASED MODEL OF RESILIENCY

    General Siniscalchi. Sir, it is a very stressful time for 
our military members and their families. But what we are 
finding is that prevention is key, and it has to start from the 
very beginning and continue throughout their entire 
professional career.
    We are looking at a tiered-based model of resiliency that 
incorporates multi-dimensions of human wellness from the 
physical to the social to the psychological and the spiritual. 
And our tier-based resiliency model begins from the beginning, 
whether it be in basic military training, technical training, 
and officer training. And we instill a culture of resiliency, 
recognizing signs and symptoms of post-traumatic stress, de-
stigmatizing behavioral care, and encouraging our military 
members, their families, to seek behavioral health when 
necessary.
    And as we continue throughout the professional career, we 
look at multiple points throughout the career to introduce 
training, whether it be through professional military education 
or through leadership training. And then as we identify groups 
that are at high risk for post-traumatic stress, for 
depression, for suicide, then the training and the education is 
tailored to them and their families to help minimize and help 
to moderate their risk.
    We have used a Mortuary Affairs Model from Dover Air Force 
Base that has incorporated strength-based training and 
resiliency, and we incorporated that model throughout our 
different levels of command-based resiliency programs.
    We have targeted pre- and post-deployment training, and 
while in theater, those individuals who have been serving 
outside the wire or have been exposed to multiple trauma, then 
as they pass through Germany, they go through our Deployment 
Transition Center, and that helps to prepare them as they go 
back to their families and to their bases. And it better 
enables them to reintegrate and rejuvenate as they come back 
from deployment.
    We have reached out to our senior leaders, who have 
deployed and have experienced post-traumatic stress. And we 
have two of our senior leader nurse officers--critical care 
nurses, Lieutenant Colonel Mary Carlisle and Lieutenant Colonel 
Blackledge. And they came back from multiple deployments and 
recognized that they were experiencing signs of post-traumatic 
stress. And in our effort to incorporate behavioral health into 
our family home model and to de-stigmatize behavioral health, 
both of these senior nurses sought behavioral healthcare, and 
then decided to take their message forward. And they have 
produced videos in multiple forums. They have shared their 
experiences that not only they went through individually, but 
what their families also went through when it came to post-
traumatic stress.
    We recently had a nursing conference last week in Dallas, 
and Lieutenant Colonel Blackledge came and shared her message 
to close to 500 nurses and technicians. And we also had a 
social worker on site who met in small groups with our nurses 
and technicians recently coming back from deployment who 
experienced post-traumatic stress.
    I think the best approach that we can take is the tiered 
model for resiliency, targeting those groups that are at high 
risk, de-stigmatizing mental health, encouraging all of our 
members to openly communicate when they are recognizing signs 
of stress, to focus pre-deployment, during deployment, and 
post-deployment, and then looking at success stories out there, 
which have been the Mortuary Affairs Group at Dover, and then 
emulating programs that they have put in place.
    Chairman Inouye. Thank you very much.
    General Siniscalchi. Thank you, sir.
    Chairman Inouye. Senator Cochran.
    Senator Cochran. Mr. Chairman, I have been impressed with 
the comments that I have read and the testimony that you 
prepared for our subcommittee before the hearing. And we thank 
you for that. I was particularly impressed with the training 
programs, and I was looking at the Air Force experience as 
defined in your testimony that you prepared, General 
Siniscalchi.
    We appreciate the fact that it does not just happen on 
instinct or spontaneous judgment, but a lot of people spend a 
lot of time drawing on their experiences and presenting it to 
others who would be confronted with long flight times coming 
back from combat areas, critically injured soldiers and sailors 
who have to have special care and treatment. And the scope and 
involvement of so many people in the success of these 
operations is really quite awesome. I cannot imagine any 
military force in the world being able to come close to what 
our military, and particularly the Nursing Corps in all of our 
services, have done to help make it such a successful and 
caring, lifesaving experience for many men and women.
    Do you have any comments about that, and is there funding 
available in the request for funding that will continue these 
programs and help support what you have designed as the best 
that you know, the state of the art?

          FUNDING TO SUPPORT AN INCENTIVE SPECIAL PAY PROGRAM

    General Siniscalchi. Sir, funding is available. Our 
Incentive Special Pay Program, first and foremost, is helping 
us to retain our clinical experts. So, being able to have 
funding to support an Incentive Special Pay Program is helping 
us to retain seasoned clinicians.
    Our strength in the care that we are to provide and to have 
the successes that we--that you have just mentioned comes 
through our ability to build partnerships. As we continue to 
partner with our sister services in critical care training, as 
we continue to partner with academic institutions for our nurse 
transition program, we currently have partnerships at 
Baltimore, at St. Louis, University of Cincinnati for our C-
Stars, our critical skills sustainment training. We have, 
again, academic partnerships and partnerships with civilian 
trauma centers that allow us to send our nurses into their 
facilities for sustained training. So our goal is to ensure 
that if we do not have robust training platforms within our 
military treatment facilities, that we establish robust 
partnerships with our sister services, with academic 
institutions, academic--or civilian trauma centers, and the VA 
so that we have a ready force with sustainment training, that 
we have platforms in place for going out the door so they can 
hone their critical care and trauma skills, so that we can 
continue to provide the care that we provide. But we do that 
through training affiliation agreements and robust 
partnerships.
    Senator Cochran. Thank you.
    Mr. Chairman, thank you.
    Chairman Inouye. Thank you.
    Senator Mikulski.
    Senator Mikulski. Mr. Chairman.
    First of all, I would like to say to the entire nursing 
leadership of all the services, we just want to thank you for 
what you do every day. Every day in every way, you do high tech 
and high touch patient-centered healthcare, and I just want you 
to know I think all the Members of the Congress, they do not 
thank you every week--we cannot thank you enough for what you 
do.
    And, Admiral Niemyer, I understand you are a graduate of 
the University of Maryland. Is that right?
    Admiral Niemyer. Yes, ma'am. I am in your State. I am a 
home grown Annapolis girl.
    Senator Mikulski. I know. I have got the accent, you know. 
We both have the same accent, and I graduated from the 
University of Maryland School of Social Work.

               NAVAL BETHESDA--WALTER REED NURSE STAFFING

    Admiral Niemyer. Yes, ma'am, I saw that.
    Senator Mikulski. I think we were a couple of yearbooks 
away from each other, but nevertheless, we were at the downtown 
campus.
    I have two questions, one related to acute care, and then 
the other to this more chronic behavioral post-deployment care.
    Admiral, we are going to be opening a Naval Bethesda Walter 
Reed, and my question is, number one, as we gear up, first of 
all, who is going to actually be in charge of the nursing 
clinical services? It is an unusual governance mechanism. We 
are looking forward to it. I am really excited about it. And, 
perhaps, General, you could help. Who is going to be in charge? 
And then the second question: Do you feel that as we are 
gearing up, that there will be adequacy for both nursing care 
as well as the very important Allied Health Services?
    Admiral Niemyer. Yes, ma'am. The current Director of 
Nursing Services at the now National Naval Medical Center, soon 
to be Walter Reed Military Medical Center, is Colonel Ellen 
Forster, she is an Army colonel. The nurses there, and at Fort 
Belvoir and Walter Reed, have blended nicely to create an 
executive nursing staff to work together. So, to answer your 
question, the governance and who is in charge of the nurses at 
Bethesda, it will be Colonel Ellen Forster. I believe she is 
here in the room today as well.
    Senator Mikulski. Is she here? Could she hold up her hand? 
Well, we are glad to see you, and we will be out to see you.
    Tell me about adequacy. Thank you.
    Admiral Niemyer. In terms of adequacy, from my 
understanding, yes. As we move the patients over, we have the 
nursing staff and the facility support to take care of the 
patients there. So, in terms of adequacy, I do not see any 
issues in bringing our patients and combining our patient force 
there.
    Senator Mikulski. General.
    General Horoho. Ma'am, one of the things is looking a 
little bit broader than Walter Reed Military Medical Center is 
actually looking at Belvoir, because both Belvoir and Walter 
Reed are Tri-Service-based hospitals, and looking at an 
integrated healthcare system. And so, with that, one of the 
things that we did on the nursing side is we have already sent 
Army, Navy, and Air Force nurses to Champion training to 
support the Patient CareTouch System, to really look at 
providing one standard of nursing care, decreasing variance, 
and really focusing on the patient being in the center, and 
improving the health of the patient and their family members. 
So, I think adequacy of training is going to be just fine, and 
I actually think it may be expanded as we learn from each of 
our services what we offer the best in a large beneficiary 
population in the National Capital Area.
    Senator Mikulski. First of all, that is so heartening to 
hear. I go back, again, to the awful times of Walter Reed in 
2007. And now we are looking ahead, and part of the looking 
ahead was not only the immediate treatment of acute care, which 
I think everybody says is actually stunning, stunning in the 
annals of medicine, military or civilian. It is truly stunning 
in battlefield to back home.
    But I want to hear, if I could just for a minute, this 
Patient CareTouch System, because I think that was what I was 
trying to get at with General Schoomaker. It says patient 
advocacy, enhanced care team communication, clinical capacity, 
and evidence-based, which we want, and healthy environment. 
Could you describe for me, from the patient standpoint, what 
does that mean, because we hear touch tones, benchmarks, yadda 
yadda.
    General Horoho. Yes, ma'am. If I can back up first and just 
explain how we even came to develop the Patient CareTouch 
System. We actually looked across Army, Navy, and Air Force, 
and looked at what were the common elements of high-performing 
systems. We also then looked across the civilian sector to see 
the magnet hospitals and what did they have in common. And then 
we realized that there was not one system out there that put 
all of those elements together. So we developed that and we 
piloted it at Fort Campbell, Kentucky. And what we found is 
that we actually had an increase in patient satisfaction. We 
had an increase in communication between our clinicians and the 
ancillary staff and the physicians. We had patient involvement 
with the family members and positive feedback. We had a 
decrease in left without being seen in our emergency rooms. We 
had a decrease in medical errors. We had an increase in 
critical lab value reporting. So, all of our nurse-centric and 
nurse-sensitive measures we saw very positive outcomes. So, 
after we piloted that for about 9 months and made some 
adjustments is when we then developed the training program to 
support that.
    And the Patient CareTouch System, what it does is it 
actually focuses on having the patient in the center of every 
touch point--every place, whether it is in the ambulatory arena 
or whether it is inpatient, that we make sure that the patient 
is involved in decisionmaking. We do hourly nursing rounds. We 
actually use white boards to communicate so that if family 
members come in, instead of the patient having to say, this is 
what the physician just told me, this is what the nurse just 
did, these are the reports we are waiting for, we take that 
burden off of our patient, and it is the clinical team working 
together, better communicating that information.
    We also identified data mechanisms and data that we wanted 
to track that really led to positive outcomes in healthcare, 
because we needed to be able to say what is the value of nurses 
providing patient care, whether it is inpatient or outpatient? 
And how do I know, as the Chief of the Army Nurse Corps, 
whether or not we are making improvements in patient care? So, 
we have a database now that looks at the health of our 
patients, that the head nurse or the clinical officer in charge 
can look at their patient and see how they are doing in patient 
care performance. That is rolled up to the Deputy Commander of 
Nursing, and then I across the Corps can then look at the 
health of our patients.
    We also added a peer review, so if you look at our officer 
evaluation----
    Senator Mikulski. My time is going to run out.
    General Horoho. I am sorry.
    Senator Mikulski. But that is the evaluation.
    General Horoho. There is a lot. There is a lot----
    Senator Mikulski. I am going to stick to--well, what I 
would appreciate, because the chairman has been generous with 
my time, though I know he is very passionate about this because 
it is the follow through. As nurses, social workers, we say 
this. It is not only when they are in the ER or the OR, it is 
the rest of the R; it is rehabilitation, it is follow through, 
it is the management of chronic pain, etc.
    What I would like is a white paper actually, or any color--
a paper describing really what it is and what it does, and 
perhaps some casing samples, I think in case examples, which I 
think you do, too, in addition to this epidemiology and all you 
are looking at. So, I really would follow this through because 
I think you are on to something, and I think you are on to 
exactly what I am on to, that you need a patient advocate and 
all the way through inside. So, let us work together.
    [The information follows:]

    A top to bottom review of Army Nursing revealed that high 
quality care was being delivered but that it varied from 
facility to facility. The variability challenged patients, 
their families, and the nurses providing care. Notable in this 
review was the impact that the high technology environment had 
on patient care and a shift from those things that are 
considered unique to the art of nursing.
    The Patient CaringTouch System was developed in order to 
optimize care delivery. A pilot program was conducted at 
Blanchfield Army Medical Center in 2008 and this pilot revealed 
performance improvement across multiple dimensions within 6 
months of implementation, and suggested that broad 
implementation of the Patient CaringTouch System can create 
real value for Army Medicine. The following areas showed 
statistically significant improvement: (1) Decreased medication 
errors, (2) decreased risk management events, (3) decreased 
left without being seen from the emergency department, (4) 
increased pain reassessment, (5) increased critical lab 
reporting, (6) increased nurse retention and intent to stay
    The Patient CaringTouch System is what Army Nursing (AN) 
believes and values about the profession of nursing, delineates 
AN professional practice, articulates a capability-building and 
talent management strategy to ensure the right quantity and 
quality of AN leaders, and describes how AN delivers evidence-
based care in accordance with best practice standards across 
care environments.

    Senator Murkowski. I worked with your predecessors on the 
nursing shortage. We want to continue that. And we have a real 
champion in Senator Inouye. We all--we are all in love with 
Senator Inouye. And--but we want to thank you again for your 
service and look forward to working with you.
    General Horoho. Thank you.
    Admiral Niemyer. Thank you, Senator.
    Chairman Inouye. Thank you very much.
    Senator Murkowski.

                             SEXUAL ASSAULT

    Senator Murkowski. Thank you, Mr. Chairman. And I 
appreciate the time that the subcommittee has given to this 
very important testimony here today. Thank you all again for 
your service.
    I want to ask a question this morning about military sexual 
trauma. The fact that the three of you, this panel, is all 
female has nothing to do with my question. I had actually hoped 
to ask it to panel one, but I ran out of time. So, but it is 
equally applicable from the nursing perspective as well.
    As you are aware, the Women's Veterans Health Care 
Improvement Act put these new responsibilities on the VA to 
care for our discharged members of the armed forces who are 
suffering from military sexual trauma. The question to you all 
is, are we doing enough within the military medicine field here 
to identify, to treat these cases of military sexual trauma at 
the time that the service member has been victimized, or is 
this going to be a situation where the treatment for these 
individuals will be at the end when the service member is now 
part of the VA system and then discharged? And then, in 
addition to answering that question, if you will, are we doing 
okay, I guess, in terms of maintaining the records that we will 
need in determining the incidence of military sexual trauma and 
the outcomes in treating these victims? Is the process set up 
to work, and then, again, are we tending to the situation at 
the time that the sexual trauma has occurred, or are we waiting 
until this individual is part of the VA system? So, if you 
could just very quickly--and I recognize that this is an issue 
of time here this afternoon, but this is a very important 
issue, I think, as we know within all branches of our service 
right now. And I will throw it out to anyone who wants to 
start.
    Admiral Niemyer. I would be happy to just make a comment. I 
think the issue is so much broader than the medical parts, and 
although I cannot speak directly to your question about the 
records at this point, I would be happy to provide that back as 
a Navy response.
    The issue is so much broader than medical, and even today, 
I read this morning a white paper on sexual trauma. We have not 
progressed where we need to be. It is still a prevalent issue, 
and despite much of the training that we have done and the 
focus, it still remains an issue.
    That being said, I think we are doing a great deal in the 
military today with our line leadership to highlight this very 
prevalent issue and to focus on decoupling the alcohol 
incidence that at times accompanies sexual assault. We have a 
zero tolerance in the Navy, and I know for the other services 
as well.
    So, I can speak on the broad sense and would be happy to 
provide a more detailed medical response on that. But like 
suicide, any assault, and any particularly when it is our own 
folks, it is something that we clearly have zero tolerance for.
    Senator Murkowski. Oh, I would welcome a follow-up from you 
from the Navy's perspective if I could.
    Admiral Niemyer. Yes, ma'am.
    [The information follows:]

    Senator, Navy Medicine has taken an active role in 
supporting victims of sexual assault through the provision of 
medical care and the ability to support legal action by the 
completion of a sexual assault forensic examination when a 
victim presents to our facilities after an assault. Specific 
Navy Bureau of Medicine and Surgery (BUMED) initiatives include 
the establishment of a training program on the sexual assault 
forensic examination for medical providers stationed at 
overseas (OCONUS) commands. Not all of our medical treatment 
facilities (MTFs) within the United States offer in-house 
forensic evidence exams after an assault, but great care has 
been taken to establish Memorandums of Understanding (MOUs) at 
high-quality civilian facilities to meet this need. In 
addition, BUMED has initiated a study with the Center for Naval 
Analysis to gain understanding why some victims are choosing 
not to seek medical care or have a forensic examination at the 
time the assault occurs. Interventions will be initiated based 
on the finding of the study.
    The incidence and tracking of sexual assaults is reported 
via two sources. Naval Criminal Investigative Services reports 
and tracks unrestricted cases and the Sexual Assault Response 
Coordinators monitor and track the cases for victims who choose 
a restricted report. The challenge of accurate record keeping 
in the Navy is two pronged. First is the issue of under 
reported data. As many victims of sexual assault, both in the 
military and our society in general, continue to be concerned 
with the stigma associated with the crime and the fear of 
privacy breaches. Second, and specific to Navy Medicine, is the 
electronic medical record. Currently the required documentation 
for the forensic medical exam is Defense Form 2911 (per the 
DOD-I 6495.02). This form is not in electronic format but 
requires a scanned entry to be maintained in the electronic 
medical record, which is happening.
    Navy Medicine has an important and specialized role in 
caring for sexual assault victims. Our care for sexual assault 
victims encompasses the full scope of medical and psychological 
care with a priority on care that includes access to personnel 
trained to perform forensic examinations and psychological care 
aimed at providing the means to resume a healthy lifestyle. We 
realize that sexual assault affects more than just our Sailors 
and Marines. Sexual assault erodes unit cohesion, denigrates 
Navy core values and can adversely affect fleet readiness and 
retention. We allow victims of sexual assault the right to 
choose the option for care that is best for them, allowing them 
time to regain control of normal life functions. Our leaders 
are highly encouraged to use Sexual Assault Awareness Month to 
further educate sailors about the Navy sexual assault 
prevention and response program to include the role of medical 
personnel. Posters, educational leadership guides and other 
materials are readily available for download to assist in 
providing quality educational programs, encouraging an emphasis 
on a climate that values responsible behavior and active 
intervention. Navy Medicine, along with all Navy leaders stands 
ready to meet the challenge of eliminating sexual assault from 
our ranks.

    Senator Murkowski. General.
    General Horoho. Ma'am, we started about 2 years ago with 
Secretary Geren of having a campaign to increase awareness, 
that it really was an affront to our warrior ethos, whether it 
is a female being assaulted, or if it is a male being 
assaulted. So we looked at it with both demographics.
    I believe we have enough trained counselors to provide that 
level of care. Part of it, though, is creating that safe 
environment for people to feel comfortable coming forward, 
which is what you are talking about, the early intervention. 
And I think that is a work in progress, to be perfectly honest.
    We have also worked very closely with the VA. We have a 
midwife, Colonel Carol Hage, who actually works at the Office 
of the Surgeon General that has established a partnership with 
the VA to look at women's health issues, and this is one piece 
of that, because the demographics of the VA have changed, and 
then the impact of deployment with behavioral health and other 
issues, we wanted to make sure that we had the right programs 
in place to support. So we are evolving as time goes on.
    Senator Murkowski. Are you satisfied with the records that 
are being kept at this point, or do you know?
    General Horoho. Ma'am, if they come in and it gets into our 
electronic health record, then absolutely it is being 
documented and it is being kept in the system. And then we have 
got a lot of work that is being done right now with DOD 
partnering with the VA so that we have one electronic health 
record sharing that information. So, I think once it is in the 
system, it is absolutely in the system and is being maintained.

              INCIDENCE OF SEXUAL ASSAULT IN THE MILITARY

    Senator Murkowski. We've got to get in the system.
    General Horoho. Yes, ma'am.
    Senator Murkowski. General.
    General Siniscalchi. Thank you, ma'am, for your question. 
And we all are concerned about the incidence of sexual assault 
in the military.
    In 2004, General Casey McLean from the Air Force was 
charged to stand up a task force, and did a remarkable amount 
of work to advance training and prevention regarding sexual 
assault. As a result of the work done by the group that she 
led, we moved to restricted and unrestricted reporting of 
sexual assault. There had been numerous years from this initial 
task force where the Air Force focused on various training 
programs, various approaches to reduce sexual assault, and ways 
to advance treatment when sexual assault did occur, and then 
focusing on restricted and unrestricted reporting.
    Now in 2010, there was a Gallup survey that the Air Force 
did to establish a baseline looking at the incidence of sexual 
assault. When the results of that Gallup survey came out, there 
was a Sexual Assault Prevention Council that was stood up, and 
I was asked to represent the medical--surgeon general--on this 
council. So, this group of senior leaders did a very in-depth 
analysis of this Gallup survey, the result. And what we found 
was that once a sexual assault occurs, that across 100 percent 
of our military treatment facilities within the United States, 
overseas, and at deployed locations, that we have the 
appropriate response teams in place, whether they be sexual 
assault forensic examiners, sexual assault trained nurses, or 
sexual assault examiners, that they are either within the 
facilities or that we have memorandums of understanding 
established with a civilian facility to provide that level of 
response.
    And so, the response to a sexual assault, we have made 
tremendous strides. When it occurs, the care--the immediate 
care--we found that one of our longest treatment lines to 
response was at one of our overseas locations, and that 
treatment was still under 2 hours. We have really made great 
strides in treating sexual assault.
    However, what the Gallup report showed is that there still 
is significant improvement that needs to be made when it comes 
to prevention and training. Our working group is now looking at 
ways to enhance training and areas that were identified focused 
on leadership. We are looking at training programs, whether 
they be through, you know, modular training, distance learning 
programs, face-to-face training, to enhance awareness and 
sexual assault training, and then put better programs in place 
that focus on prevention.
    Senator Murkowski. Well, I appreciate what you have 
provided me. If there is any follow-up that you can offer, I 
would be interested in that as well. I often wonder whether the 
same stigma that attaches to just the need for services for 
behavioral health might also attach when it comes to issues as 
they relate to sexual trauma, sexual harassment, because that 
is also part of what we deal with within the definition of 
military sexual trauma. And it is something that as we think 
then as to the treatments beyond, again, it is not just the 
physical, but it is as we deal with those mental health issues 
that may last for considerable periods of time. So, this is an 
issue that I appreciate your attention to and to the surgeon 
generals that I know are all still here. I thank you for that. 
But any efforts that we can make to improve this is greatly 
appreciated.
    With that, I thank the chairman and the vice chairman.
    Chairman Inouye. Thank you very much.

                     ADDITIONAL COMMITTEE QUESTIONS

    General Schoomaker, Admiral Robinson, General Green, 
General Horoho, Admiral Niemyer, and General Siniscalchi, thank 
you very much for your testimony, and, above all, thank you for 
your service to our Nation.
    [The following questions were not asked at the hearing, but 
were submitted to the Department of response subsequent to the 
hearing:]

Questions Submitted to Lieutenant General Eric B. Schoomaker and Major 
                        General Patricia Horoho
            Questions Submitted by Chairman Daniel K. Inouye

         SOURCES OF HELP FOR SERVICEMEMBERS AND THEIR FAMILIES

    Question. General Schoomaker, are there efforts within the 
Department of Defense and amongst the Surgeons General to coordinate 
their approach on access to psychological healthcare needs and work 
towards one dedicated DOD Web site and phone line for all services?
    Answer. The Defense Centers of Excellence for Psychological Health 
and Traumatic Brain Injury (DCoE) is the Department of Defense (DOD) 
effort to coordinate psychological healthcare needs for servicemembers 
and their families across all services. The DCoE was established to 
assess, validate, and oversee prevention while facilitating the 
resilience, recovery and reintegration of servicemembers and their 
families needing help with psychological health and traumatic brain 
injury. The DCoE Web site (www.dcoe.health.mil) has a wealth of 
information to include information on the 24/7 outreach center. This 
center can be reached via phone at 866-966-1020, email at 
[email protected], or via live chat.
    Military One Source is a single virtual portal to behavioral health 
(BH) care to meet the needs of all servicemembers and their families, 
including Guard and Reserve, regardless of activation status. This DOD 
level resource serves as an extension of installation services to 
improve access to BH care while reducing stigma.

                          PSYCHOLOGICAL HEALTH

    Question. General Schoomaker, there has been an effort to expand 
psychological treatment options across the Army healthcare system. How 
is the Army providing expanded access to these services, both for 
soldiers and their families?
    Answer. In the past year the Army implemented the Comprehensive 
Behavioral Health System of Care Campaign Plan. This initiative is 
nested under the Army Campaign Plan for Health Promotion, Risk 
Reduction and Suicide Prevention. The Comprehensive Behavioral Health 
System of Care is intended to further standardize and optimize the vast 
array of behavioral health policies and procedures across the Medical 
Command to ensure seamless continuity of care to better identify, 
prevent, treat and track behavioral health issues that affect soldiers 
and families during every phase of the Army Force Generation cycle.
    The U.S. Army Medical Command currently supports over 90 behavioral 
health programs. The ``Virtual Behavioral Health program for 
Redeploying Soldiers'' (VBH) was established to maximize behavioral 
health assets and modern communications technology to provide uniform 
contact with all redeploying soldiers. VBH is meant to provide a 
positive experience for soldiers, so that they are more likely to seek 
behavioral health assistance in the future if needed. Additionally, the 
Army is enhancing behavioral health services provided to its Family 
members through Child, Adolescent and Family Assistance Centers and the 
School Behavioral Health Programs.
    In theater there has been a robust Combat and Operational Stress 
Control presence since the beginning of the war, with deployed 
behavioral health assets supporting both Operation Enduring Freedom and 
Operation New Dawn. Beginning in fiscal year 2012, the Army will 
increase behavioral health teams assigned to all its brigade size 
operational units. The increase will provide two behavioral health 
providers and two behavioral health technicians assigned to every 
Brigade Combat Team, Support Brigade and Sustainment Brigade in the 
Active, Reserve and National Guard Army inventory. The process will be 
complete by fiscal year 2017 and increase the total available uniformed 
behavioral health force by over 1,000 additional personnel.

                     PATIENT CENTERED MEDICAL HOMES

    Question. General Schoomaker, the Army's new community-based 
medical homes are located off-post in communities in order to provide 
increased capacity for primary care. How is the Army expanding this 
program and when will it be available service-wide?
    Answer. By the end of fiscal year 2011 the Army will have opened 17 
Community Based Medical Homes (CBMHs) in 11 markets. Two additional 
CBMHs will open in early 2012 bringing the total to 19 clinics in 13 
markets and complete phase 1 of the project. Phase 1 focused on meeting 
the primary care needs of our active duty family members. Once our 
CBMHs are proven to achieve desired results (improved access, 
satisfaction and health, and reduced utilization and cost), the Army 
plans to expand our community based presence. Phase 2 of the project 
will move some primary care services off-post to generate on-post space 
for specialty services and Warrior care. By doing so we will be able to 
better leverage our advanced on-post medical infrastructure, 
consolidate on-post services, and achieve the advantages of CBMHs. 
Phase 2 will begin in late 2012. Phase 3 of the project will explore 
opening additional services such as physical therapy, obstetrics, 
pediatrics, imaging, and refill pharmacy in community-based settings to 
generate positive value for DOD. Phase 3 planning will begin in late 
2011 with clinic expansion possible by 2013.

                       RECRUITMENT AND RETENTION

    Question. General Horoho, as the United States enters our tenth 
year of intensive combat operations, nurses have been heavily engaged 
in both wartime and humanitarian missions. How has the deployment tempo 
of nurses serving in critical nursing career fields affected the 
ability of the Army to recruit and retain nurses in these particular 
high demand fields?
    Answer. Six month deployments were initiated in summer of 2008 
which has had a positive effect on improving and maintaining the 
resiliency among Army critical care nurses. These deployments are 
better for the nurses and their Families. The critical care nurses as a 
group are very resilient and the majority do well post-deployment. In 
fiscal year 2010, the Army was able to recruit 642 nurses, meeting 105 
percent of its active duty need and 94 percent for the reserve. This 
includes some precision recruiting of experienced critical care nurses.

                            NURSING RESEARCH

    Question. General Horoho, I understand that the Army Nurse Corps 
has realigned nursing research assets, has embraced evidence based 
practice, and is an active participant in the TriService Nursing 
Research Program. How has this impacted nursing research opportunities 
in the Army?
    Answer. Army Nursing follows the American Nurses Association 
research participation guidelines that it is the expectation that 
nurses at every level participate in research activities appropriate to 
their educational preparation. Every nurse is involved in Evidence 
Based Practice (EBP) of which, research is one component.
    We are building a culture in all nurses at all levels that evidence 
drives practice. The goal is to have a core group of champions at all 
levels to sustain the application of research and use of evidence. EBP 
is built into curriculum at every level for Army professional nursing 
courses. This includes EBP and research lectures to the Clinical 
Transition Program, hospital or facility orientation, all specialty 
courses (Intensive Care Unit, Perioperative) and preceptor training. 
Army nursing has the support of Tri-Service Nursing Research Program in 
EBP and research grant camps.

                             NURSING ISSUES

    Question. General Horoho, are Army military treatment facilities 
staffed to the actual patient load or to the number of beds?
    Answer. The Army staffs to nursing care hours, the same as both the 
civilian community and Veterans Administration, using a research-based 
workload management system which adjusts for complexity of patient care 
and type of nursing care provider required.
    Question. General Horoho, nurses working in patient care areas 
often voice concerns that there are not enough nurses performing 
patient care duties. What is the ratio of Army nurses delivering 
traditional hands on nursing care to those conducting research, 
performing administrative duties or involved in functions that are not 
directly involved in the delivery of patient care?
    Answer. The ratio of nurses delivering direct patient care vs. 
research and administrative duties is approximately 5:1 or 83 percent.
                                 ______
                                 
              Questions Submitted by Senator Patty Murray

                           MEDICAL COMMUNITY

    Question. General Schoomaker, when the Army made the decision to 
``Grow the Force,'' did it factor the size of its medical community 
into its billet needs? Was military construction for medical facilities 
factored into this process?
    Answer. Yes, the U.S. Army Medical Command (MEDCOM) participates in 
the Total Army Analysis (TAA) which is a phased force structure 
analysis process. Furthermore, MEDCOM employed a multi-factorial 
process in determining specific needs to support Grow the Army that 
included population changes, access to care challenges, network 
availability, the inability to hire civilian staff, medical treatment 
facility productivity and new operational requirements. Military 
construction of medical facilities was factored into the process.
    Question. How has the Army evaluated the capacity of its medical 
community against the current and future structure?
    Answer. The Army evaluates capacity annually using the enrollment 
capacity model (ECM). Inputs to the ECM are current and expected force 
structure, productivity benchmarks, and expert clinical input. The ECM 
allows the Army to project needed or unused capacity for all Army 
military treatment facilities to meet the needs of its beneficiaries.

                             MENTAL HEALTH

    Question. Does the Army have enough mental health providers to meet 
soldier and family member needs?
    Answer. While the Army has increased its behavioral health 
inventory by 90 percent since 2007, we still do not have enough 
providers and continue to work toward hiring more. As of February 2011, 
the Army had 4,998 behavioral healthcare providers. The current 
estimated active component Army behavioral health requirement is 6,107 
providers, which represents an unmet requirement of 1,109 providers.
    Question. If there is a gap in mental health providers, what 
efforts are being taken to get more providers in the system?
    Answer. The Army is using numerous mechanisms to recruit and retain 
both civilian and uniformed behavioral health (BH) providers including 
bonuses, scholarships, and an expansion in training programs. The U.S. 
Army Medical Command has increased funding for scholarships and bonuses 
to support expansion of our provider inventory and provided centrally 
funded reimbursement of recruiting, relocation, and retention bonuses 
for civilian BH providers to enhance recruitment of potential 
candidates and retention of staff. The Army expanded the use of the 
Active Duty Health Professions Loan Repayment Program and offers a 
$20,000 accessions bonus for Medical and Dental Corps health 
professions scholarship applicants; has allowed recruitment of legal 
non-resident healthcare personnel to fill critical shortages; used a 
one-time Critical Skills Retention Bonus (CSRB) for social workers and 
BH nurses and the Army Medicine CSRB for clinical psychologists; and 
implemented an officer accessions pilot program that allows older 
healthcare providers to enter the Army, serve 2 years, and return to 
their communities.
    Additionally, in partnership with Fayetteville State University, 
MEDCOM developed a Masters of Social Work program which graduated 19 in 
the first class in 2009. The program has a current capacity of 30 
candidates. This program is fully funded by the Army with all graduates 
incurring a 62 month service obligation. To improve the accession of 
Clinical Psychologists, MEDCOM increased the number of Health 
Professions Scholarship Allocations dedicated to Clinical Psychology 
and the number of seats available in the Clinical Psychology Internship 
Program.
    Question. What programs are being undertaken to address the mental 
health needs of spouses and dependent children?
    Answer. The Army has an extensive array of behavioral health (BH) 
services and resources that have long been available to address the 
strain on military Families. These services include but are not limited 
to routine BH care, Chaplains, Military One Source, Comprehensive 
Soldier Fitness, Psychological School Programs and Army Community 
Service (ACS), Family Assistance for Maintaining Excellence (FAME), and 
the Warrior Resiliency Program (WRP). New initiatives include the 
Comprehensive Behavioral Health System of Care Campaign (CBHSOC) and 
our Child and Family programs available through the Child, Adolescent 
and Family Behavioral Health Office (CAF-BHO).
    The CAF-BHO is the lead office within the Army Medical Command 
(MEDCOM) for integrating and coordinating Child and Family BH programs. 
CAF-BHO promotes optimal military readiness and wellness in Army 
Children and Families through the Child and Family Assistance Centers 
(CAFAC), School Behavioral Health (SBH) and Medical Home BH support. 
Plans are being considered to implement CAFACs and SBHs across the Army 
to meet the goals of the Army's CBHSOC Plan.
    CAFACs provide cost-effective, comprehensive, integrated BH system 
of care to support military Children, their Families, and the Army 
Community throughout the Army Force Generation (ARFORGEN) and Family 
Life Cycle. CAFACs focus on coordinating, integrating, and 
synchronizing available BH and related services on an installation, and 
filling identified service gaps. The programs use a Public Health Model 
continuum of care, focusing on prevention and early intervention to 
promote wellness and resilience, and providing a higher level of BH 
care when needed.
    SBH programs provide cost-effective, comprehensive BH services to 
support military children, their families, and the Army community in 
schools. The overarching goal is to facilitate access to care by 
embedding BH within the school setting, and to provide state of the art 
prevention, evaluation, and treatment through standardization of SBH 
services and programs. Services are directed at improving student 
academic achievement, maximizing wellness and resilience of Army 
children and families, and ultimately promoting optimal military 
readiness.

                         ALTERNATIVE TREATMENT

    Question. What efforts are being taken to provide for alternate 
sources of pain management? Has the Army looked at civilian best 
practices? What are their plans for incorporating them?
    Answer. The U.S. Army Medical Command (MEDCOM) Comprehensive Pain 
Management Campaign Plan (CPMCP) is a phased effort that has been 
working to standardize pain care across MEDCOM, establish 
interdisciplinary pain centers in each Regional Medical Command, de-
emphasizing medication-only treatment of pain, address the challenge of 
poly-pharmacy with improved oversight of those on multiple medications, 
and improve access to non-medication pain treatments--complementary and 
alternative medicine (such as acupuncture, massage therapy, and 
movement therapies such as yoga.
    Expanding the availability of non-medication approaches for pain 
management has been an area of special emphasis and careful execution. 
The Army has continued to reach out to civilian experts who have had 
experience and success in incorporating integrative medicine into their 
medical practices and healthcare systems. Clinical practice and 
research initiatives with Samuelli Institute and Bravewell 
Collaborative are two examples of the MEDCOM's ongoing collaboration 
with civilian experts.
    MEDCOM has also been developing a model for MEDCOM/Veterans 
Affairs/civilian academic medicine pain management consortiums. These 
collaborative efforts have been developed to share clinical expertise, 
best practices, and education/training opportunities across these 
organizations. The first of these consortiums is located in the 
Seattle, Washington area and involves Madigan Army Medical Center, 
Puget Sound Veterans Affairs Hospital, and University of Washington 
Center for Pain Relief.

                          TASK FORCE TREATMENT

    Question. I am concerned about the increasing amputation rates 
among servicemembers and understand there was a task force recently 
established with experts in trauma, orthopedic surgery, wound patterns 
and analysis and rehabilitation specialists.
     What is the status of this task force?
     What best practices have been identified with treating these 
casualties?
     What do these trends mean for future combat care?
     Is there any applicability to civilian trauma care? Has the Army 
looked at public-private ventures to create more training opportunities 
for state-side medical personnel?
     Have any additional methods been identified to prevent, protect 
and reduce the impact of these injuries?
    Answer. The Dismounted Complex Blast Injury Task Force was 
established in early February 2011 and recently completed an analysis 
of trauma data that addresses many of these concerns. The Task Force 
report is nearly complete and will include recommendations on the best 
clinical practices to care for these soldiers and their families from 
the point of injury and throughout the evacuation, care, and 
rehabilitation continuum. The report will also include recommendations 
for future combat care and protection of our Warriors, and strategies 
for the mitigation of injury severity.
    These injuries represent the extreme of combat injuries, and go far 
beyond the most severe injuries ever encountered in civilian trauma. 
Our surgeons and rehabilitation experts have the most current 
experience in these uncommon injuries. Where we rely upon civilian 
expertise and cooperation is in the area of regenerative medicine 
approaches, skin and muscle reconstruction and associated 
rehabilitation.

                            MEDICAL TRAINING

    Question. The Army is producing medics with a wealth of experience 
in a variety of medical specialties like trauma care. Has there been 
any effort to align training programs with civilian training 
requirements? If no, then why not?
    Answer. The Army aligns training programs with civilian training 
requirements in areas where civilian requirements match military 
medicine mission. Applying civilian trauma care principles without 
adapting them to the tactical environment is not only frequently 
ineffective but may lead to more casualties. In October 2001, evidence 
based research drove the Army to incorporate the National Registry of 
Emergency Medical Technicians--Basic (EMT-B) as the necessary baseline 
for all students of the U.S. Army Combat Medic course. This program 
emphasizes increased trauma training by incorporating a standardized, 
externally validated civilian curriculum into the Army's program. 
National certification is a Combat Medic (68W) graduation and 
sustainment requirement. The basic skills of the Combat Medic overlap 
with competencies of the EMT-B; however, the Combat Medic has been 
trained to be more uniquely skilled and capable of providing advanced 
combat casualty care. Care in combat is focused not just on injuries 
suffered by the soldier but on the tactical situation surrounding the 
event. The Department of Combat Medic Training holds annual curriculum 
committee meetings to assess training needs, considering civilian 
training requirements, evidence-based research, and lessons learned.

                   ACQUISITION COMMUNITY INTERACTION

    Question. How well does your medical community interact with your 
acquisition community? As different injuries are identified as 
prevalent within your service, what are the procedures to work with the 
acquisition community to acquire equipment, tools, or clothing to limit 
or prevent these injuries?
    Answer. The U.S. Army Medical Department (AMEDD) is fully 
integrated with the Acquisition community under the DOD 5000 process 
which governs and implements policies of the defense acquisition 
system. The U.S. AMEDD Center and School serves as the Combat Developer 
defining requirements and the U.S. Army Medical Research and Materiel 
Command (USAMRMC) serves as the Materiel Developer providing materiel 
solutions. The Commanding General, USAMRMC, serves as the Deputy for 
Medical Systems to the Assistant Secretary of the Army for Acquisition, 
Logistics, and Technology (ASA(ALT)). In this role the Commanding 
General, USAMRMC, is the senior medical officer providing information 
to the ASA(ALT) regarding medical acquisition initiatives and the 
medical implications of non-medical acquisition initiatives.
    There are multiple ways that the needs identified on the 
battlefield are incorporated into the acquisition process to include 
working with the Rapid Equipping Force, the Army Materiel Command's 
Forward Area Support Team--which is deployed in Theater and includes at 
least one medical representative, the Combatant Command Technology 
Assessment and Requirements Analysis, the other services, and the 
operational needs statement process to name a few. In each initiative 
mentioned above, personnel closely affiliated with the acquisition 
community are intimately involved with every step of the process from 
capturing the Warfighter's requirements, through fielding a potential 
solution. Each of these initiatives complements the traditional 
acquisition process and allows the AMEDD to respond to Warfighter 
identified needs in a timely and controlled fashion. The Army utilizes 
the Joint Theater Trauma Registry to analyze the types and trends of 
injuries and the causes to inform the developers on improving 
operational approaches and materiel solutions.
                                 ______
                                 
               Questions Submitted by Senator Tim Johnson

                        ELECTRONIC HEALTH RECORD

    Question. Secretary Gates and Secretary Shinseki recently announced 
that the Department of Defense and the Department of Veterans Affairs 
will develop a joint electronic health record. On April 1, 2011, the 
Department of Veterans Affairs also announced that it will form an open 
architecture community around the VA's electronic health record, VISTA. 
Are these the same thing or will each Department still keep its own 
version of VISTA and AHLTA?
    Answer. Yes, these are the same. Secretary Gates and Secretary 
Shinseki met in March and agreed to a joint electronic health record 
called iEHR (integrated electronic health record) that will replace 
VISTA and AHLTA.
    Question. Do the Departments envision the joint electronic health 
record replacing VISTA and AHLTA?
    Answer. Yes, Secretary Gates and Secretary Shinseki met in March 
and agreed to a joint electronic health record called iEHR (integrated 
electronic health record) that will replace VISTA and AHLTA.
    Question. When will the Departments release details and a 
comprehensive plan forward on the joint electronic health record?
    Answer. The two Departments will meet over the coming months to 
develop a comprehensive implementation plan. Once complete, we envision 
the plan and details will be released by the Departments.
                                 ______
                                 
       Questions Submitted to Vice Admiral Adam M. Robinson, Jr.
            Questions Submitted by Chairman Daniel K. Inouye

         SOURCES OF HELP FOR SERVICEMEMBERS AND THEIR FAMILIES

    Question. Each service has taken a different approach to address 
the psychological health needs of their service members and their 
families. In addition, the Department of Defense and the Tricare 
contractors have also instituted programs to help provide this type of 
care. Rather than streamlining those services, new Web sites and phone 
lines are created. On top of those efforts, the private sector, the 
Department of Veteran's Affairs, and non-profits are all trying to 
address these issues. This is all well intended but more often than not 
it is challenging for servicemembers and family members to guide their 
way through a maze of avenues to seek for sources to help.
    On one Navy pamphlet to combat operational stress there are 16 
different Web sites and phone numbers and on another there eight. Each 
one has very little information associated with them, forcing the 
individual to access each Web site to decipher if that meets their 
needs. One Air Force pamphlet has 13 and on one Army pamphlet there are 
19. People seeking help should not have to go through a maze like this.
    Admiral Robinson, as I mentioned in my opening statement it can be 
quite confusing for a servicemember who is seeking help to deal with 
combat stress or other psychological health needs. On one Navy pamphlet 
provided to me there is a list of 16 different Web sites or phone 
numbers for sources of help. It takes so much to get someone to seek 
the help they need, we don't want to discourage them by making it 
difficult to find the appropriate help. Could you explain how you are 
attempting to consolidate these efforts and make the process less 
confusing for those that need it?
    Answer. The Navy is committed to fostering a culture that promotes 
resilience and wellness, and that empowers leaders to ensure the health 
and readiness of service members and their families. We concur that 
there have been a proliferation of services available to service men 
and women affected by post traumatic stress and traumatic brain injury. 
We must balance the desire to provide service members with options; 
understanding that one size does not fit all, with the possibility of 
creating confusion by providing too many alternatives.
    To address this issue we are working with the Naval Center for 
Combat and Operational Stress Control (NCCOSC) to develop consolidated 
strategic communications for psychological health initiatives across 
the Department of the Navy. Similarly we are working with the Defense 
Center of Excellence to consolidate resources and Web sites supported 
by the Military Health System and Department of Defense.
    Furthermore, across DOD strides are being taken to address 
effecencies within the multiple programs offered to our wounded, ill 
and injured service members. The Department of Defense (DOD) Task Force 
on the Care, Management and Transition of Recovering Wounded Ill and 
Injured Members of the Armed Forces, also known as the Recovering 
Warrior Task Force (RWTF) provides DOD with advice and recommendations 
on matters related to the effectiveness of the policies and programs 
developed and implemented by DOD, and by each of the military services 
in caring for our wounded, ill and injured service members. The goal of 
this task for is to look at best practices and various ways in which 
DOD can more effectively address matters relating to the care, 
management, and transition of these warriors.

                        RECRUITING AND RETENTION

    Question. The Air Force is short surgeons, family practitioners, 
clinical psychologists, and technicians. In addition to compensation, 
the Air Force identifies the lengthy hiring process for both officers 
and civil service health professionals as a top recruiting challenge.
    The Army faces personnel shortages in numerous healthcare 
specialties including: neurosurgeons, nurse anesthetists, behavioral 
health experts, physical therapists, oral surgeons, and others. Some of 
these areas are staffed at less than 50 percent of need. The Army is 
seeking to increase compensation for critical skills to reduce the gap 
between civilian and military pay, as well as leverage its Health 
Professions Scholarship Program.
    Overall, the Navy has somewhat improved recruitment and retention 
of medical officers over the last 3 years. The greatest challenges 
remain in the areas of general surgery, family medicine, oral surgeons, 
general dentists, and psychiatry. The problem is more severe in the 
reserve component.
    Admiral Robinson, some medical specialties are severely 
understaffed, particularly in the reserve component. For example, less 
than one-quarter of critical care medicine and cardiology positions are 
filled. How is the Navy ensuring that it has the number of reserve 
physicians it needs?
    Answer. Direct appointment recruiting of physicians and dentists 
remains a challenge, primarily because these healthcare professionals 
have well-established medical practices and are very well compensated 
in the civilian market. Interrupting their civilian medical careers is 
often personally and financially unattractive to many private medical 
providers. Additionally, retention has improved in the active forces, 
reducing Navy Veterans available for Reserve appointments.
    We are developing incentives within budgetary constraints to target 
specific communities that are, and will remain, critical to our 
mission. A credible recruiting bonus is critical and remains the 
primary incentive to attracting these professionals.
    We have collaborated with Navy Recruiting Command at a recently 
held Medical Stakeholders Conference and have developed a Medical 
Professionals Task Force Charter group in an effort to improve access 
and to collaboratively market targeted specialties to achieve 
recruiting goals. Working closely with Navy Recruiting Command, we have 
also restructured the Training Medical Specialties Drilling option (one 
of the most successful Physician recruiting options) to ensure the 
program is meeting the needs of Navy Medicine as well as attracting 
candidates.
    Despite these Reserve shortages, Navy Medicine continues to meet 
its global commitments in support of all contingency operations.

                           MILITARY MEDICINE

    Question. Since fiscal year 2010, the Department of Defense (DOD) 
has requested funds for the advancement of military medicine. Prior to 
that, the majority of these funds were provided to the Department 
through earmarks and nationally competed programs added to the Defense 
budget by Congress. In the fiscal year 2012 budget request the 
Department is requesting $438 million through the Defense Health 
Program and the Defense Advanced Research Projects Agency (DARPA) to 
further these efforts.
    Admiral Robinson, we are currently investing in medical research 
applicable to the needs of our current warfighter but what do we know 
about the issues we might face in the future and how are we attempting 
to stay ahead of that curve?
    Answer. In my testimony, I outlined a strategic vision for Navy 
Medicine that keeps us as a world leader in patient and family centered 
medical care. We manage the spectrum of current needs, while ensuring 
that the urgencies of the present do not diminish the intensity of our 
focus on the future. That focus is a critical element of our RDT&E and 
medical education vision and mission.
    One-third of our research portfolio of over 1,200 individual 
research studies is focused on the delivery of technologies to the 
Warfighter in the near-term through advanced development. Another third 
targets the next 10 to 20 years (technology development), with the 
balance addressing technology innovation for 20 to 50 years out (basic 
research). Where appropriate, this research is executed both at our 
research and development facilities in CONUS and overseas as well as in 
our Medical Treatment Facilities (MTF) by our experienced clinicians 
and our most promising graduate trainees, where appropriate. Navy 
Medicine demonstrates excellence in research in each domain. While our 
research focuses on Navy and Marine Corps requirements, our efforts 
complement and are closely coordinated with our sister services, the 
Defense Health Program, and DARPA.
    We are expanding the envelope of the possible, providing 
technologies, procedures, and practices that promote reintegration of 
our wounded warriors into productive roles in the services and in 
society. We will continue to expand on our progress in the areas of 
rehabilitative and regenerative medicine. The revolutionary advances we 
have made in wound management are a prelude to upcoming developments in 
prosthetics, transplantation, and regeneration.
    We recognize the critical role personalized medicine will play in 
maintaining the capabilities of our Fleet and Marine Forces. With small 
unit, agile forces on the ground and reduced manned ships at sea, the 
importance of each individual is magnified. Our progress in 
individualized medical care, personalized health maintenance and 
promotion, and enhanced individual and unit readiness will play a 
critical role in the future effectiveness of the DOD.
    History tells us that during peace-time and during armed conflict, 
more of our service members are rendered less than fully operational by 
disease than by bullets and bombs. As we evolve our global military 
presence, Navy Medicine is enhancing our capabilities through global 
health initiatives with our international partners and through a global 
presence. We are at the forward edge of battle in combating emerging 
diseases and solving health problems worldwide.
    Every day, the CONUS and OCONUS Navy Medical Research labs and the 
MTF-based Clinical Investigation Programs conduct cutting edge research 
to answer issues, both current and projected to arise. These facilities 
are necessarily lean and our researchers are few in number, but they 
have made significant contributions to the men and women who wear the 
cloth of our Nation and for the world. We will continue to develop 
innovative technologies to save the life and limb and to expand the 
operational envelope of our Navy and Marine Corps Warfighters.

                          PSYCHOLOGICAL HEALTH

    Question. There has been a significant expansion of psychological 
healthcare across the military health system. This includes increasing 
the number of specialists in psychiatry, psychology, mental health, and 
social work, to provide more services at a greater number of locations. 
Psychological treatment options are also being integrated into primary 
care to provide more comprehensive and holistic support.
    Early identification and treatment of psychological health issues 
can accelerate healing and improve long-term outcomes. This is 
supported by numerous campaigns to train service members to identify 
warning signs of excessive stress, suicidal tendencies, depression, or 
other mental health concerns. Given the stress of combat operations and 
repeated deployments, the services are striving to place more 
psychological health providers in theater, as well as continued 
screening for symptoms long after service members return.
    Admiral Robinson, the services are seeking to provide early 
identification and treatment of psychological health needs in theater 
by deploying additional psychological health professionals to forward 
operating bases. Since the Marines are sometimes located in remote 
locations with limited access to even basic services, how can the Navy 
ensure this care reaches them?
    Answer. Within the Marine Corps, we continue to see the 
effectiveness of the Operational Stress Control and Readiness (OSCAR) 
program, as well as the OSCAR Extender program. OSCAR embeds full-time 
mental health personnel with deploying Marines and uses existing 
medical and chaplain personnel as OSCAR Extenders together with trained 
senior and junior Marines as mentors to provide support at all levels 
to reduce stigma and break down barriers to seeking help. Embedded 
mental health providers can provide coordinated, comprehensive primary 
and secondary prevention efforts throughout the deployment cycle, 
focusing on resilience training, stress reduction efforts, and when 
necessary, timely access to a known provider with reduced stigma 
associated with mental health intervention. Our priority remains 
ensuring we have the service and support capabilities for prevention 
and early intervention available where and when it is needed. OSCAR is 
allowing us to make progress in this important area.

                     PATIENT CENTERED MEDICAL HOMES

    Question. The fiscal year 2012 budget request supports the phased 
implementation of the Patient Centered Medical Home concept for 
delivering primary care for all three services. This concept, 
originating in the private sector, seeks to improve quality of care and 
the patient experience by integrating primary care into a comprehensive 
service. Patients will have an ongoing relationship with a personal 
physician leading a team of professionals that collectively takes 
responsibility for the individual's or family's healthcare needs.
    The Army is beginning with Community Based Medical Homes, which are 
Army-run clinics located off-post. They function as extensions of the 
Army hospital and are staffed by civil servants. Seventeen are 
currently underway in communities which needed increased access to 
primary care, including one in Hawaii.
    The Air Force was the first service to implement the concept, which 
it termed the Family Health Initiative, beginning in 2008. It will soon 
be expanding the concept across all the clinics service-wide. The Navy 
is also ramping up its program to convert its facilities, started in 
May 2010, called Medical Home Port. Over 200,000 sailors and family 
members are already enrolled.
    Admiral Robinson, as the Navy creates additional Medical Home 
Ports, how will this new reorganization lead to more comprehensive 
service to patients and better continuity of care?
    Answer. Medical Home Port is Navy Medicine's Patient-Centered 
Medical Home (PCMH) model, an important initiative that will 
significantly impact how we provide care to our beneficiaries. In 
alignment with my strategic goal for patient and family centered care, 
Medical Home Port emphasizes team-based, comprehensive care and focuses 
on the relationship between the patient, their provider and the 
healthcare team. The Medical Home Port team is responsible for managing 
all healthcare for empanelled patients, including specialist referrals 
when needed. Patients see familiar faces with every visit, assuring 
continuity of care. Appointments and tests get scheduled promptly and 
care is delivered face-to-face or when appropriate, using secure 
electronic communication.
    It is important to realize that Medical Home Port (MHP) is not 
brick and mortar; but rather a philosophy and commitment as to how you 
deliver the highest quality care. A critical success factor is 
leveraging all our providers, and supporting information technology 
systems, into a cohesive team that will not only provide primary care, 
but integrate specialty care as well. We continue to move forward with 
the phased implementation of Medical Home Port at our medical centers 
and family medicine teaching hospitals, and initial response from our 
patients is very encouraging. To date, there are 68 MHP teams across 
seven Navy Medical Treatment Facilities with over 225,000 beneficiaries 
enrolled.
                                 ______
                                 
              Questions Submitted by Senator Patty Murray

                        MEDICAL FORCE STRUCTURE

    Question. Has the Navy evaluated the capacity of its medical 
community against the current and future structure?
    Answer. Navy Medicine evaluates annually and as needed our current 
and future total force structure in response to changing requirements 
to ensure that the correct mix of medical, dental, medical service, 
nurse and hospital corps professions are available to support our 
Nation's needs. Included in these analyses are our total force of 
active, reserve, civilian and contract professional to meet the 
operational and beneficiary missions.

                     MENTAL HEALTH FORCE STRUCTURE

    Question. Does the Navy have enough mental health providers to meet 
soldier and dependent needs? If there is a gap in mental health 
providers, what efforts are being taken to get more providers in the 
system? What programs are being undertaken to address the mental health 
needs of spouses and dependent children?
    Answer. We are committed to improving the psychological health, 
resiliency and well-being of our Sailors, Marines and their family 
members and ensuring they have access to the programs and services they 
need. We recognize that shortfalls within the market of qualified 
mental health providers has led to challenges in contracting and 
filling provider and support staff positions; however, recruitment and 
retention of uniformed personnel have improved. Current Navy inventory 
for mental health professionals (February 2011) is as follows:
  --Psychiatrist: 73 percent--projected to be at 86 percent end of 
        fiscal year 2012.
  --Psychologist: 75 percent--projected to be at 93 percent end of 
        fiscal year 2012.
  --Clinical Social Worker: 48 percent--projected to be at 44 percent 
        end of fiscal year 2012. This is due to significant billet 
        growth, from 35 billets in fiscal year 2010 to 86 billets in 
        fiscal year 2012.
  --Mental Health Nurse Practitioner: 57 percent--projected to be 100 
        percent end of fiscal year 2012.
  --Mental Health Nurse: 111 percent.
    Mental Health Professional recruiting remains a top priority. Navy 
uses numerous accession and retention bonuses to attract and retain 
mental health professionals. Medical Special and Incentive Pays are 
critical to attracting and retaining Navy medicine professional staff 
inventory.
  --Psychiatrists.--In fiscal year 2011 there is a $272,000 critical 
        wartime skills accession bonus available to Psychiatrists 
        entering the Navy. In addition, up to $63,000/year is available 
        through Incentive Special Pay/Multi-Year Special Pay for 
        current Navy psychiatrists who qualify.
  --Psychologists & Clinical Social Workers.--The Accession Health 
        Professionals Loan Repayment Program pays out up to $40,000 to 
        qualified licensed clinical social workers up to $80,000 to 
        clinical psychologists. The Health Professions Scholarship 
        Program is available to attract and train clinical 
        psychologists by paying for tuition, books, fees and a stipend. 
        The Health Services Collegiate Program is available to attract 
        and train licensed clinical social workers paying E6 salary and 
        benefits while candidates are in training. In addition, a 
        clinical psychologist accession bonus pays up to $60,000 for a 
        4 year obligation, and clinical psychologist incentive pay is 
        $5,000/year. The clinical psychologist retention bonus pays up 
        to $80,000 for a 4 year obligation, and the licensed clinical 
        social worker accession bonus pays up to $30,000 for a 4 year 
        obligation. Board certification pay of $6,000/year for both 
        specialties is also available to these mental health 
        professionals. A retention bonus for clinical social workers 
        has recently been submitted and is pending review and approval.
  --Mental Health Nurse Practitioner & Mental Health Nurse.--In fiscal 
        year 2011 there is up to $30,000 available through the Nurse 
        Corps accession bonus for nurses entering the Navy. In addition 
        up to $20,000/year is available through Registered Nurse 
        Incentive Special Pay.
    When our Sailors and Marines deploy, families are their foothold. 
Family readiness is force readiness and the physical, mental, 
emotional, spiritual health and fitness of each individual is critical 
to maintaining an effective fighting force. A vital aspect of caring 
for our service members is also caring for their families. FOCUS is a 
family centered resiliency training program based on evidenced-based 
interventions that enhances understanding, psychological health and 
developmental outcomes for highly stressed children and families. FOCUS 
has been adapted for military families facing multiple deployments, 
combat operational stress, and physical injuries in a family member. 
The program provides community outreach and education, resiliency skill 
building workshops and at the center of the program a 8-week, skill-
based, trainer-led intervention that addresses difficulties that 
families may have when facing the challenges of multiple deployments 
and parental combat related psychological and physical health problems. 
It has demonstrated that a strength-based approach to building child 
and family resiliency skills is well received by servicemembers and 
their family members. Notably, program participation has resulted in 
statistically significant increases in family and child positive coping 
and significant reductions in parent and child distress over time, 
suggesting longer-term benefits for military family wellness. To date 
over 200,000 Service members, families and community providers have 
received FOCUS services.
    In addition to FOCUS, the Reserve Psychological Health Outreach 
Program (RPHOP) identifies Navy and Marine Corps Reservists and their 
families who may be at risk for stress injuries and provides outreach, 
support and resources to assist with issue resolution and psychological 
resilience. An effective tool at the RPHOP Coordinator's disposal is 
the Returning Warrior Workshop (RWW), a 2-day weekend program designed 
specifically to support the reintegration of returning Reservists and 
their families following mobilization.
    The Naval Special Warfare (NSW) Family Resiliency Enterprise (FRE) 
program was designed toward enhancing the performance and readiness of 
the force by increasing resilience of the service member and his or her 
family--and thus the team, squadron, group and overall NSW community. 
To date, each NSW SEAL Team has conducted seven or more consecutive 
combat deployments resulting in cumulative exposure to wartime events 
and extensive familial separations. The goal has been to build 
resilience by collecting baseline information (seven main areas: 
psychological, neuropsychological, physiological, relationships, 
spirituality, finances, and lifestyle) about service members and their 
spouses/significant others; identifying areas of concern and providing 
training as indicated; and providing forums (overnight retreats) for 
family members to network to build support during deployments, as well 
as celebrate return from deployment and facilitate reintegration. To 
date, about 5,500 participants have attended NSW FRE retreats.

                       MEDICAL TRAINING PROGRAMS

    Question. The Navy is producing medics with a wealth of experience 
in a variety of medical specialties like trauma care. Has there been 
any effort to align training programs with civilian training 
requirements? If no, then why not?
    Answer. Yes, our enlisted training programs are aligned and often 
exceed civilian training programs. Similar to civilian medical 
training, military medical training is nationally accredited by the 
American Council on Education and the Council on Occupational 
Education, representing higher education and quality for the U.S. 
Government. The academic programs for enlisted medic training are under 
the auspices of the National License Practical Nursing guidelines for 
our basic hospital course and the National Emergency Medical Technical 
for field training.
    The Navy Credentialing Opportunity Online (COOL) program provides 
expanded opportunities to earn civilian occupational licenses and 
certifications. The program promotes recruiting and retention and 
further enhances the Sailor's ability to make a smooth transition to 
the civilian workforce. The Navy's credentialing program has two key 
components--dissemination of information on civilian licensure and 
certification opportunities and payment of credentialing exam fees.
    Community College of Air Force (CCAF) is a multi-campus community 
college accredited through the Southern Association of Colleges and 
awards course college credits to the enlisted personnel of the Air 
Force (AF) Medical Program. Navy corpsman participating in consolidated 
courses with the Air Force (AF), such as those offered at Medical 
Enlisted Training Campus (METC) in San Antonio, Texas or Sheppard AFB, 
are awarded college credits for training (i. e. emergency medicine, 
biomed tech, surgical tech, radiology, etc.) in both hospital corpsman 
basic and technical medical course work.
    In addition, Navy Medicine is formally affiliated with the LA 
County Trauma Center, California, approved by American College of 
Surgeons and sends medical teams (nurses, physicians and corpsman) to 
train in level 1 trauma care. This training opportunity allows for 
integration of knowledge and skill performances of civilian and 
military working side by side in trauma teams.

                      MEDICAL ACQUISITION PROGRAMS

    Question. How well does your medical community interact with your 
acquisition community? As different injuries are identified as 
prevalent within your service, what are the procedures to work with the 
acquisition community to acquire equipment, tools, or clothing to limit 
or prevent these injuries?
    Answer. Let me share how various aspects of Navy Medicine work 
together to improve medical care for Wounded Warriors.
    In the scenario you describe, surgeons at a forward operating base 
would note a change in the type or severity of injuries being treated. 
The change might be caused by new weapons or tactics employed by the 
enemy. The surgeons at the forward operating base would describe the 
new injuries and define a new medical capability needed to meet the 
threat. In this scenario, this information would go to the Navy 
Medicine Specialty Leader for Surgery. This senior surgeon represents 
the entire surgical community to Navy Medicine at large. There are 
specialty leaders for all aspects of clinical care.
    The Surgical Specialty Leader validates the new capability that is 
needed and determines whether the new capability can be satisfied by 
using a new surgical protocol or through the use of new or additional 
equipment not currently in theater. If the new capability can be 
achieved through the use of new surgical protocols, the Surgical 
Specialty Leader initiates the change in procedure.
    If the Surgical Specialty Leader determines new or additional 
medical equipment is needed, Navy Medicine's clinical engineers will 
write the specifications for the new equipment and our acquisition 
office will purchase it. These three groups--specialty leaders, 
clinical engineers, and acquisition professionals--have established 
procedures to validate, define, and procure medical supplies and 
equipment for our forward deployed providers.
    If the Surgical Specialty Leader determines that the new and needed 
medical capability cannot be satisfied using existing equipment or 
techniques, then the requirement is turned over to the Navy Medicine 
Research Center. These skilled and dedicated researchers work with 
colleagues in academia and industry to put new medical capability into 
the hands of our clinicians.
                                 ______
                                 
               Questions Submitted by Senator Tim Johnson

                       ELECTRONIC HEALTH RECORDS

    Question. Secretary Gates and Secretary Shinseki recently announced 
that the Department of Defense and the Department of Veterans Affairs 
will develop a joint electronic health record. On April 1, 2011, the 
Department of Veterans Affairs also announced that it will form an open 
architecture community around the VA's electronic health record, VISTA. 
Are these the same thing or will each Department still keep its own 
version of VISTA and AHLTA?
    Do the Departments envision the joint electronic health record 
(EHR) replacing VISTA and AHLTA?
    When will the Departments release details and a comprehensive plan 
forward on the joint electronic health record?
    Answer. Department of Defense (DOD) is leading the way forward on 
Electronic Health Records (EHR) and Navy Medicine is providing support 
for this mission.
    DOD and Veterans Affairs (VA) will continue to synchronize EHR 
planning activities for a joint approach to EHR modernization. The 
Departments have already identified many synergies and common business 
processes, including common data standards and data center 
consolidation, common clinical applications, and a common user 
interface. The VA has released a request For proposal to evaluate open 
source management options, and DOD is working with the VA to identify 
opportunities to contribute and participate in the open source 
collaboration. As the open source communities mature, DOD and VA will 
continue to analyze open source components that fit the architectural 
construct for use in the future EHR.
    The following excerpt from the April 6, 2011 testimony of Ms. Beth 
McGrath, DOD Deputy Chief Management Officer, before the House Armed 
Services Subcommittee on Emerging Threats and Capabilities additionally 
supports the commitment by both the DOD and VA to develop a joint 
approach to EHR modernization.

    ``In the field of health IT, DOD and the Department of Veterans 
Affairs (VA) have committed to a full and seamless electronic exchange 
and record portability of healthcare information in a secure and 
private format, wherever needed, to ensure the highest quality and 
effective delivery of healthcare services for our military 
servicemembers and Veterans, from their accession into service and 
throughout the rest of their lives. To this end, the Departments are 
collaborating on a common framework and approach to modernize our 
Electronic Health Record (EHR) applications. On March 17, the Secretary 
of Defense and Secretary of Veterans Affairs affirmed we will continue 
to synchronize our EHR planning activities to accommodate the rapid 
evolution of healthcare practices and data sharing needs, and to speed 
fielding of new capabilities. The Departments have already identified 
many synergies and common business processes, including common data 
standards and data center consolidation, common clinical applications 
and a common user interface.''

                      VISION CENTER OF EXCELLENCE

    Question. As Chairman of the Military Construction and VA 
Appropriations Subcommittee, I have closely followed the development of 
the Vision Center of Excellence and pressed for better cooperation 
between the Department of Defense and the VA. I have been frustrated 
with the delays in funding, full military staffing, and operational 
support for this important project.
    Admiral Robinson, what are the Navy's budgetary plans for fiscal 
year 2012-fiscal year 2015 for the Vision Center of Excellence? Where 
is the Navy currently at with staffing the Vision Center of Excellence? 
What staffing levels--military, Federal, and contractor support--are 
necessary to be fully operational and when do you anticipate reaching 
that point?
    Answer. The Joint DOD/VA Vision Center of Excellence (VCE) is a 
demonstration of a high level of cooperation between the DOD and VA. It 
continues to advance the coordination of vision care and research 
across both Departments and the VCE's work on the Joint Defense and 
Veterans Eye Injury and Vision Registry is an excellent example of how 
the two Departments can integrate processes. Further, the VCE has an 
integrated staff and is funded by both Departments.
    Oversight and direction of the VCE is accomplished jointly, 
specifically by the VA/DOD Health Executive Council (HEC) and the Joint 
Executive Council (JEC). The VCE is included in the VA/DOD JEC Joint 
Strategic Plan reported to Congress annually.
    The Navy has operational authority for the VCE, and the Assistant 
Secretary of Defense for Health Affairs has funding responsibility. The 
Navy is developing a transition plan for the transfer of funding and 
staffing responsibility from Health Affairs to the Navy.
    My office works closely with Health Affairs to adequately fund the 
VCE. Most of the leadership is in place now and additional key staff 
will be on board in fiscal year 2012. The VCE is funded at $17.9 
million in fiscal year 2012, which will support requisite operations, 
registry development, contractors, and DOD civilians (an increase of 18 
from the current 6 DOD civilian staff). Additionally, there are a total 
of 13 Federal staff members at the VCE, including 5 VA and 2 military. 
Our estimate is 111 staff will be required to achieve full operating 
capability by fiscal year 2017. We will continue to work with the VCE 
the requirements, as well as continue to evaluate all of our 
organizations to support DOD efficiency initiatives.

             JOINT VETERANS EYE INJURY AND VISION REGISTRY

    Question. Admiral Robinson, what is the status of the 
implementation of the Joint Defense Veterans Eye Injury and Vision 
Registry? How soon will this become fully operational? Does the Navy 
have the funding necessary for full implementation?
    Answer. Development of the Defense and Veterans Eye Injury and 
Vision Registry is progressing very well and is 6 months ahead of 
schedule. During the first year of operations of the Vision Registry, 
the Joint Department of Defense (DOD) and Department of Veterans 
Affairs (VA) Vision Center of Excellence (VCE) will validate the 
registry capabilities; collect and enter ocular data of Service Members 
and Veterans with ocular injuries into the registry; and identify 
future registry requirements and capabilities. We expect the Vision 
Registry to be fully operational by first quarter fiscal year 2013.
    The VCE is developing the Vision Registry to be a dynamic tool. As 
the first central repository of DOD and VA clinical ocular related 
data, the Vision Registry will provide the quantitative data necessary 
to perform longitudinal analyses for the development of preventative 
measures and for recognition of best practices for treatment and 
rehabilitation of injuries and disorders of the visual system.
    Personnel and operational costs for the Vision Registry sustainment 
and continued development are included in the proposed VCE fiscal year 
2013-17 POM.
                                 ______
                                 
       Questions Submitted to Lieutenant General Charles B. Green
            Questions Submitted by Chairman Daniel K. Inouye

         SOURCES OF HELP FOR SERVICEMEMBERS AND THEIR FAMILIES

    Question. General Green, what role do you see the private sector 
playing in your efforts to reach out to servicemembers and their 
families to provide access to psychological health services?
    Each Service has taken a different approach to address the 
psychological health needs of their servicemembers and their families. 
In addition, the Department of Defense and the Tricare contractors have 
also instituted programs to help provide this type of care. Rather than 
streamlining those services, new Web sites and phone lines are created. 
On top of those efforts, the private sector, the Department of 
Veteran's Affairs, and non-profits are all trying to address these 
issues. This is all well intended but more often than not it is 
challenging for servicemembers and family members to guide their way 
through a maze of avenues to seek for sources to help.
    On one Navy pamphlet to combat operational stress there are 16 
different Web sites and phone numbers and on another there eight. Each 
one has very little information associated with them, forcing the 
individual to access each Web site to decipher if that meets their 
needs. One Air Force pamphlet has 13 and on one Army pamphlet there are 
19. People seeking help should not have to go through a maze like this.
    Answer. Private sector organizations and individual providers play 
a critical role in the delivery of psychological health services to 
service members and families. TRICARE providers, community resources 
and non-medical counseling options supplement the direct military 
medical care system. They also offer options which may be perceived as 
bearing lower stigma for military families.
    In the Air Force, most formal mental healthcare for family members 
is provided by TRICARE providers or through other community agencies. 
Unfortunately, anecdotal reports from geographically remote bases 
particularly indicate that child and adolescent mental health services 
may be hard to find. There is a nation-wide shortage of qualified 
mental health providers. This situation becomes more problematic in 
remote locations or where there are low numbers of providers accepting 
TRICARE.
    While not providing formal mental healthcare, Military One Source 
counselors available through on-line or toll-free call referral, or 
Military and family life consultants and child and youth behavioral 
consultants working out of base Airman and Family Readiness Centers 
provide confidential, non-medical, short term counseling services to 
address issues common in the military community, with no medical 
documentation.
    Case management and referral management occurs both through private 
and military offices. Medical treatment facilities assist in locating 
specialty care for their enrolled patients and TRICARE regional 
contractors offer this service as well. Additionally, there are 
numerous private and local advocacy groups and offices that aid with 
access to services. The Defense Veterans Brain Injury Center provides 
coordination of care for individuals suffering from a Traumatic Brain 
Injury (TBI).
    Indeed there are many Web sites, agencies and advocacy groups 
providing resources for individuals and families with needs in the area 
of mental health. There are DOD/VA workgroups in place which are 
working to further consolidate and simplify these resources and 
establish one site for patients to seek medical information regarding 
psychological health. The breadth of resources is reflective of the 
wide array of topics being addressed: from type of problem (post 
traumatic stress disorder, depression, suicide, deployment related 
issues, TBI) to demographic or beneficiary issues (Guard/Reserve, 
Active Duty, family/individual, and age). Fortunately, in the military 
medical system, each patient has his/her own primary care physician as 
the first and best advocate to assist in the management of services.
    Because of the importance of the relationship with a primary care 
manager, the Air Force is placing behavioral health providers in 
primary care clinics. Where this is in place, patients see mental 
health providers for targeted, brief care in the primary care clinic 
avoiding the stigma of making a mental health clinic appointment. When 
further care is required the provider can refer the patient to the 
community to see a private sector or TRICARE provider or other 
appropriate resources.

                           MILITARY MEDICINE

    Question. General Green, a key element to the improvement of care 
is how fast we are able to transport servicemembers from the point of 
injury to the care they need. Can you detail some of the advancements 
in our aeromedical evacuations and what areas you are researching to 
further these efforts?
    Since fiscal year 2010, the Department of Defense has requested 
funds for the advancement of military medicine. Prior to that, the 
majority of these funds were provided to the Department through 
earmarks and nationally competed programs added to the Defense budget 
by Congress. In the fiscal year 2012 budget request the Department is 
requesting $438 million through the Defense Health Program and the 
Defense Advanced Research Projects Agency to further these efforts.
    Answer. Evolutionary advancements in technology, and improvements 
in clinical interventions enable movement of the most severely injured 
or ill patients. Recent technology advancements introduced by the Air 
Force include: advanced ventilators, video assisted intubation devices, 
improved aircraft configuration equipment for litter patients, improved 
aircraft lighting systems, an extracorporeal membrane oxygenation 
device for adult patients, and improved virtual training for medical 
personnel to name a few.
    Aeromedical evacuation today is done flawlessly but must always be 
focused on continuous improvement to care for ever more complex 
patients. Based on operational outcomes, effects, and well defined 
capability gaps, the major focus areas for enroute care research are: 
patient stabilization; patient preparation for movement; patient 
staging; impacts of in-transit environment on patient physiology and 
medical crew/attendant performance; occupational concerns for medical 
staff; human factors and patient safety; medical personnel training and 
equipment; environmental health issues; infectious disease and cabin 
infection control; burn and pain management; resuscitation; life saving 
interventions; nutrition; alternative medicine; and a wide variety of 
organ system effects (neurologic, psychologic, orthopedic, pulmonary, 
cardiovascular, gastrointestinal, renal, and respiratory). Air Force, 
Army, Navy, public and private academia, and industry partners are 
engaged in research in these focus areas.

                     PATIENT CENTERED MEDICAL HOMES

    Question. General Green, the Air Force continues to transition its 
clinics to the patient centered medical home model. This concept 
organizes health professionals into teams able to provide more 
comprehensive primary care. Each patient's personal physician leads the 
team and serves as a continuous point of contact for care. Has the Air 
Force seen improvements in patient satisfaction or cost control with 
this initiative?
    The fiscal year 2012 budget request supports the phased 
implementation the Patient Centered Medical Home concept for delivering 
primary care for all three services. This concept, originating in the 
private sector, seeks to improve quality of care and the patient 
experience by integrating primary care into a comprehensive service. 
Patients will have an ongoing relationship with a personal physician 
leading a team of professionals that collectively takes responsibility 
for the individual's or family's healthcare needs.
    The Army is beginning with community based medical homes, which are 
Army-run clinics located off-post. They function as extensions of the 
Army hospital and are staffed by civil servants. Seventeen are 
currently underway in communities which needed increased access to 
primary care, including one in Hawaii.
    The Air Force was the first service to implement the concept, which 
it termed the Family Health Initiative, beginning in 2008. It will soon 
be expanding the concept across all the clinics service-wide. The Navy 
is also ramping up its program to convert its facilities, started in 
May 2010, called Medical Home Port. Over 200,000 sailors and family 
members are already enrolled.
    Answer. The Air Force Medical Service has seen improvement in 
patient satisfaction and access at locations that have implemented FHI. 
Early data from the RAND (Research and Development) evaluation of the 
Air Force Medical Home Model (RPN PA06R-R190) study show a 1.3 percent 
increase in patient satisfaction. Additionally, continuity between 
patients and their providers is on the rise changing from an average of 
40 percent of patients seen by their assigned clinical to 60 percent 
following FHI implementation. Continuity with the assigned team is even 
higher averaging greater than 80 percent of the time seeing either the 
physician or the extender on the health team. A secondary effect of 
this improved continuity is decreased demand for acute appointments and 
improved access to care. Patients have shown less need for follow-up 
appointments as their assigned providers are able to provide more 
comprehensive care to patients they know, driving down the total number 
of overall healthcare visits. Provider satisfaction with this model of 
care has also led to a 5 percent reduction in attrition of our family 
physicians.
    We are also monitoring Emergency Department (ED)/Urgent Care Clinic 
utilization to see if the increased continuity can reduce high cost ED 
visits. As continuity increases patients learn that visits to their 
assigned provider, who are familiar with their medical history, offer 
advantages over convenience of acute care clinics. The roll out of 
Relay Health secure patient messaging over the next year will allow 
simpler communication with patients electronically and further enhance 
continuity.
    Disease management and case management programs built into PCMH are 
maturing and health indicators (such as diabetes compliance) are 
improving. The patient linked as partner with a specific healthcare 
team allows our extensive informatics network to provide decision 
support to both patients and the care team. Aggregating patient data 
into the informatics network will allow better care to populations as 
we tie specialty consultants and analytic experts together to improve 
care. It all starts with the partnership between patient and the 
healthcare team in PCMH.
                                 ______
                                 
              Questions Submitted by Senator Patty Murray

    Question. Has the Air Force evaluated the capacity of its medical 
community against the current and future structure?
    Answer. Yes, the Air Force uses current and projected mission 
changes to align resources where most appropriate. Beginning with Base 
Realignment and Closure 2005, and continuing in subsequent program 
objective memorandum (POM), the Air Force Medical Service (AFMS) has 
realigned manpower and medical facility capability based on changing 
mission requirements, including those mission changes associated with 
BRAC decisions or other Department of Defense mission movements or 
beneficiary changes.
    We continue to use staffing models, beneficiary population, and 
projected mission changes from the Air Force and the Office of the 
Secretary of Defense communities to place resources where they can be 
most effective, and where our deploying medics can receive the most 
current, diverse case-mix. Beginning in the fiscal year 2010 POM, and 
continuing today, the AFMS is aligning resources back into our 
inpatient platforms, with plans to increase enrollment by 35,000 and 
increasing inpatient capability at several of our larger Military 
Treatment Facilities. Specifically, the AFMS increased Joint Base 
Elmendorf by 200 personnel to account for force structure changes, 
beneficiary recapture opportunity, and to improve currency. Similar 
initiatives are in progress at Joint Base Langley-Eustis, and Eglin and 
Nellis Air Force Bases in response to mission changes. These efforts 
will result in medical personnel being better prepared for deployment 
to the area of responsibility), and will bring care back into the 
Direct Care System, a critical long-term goal to reduce costs and 
improve efficiency.
    The AFMS reviews current and future healthcare needs and directs 
changes within the assigned force structure (specialties) of each 
Corps. Under direction of the National Defense Authorization Act 2010, 
Section 714, the AFMS is increasing the active duty mental health 
authorizations by 25 percent to better address the needs of our service 
members and their families. These additional authorizations are built 
based both on the identified needs of our beneficiaries as well as our 
projected ability to recruit and retain professionals in these 
specialties. Although all active duty mental health professions will 
increase in the next 5 years, the largest growth will be in social 
workers, who we have had recent success in recruiting. We will also 
increase both psychiatrists and psychiatric nurse practitioners to 
increase our ability to provide psychiatric medication management 
services. We recently reviewed our current force structure to realign 
mental health resources and support the needs of our beneficiary 
population while maintaining manning levels within the current Air 
Force manpower constraints. Additionally, the AFMS is adding more 
contract mental health professionals as a gap-fill measure until the 
added active duty manpower needs are filled. This increase in mental 
health manning does not increase the overall manning numbers of the 
AFMS, but realigns the mix of specialty resources of our current 
medical program to more effectively recapture costs and provide 
expanded mental health services of these essential programs.
    Question. Does the Air Force have enough mental health providers to 
meet soldier and dependent needs?
    Answer. Through the TRICARE network and community organizations, 
the Air Force Medical Service (AFMS) has the mental health staffing to 
meet the treatment needs for Airmen and family members. The 
availability of resources varies depending on geographical region and 
catchment area but it is adequate to provide for mental health needs in 
a manner equal to other types of insurance.
    Question. If there is a gap in mental health providers, what 
efforts are being taken to get more providers in the system?
    Answer. There is a nationwide shortage of mental health providers 
which the AFMS confronts in a three-pronged approach addressing: (a) 
educational programs and scholarships, (b) direct compensation, and (c) 
quality of life (QOL) initiatives.
    (a) Due to historical difficulties recruiting fully qualified 
specialists, the AFMS places emphasis and funding into educational 
scholarships.
    (b) We use accession bonuses to recruit fully qualified specialists 
into the Air Force and retain them through the use of retention 
bonuses.
    (c) The AFMS addresses QOL initiatives such as family services, 
medical practice, educational or leadership opportunities, or frequency 
of moves and deployments to recruit and retain our health 
professionals.
    Question. What programs are being undertaken to address the mental 
health needs of spouses and dependent children?
    Answer. A variety of programs provide support for the mental health 
needs of spouses and dependent children. Each installation has a Family 
Advocacy Program (FAP) that provides outreach and prevention services 
to families. One novel FAP approach is the New Parent Support Program 
(NPSP), which provides support and guidance in the home to parents 
screened as high risk for family maltreatment. Educational and 
Development Intervention Services (EDIS) are provided by a child 
psychologist for special education children in DOD schools. Other 
programs provide education on common family issues like good parenting, 
couples communication, or redeployment integration. Counseling for 
families is also available. Military One Source is a DOD program using 
a civilian network that provides face-to-face, telephonic, or online 
counseling/consultation to service members and families for up to 
twelve sessions. Also providing nonmedical counseling, Airman and 
Family Readiness Centers have Military and family life consultants and 
child and youth behavioral consultants. These provide confidential, 
non-medical, short term counseling services to address issues common in 
military families such as deployment stresses and relocation. Other 
nonmedical counseling alternatives for family members not able to be 
seen at military medical treatment facilities have access to services 
through community TRICARE providers. These providers offer an array of 
services from individual counseling and group therapy, to inpatient 
behavioral healthcare.
    Question. The Air Force is producing medics with a wealth of 
experience in a variety of medical specialties like trauma care. Has 
there been any effort to align training programs with civilian training 
requirements? If no, then why not?
    Answer. We have established multiple training affiliations with our 
civilian counterparts in numerous settings aimed at providing mutual 
exchange of education. The purpose is not to align our training 
programs with civilian requirements, but to optimize the respective 
programs for both military and civilian students for the best outcomes. 
We have military instructors embedded in civilian institutions where we 
have military students for both GME (Graduate Medical Education) and 
sustainment training. In turn, several civilian schools use our medical 
facilities for student training with experiences unique to the 
military.
    Many of our surgical trauma experts are now in faculty positions in 
different private sector university hospitals. Our Centers for 
Sustainment of Trauma and Resuscitation Skills share expertise at 
University of Maryland, University of Cincinnati and St Louis 
University. Our Sustainment of Trauma and Resuscitation Skills Programs 
also share expertise with Tampa General Hospital, University of 
California--Davis, Scottsdale Medical Center, Miami Valley Medical 
Center, and University of Texas-San Antonio. We also have surgeons 
working closely with the Veterans Administration Hospitals, University 
of Alabama-Birmingham and University of Pittsburgh Medical Centers.
    Three of the four Centers of Excellence for the Nursing Transition 
Program are civilian medical centers, two having achieved Magnate 
status. These institutions provide a rich environment for our new nurse 
graduates as they transition from new nurse graduate to military nurse. 
Our military instructors and students provide our civilian colleagues 
with unique training opportunities as experiences with the phenomenal 
care we give our wounded warriors, establishing a collaborative process 
of information sharing for optimal patient outcomes.
    Question. How well does your medical community interact with your 
acquisition community? As different injuries are identified as 
prevalent within your service, what are the procedures to work with the 
acquisition community to acquire equipment, tools, or clothing to limit 
or prevent these injuries?
    Answer. The medical community and acquisitions community work 
closely together. Human Systems Integration has been a focus of the Air 
Force Medical Service and the Vice Chief of Staff of the Air Force for 
over 7 years to ensure new high cost military equipment addresses the 
needs of the human that will operate it. There are continuous efforts 
with Air Force logistics and the Army to mitigate the impact of combat 
injuries by evaluating protective equipment and improving it. Once 
protective equipment is identified as needed, our Air Force Medical 
Service Medical Logistics Division at Fort Detrick, Maryland, works 
with the acquisition community to contract for needed medical supplies, 
equipment and services based on clinically identified requirements and 
specific items are obtained as needed.
                                 ______
                                 
               Question Submitted by Senator Tim Johnson

    Question. Secretary Gates and Secretary Shinseki recently announced 
that the Department of Defense and the Department of Veterans Affairs 
will develop a joint electronic health record. On April 1, 2011, the 
Department of Veterans Affairs also announced that it will form an open 
architecture community around the VA's electronic health record, VISTA. 
Are these the same thing or will each Department still keep its own 
version of VISTA and AHLTA?
    Do the Departments envision the joint electronic health record 
replacing VISTA and AHLTA?
    When will the Departments release details and a comprehensive plan 
forward on the joint electronic health record?
    Answer. The Department of Veterans Affairs and the Department of 
Defense are collaborating on the Integrated Electronic Health Record 
(iEHR) program which will operate in the future as a common EHR. Given 
the iEHR is a complex, multi-year development program, a DOD-VA 
Integrated Program Office is being created to coordinate the 
development and deployment of the iEHR and then the sun-setting of 
VISTA and AHLTA. During the initial planning, the Departments have 
identified common business processes and practices, including common 
data standards, data center consolidation, common clinical 
applications, and a common user interface. Coordinating the efforts 
between the Departments sets the course toward a seamless electronic 
health record exchange and portability of health information in a 
secure and private format.
    The EHR Senior Working Group and various subgroups are currently 
assembling the information needed to put together a comprehensive plan. 
The plan is considering the budget, architecture, security, policies, 
and business processes. A high level project plan is being constructed 
that includes cost models, proposed timelines, and joint assumptions. 
The Secretary of Defense and the Secretary of the Veterans Affairs are 
scheduled to receive a status brief on cost, schedule and performance 
on May 2, 2011.
                                 ______
                                 
        Questions Submitted to Rear Admiral Elizabeth S. Niemyer
            Questions Submitted by Chairman Daniel K. Inouye

                 PEDIATRIC INJURIES ON THE BATTLEFIELD

    Question. Since 2002, DOD hospitals in Iraq and Afghanistan have 
treated over 2,000 injured children with over 1,000 of these children 
having suffered from blast injuries. Children have unique physiological 
responses to illness and injury. Therefore, the treatment of children 
demands specific training, equipment and approaches that are different 
than those required for adults. Children injured in war zones are 
sometimes treated as ``little adults'', and the healthcare 
professionals do not have the experience or training necessary to 
appropriately care for pediatric trauma injuries.
    Admiral Niemyer, our military medical personnel in theater are 
treating a wide array of civilian cases in addition to caring for our 
servicemembers. As a result, they are seeing numerous pediatric 
injuries similar to injuries sustained by adults. Has the Navy 
implemented any pre-deployment training for nurses to address the 
unique needs of pediatric casualties of war?
    Answer. In 2002, the Navy established the Navy Trauma Training 
Center (NTTC), a joint cooperative medical venture with the Los Angeles 
County-University of Southern California Medical Center, to train our 
nurses, doctors, and corpsmen in real world trauma medicine skills and 
experiences. Staff teaching this course solicit feedback from students 
who have completed the course and deployed. Over time our personnel 
noted a change in the demographic population of those injured in 
Afghanistan to include children. This feedback was used to begin 
incorporating a more robust training module highlighting the 
physiologic differences and responses to pediatric trauma, injury 
patterns, and pediatric specific treatments. Furthermore, because of 
this feedback clinical rotations in the Pediatric Intensive Care Unit 
and Pediatric Trauma Emergency Department have increased. Approximately 
75 percent of NTTC students deploy with Marine units.
    One of our pediatricians, Captain Jon Woods, was involved with 
extensive pediatric trauma in Afghanistan. He identified the 
requirement for qualified nurses trained specifically in military 
transport of pediatric patients. Staff at Naval Medical Center San 
Diego took this information and are in the process of creating a 
certified training program using their extensive simulation resources. 
The plan is to create a simulated space equivalent to that found inside 
a Blackhawk transport helicopter, where students in full battle gear 
will have pediatric trauma simulation experiences in which care is 
affected by significant limitations in visibility, communication, and 
movement.

                       RECRUITMENT AND RETENTION

    Question. Despite well known shortages in the nursing profession, 
the three services have continued to do well in recruiting nurses into 
the military. Last year, the Air Force testified that one of the 
challenges the nurse corps faced was the development of new flight 
nurses and technicians in the pipeline to meet the needs of the ever 
growing aeromedical evacuation mission. Flight nurses remain the lowest 
manned specialty in the nurse corps (78 percent), and have one of the 
highest demands. For the fifth consecutive year the Navy has achieved 
their active component nursing goal (92 percent manning) and they have 
2,852 nurses currently serving around the world. In fiscal year 2010, 
the Army was able to recruit 642 nurses, meeting 105 percent of its 
active duty need and 94 percent for the reserve.
    Admiral Niemyer, how are deployments affecting the Navy nurse 
corps' ability to retain experienced nurses, particularly those working 
in high demand, low occupancy nursing career fields?
    Answer. With the ongoing war efforts, we are keenly aware of the 
need to grow and retain nurses in our critical war-time subspecialties. 
Though loss rates have improved overall, there remains a gap in the 
inventory to authorized billets for junior nurses with 5 to 10 years of 
commissioned service.
    Key efforts which have positively impacted retention include 
Registered Nurse Incentive Special Pay (RN-ISP), which targets bonuses 
to undermanned clinical nursing specialties, and the Health 
Professional Loan Repayment Program (HPLRP), which offers educational 
loan repayment up to $40,000. Full-time Duty Under Instruction (DUINS) 
further supports Navy recruitment and retention objectives by 
encouraging higher levels of professional knowledge and technical 
competence through graduate education. Training requirements are 
selected based on Navy nursing needs for advanced skills in war-time 
critical subspecialties. Seventy-six applicants were selected for DUINS 
through the fiscal year 2011 board.
    Tracking specific reasons for losses is complex, but currently the 
Center for Naval Analysis is completing a follow-up study where intent 
to leave is one of the outcome variables. As the economy improves and 
civilian nursing opportunities expand through the Affordable Care Act, 
we might once again be faced with recruiting and retention challenges. 
In anticipation of these challenges, we are inviting nursing students 
and new graduate nurses to participate as American Red Cross volunteers 
at our hospitals and clinics to enhance exposure to the military. 
Additionally, we assigned a Nurse Corps Fellow to my staff to monitor 
recruitment and retention, and to ensure that both remain a priority.

                            NURSING RESEARCH

    Question. Scientific inquiry, planned and conducted by nurses, is a 
vital part of improving the health and healthcare of Americans. Nursing 
research has been a long time catalyst for many of the positive changes 
that we have seen in patient care over the years. The National 
Institute of Nursing Research defines nursing research as the 
development of knowledge to build a scientific foundation for clinical 
nursing practice, prevent disease and disability, manage and eliminate 
symptoms caused by illness, and enhance end-of-life and palliative 
care. The TriService Nursing Research Program (TSNRP) is one such venue 
to help ensure nursing care remains evidence based.
    Admiral Niemyer, nurses have a long history of promoting quality 
healthcare that is not only focused on the needs of the patient but 
also on the needs of their families. Nursing research has played a big 
part in how we take care of patients today. How are you ensuring that 
Navy nurses at all levels in the organization understand the research 
process and are given opportunities to participate in nursing research 
efforts?
    Answer. The Navy Nurse Corps has aligned nursing research 
priorities with military relevant Surgeon General's priorities and has 
embraced evidence based practice. ``Invigorating Nursing Research'' is 
a priority and one of the five Navy Nurse Corps' Strategic Goals for 
2011. It is aligned with the Navy Medicine Goal of Research and 
Development and Clinical Investigation programs. Also an active 
participant in the Tri-Service Nursing Research Program (TSNRP), the 
Navy Nurse Corps' aim is to continually increase the interest, 
submission, and subsequent selection of military relevant funded 
research projects to improve the health of our patients and/or add to 
the body of nursing knowledge.
    Our Nursing Research assets are aligned regionally and are aimed at 
providing guidance, communication, and mentoring to nurses at all 
levels of the organization. These assets actively advertise and provide 
TSNRP and other educational research and evidence based practice course 
offerings through presentations, site visit training, postings on the 
Navy Knowledge Online Navy Nurse Corps Web site, and enterprise-wide 
emails. Due to the efforts of the Strategic Goal Team and the synergy 
of the research assets in the region (both active component and reserve 
component), an overwhelming successful number of nurses have applied to 
participate in the TSNRP Research Development Course offered in San 
Diego in May 2011. Twenty-one Navy Nurses were selected to fill 25 Tri-
Service seats.
                                 ______
                                 
              Questions Submitted to Kimberly Siniscalchi
            Questions Submitted by Chairman Daniel K. Inouye

                       RECRUITMENT AND RETENTION

    Question. General Siniscalchi, last year you testified that one of 
the challenges the nurse corps faced was the development of new flight 
nurses and technicians in the pipeline to meet the needs of the ever 
growing aeromedical evacuation mission. Would you please provide us 
with an update on the status of those initiatives to increase this 
career field?
    Despite well known shortages in the nursing profession, the three 
services have continued to do well in recruiting nurses into the 
military.
    Last year, the Air Force testified that one of the challenges the 
nurse corps faced was the development of new flight nurses and 
technicians in the pipeline to meet the needs of the ever growing 
aeromedical evacuation mission. Flight nurses remain the lowest manned 
specialty in the nurse corps (78 percent), and have one of the highest 
demands.
    For the fifth consecutive year the Navy has achieved their active 
component nursing goal (92 percent manning) and they have 2,852 nurses 
currently serving around the world.
    In fiscal year 2010, the Army was able to recruit 642 nurses, 
meeting 105 percent of its active duty need and 94 percent for the 
reserve.
    Answer. Despite this critically manned, high demand specialty, 
Aeromedical Evacuation (AE) nurses and technicians continue to perform 
superbly with a 100 percent mission success. In fiscal year 2010, AE 
authorizations increased and as a result, the percentage of staffed 
versus authorized dropped significantly. At the same time, we relocated 
the Air Force School of Aerospace Science from Brooks City-Base, San 
Antonio to Wright-Patterson AFB, Ohio, which temporarily affected our 
training pipeline.
    Several initiatives are now underway to fill AE requirements. To 
improve retention, flight nurses are now offered Incentive Special Pay 
(ISP). The ISP program is making a positive impact on professional 
satisfaction and retention. To maximize our training investment in both 
AE nurses and technicians, the Air Force Personnel Center initiated 
several changes to allow nurses and technicians to complete a full 3-
year tour with the option to extend. An AE force development model was 
developed to allow nurses and technicians to weave in and out of flying 
assignments throughout their career. Developmental leadership positions 
were also established so nurses and technicians can return to AE and 
provide the much needed leadership and clinical mentorship for our 
junior AE nurses and technicians. Previous flyers are being asked to 
volunteer to return to flying assignments and many are eager to have 
the opportunity to return to flying. We project filling 100 percent of 
our allocated training seats this year.
    In addition, we are currently working on AE training 
transformation. We scheduled a utilization and training workgroup in 
fiscal year 2011 to streamline training by leveraging distance learning 
and creating modular training. The new format will increase the volume 
of Phase I students and decrease training time needed for Phase II 
students with a flying assignment pending. Our partnership with Wright 
State University in Dayton, Ohio is progressing well as we continue to 
refine the new graduate program in Flight Nursing. This new program 
offers didactic and clinical training in flight nursing, disaster 
preparedness/homeland defense, and adult health clinical nurse 
specialist. Our first student graduates in May 2012.

                            NURSING RESEARCH

    Question. General Siniscalchi, how are you fostering nurse 
researchers in the Air Force?
    Scientific inquiry, planned and conducted by nurses, is a vital 
part of improving the health and healthcare of Americans. Nursing 
research has been a long time catalyst for many of the positive changes 
that we have seen in patient care over the years. The National 
Institute of Nursing Research defines nursing research as the 
development of knowledge to build a scientific foundation for clinical 
nursing practice, prevent disease and disability, manage and eliminate 
symptoms caused by illness, and enhance end-of-life and palliative 
care. The TriService Nursing Research Program (TSNRP) is one such venue 
to help ensure nursing care remains evidence based.
    Answer. In addition to our Master Clinician's and Master Research 
career paths, we recently developed a nursing research fellowship and 
the first nurse started in August 2010. This 1 year, pre-doctoral 
research fellowship, focuses on clinical and operational sustainment 
platforms. The intent of this program is for the fellow to develop a 
foundation in nursing research and ultimately pursue a Ph.D. Following 
the fellowship, they will be assigned to work in Plans and Programs 
within the Human Performance Wing of the Air Force Research Laboratory. 
This direction is consistent with the National Research Council of the 
National Academies recommendations for research career paths.
    Under Air Force Colonel Marla De Jong's leadership, and for the 
first time in its history, TSNRP offered research grant awards to 
nurses at all stages of their careers--from novice nurse clinician to 
expert nurse scientist. The Military Clinician-Initiated Research Award 
is targeted to nurse clinicians who are well-positioned to identify 
clinically important research questions and conduct research to answer 
these questions under the guidance of a mentor. The Graduate Evidence-
Based Practice Award is intended for Doctor of Nursing Practice 
students who will implement the principles of evidence-based practice 
and translate research evidence into clinical practice, policy, and/or 
military doctrine. It is critical that funded researchers disseminate 
the results of their studies so that leaders, educators, and clinicians 
can apply findings to practice, policy, education, and military 
doctrine as appropriate. This grant will enhance this dissemination and 
uptake of evidence.
    Further opportunities to maximize the potential of our Airman and 
grow the next generation of noncommissioned officers are available 
through the Air Force Institute of Technology for certain key enlisted 
specialties. To date, we have three such positions identified; one in 
education and training at the Air Force Medical Operations Agency, 
another within our Modeling and Simulation program at Air Education and 
Training Command, and the third within the research cell at Wilford 
Hall Medical Center. Our most recent addition to the research cell is 
Senior Master Sergeant Robert Corrigan, who just arrived to Wilford 
Hall Medical Center.

                             NURSING ISSUES

    Question. General Siniscalchi, the acuity of patients, level of 
experience of nursing staff, layout of the unit, and level of ancillary 
support are all key components in establishing the ``right'' nurse-
patient ratio for any unit. This year I reintroduced The Registered 
Nurse Safe Staffing Act which addresses those concerns. How does the 
Air Force ensure adequate nurse staffing levels on inpatient units?
    A new study published in the New England Journal of Medicine shows 
that inadequate staffing is tied to higher patient mortality rates 
which supports the principles that call for nurse staffing to be 
flexible and continually adjusted based on patients' needs and other 
factors.
    Answer. A workload data review is conducted on a facility's patient 
census and acuity to establish a workload average over a 4 year period. 
From this data review, staffing levels are set at 15 to 20 percent 
greater than the average census to cover the anticipated patient load. 
Through the Tri-Service Patient Acuity and Staff Scheduling System 
Working Group, a model is being developed to staff according to patient 
need, nurse experience, and acuity versus a fixed nurse to patient 
ratio. Currently, there is no national standard for nurse staffing, 
however, the American Nurses Association provides a compilation of 
State regulated requirements which are taken into consideration for the 
current Air Force manpower model.
    In step with our manpower and staffing initiatives, our Air Force 
Medical Operations Agency in conjunction with the Department of Defense 
(DOD), implemented the Patient Safety Reporting (PSR) System in Air 
Force Military Treatment Facilities worldwide. The PSR provides staff 
with a simple process for reporting patient safety events using DOD 
standard taxonomies, which enhance consistency and timely event 
reviews. The PSR event data will be analyzed for trends and assist in 
identifying targets for process improvement, both at Air Force and DOD 
levels.
    Question. General Siniscalchi, how many nursing positions does the 
Air Force have for senior nurses to remain in direct patient care?
    Answer. We have developed a career track for Master Clinicians and 
Master Research positions through the rank of Colonel. This career 
track will allow our expert clinicians and researchers to stay within 
their realm of expertise without sacrificing promotion opportunity.
    Master Clinicians are board certified nursing experts with a 
minimum preparation of a master's degree and at least 10 years of 
clinical experience in their professional specialty. They serve as the 
functional expert and mentor to junior nurses. Our Master Researchers 
are Ph.D. prepared and have demonstrated sustained excellence in the 
research arena.
    Both of these highly respected positions are critical in the 
advancement of nursing practice and to the mentoring of our novice 
nurses. Currently we have 19 Master Clinician and 3 Master Researcher 
positions established at designated areas. In addition to our Master 
Clinicians, 3,073 of our 3,355 nurses or 92 percent of our nurses are 
in direct patient care positions.
    Question. General Siniscalchi, how many nursing positions does the 
Air Force have for senior nurses to remain in direct patient care?
    A new study published in the New England Journal of Medicine shows 
that inadequate staffing is tied to higher patient mortality rates 
which supports the principles that call for nurse staffing to be 
flexible and continually adjusted based on patients' needs and other 
factors.
    Answer. We have developed a career track for Master Clinicians and 
Master Research positions through the rank of colonel. This career 
track will allow our expert clinicians and researchers to stay within 
their realm of expertise without sacrificing promotion opportunity.
    Master Clinicians are board certified nursing experts with a 
minimum preparation of a master's degree and at least 10 years of 
clinical experience in their professional specialty. They serve as the 
functional expert and mentor to junior nurses. Our Master Researchers 
are Ph.D. prepared and have demonstrated sustained excellence in the 
research arena.
    Both of these highly respected positions are critical in the 
advancement of nursing practice and to the mentoring of our novice 
nurses. Currently we have 19 Master Clinician and 3 Master Researcher 
positions established at designated areas. In addition to our Master 
Clinicians, 3,073 of our 3,355 nurses or 92 percent of our nurses are 
in direct patient care positions.

                          SUBCOMMITTEE RECESS

    Chairman Inouye. The subcommittee will reconvene on 
Wednesday, April 13 at 10:30 for a classified briefing with the 
Commander of the United States Pacific Command. Until then, we 
stand in recess.
    [Whereupon, at 12:34 p.m., Wednesday, April 6, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]
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