[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]




 
   ACCESS TO MENTAL HEALTH CARE AND TRAUMATIC BRAIN INJURY SERVICES: 
          ADDRESSING THE CHALLENGES AND BARRIERS FOR VETERANS

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

                                HEARING

                               before the

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATION

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                        TUESDAY, APRIL 24, 2014

                               __________

                           Serial No. 113-66

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
       
       
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
       
       
       
       
       


         Available via the World Wide Web: http://www.fdsys.gov
         
         
         
         
         
                        U.S. GOVERNMENT PUBLISHING OFFICE
 87-679 PDF                      WASHINGTON : 2015       
_________________________________________________________________________________
For sale by the Superintendent of Documents, U.S. Government Publishing Office,
      Internet:bookstore.gpo.gov. Phone:toll free (866)512-1800;DC area (202)512-1800
     Fax:(202) 512-2104 Mail:Stop IDCC,Washington,DC 20402-001
        
         
         
         
         
         
         
         
                     COMMITTEE ON VETERANS' AFFAIRS
                                          
                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              MARK TAKANO, California
BILL FLORES, Texas                   JULIA BROWNLEY, California
JEFF DENHAM, California              DINA TITUS, Nevada
JON RUNYAN, New Jersey               ANN KIRKPATRICK, Arizona
DAN BENISHEK, Michigan               RAUL RUIZ, California
TIM HUELSKAMP, Kansas                GLORIA NEGRETE McLEOD, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
DAVID JOLLY, Florida
                       Jon Towers, Staff Director
                 Nancy Dolan, Democratic Staff Director

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATION

                    MIKE COFFMAN, Colorado, Chairman

DOUG LAMBORN, Colorado               ANN KIRKPATRICK, Arizona, Ranking 
DAVID P. ROE, Tennessee                  Member
TIM HUELSKAMP, Kansas                MARK TAKANO, California
DAN BENISHEK, Michigan               ANN M. KUSTER, New Hampshire
JACKIE WALORSKI, Indiana             BETO O'ROURKE, Texas
                                     TIMOTHY J. WALZ, Minnesota

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.






                            C O N T E N T S

                              ----------                              
                                                                   Page

                        Tuesday, April 24, 2014

Access to Mental Health Care and Traumatic Brain Injury Services: 
  Addressing the Challenges and Barriers for Veterans............     1

                           OPENING STATEMENTS

Hon. Mike Coffman, Chairman......................................     1

Hon. Ann Kirkpatrick, Ranking Member.............................     2

                               WITNESSES

Mr. Derek Duplisea, Regional Alumni Director, West Wounded 
  Warrior Project................................................     4
    Prepared Statement...........................................    33

Ms. Ariana Del Negro, Co-Founder, Veterans Leadership Assistance.     6
    Prepared Statement of Ms. Ariana Del Negro and Cap. Charles 
      Galtin.....................................................    40

Captain Charles Gatlin, U.S. Army (Ret.), Veteran................     7

Mr. David Anderson, Veteran and American Legion Commander, Post 
  51, Sacaton, Arizona...........................................     8

Mr. Jerry Boales, Veteran and Chairman of Rock Soldiers for 
  Wounded Warriors...............................................    10
    Prepared Statement...........................................    54

Mr. John Davison, Father of a Wounded Warrior....................    13
    Prepared Statement...........................................    56

Mr. Bradley Hazell, Veteran......................................    15
    Prepared Statement...........................................    63

Lisa Kearney, PhD, Senior Consultant, National Mental Health 
  Technical Assistance, Office of Mental Health Operations, 
  Veterans Health Administration.................................    23
    Prepared Statement...........................................    64

        Accompanied by:

    Dr. Joe Scholten, M.D., National Director of Special 
        Projects, Physical Medicine and Rehabilitation Services, 
        Veterans Health Administration

    Mr. Jonathan H. Gardner, MPA FACHE, Director, Southern 
        Arizona VA Health Care System, Veterans Health 
        Administration

    And

        Mr. Joshua D. Redlin, LCSW, Team Leader, Tucson Vet 
            Center, U.S. Department of Veterans Affairs

                        STATEMENT FOR THE RECORD

Ms. Tina Ostrowski, COTA/L, CBIS, Community Bridges, 
  Rehabilitation Institute of Montana............................    69
Statement of Congressman Kyrsten Sinema..........................    70
Statement of Hon. Ron Barber.....................................    71


   ACCESS TO MENTAL HEALTH CARE AND TRAUMATIC BRAIN INJURY SERVICES: 
          ADDRESSING THE CHALLENGES AND BARRIERS FOR VETERANS

                              ----------                              


                        Thursday, April 24, 2014

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
      Subcommittee on Oversight and Investigations,
                                                   Washington, D.C.
    The subcommittee met, pursuant to notice, at 1:00 p.m., in 
Southern Arizona VA Health Care System, Conference Room B, 3601 
South Sixth Avenue, Hon. Mike Coffman [chairman of the 
subcommittee] presiding.
    Present:  Representatives Coffman and Kirkpatrick.
    Also Present: Representative Sinema.

           OPENING STATEMENT OF CHAIRMAN MIKE COFFMAN

    Mr. Coffman. Good morning. This hearing will come to order.
    I want to welcome everyone to today's hearing titled 
``Access to Mental Health Care and Traumatic Brain Injury 
Services: Addressing the Challenges and Barriers to Veterans.''
    I would also like to ask unanimous consent that 
Representative Sinema of Arizona be allowed to join us here on 
the dais to address the issues before us today.
    Hearing no objection, so ordered.
    Providing the necessary care and treatment for traumatic 
brain injury has to be among the highest priorities of the 
Department of Veterans' Affairs. The nation's returning 
soldiers who have survived devastating blasts from improvised 
explosive devices and ordnance deserve the best possible 
medical care for their injuries that this nation can offer.
    They also deserve compensation for the disabilities 
connected to their military service. Given the prevalence of 
TBI among the veterans of Operation Enduring Freedom and 
Operation Iraqi Freedom, all veterans receiving medical care at 
VA are required to undergo screening for it. According to the 
Defense Centers of Excellence for Psychological Health and 
Traumatic Brain Injury, more than 287,000 service members have 
sustained traumatic brain injury between 2000 and the third 
quarter of 2013. Almost 80 percent of these injuries were 
classified as mild TBI. According to Dr. Robert Petzel, 
Undersecretary of Health, there has been an almost 70 percent 
decline in the number of severe TBI cases in recent years, 
while the number of mild to moderate cases has increased. He 
said, ``It costs much less to treat that group than the 
polytrauma cases.'' As a result, the Administration's budget 
request for Fiscal Year 2015 is for $229 million for TBI 
medical programs, down nearly 1.3 percent from Fiscal Year 
2014.
    Today, we will hear from veterans and their families about 
the serious long-term consequences of traumatic brain injury. 
We will hear about the continued challenges veterans have to 
getting access to necessary services for TBI. Even with mild 
TBI, which constitutes the great majority of cases, VA is 
failing to provide proper screening and may be 
undercompensating veterans with very real disabilities.
    Today, Captain Charles Gatlin and his wife, Ariana Del 
Negro, will testify about the traumatic brain injury Gatlin 
suffered in an IED blast and about their subsequent struggles 
with VA. When Captain Gatlin was medically discharged from the 
Army, he had a 70 percent disability rating from the Department 
of Defense. Notwithstanding the fact that Captain Gatlin had 
already undergone three comprehensive neuro-psychological tests 
by doctors at the Department of Defense that indicated mild 
TBI, Captain Gatlin was subjected to a perfunctory test by a 
psychologist at VA when he moved to Fort Harris in Montana in 
2009. As a result of this test, Captain Gatlin received a 
rating of only 10 percent disability by the VA. Significantly, 
the psychologist who administered the VA screening has been 
brought up on adverse licensing charges by the Board of 
Psychologists for the State of Montana. The Board has 
reasonable cause to believe that the VA psychologist misused a 
diagnostic test and failed to conduct his assessment in 
accordance with the applicable standard of care.
    The VA has enlisted the Department of Justice to defend the 
psychologist on the grounds that state licensing laws are 
preempted. Essentially, the Department of Justice is arguing 
that VA can use unqualified personnel and substandard tests at 
its discretion in disability determinations.
    Substandard sampling for TBI research apparently is also a 
problem at VA. According to a recent study, only 5.4 percent of 
eligible veterans participated in responding to VA's Markers 
for the Identification of Norming and Differentiation of TBI 
and PTSD. The MIND study is what it was called. The poor 
response rates cast significant doubt that the $3 to $4 million 
in taxpayer money on the MIND study over the past five years 
was well spent.
    I want to thank all the witnesses for appearing at this 
hearing today. Your testimony is important and in the end will 
lead to more consistent, comprehensive, and compassionate care 
for our nation's veterans. It is our job to see that we get it 
right and we do not fail those who have sacrificed so much for 
this country.
    With that, I now recognize Ranking Member Kirkpatrick for 
opening statements.

      OPENING STATEMENT OF ANN KIRKPATRICK, RANKING MEMBER

    Mrs. Kirkpatrick. Thank you, Mr. Chairman and Congresswoman 
Sinema, for being here today for the veterans and their 
families in District 1 in Arizona and across the country.
    I would also like to acknowledge that our colleagues, 
Congressman Barber, Grijalva and Gosar, have members of their 
staff here today. They are in Yuma for the dedication of the 
John Roll United States Courthouse.
    I also thank all of you who are here today, whether to 
participate or to observe. Your presence is greatly 
appreciated.
    As members of the Oversight Investigations Subcommittee and 
as members of Congress, we have a duty to stand up for our 
veterans. It is our job to fight for those who have served. I 
called for today's hearing because ensuring access to timely, 
safe, quality health care for our veterans is one of my top 
priorities. We need to examine the connection between TBI and 
PTS and access to care.
    Many of us are aware of the troubling reports about the 
Phoenix VA Medical Center and the patient deaths allegedly 
caused by long wait times for an appointment or consult. While 
we don't have all of the facts, we do know that delayed care is 
denied care. And I have already called for a hearing on this 
after the Inspector General's investigation is completed.
    I am deeply concerned that lengthy appointment wait times 
in the VA system may be discouraging veterans from seeking help 
when they need it most. With TBI being the signature injury of 
the Iraq and Afghanistan wars, we know that having a traumatic 
brain injury can amplify the symptoms of PTS. Many of our 
veterans suffered TBIs, and they also suffer from PTS. Their 
needs need to be sustained and they need quality care for the 
rest of their lives.
    In Arizona, many of these veterans live in rural areas, 
including our Native American veterans. These men and women 
need the same care and the same services as veterans in urban 
areas near large VA medical facilities like Tucson.
    The VA health care system must be able to provide timely, 
high-quality care to the veterans who are already in the VA 
system and be ready for the expected increase in the number of 
veterans who will soon become part of the VA system.
    This hearing will focus on how VA is addressing the needs 
of our veterans who have sustained traumatic brain injuries and 
suffer from mental health conditions. From this hearing, I hope 
to identify where improvements by the VA are needed and to 
identify some best practices and resources to care for our 
veterans. I hope this feedback can help break down barriers for 
access to mental health services.
    The Tucson VA is one of 23 polytrauma network sites, and I 
look forward to hearing from our panelists from the Southern 
Arizona VA Medical Health System on how they are providing 
treatment for our veterans with TBI and PTS.
    I also want to thank our first panel for sharing your 
stories with us. I know it must be difficult, but hearing from 
you allows me and this subcommittee to better understand the 
challenges and barriers to proper care. I, along with the 
subcommittee, continue to hear stories of many struggles 
veterans face when trying to access VA mental health and TBI 
services. Whether it is a delay in care, a denial of care, or 
care is just not available, frustration with the system may 
lead to the veteran foregoing needed care altogether, which is 
unacceptable and can lead to crisis.
    I look forward to hearing from our panelists today and have 
a productive discussion on these very important issues.
    Thank you, Mr. Chairman. I yield back.
    Mr. Coffman. Thank you, Ranking Member Kirkpatrick.
    With that, we have the first panel at the witness table. On 
this panel we will hear from Mr. Derek Duplisea, Regional 
Alumni Director of the Wounded Warrior Project; Captain Charles 
Gatlin, United States Army, retired, and his wife, Ariana Del 
Negro, Co-Founder of Veterans Leadership Assistance.
    I would now like to allow Ranking Member Kirkpatrick to 
introduce the remaining witnesses on our first panel.
    Mrs. Kirkpatrick. Thank you, Mr. Chairman.
    It is my pleasure to introduce a few members from our first 
panel.
    Mr. David Anderson is a veteran and the Post Commander at 
the American Legion. David is also Native American, and we are 
very interested in hearing your perspective. Thank you for 
being here.
    Mr. Jerry Boales, also a veteran, is Chairman of the Rock 
Soldiers for Wounded Warriors. He just had surgery, and this 
committee meeting was so important to him that he made it here 
today. Thank you very much.
    Mr. John Davison is a dear friend of mine from Flagstaff, 
father of a wounded warrior who just committed suicide, and I 
spoke at the funeral service. This is tough for me and for John 
and his family, so there may be some tears.
    Then I would like to introduce Brad Hazell. Brad is also a 
veteran, and Brad worked in my congressional office in Casa 
Grande, has a stunning reputation for helping our veterans, and 
we look forward to your testimony.
    Thank you.
    Mr. Coffman. Each of your complete written statements will 
be made part of the hearing record.
    Mr. Duplisea, you are now recognized for 5 minutes.

                  STATEMENT OF DEREK DUPLISEA

    Mr. Duplisea. Chairman Coffman and Ranking Member 
Kirkpatrick, thank you for inviting Wounded Warrior Project to 
testify on behalf of both the professional and personal concern 
for me. In 2006, in August, right before my second deployment 
to Iraq was to end, a suicide bomber left me severely wounded, 
effectively ending my 13-year U.S. Army career as a cavalryman, 
airborne-armor paratrooper, and scout. I spent the next two 
years recovering from injuries that included a severe 
penetrating traumatic brain injury, a shattered right femur, a 
completely shattered right arm that was nearly amputated, 
burns, nerve damage, and PTSD. I've been working with and on 
behalf of wounded warriors since a few months after I medically 
retired from the U.S. Army in 2008.
    I am proud to serve as the Western Regional Director for 
Wounded Warrior Project's Warrior Engagement Programs. In 
addition to operating 20 direct-service programs for almost 
50,000 warriors with whom we work, Wounded Warrior Project 
conducts an annual survey. Our most recent survey found that 
three most common reported health problems among our warriors 
are PTSD at 75 percent, anxiety at 74 percent, and depression 
at 69 percent. More than 44 have experienced a TBI.
    The survey shows that for many, the effects of mental and 
emotional health problems are even more serious than the 
effects of physical problems, with more than 25 percent in poor 
health as a result of a severe mental health condition.
    On mental health care, access to mental health care is 
clearly vital, but access alone isn't enough. Care must also be 
both timely and effective. We see wide variability in VA mental 
health care from facility to facility. My own experience at the 
Tucson VA has been very positive, but many other facilities 
still seem to lack enough mental health staff despite VA adding 
some 1,300 new mental health professionals.
    VA has also put a new emphasis on scheduling new mental 
health appointments within 14 days, but there is also a big 
difference between being seen for an initial assessment and 
actually starting treatment, which may not occur for weeks or 
months, leaving some veterans feeling desperate.
    Despite the hard work of dedicated, professional clinicians 
at many VA facilities, we still see evidence of a system that 
is understaffed and under stress. Here are some examples we see 
around the country.
    Veterans who need individual therapy are frequently being 
pushed into group therapy or taking the group option because 
the wait time for the individual treatment is too long. Some 
rural VA clinics are placing veterans who have depression or 
anxiety on waiting lists or not providing them treatment at all 
to give priority to those with combat-related PTSD. A large 
number of warriors are reaching out to our organization for 
help in finding mental health treatment options because of VA 
timeliness issues.
    VA facilities can seldom provide treatment proactively as 
needed and instead can only react when the veteran's condition 
deteriorates to a point of crisis. And, as we learned from a 
recent survey, of those who sought VA care for military sexual 
trauma-related conditions, 49 percent reported difficulty 
accessing that care.
    We don't suggest that these are simple problems, but it is 
not good enough to say that the VA has seen a high percentage 
of veterans when treatment is often sporadic or limited to 
providing medications. Access to timely, effective treatment 
should be the norm, not simply a distant goal.
    Regarding traumatic brain injury, we are particularly 
concerned about VA's failure to implement bipartisan 
legislation Congress enacted in 2012. That law was aimed at 
providing long-term rehabilitation of veterans with TBI, and it 
calls for VA to apply a new model of TBI rehabilitation. Under 
the law, rehab services are not to be cut off based on the view 
that the patient has plateaued. The law also directs VA to 
provide any community-based services or support that might 
contribute to maximizing the veteran's independence.
    The point is that rehab services should not end when the 
veteran returns home. For many, the rehab journey only starts 
then. But we see no evidence that the VA has implemented this 
law or that it had any effect on VA practice. It remains common 
for warriors to have TBI rehab services discontinued after a 
set number of treatment sessions or based on the view that the 
warrior has plateaued. Families report that they are left to 
their own devices to continue the warrior's rehabilitation. The 
upshot is that 25 percent are paying out-of-pocket for services 
VA is not providing. One-quarter of those pay more than $300 
monthly out-of-pocket to provide rehabilitative services.
    The Wounded Warrior Project is not just complaining. We 
have established a program of our own, providing 140 warriors 
with severe TBI the very kind of community support the VA 
should be providing. We will be expanding the program to help 
more warriors, but we also want VA to implement the TBI law and 
urge the subcommittee to press that point back in DC.
    Finally, we look forward to working with you here in 
Arizona and the nation's capital to improve the care of 
veterans with mental health needs and those with TBI. In the 
Army, we were always taught to have faith in our equipment. My 
helmet here today testifies to that faith. If I was not wearing 
this helmet, I would not be here today. We now put our faith as 
warriors and veterans in you, the government and the VA.
    Thank you.

    [The prepared statement of Derek Duplisea appears in the 
Appendix]

    Mr. Coffman. Thank you, Mr. Duplisea, and thank you so much 
for your service. I come from a Colorado military family. I am 
a congressman from Colorado, and my father was a World War II 
veteran. I was in the first Gulf War and Iraq War.
    Mr. Duplisea. Thank you.
    Mr. Coffman. Thank you.
    Ms. Del Negro and Captain Gatlin, you are now recognized 
for 5 minutes.

                 STATEMENT OF ARIANA DEL NEGRO

    Ms. Del Negro. Thank you, Mr. Chairman, Ranking Member 
Kirkpatrick. My name is Ariana Del Negro, and my husband, 
Captain Charles Gatlin, and I would like to formally submit our 
written testimony for the record.
    We are here today to voice our profound concerns regarding 
the VA's handling of C&P claims for residuals of traumatic 
brain injury and unethical practices not only at the Fort 
Harrison VA in Helena, Montana, but potentially across all VA 
systems. The consequences are far-reaching. The emotional, 
physical, and financial tolls placed upon the veterans and 
their families in seeking to right wrongs in the system is 
unacceptable and warrants immediate corrective action.
    As Chairman Coffman mentioned, my husband, whose scout 
recon platoon was retired from the Army in 2009 having received 
a 70 percent rating for his traumatic brain injury, which 
starkly contrasted with the Montana VA, who gave him a 10 
percent. The discrepancy between the DoD's rating and the VA's 
rating and the failure in accountability of the latter are the 
basis of our concerns with the VA. The lower rating assigned 
was a consequence of the fact that the examiner, a clinical 
psychologist, was not licensed to conduct neuropsychological 
testing. The test he used was a screening measure for dementia, 
not TBI, and he misinterpreted the results, thus providing C&P 
raters medically inaccurate information on which to base their 
disability rating.
    As my husband will attest to next, our efforts to rectify 
this straightforward matter have been met with hostility and 
stonewalling from weak leadership. What will it take for a 
system to be held accountable, where the interests of the 
veteran are placed before the bureaucracy of the system?

    [The prepaperd statements of Ariana Del Negro & Charles R. 
Galtin appears in the Appendix]

              STATEMENT OF CAPTAIN CHARLES GATLIN

    Captain Gatlin. This stands as a Ranger creed: ``Never 
shall I fail my comrades. I will keep myself fit and alert, 
physically strong, and morally straight, and I will shoulder 
more than my share of the task, whatever it may be, 100 
percent, and then some.'' The VA needs to learn that.
    Good afternoon, Honorable Chairman and Ranking Member 
Kirkpatrick. My name is Captain Charles Gatlin, and I thank you 
very much for the opportunity to participate and discuss an 
epidemic of dynamic proportions that has manifested within my 
State of Montana, the recently dysfunctional nature and 
incompetence of the Fort Harrison VA, VHA and VBA.
    I would like to submit my oral testimony annotating my 
unequivocal level of frustration with fraud, waste and abuse 
with respect to TBI systems operation and associated personal 
and professional misconduct of the Montana VA.
    The VA in Montana is experiencing problems with respect to 
accountability and patient care. While I realize that no one 
system is perfect, at what point do senior echelon staff and 
officials choose to ignore, even mitigate, major concerns 
brought to their attention by qualified veterans? To neglect 
these forces of action, which could be construed as the 
equivalent of fraud, waste and abuse to the veteran, and will 
only cost the American taxpayer a tidy sum, to place an 
additional social and emotional burden on our nation's 
returning wounded, their families, and particularly those with 
varying levels of TBI and other injuries.
    Montana has a very challenging geography that already makes 
sustained access to care difficult. But to compound these 
issues with gross incompetence, neglect, and cutting corners is 
a tremendous disservice to our veterans perpetrated by staff at 
Fort Harrison and other regional offices.
    Ladies and gentlemen, this needs to be corrected, and this 
needs to be corrected immediately.
    To bring attention to the severity of the potential 
criminal nature of these acts, I will briefly highlight several 
observations within the Montana, Salt Lake, Denver VA offices 
and how their collusive interactions have led me to be sitting 
here before you today.
    Within the Montana VA, physicians are knowingly operating 
outside the scope of their licenses, which results in 
intentional and systematic lowering of the quality care and 
disability ratings. As an example, one such clinician, Robert 
J. Bateen, Ph.D., made clinical conclusions outside the scope 
of his expertise. In the eyes of the VA, this is acceptable. 
However, he was in violation of several tenets of his license 
by his peers at the Montana State Board of Psychologists.
    When Dr. Trena Bonde, the Medical Chief of Staff, was 
approached with this objective and factual information, along 
with a request for formal and informal reviews, the veteran, 
myself, was referred to a VA attorney. I ask you, is this how 
we treat wounded vets? Substandard care and the argument that 
the VA is immune to state oversight, ethics, and administrative 
policies? Sadly, this type of behavior and disregard for 
patients and veterans are common occurrences within the Fort 
Harrison system. When veterans must be proactive and seek 
administrative recourse to correct injustices, they are ignored 
and told they are attacking the VA.
    When I asked to see an M.D. to administer a proper 
diagnosis, why am I referred to a VA regional counsel, Jeff 
Stacy? When veterans seek recourse through varying levels of 
leadership and appointed directorships such as Willy Clark and 
John Skelly, why are they referred to legal counsel? All of 
which, I might add, are in direct violation of internal VA 
policy, Federal code, and rules set forth by the Office of 
Regulation and Policy Management.
    When I speak with regional counsel to seek clarification 
and get a conference call between the VBA and the VHA to figure 
out what is going on, I am told I am disingenuous and faking my 
injury. Is this how the system operates?
    For all intents and purposes, I have just outlined fraud, 
waste, and abuse on the individual level, and there remains no 
accountability.
    I bring this up in hope of clarifying my position with this 
epidemic that is going on.
    Now consider this, and I will be very brief. Montana has 
the second-highest VA population in the United States, roughly 
10 percent. Couple that with a very unique population 
distribution and challenging geography and you will see why the 
transparent accountability with respect to resources and care 
become evident.
    Thank you, Chairman, esteemed members of the committee, for 
the opportunity to speak on behalf of not only service men and 
women in uniform but retirees, honorably discharged vets, 
concerned citizens, and most especially caregivers.
    Thank you for your time.
    Mr. Coffman. Thank you both. And, Captain Gatlin, thank you 
again for your service.
    Mr. Anderson, you are now recognized for 5 minutes.

                  STATEMENT OF DAVID ANDERSON

    Mr. Anderson. Thank you, Mr. Chairman and members of the 
committee. My name is David Anderson. I am from Akimel O'odham 
Tribe, better known as Gila River Indian Community. I am a 20-
year veteran. I am also an American Legion Post Commander 
within the Gila River Indian Community. I am also a Founder and 
Chairperson for O'odham veterans. Native Americans as a whole 
are the largest minority in the Armed Forces, but we are the 
least amount in utilizing our VA benefits.
    Now, saying that, the VA does help us out. I mean, they 
have come a long way in the last 10 years. But people like 
Phyllis Spears here in the Tucson VA, Mike Leone in the Phoenix 
office have helped me tremendously over the last four years 
trying to get Native Americans signed up for veterans benefits.
    I am saying that also there are--I don't want to say there 
are only problems there because there are good people here in 
the VA. So I would like to say that.
    Like I said, I received a TBI in 1987 when nobody knew what 
a TBI was. I got promoted to E7 in seven years. I was at the 
top of the Army, 1 percent of the Army on my career 
progression. But after I got a TBI, I was on every urinalysis. 
Everybody didn't know what was going on. Everybody was, like, 
``Oh, he's on drugs.'' When you go to that super-soldier and 
you are on that downward spiral, people didn't know, and I am 
glad that we are looking at this to help our veterans.
    But in saying that, 22 veterans die every day in the United 
States. We are more suicides than what we have lost in 
Afghanistan and Iraq, which is a sad thing to say.
    When I got out in 2000, I started through the VA process in 
2003. Going through that process with my mental health 
caregiver, right off the bat the VA wants to give you drugs 
instead of dealing with the situation. I was sleeping 18 hours 
a day, and when I was told, I said I don't want to sleep 18 
hours a day, I am getting more depressed, I feel like I am 
falling off what I already had, you know? And their comments to 
me were, well, either take these drugs or we are done here.
    Of course, I had PTSD, TBI, and I said, okay, I guess we 
are done here, you know? And through my faith and my tribe and 
other veterans, I fought that and fought that, and somewhat 
recovered. From alcoholism to fighting with the police, getting 
thrown in jail, I went through that whole gambit of troubles 
that we see our young veterans going through.
    I counsel young veterans on a daily basis, and I see the 
problems that we are having. I have one veteran who said he had 
talked about hurting himself, so he got a one-way trip to here. 
They took him off the gurney, strapped him down and gave him 
drugs, pushed him in a room with 12 other people.
    There is no crisis management within the VA to deal with 
these situations, and I guess that is my whole deal. PTSD is 
not a new disease or a new anything within the U.S. services. I 
mean, our Native tribes, when we went away to battle, we could 
not come back to the village for three to five days until you 
got cleansed, until you got all of this out. It is nothing new, 
but the VA does not cure people. They medicate people.
    That is where we need to look at our professional services 
and to get away from those drugs and to really deal with the 
problem here, and that is what I am here to say. We need to 
out-source those problems.
    I am trying to get an MOU with our tribal hospital and the 
VA, which the VA in pamphlets has said, oh, yes, this is the 
best thing since sliced white bread. But they only want to pay 
for in-source kind. All tribal hospitals are small in size. We 
out-source things. We don't have a cardiologist. We don't have 
a bone specialist. We out-source them. But the VA is still not 
willing to pay for those out-sourcings.
    We don't have the time, like these people are saying, to 
get these people proper medical treatment without the out-
sourcing. We can't send them to the VA because they will never 
be seen, and that is why we are looking to out-source them, our 
Native American veterans, to get the proper treatment.
    I guess I would look at this committee for help on that 
because, as veterans, like I said, we are the largest minority 
in the Armed Forces, and this is what we need, is to be able to 
out-source and to help our veterans. As we all know, most 
Native American communities are alcohol and drug abuse, which 
is not helping our veterans. But I think if we are allowed to 
out-source them to get them the proper treatment, then as 
Native Americans go, I think we would be a lot better off than 
trying to send them to a veterans hospital where there is no 
help. They are over-burdened. They are over-booked.
    I come from the Grande Office. We have one doctor for over 
5,000 patients. We had two more doctors come in. I got to see 
my new doctor. He was there for three weeks and then left. I 
have no idea who my new doctor is, or have I ever seen him 
because the snow bird is right here, and getting an appointment 
when they are here is non-attainable.
    I would like to say on my family side, my father put in 26 
years. I have two brothers. All three of us retired from the 
military. My son just graduated AIT at Fort Huachuca, and he is 
going to Colorado, Fort Carson, 10th Special Forces Group. So, 
I am saying that.
    I thank the committee for letting me address you. Thank 
you.
    Mr. Coffman. Well, Mr. Anderson, thank you so much for your 
service, for the service of your family.
    Mr. Coffman. Mr. Boales, you have 5 minutes. Thank you.

                   STATEMENT OF JERRY BOALES

    Mr. Boales. Chairman Coffman, Ranking Member Kirkpatrick, 
and members of the committee, my name is Jerry Boales, and I am 
the Director of Rock Soldiers for Wounded Warrior non-profit. 
Here in Arizona we service wounded warriors here in Arizona. 
Anyway, the testimony I am going to give today is the first 
time I have spoken openly about my personal experiences 
concerning this issue.
    In 1989, I was stationed in the U.S. Army at Fort Riley, 
Kansas. During my time there I was attacked by three male 
soldiers, grabbed and pulled in a room. I was forcibly held 
down by two of the males while one forcibly raped me. I was 
then raped by the second male. The third male did not do 
anything except hold me while this was going on. I was told 
that if I said anything, I would be killed. I was in so much 
pain and shock that basically I was dragged to the stairs and 
was thrown down a flight of stairs, 20 stairs, and left alone. 
I passed out and woke up by the cadre. I could not move, so 
they sent me to the hospital on base. I became paralyzed 
emotionally, which I literally had to have a cattle prod taken 
and pressed on my feet to bring me out of the paralysis 
condition.
    At this time I was so ashamed about what had happened that 
I did not report this incident, and I even told my father that 
I had slipped down some stairs and broke my arm. I had spent 
several days in the hospital for this incident, knowing that I 
had been raped.
    In 1990 I was discharged from the Army, so for the next 16 
years I kept this to myself. I was married, had three children, 
and one night because of a nightmare, something snapped within 
me. The nightmares became so bad that I could not sleep and 
literally I was a walking zombie for not allowing myself to 
sleep. Finally after six years, I started seeing a nurse 
practitioner/counselor at the Show Low VA. I told her my story, 
and after a year she left and I had to see someone else. I 
would have to start all over again, which I just couldn't do.
    So after about a year and a half, my wife encouraged me to 
seek help once again. I was really not wanting to talk to a 
male doctor about my experiences. I wasn't getting any better, 
so I did go back to the VA. I saw a physician, Dr. Davis. He 
could prescribe medications, so I continued to see Dr. Davis 
for almost two years. This was one-on-one counseling visits.
    This time, I was recommended by Dr. Davis to submit for 
PTSD, depression, unemployability, which he documented, and I 
can also add that in his notes he related the military sexual 
trauma. I was denied PTSD relating from the military sexual 
trauma due to lack of evidence. However, I was service 
connected for depression 100 percent temporary, to be 
reevaluated after two years. I was originally denied Social 
Security disability twice, which took over another two years to 
get that approved through the use of a lawyer. This was because 
I could not work and was already diagnosed as chronic 
depression by the Veterans Administration.
    I lost my family. I found myself living in a cabin as a 
recluse in Show Low almost two years. Before the cabin, I lived 
in a room in my ex-wife's home which I shut myself in and went 
out only after people were not around. I shopped at Walmart at 
2 a.m. so I did not have to see people. I would go fishing at 
daybreak before anyone would be there.
    In August of 2010, my son serving in the Army had been 
wounded in Afghanistan. He broke his neck, shattered his leg. I 
spent from August 2010 to November 2010 at Brooke Army Medical 
Center during my son's recovery. It was just me there with him. 
We had a lot of time to talk, but one of the last things he 
said to me during these conversations was, ``Dad, promise me 
that you go seek help,'' which I did after returning to Show 
Low, and I contacted the Tucson VA, not the Phoenix VA, the 
Tucson VA.
    I requested to make arrangements to get into the inpatient 
substance abuse program. February 2011 was the quickest time 
that I could go there, which I did. I stayed inpatient for 
three months and was finally able to get into the military 
sexual trauma inpatient group, which is a one-year program. So 
after being inpatient for three months at the VA Medical 
Center, I then left and would live in Casa Grande. I would 
commute once a week to Tucson for my group sessions. I did this 
for nine months. The group counseling was very intense, 
starting with a group of eight male veterans ranging from the 
Korean War, Vietnam, and current war. We ended with three 
finishing the program due to the intensity and having to relive 
the actual experiences.
    Currently, today I see a therapist at the VA CBOC clinic in 
Casa Grande averaging every two weeks since October of 2013. I 
have submitted three times to the Veterans Administration for 
PTSD related to the military sexual trauma. I have been denied 
three times because of lack of evidence. I did not speak up 
when this rape occurred. I was too ashamed.
    I want to acknowledge the Veterans Administration for 
finally recognizing that military sexual trauma is and has been 
an ongoing problem. However, being recognized is one thing; not 
being service connected and compensated with benefits is 
another. This feels that it is a slap in the face, like it 
never happened. If it is only being recognized for treatment, 
then the VA is only putting a Band-Aid on the problem. I am 
speaking for all male veterans who are going through these 
difficult experiences of military sexual trauma, as well as 
females too.
    I realize that military sexual trauma is very difficult for 
anyone to talk about. But more and more, we are now seeing 
these experiences come out in the limelight. What is needed 
now? We need fair evaluation of personal stressors and 
physician diagnoses to service-connect and give our veterans 
benefits, what they deserve and, most important, need.
    I would also like to comment on the veteran access to 
medical care, especially in the rural areas, based on my 
experiences. I first want to bring up that when I was in the 
military sexual trauma program for that nine months in 
outpatient, I had to drive 70 miles one way to attend sessions, 
Casa Grande to Tucson. This is 140 miles roundtrip. Even today, 
to continue the military sexual trauma individual or group 
counseling, I would still have to drive that distance. The 
program is good; the distance is not for any veteran in this 
situation.
    I might add, even in Show Low, if it was to see a 
specialist for my knee or shoulder, I would have to travel to 
Phoenix, which was almost 400 miles roundtrip. Living in a 
rural area, I would like to see more specialists and physicians 
that can do immediate care, not having veterans constantly 
trying to get appointments. I recently had to deal with the 
same problem----
    Mr. Coffman. Mr. Boales, you are over time. Please sum up. 
Thank you.
    Mr. Boales. I would like to see a fully staffed VA clinic 
and maintain that VA staff to assure myself and all veterans 
quality health care in a reasonable timeframe. I also recommend 
a vet center in this area that veterans can go to and seek 
counseling for PTSD, TBI, sexual trauma and concerns related to 
these issues. It is important to me, and I know it is important 
to every veteran living in the Casa Grande Valley.

    [The prepared statement of Jerry Boales appears in the 
Appendix]

    Mr. Coffman. Thank you, Mr. Boales. Thank you for your 
service.
    Mr. Davison, you are now recognized for 5 minutes.

                   STATEMENT OF JOHN DAVISON

    Mr. Davison. Thank you, Honorable Chairman Coffman, Ranking 
Member Kirkpatrick, Ms. Sinema. It is a pleasure to be with you 
today. I am here representing my son, Lance Clinton Davison, 
who is deceased, who we lost recently, just before sunrise on 
February 9th, Sunday, February 9th. He succumbed to his wounds 
that he received in two wars, Afghanistan and Iraq in the 
Middle East, and he took his life.
    I have submitted written testimony to the subcommittee with 
addendums that appropriately characterize and honor my son and 
his service to his country. But in the few minutes that I have, 
I wanted to read a letter that Lance had written in his defense 
to the Superior Court of Maricopa County about two years ago, 
and I think it pretty well sums up his circumstance and his 
frustration with not only the military and the VA but also with 
himself. So I will read that now.
    ``My name is Lance Davison. I am writing and petitioning to 
have my judgment set aside or vacated; also to reinstate my 
right to bear arms for employment purposes. I understand the 
initial severity and the potential of my actions on the night 
in question. It changed my life and deeply affected others. 
However, I contend this incident is a result of psychological 
stress from years of service to my country and community.
    ``I am a United States Marine in a Special Operations Unit 
known as MARSOC, Marine Special Operations Command, with nine 
years of service and multiple deployments to Afghanistan and 
Iraq. I was decorated multiple times for my actions. I was 
formerly a police officer, with citations for my actions in 
line of duty.
    ``For nearly seven years, my country asked me to perform 
acts of violence on its behalf. I have lived and experienced 
life well outside the normal human condition. I firmly believe 
there exists a mental threshold that each man owns. I may have 
spent mine.
    ``I developed a condition commonly referred to as PTSD. 
Years in combat zones have left me wounded both physically and 
psychologically. I have witnessed war on a very personal level, 
and have even become comfortable with it. When I returned home 
I was diagnosed with PTSD and immediately placed on drugs, in 
my best interest. My wife at the time was concerned that I had 
changed, and maybe the drugs would help.
    ``Post-traumatic stress was amplified after a shootout as a 
police officer in which I nearly lost my life again. I don't 
fault the professionals at the Veterans Administration. I was 
kept on a regimen of drugs that have psychotropic properties, 
drugs I have found I was very sensitive to. The administering 
of drugs started after my last deployment after I sustained 
injuries in combat. These drugs were DoD approved.
    ``However, upon my discharge from the Marines, I was given 
another set of drugs through the Veterans Administration. Each 
regional hospital has its own formularies or set of drugs 
doctors administer, so the experimentation began to find a 
cocktail that doesn't upset my mental chemistry.
    ``So when I moved from the Northern Arizona Health Care 
System to the Phoenix Regional Health Care System, I was 
administered a new cocktail of sleep aides, antidepressants and 
drugs that classify as psychotropic. By the time I was finally 
pulled off the drugs and it was deemed that I was too 
chemically sensitive, I had 32 different cocktails, 32 
different combinations of drugs.
    ``The circumstances I found myself in was that I never had 
a consistent care provider. People would leave and move on to 
other jobs, so there was no safety net. Episodes would occur, 
and it was always attributed to PTSD. No one immediately 
examined the pharmaceuticals.
    ``On some level, PTSD was a major factor, but there was 
these drugs that were constantly changing. The dosages would 
increase, other drugs would be added, until I could barely 
function.
    ``I was taken off the drugs after there was concern that 
TBI, traumatic brain injury, may be causing some of the 
symptoms. After six years of being on medication, I stopped. 
That was February 8, 2011. No one fully knows the effect of 
these pills on an individual with blast injuries.
    ``There is also a condition called serotonin syndrome. Like 
any other drug, a detox period is needed. I had severe 
withdrawal. My mind was frayed. In no other state would I ever 
burn my porch and driven my truck into a pool. I was 
hallucinating and was simply reliving my time in Iraq in 2003.
    ``I experienced a dissociative episode that involved my 
brain's inability to produce serotonin and other regulating 
chemicals. I urge you to read the medical records provided. I 
was drinking, and for that immediately the onus shifts. I was 
attempting to alleviate my symptoms and the kaleidoscopic 
mental circus. I have taken responsibility for my actions and 
poor decision to self-medicate with alcohol. I have taken 
responsibility for handling my situation and my condition 
poorly. I went above the court's recommendation and spent 50 
days in an inpatient PTSD and alcohol treatment program.
    ``However, just like in combat, there are no right answers. 
You just search for the best answer. This incident wasn't born 
of malice or criminal intent, just an unfortunate sequence of 
events and an old, broken Marine trying to make sense of it 
all.
    ``I ask the court to vacate or set aside the judgment and 
reinstate my right to bear arms so I can continue with my 
profession, move forward as a successful, functioning, and 
contributing individual.
    ``Thank you for your time and consideration.''
    So from that point on, Lance took charge of his life. He 
created his own disabled veteran-owned business and was doing 
well, and we were all very blindsided by the tragedy that 
struck him because we thought he had been making such positive 
improvement. But it is obvious, as you can see, his past just 
was very problematic.
    So I hope that the subcommittee will take these issues very 
serious, and the best way to honor Lance and military personnel 
like him, veterans that have PTSD and TBI, is to correct the 
problem so that no other young men or women have to make this 
choice, because I do believe that Lance's character is firm and 
that he just didn't want to become what it was making him, so 
he had to make a choice.
    Thank you.

    [The prepared statement of John Davison appears in the 
Appendix]

    Mr. Coffman. Mr. Davison, thank you so much for your 
testimony and for the service of your son, and I am very sorry 
for your loss.
    Mr. Hazell, you have 5 minutes.

                  STATEMENT OF BRADLEY HAZELL

    Mr. Hazell. Thank you, Chairman Coffman, Ranking Member 
Kirkpatrick, Representative Sinema. Thank you very much for 
having me here today.
    I served in the Marine Corps from 1999 to 2005, where I 
served two tours in Iraq. During my second tour in Iraq as an 
infantry squad leader, my squad was hit by two IEDs, the second 
of which killed one of my Marines and wounded three, myself 
included.
    Upon returning to the States, I resumed my life and 
returned to my civilian job. I had already started to struggle 
with PTSD symptoms. Within a year of being home I had gotten to 
the point where I was self-medicating with alcohol daily. 
Eventually I came to the conclusion that I could no longer deal 
with these issues myself, and one night I called the Veterans 
Crisis Line. The following day I went to the closest VA clinic, 
which was located in Alexandria, Virginia. I was extremely 
fortunate that, due to my desperation, the VA counselor saw me 
that day even though I had not yet been enrolled in the VA 
system.
    I began weekly sessions with a counselor and had monthly 
appointments with a psychiatrist. Eventually I agreed to be 
treated at an inpatient facility located in Martinsburg, West 
Virginia. First I was treated for alcohol abuse, and then I was 
treated for PTSD. Unfortunately, due to the intense emotions 
that accompanied the PTSD program, I withdrew myself and 
returned to work. Within a year I decided to return home to 
Arizona, when I moved to Phoenix. I was given a three-month 
supply of medications with instructions to enroll in the VA 
Health care System upon my return.
    Upon arriving in Arizona, I immediately began looking for 
work. I had two jobs, both of which lasted two months. I ran 
out of my medication and attempted to manage my PTSD on my own. 
After being without medications for over a month, I became 
emotionally distraught and finally enrolled in the Phoenix VA 
Health care System. When I attempted to make an appointment to 
be seen by a psychiatrist so I could resume my medication, I 
was informed that I had to wait at least a month, if not 
longer. At this point, I had already been without medication 
for two months.
    I pleaded with the hospital to see if they could at least 
refill my prescriptions that I had when I had been living in 
the DC area. The Phoenix VA Hospital's solution was to treat me 
inpatient at their mental health ward. This only made matters 
worse. Within three days I demanded to be released and signed 
myself out of the hospital. The doctor refused to put me on the 
same medication, stating that some of the medications were not 
in the Phoenix VA Health care System's formulary.
    After leaving the mental health ward in Phoenix, I moved in 
with my mother in Casa Grande. Living in Casa Grande, I was now 
in the jurisdiction of the Southern Arizona VA Health care 
System. My experience has been much better since. I was seen 
within two weeks by a psychiatrist at the Tucson VA Hospital 
and started therapy with a counselor at the Casa Grande 
Community Based Outpatient Clinic. The Southern Arizona VA 
Health care System fell under yet another formulary, and they 
were able to put me on the same medications that I was on while 
living in DC. Over several years my medication was decreased 
and I vastly improved.
    Unfortunately, PTSD hits in waves. I missed an anniversary 
date from an incident in Iraq during which several Marines from 
my unit were killed. This sent me into a severe depressive 
episode. I canceled my appointments with my counselor and my 
psychiatrist. After several months of this depressive episode I 
eventually tried to take my own life by overdosing on a three-
month supply of sleeping pills. I awoke several days later in 
an intensive care unit and was then transferred to the Tucson 
VA mental health ward, where I stayed for several weeks.
    Prior to discharge, a safety plan was implemented and I was 
placed on a high-risk list with the VA Health care System. That 
being said, when I was discharged and I first tried to make a 
counseling appointment when I left the hospital, I was told it 
would be several weeks until I could be seen. When I informed 
the receptionist about my recent hospitalization, she saw the 
flag in the system and I was seen several days later.
    I remained on the high-risk list for several months until 
my mental health care providers deemed that I was safe to be 
taken off. Since that time I began working as a veterans' 
advocate, helping veterans navigate the Veterans Benefits 
Administration. To this day, I am still treated by the Southern 
Arizona VA Health care System.
    Thank you very much for your time.

    [The prepared statement of Bradley Hazell appears in the 
Appendix]

    Mr. Coffman. Mr. Hazell, thank you so much for your service 
to the United States Marine Corps, to this country.
    We will begin our round of questions.
    Captain Gatlin, you were examined by three Department of 
Defense physicians over the course of three years and received 
a 70 percent disability rating for mild TBI when you were 
medically retired. How do you explain the 10 percent rating by 
the Veterans Administration?
    Captain Gatlin. Honestly, I can't. I am still up in the air 
with it. I just can't believe it.
    The way the VA works I think with the C&P exam is you have 
I think it is an hour video that you watch, and you have to 
post back questions on the Internet. We could all take it right 
now and we could all see patients because you don't have to 
have a license to do it. I think that is a huge issue, first 
and foremost.
    Two, I think that the VA--and I can't really speak to the 
larger picture, just the Montana, Helena VA, the Fort Harrison 
VA. Their system intentionally lowered ratings. They are using 
faulty tests, and they know it. Hopefully, that will come out a 
little bit later.
    And three, I think it is this. We all watch sports I guess 
to some extent, and if you ever keep up with the NFL, it 
changes. You have head concussion rules coming out there now. 
The kickoff has been moved. They are talking about moving the 
extra point, which I am totally against, by the way.
    [Laughter.]
    Captain Gatlin. But when you look at the VA, with the 
quality of soldiers coming back, some of their socioeconomic-
geopolitical problems, something has to change. I mean, I don't 
know when these rules were put in place, but they have to 
change. They are not progressive, and they are so dug in. When 
you come in to get them, they tell you that you are attacking. 
I mean, what is a young soldier, let's say 18 to 22 years old, 
TBI as a secondary injury behind a more primary life-
threatening injury, married, a couple of kids, living in the 
middle of nowhere Montana, what are they going to do? I mean, 
maybe they don't have the initiative or the attitude that I 
have sometimes--I get criticized for it a lot--to be able to 
come forward and stand up for themselves and stand up for 
others.
    So what they are doing, Congressman, is they are 
systematically lowering ratings and keeping their fingers 
crossed that nobody says anything about it.
    Mr. Coffman. Mr. Duplisea, VA has proposed diminished 
funding for TBI treatment. Please describe the Wounded Warrior 
Project's reaction to this proposal, if there is a position.
    Mr. Duplisea. We consider the proposed cut in funding 
troubling. One big reason for that like I said in the 
testimony, is that Congress--you--have already enacted a law, 
that requires VA to improve long-term TBI rehabilitative care. 
We want VA to implement that law. Like I said in the testimony, 
when someone is suffering from a TBI--and I had a severe TBI, 
and clinicians use the word ``plateau,''that suggest there's no 
room for further improvement. Personally I just don't believe 
in that word in someone with a TBI. The brain is the most 
complex organ in the body. I think it is hard for a doctor or a 
clinician to say that someone has plateaued when that warrior 
inside knows they have not plateaued.
    And what is to say, too, that after that warrior has gone 
through step-by-step-by-step help, and we stop it, that warrior 
will not regress?
    Mr. Coffman. Ms. Del Negro, can you briefly describe the I 
guess it is RBANS--and I understand that is Repeatable Battery 
for the Association of Neuropsychological Status--assessment 
tool and how it was misused during the C&P examination? Do you 
know if it has been used elsewhere?
    Ms. Del Negro. I am not a medical professional, but I do 
dabble a little in the medical arena. My familiarity with RBANS 
was non-existent prior to this experience, and it was only upon 
us bringing it to the attention of the Board of Psychologists 
that we learned, in fact, that RBANS is a screening test that 
is primarily used for dementia in the elderly. It has been 
studied in various different very small studies for its 
application to evaluate cognitive dysfunction in other disease 
states such as Alzheimer's, and in moderate and severe brain 
injury as well, but the results are not well established enough 
to be making firm generalizations about its use in practice.
    The psychologist who used the test, my impression dealing 
with the system is that the test was not endorsed by the 
system, the CPEP training, as my husband was mentioning before. 
Rather, however, despite the fact that he used this test and he 
used it inappropriately--for instance, the results of the 
testing actually confirmed what my husband's complaints were, 
but he disregarded those test results and attributed any 
complaints of cognitive disorder to PTSD.
    So it was just profoundly unprofessional all around, but 
the RBANS is being used or has been used previously at, I 
believe it was, the Texas VA, and that was at the admission of 
the psychologist in question, who issued in his statement that 
this was a test that had been used in other VAs, and his 
immediate supervisors condoned the test. They said he followed 
protocol.
    Mr. Coffman. Thank you.
    Mrs. Kirkpatrick.
    Mrs. Kirkpatrick. Thank you all for your testimony and for 
being here today. I have a question for each one of you. I want 
to hear from each one of you.
    We know there are multiple problems in the system, but in 
an effort to move forward in a positive way after today's 
hearing, I would just like to ask each one of you what would be 
the number-one thing the VA could have done to make a 
difference in your experience?
    And, Mr. Hazell, we will start with you.
    Mr. Hazell. Whenever veterans move from one area to 
another, the VA doesn't keep track of them. When I moved from 
DC to Phoenix, it would have been nice if there would have been 
something set in place to automatically transfer my files so I 
could have resumed receiving treatment immediately. 
Additionally, all the hospitals operate on their own 
independent system. As a result, none of them use the same 
criteria for how they prescribe medication. So once again, 
veterans have to start from scratch. Thank you.
    Mrs. Kirkpatrick. Mr. Davison.
    Mr. Davison. I just wanted to say that I think that one of 
the primary things that the VA needs to do is we need to have a 
complete and thorough investigation and review and evaluation 
and an updated strategy to deal with PTS and TBI. It is the 
signature medical condition for OEF and OIF veterans. Only 
through that kind of evaluation and scrutiny can we--we are 
learning new things every day in science and technology, and I 
think that just hasn't been applied yet and we are really doing 
old-school-type things to deal with these veterans' problems, 
and we need to come up to speed to the 21st century.
    Mrs. Kirkpatrick. Mr. Boales.
    Mr. Boales. For me, it would be keeping our rural area 
CBOCs 100 percent staffed and maintaining that 100 percent 
staffing. And even at 100 percent staffing, in certain 
departments such as Casa Grande CBOC, CBOC's physical therapy 
department, it is not staffed near enough with only one person 
to accommodate the needs of all of our veterans recovering from 
major joint surgeries in Pinal County, let alone all the other 
physical therapy needs our veterans need.
    Mrs. Kirkpatrick. Mr. Anderson.
    Mr. Anderson. A big part where that would be is don't start 
off with a big mixture of drugs, start off at a smaller dose. 
If they need a little bit more, then go from there. Don't start 
at the top and go from there, because then they want more and 
more.
    Also, I would like to see them utilize those veterans that 
are at a certain level of recovery from TBIs or PTSD, similar 
to the AA where you have another veteran that you can call that 
understands your problems, that understands what you are going 
through. You are like those people. Have a buddy system where 
he can call and you can talk about it, instead of getting 
strapped to a chair and shoved in a room and given drugs.
    One more deal on that is we have a lot of service members 
that got dishonorably discharged that aren't eligible for 
veteran care, and a lot of that is PTSD. What about those 
soldiers? Mr. Chairman, you have been in the service. You know 
that you have seen those guys come back after a conflict and 
get into trouble, whether it be DUI, alcohol abuse, spousal 
abuse, domestic violence, where they are dishonorably 
discharged from the service. That is like having a felony on 
your record. Those people also need to be looked at and taken 
care of.
    Mrs. Kirkpatrick. Thank you, thank you.
    I just have a few more minutes, so I will just quickly go 
through the last three.
    Captain Gatlin.
    Captain Gatlin. Leadership, honesty, transparency, and 
accountability. When you have a problem, maybe it is not a 
problem yet. At what point does Tier Level 1 leadership step 
down and kind of see what is going on? It is kind of like a 
general walking amongst the privates. ``Hey, what's going on?'' 
The private kind of feels better. The general has firsthand 
feedback to what is going on.
    The VA just plays the VBA against the VHA. I don't know if 
you have ever read John Grisham's ``The Rainmaker'' with the 
great benefits, but that is the VA. That is how they operate. 
And you, if you don't have the initiative or the resources, you 
get pushed out and you get frustrated when all these things 
these gentlemen were just talking about start to occur.
    So leadership, honesty, transparency, accountability by 
senior echelon leadership.
    Mrs. Kirkpatrick. Thank you.
    Ms. Del Negro.
    Ms. Del Negro. I think that was very well stated in terms 
of picking which option I wanted to go with. I think I would 
just say that the system doesn't care or is not aware of the 
stresses that are being placed upon the family. When you have a 
veteran who has a deep TBI, and then the emotional underlying 
issues, then the stresses from that situation are compounded, 
and that can affect the family members and the caregivers, and 
the burden the system is placing on those families is 
ridiculous.
    So I wish that they had been able to acknowledge that and 
address it accordingly.
    Mrs. Kirkpatrick. Thank you.
    Mr. Duplisea.
    Mr. Duplisea. My experience at the Tucson VA has been 
exemplary. But for warriors, veterans outside of Tucson, I ask 
that Congress enforce the TBI law for lifetime care and give 
effective and timely care for mental health issues such as 
PTSD, depression, anxiety in warriors that exhibit suicidal 
ideations.
    Mrs. Kirkpatrick. Thank you all very much.
    Thank you for extending my time, Mr. Chairman. I yield 
back.
    Mr. Coffman. Congresswoman Sinema, you are now recognized.
    Ms. Sinema. Thank you, Chairman Coffman and Ranking Member 
Kirkpatrick, for allowing me to participate today and for 
holding this hearing in Arizona.
    Chairman Coffman, thank you for coming to our state. We 
have a very proud military tradition here in Arizona, and this 
issue is important to all of us.
    Congresswoman Kirkpatrick, you are a great champion for 
Arizona veterans.
    So I am glad that you brought the committee here to Arizona 
to hear directly from veterans.
    And thank you to our panelists. Thank you for your service 
to our country, your sacrifice, your family's sacrifice, and 
for your advocacy and courage to stand up for all of our 
nation's veterans.
    I believe it is critical that our veterans have access to 
appropriate care. Traumatic brain injury's mental health wounds 
are the signature wounds of the wars in Iraq and Afghanistan. 
But previous generations of our country's warriors also have 
these wounds. As was noted by the panel, we lose 22 veterans a 
day to suicide. It is unacceptable.
    I am also extremely disturbed by recent allegations about 
the Phoenix VA Medical Center in my district that delays and 
may cause the deaths of upwards of 40 Arizona veterans. We must 
get to the bottom of this and hold accountable those who are 
responsible.
    I think that no veteran should ever feel like he or she has 
no place to turn, and no family should lose their loved one 
after he or she returns home.
    My first question is for Mr. Duplisea, Mr. Anderson, Mr. 
Davison. You each testified to either your own experience or 
the experience of your son who developed a relationship with a 
VA professional, only for that employee to leave and for the 
veteran to have little or no warning, forcing them into either 
a start-over period or, in some cases, without any care at all 
for an acceptable period of time.
    We know that many PTSD and TBI patients don't have a 
reliable safety net. There was a veteran in my district, Daniel 
Summers, who committed suicide last summer. He had post-
traumatic stress disorder and a traumatic brain injury. He was 
first placed into group therapy, which was not an effective 
place for someone who served in classified service. Later, his 
VA professional left with no warning, and with nowhere to turn 
he committed suicide.
    My question for each of you who either yourself or your 
family member have experienced something similar, do you have a 
suggestion of what the VA could do differently to ensure that 
veterans like yourself and your son are not left in a situation 
without the mental health care professional who they formed a 
bond with and who they trust?
    Mr. Davison, Mr. Boales, Mr. Anderson, Mr. Duplisea, feel 
free, any of you, to answer.
    Mr. Davison. I think a critical component is to engage 
local communities. This would also be a cost-effective way to 
mitigate these problems for our veterans. If they worked with 
local veteran service organizations and communities and we all 
got involved, and the VA would consider out-sourcing and at 
least partially fund these type of efforts, I think it would 
bring it home for veterans.
    I know in my community there are a lot of veterans with 
PTSD, and what happened to Lance touched them deeply, and it 
was very tragic, and it shook them up, and they are starting to 
say we have to do something for ourselves.
    So if the VA would look at partnering with local VSOs and 
community groups and working together, because it is not just 
the VA's problem, it is not just the United States military's 
problem, it is our problem as a nation, and it is our duty, it 
is your moral obligation as leaders and as government officials 
to fulfill the promises that we have made to veterans. But it 
is also our duty as citizens and former veterans to come 
together to help them because, like you mentioned, 22 a day, it 
is a national tragedy and it is an epidemic that has extreme 
ramifications for the military and for our nation.
    You said it; it is unacceptable. We cannot allow this to 
continue.
    Ms. Sinema. Thank you.
    Mr. Boales.
    Mr. Boales. For me, Congressman Sinema, for me and my 
personal experience, I have seen over five health care 
providers, and each one of them, the reason why I saw them was 
because one left, and so I had to see another. It was hard for 
me to talk to a male, number one. So for me, the providers 
looking at the charts and reading up on the charts and knowing 
the patients, talking to the previous provider, knowing that 
this gentleman is not comfortable in certain situations.
    Two, maintaining staffing.
    And three, again, it is so imperative for me--all my care 
for the last 24 years, I have been in the Tucson VA system, 
which has been great, and I have been in the Phoenix VA Health 
care System, and the rural Health care system is so 
understaffed for the care that is needed.
    Telemed. For me, I cannot do Telemed, and that is provided. 
It is not one-to-one conducive to speak about. So that is not 
an option for me. So I am looking at 140 miles if I want to 
continue care, and I do the best I can.
    So staffing, reviewing the charts, knowing the patient, 
this gentleman is not going to be comfortable with a male. And 
yet, that is who I get. So I stopped.
    So that would be my suggestions.
    Mr. Anderson. And I am pretty much on those same 
sentiments. Like I said, my first health care provider, she 
basically told me when I first started was from Monday at 8:00 
to Friday at 5:00, that is when she was on the clock, because I 
asked her to review some tests, psychological tests that I 
received. And talking to that psychologist in Phoenix, it was 
supposed to be an hour-and-a-half test. It turned out to be six 
hours, because he kept giving me these tests and he was telling 
me stuff about my life that made so much sense. And he said, 
well, I am contracted through the VA, I can't really treat you, 
because that was kind of crossing the line there. Get with your 
health care provider.
    So that was sent to her on Friday. I had an appointment 
with her on Monday. I was all excited to see her, and she said, 
well, I didn't review that because I don't work on the 
weekends. It was that type of attitude that just kind of shot 
me down.
    And then like he was saying, the teledoc, he doesn't care. 
I mean, okay, you know what? You don't want to take my meds? 
Then, you know what? We are done here, so we stopped.
    The big problem I see is that when we do have--especially 
our young soldiers. I speak a lot for our young soldiers. When 
they come in there and they have a problem, most of them have 
young families. And if there is alcohol, drugs, got out of the 
military, having trouble at home--because that is what PTS 
does, you know? All those little problems keep piling up and 
piling up, and you are digging that hole, and you are digging 
that hole, and it takes the VA so long to recognize it and to 
try to get them some help, whether it be psychological or 
financial.
    Meanwhile, that guy is going to China. He is digging this 
hole, and it is going deep, and there are a lot of problems out 
there with our younger veterans, and we are not doing nothing 
about it.
    Ms. Sinema. Thank you.
    Mr. Duplisea. Well, the VA is a very complex system, and 
problems with the health care are also very complex, and there 
is no silver bullet or cure-all for these issues. But for me it 
comes down to staffing, and it also comes down to the 
accessibility of mental health care here in VA. You have to 
have invested proven staff that are invested in helping 
veterans, helping warriors with mental health issues.
    Here at the Tucson VA I have been very fortunate to have 
that since I came here in 2008, but it is not the same 
everywhere. I came here and I had one mental health clinician, 
then I went to another one, and they were very accommodating 
because I was working during the day and I couldn't make the 
appointments. I asked if they had a plan in place where they 
could help me to come after hours, and they did have a 
clinician who accommodated that, and I greatly benefitted from 
that counseling that I received. Actually, it lowered my severe 
PTSD to mild PTSD, from 50 percent down to 10 percent.
    So I am proof that the system does work, again here in 
Tucson, Arizona, but it is not the same everywhere. Tucson is 
the model and it is an exception, but all VAs should be just 
like Tucson.
    Ms. Sinema. Thank you.
    Thank you, Mr. Chair.
    Mr. Coffman. Thank you.
    Panel, I would like to thank you so much for your testimony 
today, for your service to this country, and for the members of 
your family that have served this country.
    Mrs. Kirkpatrick. Thank you for your selfless courage in 
coming today and testifying. You have made history. You have 
helped the committee, given us some direction in how to move 
forward. So, thank you from the bottom of my heart very much.
    Mr. Coffman. I now would like to invite the second panel to 
come up to the witness table.
    Again, thank you very much.
    On our second panel we will hear from Dr. Lisa Kearney, 
Senior Consultant for National Mental Health Technical 
Assistance of the Office of Mental Health Operations, Veterans 
Health Administration.
    She is accompanied by Dr. Joe Scholten, National Director 
of Special Projects for Physical Medicine and Rehabilitation 
Services, Veterans Health Administration; Mr. Jonathan Gardner, 
Director of Southern Arizona VA Health Care System; Mr. Joshua 
Redlin, Licensed Clinical Social Worker and Team Leader for the 
Tucson Vet Center; and Mr. Rod Sepulveda, Rural Health Program 
Manager of the Northern Arizona VA Health Care System.
    Dr. Kearney, your complete written statement will be made 
part of the hearing record, and you are now recognized for 5 
minutes.

 STATEMENT OF LISA KEARNEY, PH.D., SENIOR CONSULTANT, NATIONAL 
  MENTAL HEALTH TECHNICAL ASSISTANCE, OFFICE OF MENTAL HEALTH 
OPERATIONS, VETERANS HEALTH ADMINISTRATION; ACCOMPANIED BY JOE 
SCHOLTEN, M.D., NATIONAL DIRECTOR OF SPECIAL PROJECTS, PHYSICAL 
     MEDICINE AND REHABILITATION SERVICES, VETERANS HEALTH 
  ADMINISTRATION; JONATHAN H. GARDNER, MPA, FACHE, DIRECTOR, 
    SOUTHERN ARIZONA VA HEALTH CARE SYSTEM, VETERANS HEALTH 
ADMINISTRATION; JOSHUA D. REDLIN, LCSW, TEAM LEADER, TUCSON VET 
  CENTER, U.S. DEPARTMENT OF VETERANS AFFAIRS; ROD SEPULVEDA, 
 RURAL HEALTH PROGRAM MANAGER, NORTHERN ARIZONA VA HEALTH CARE 
                             SYSTEM

                   STATEMENT OF LISA KEARNEY

    Dr. Kearney. Thank you, sir. First, I would like to express 
our appreciation to the first panel. Thank you for sharing your 
stories with us. And especially I am very appreciative of the 
feedback that they all gave to you, and we have taken notes on 
that and will be following up on that. We very much appreciate 
that. And to Mr. Davison in particular, our hearts go out to 
you.
    Chairman Coffman, Ranking Member Kirkpatrick, and members 
of the committee, thank you for the opportunity to appear 
before you today to discuss access to treatment for veterans 
with traumatic brain injury or post-traumatic stress disorder 
once they return home.
    I am joined today by Dr. Joel Scholten, Special Projects 
Director for the Physical Medicine and Rehabilitation Program; 
Mr. Jonathan H. Gardner, Medical Center Director at the 
Southern Arizona VA Health Care System; Mr. Joshua Redlin, Team 
Leader at the Tucson Vet Center; and Mr. Rod Sepulveda, Rural 
Health Program Coordinator for the Northern Arizona VA Health 
Care System.
    VHA provides state-of-the-art, comprehensive health care 
and support services for veterans with both combat and 
civilian-related TBI through the Polytrauma System of Care. 
Through this program, the Department continues to advance the 
evaluation, treatment, and understanding of TBI in a variety of 
ways: by, one, developing and implementing best clinical 
practices for TBI; two, collaborating with strategic partners 
including veterans' families and caregivers, veterans' service 
organizations, the Department of Defense and other government 
agencies, community rehabilitation providers, and academic 
affiliates; by providing education and training and TBI-related 
care and rehabilitation; and finally, by conducting research 
and translating findings into improved clinical care.
    This system is designed to assist veterans with TBI and 
polytrauma in a seamless transition between the Department of 
Defense and VHA. It also assists a veteran with their 
transition back to their home community through the provision 
of evidence-based rehabilitation services and care 
coordination.
    VA is one of the largest integrated health care systems in 
the United States that provides specialized mental health 
treatment for PTSD. In Fiscal Year 2013, over 530,000 veterans 
received treatment for PTSD in VA medical centers and clinics. 
VA provides care for PTSD in a variety of settings, delivered 
by more than 5,200 VA mental health providers who have received 
training in the most effective known treatments for PTSD.
    VA also operates a National Center for PTSD that provides 
research, consultation, and education to clinicians, veterans, 
family members, and researchers. The National PTSD Mentoring 
Program, which works with every specialty PTSD program across 
the country, is designed to promote evidence-based practice 
within the VA.
    Southern Arizona VA serves as a polytrauma network site in 
VISN 18 and coordinates key components of post-acute 
rehabilitation care for individuals with polytrauma and TBI 
across the VISN. Since 2010, the facility has seen a 70 percent 
increase in TBI and polytrauma visits completed via TeleHealth 
with veterans residing in rural and highly rural areas, making 
up as much as 37 percent of the overall rehabilitation workload 
in Fiscal Year 2013.
    Southern Arizona has also worked closely with community 
partners to develop multidimensional programs such as the 
Adaptive Sports Program, the VISN 18 Program for Managing 
Veterans with Complex Pain, a Vision Therapy Clinic, and the 
Headache Management Clinic.
    Southern Arizona's VA Polytrauma Network site also engages 
with the Arizona Governor's Council on Spinal and Head 
Injuries, the Arizona Coalition for Military Families, the 
University of Arizona, Pima Community College, the Arizona 
Department of Economic Security, and others to better serve the 
vocational rehabilitation goals of injured veterans.
    On August 14th, 2013, Southern Arizona VA hosted a mental 
health summit with over 90 community participants. Southern 
Arizona VA will be hosting another mental health summit in 
August with a focus on mental health access.
    Southern Arizona VA provides comprehensive mental health 
services, which also includes primary care mental health 
integration. This program supports primary care PACT by 
providing a mental health psychiatrist and a team of social 
workers who are co-located in the primary care clinics. In 
Fiscal Year 2013, this program served over 5,000 unique 
patients with nearly 16,000 clinical encounters.
    In addition to providing a wide range of social and 
psychological services to eligible veteran service members and 
families, the Tucson Vet Center also provides community 
outreach, education, and coordination of services with 
community agencies.
    In closing, first let me apologize, Congresswoman Sinema. I 
did not recognize you earlier. We are glad that you are here 
today.
    VHA provides comprehensive health care and support services 
for veterans with both combat and civilian-related TBI and 
PTSD. The VHA is continually working to further enhance these 
services through quality improvement initiatives, and we are 
grateful for the support of Congress and our community partners 
to assist us in these endeavors.
    Mr. Chairman, this concludes my testimony. Thank you for 
the opportunity to appear before you today. At this time, my 
colleagues and I are pleased to respond to any questions you 
may have.
    [The prepared statement of Lisa Kearney appears in the 
Appendix]
    Mr. Coffman. Thank you for your testimony.
    Dr. Kearney, the Administration's budget request for Fiscal 
Year 2015 is for $229 million for TBI medical programs, down 
1.3 percent from Fiscal Year 2014, the current year. In light 
of this reduction, how will VA ensure that veterans with TBI 
receive quality care and are not short-changed as they live 
with their disabilities?
    Dr. Kearney. Thank you. Mr. Chairman, we are very committed 
to continuing good care for each of these veterans. I would 
like to refer this question over to Dr. Scholten, our expert in 
traumatic brain injury.
    Dr. Scholten. Mr. Chairman, thank you. And again, let me 
thank the first panel for their testimony today. We do take 
their experiences back to VA central office, as well as to the 
medical centers where we practice, in order to improve our 
practices.
    In regards to the budget for traumatic brain injury care in 
VA, we have seen, fortunately, a decrease in the number of 
severely injured service members requiring inpatient 
rehabilitation from combat-related injuries. That does 
significantly affect the overall cost or the overall 
expenditure of TBI care.
    In Fiscal Year 2013, we were down to 54 foreign theater 
injured combat wounded that were treated in our polytrauma 
rehab centers. That was down from 132 in Fiscal Year 2012.
    When we look at all of the cases, all individuals with a 
TBI diagnosis in the system, there has been a significant 
downward trend in those individuals where the cumulative cost, 
the annual cumulative costs are greater than $50,00 per fiscal 
year. So in the OEF/OIF/OND population, that has gone down from 
4.9 percent in Fiscal Year 2010 to 3.6 percent in Fiscal Year 
2013, which results in a significant decrease in total 
expenditure.
    Similarly, the percentage of non-OEF/OIF TBI cases with 
care costs greater than $5,000 per year have also decreased, 
down from 12.2 percent in Fiscal Year 2010 to 10.5 percent in 
Fiscal Year 2013. We feel that, in relation to the care that is 
being provided, we know that DoD has stepped up their efforts 
to identify individuals with traumatic brain injury. We know 
from the Congressional Budget Office that costs for TBI care 
decrease over time. So the first year is the most expensive, 
and we feel that that is contributing to the overall decrease 
in the overall cost for TBI care despite the fact that we are 
seeing more individuals with TBI.
    Mr. Coffman. Dr. Kearney, can you explain how a veteran 
receiving 70 percent disability at the time of his military 
discharge due to a mild TBI can be reduced to only 10 percent 
by the VA? How can this in any way be considered a seamless 
transition?
    Dr. Kearney. Thank you for the question, sir. I cannot 
comment specifically about this particular case. I will tell 
you that each of our examiners are trained in a particular way 
using the training that they have put before them in order to 
reevaluate, but I can't speak to this particular case. I don't 
know the details of the case to be able to respond to that 
question.
    Mr. Coffman. Are those examiners required to be licensed in 
their respective states?
    Dr. Kearney. We have a requirement for our C&P examiners to 
be licensed. There is in the VA, for psychologists in 
particular, you can be hired as a provisional psychologist in 
which they are reviewed for two years and they have supervision 
during that time, and they must obtain licensure during that 
time before they can stay with the VA. If they do not obtain 
licensure in that time, they are under clinical supervision, 
much like our trainees.
    Mr. Coffman. I think the testimony today clearly states 
that there is a problem, and it needs to be resolved.
    Could you talk about how VA coordinates with Indian Health 
Services to ensure that Native American veterans receive 
adequate reimbursement, as well as quality medical care?
    Dr. Kearney. I don't have any particular comment on Indian 
Health Services today, but I do want to ask Mr. Gardner if he 
could speak particularly to that in the Tucson area.
    Mr. Coffman. Coordination? Sure.
    Mr. Gardner. From the coordination standpoint, again, we 
deal with the Tohono O'odham Nation, which is just south of us 
here, and we do have a coordinator that goes out on a regular 
basis, interacts with the staff of the Sells (Anqone) IH unit, 
as well as looking for veterans. We have several outreach 
efforts where, in fact, we look for veterans that are 
interested in becoming a patient of ours and go ahead and get 
them enrolled.
    We attempt to make sure with our Native American veterans 
that we are culturally sensitive. We have a program in place 
here in Tucson where we have trained over 400 staff, and we try 
to put them through a process where they learn a little bit 
about the Native American way, and they are taught by Native 
American healers, and it is important to us that happen.
    We also work closely with IHS, Mr. George Bearpaw, who is 
the regional director, and coordinate with him to make sure 
that services that eligible veterans can be connected with, we 
connect with them to make sure that transfer is made.
    Mr. Coffman. Thank you.
    Representative Kirkpatrick.
    Mrs. Kirkpatrick. Dr. Scholten, nice to see you again. You 
and I visited your polytrauma unit and you gave me a tour. We 
talked about how we could prevent losing some of these veterans 
in the transition process and that it would be really good if 
the Department of Defense would notify you before the member 
becomes a veteran.
    Are you seeing an improvement in that notification? Do you 
get medical records before the military member transfers out of 
the service?
    Dr. Scholten. Thank you, Congresswoman. I would like to 
answer that question in two parts, both from my position in VA 
central office, as well as a treating physician at the 
Washington, DC, VA.
    I think most importantly from a treating physician 
standpoint, I do get medical records as patients transition 
from DoD to VA. Some of those records are available through our 
Vista Web system within the medical records system, and I have 
been pleasantly surprised to be able to see more records even 
from care delivered in theater for veterans that have entered 
the system and maybe have gotten treatment a year or so before.
    When it comes to the most seriously injured, those 
individuals that are typically treated inpatient in a military 
treatment facility and then transitioned to one of our 
polytrauma rehab centers, that process is very seamless. We 
work very hard to introduce both the injured service member and 
their family to the receiving treatment team by use of a video 
teleconference. That allows the teams and the caregivers and 
the injured service member to talk about needs, to talk about 
transition issues and logistics of the transfer, as well as get 
to know what is going to happen when they arrive at the VA.
    In addition to that, the VA liaison that is embedded at the 
military treatment facility helps to make sure that all the 
records are available. They do a nurse-to-nurse handoff as 
well. And then some records are available in the computerized 
record system. But as a safeguard, veterans carry a hand-
delivered CD copy of all of their records from the military 
treatment facility as a safeguard.
    For those individuals that are being treated at a military 
treatment facility and living in a warrior transition unit or 
residing in a WTU, the VA military liaison that is embedded 
there will contact the OEF/OIF/OND VA program manager at the 
receiving VA and ensure that information is transferred and 
that a case manager is assigned. The goal is for the case 
manager to contact that individual before the transfer actually 
happens, as well as begin to set up appointments and coordinate 
care once they arrive at the receiving VA.
    Mrs. Kirkpatrick. And what about the drug formulary? Do you 
find that it is compatible, that you can continue the same 
course of treatment that they were receiving in the military 
when they get into the VA system?
    Dr. Scholten. That varies by patient or by individual 
veteran. There are some medications that are on the DoD 
formulary and not, for instance, on the Washington, DC, VA 
formulary. However, I think it is very important to note that 
the ordering of medications is done by the practitioner, the 
physician that is working with the patient, and there is a 
discussion about what has worked in the past, what the current 
medications are. And if a medication is not on the formulary 
that it is determined to be the correct medication, there is a 
non-formulary process that you can go through and get that 
medication. So it does work.
    Mrs. Kirkpatrick. Dr. Kearney, I know there has been a big 
increase in telemedicine, and a lot of the veterans I have 
talked to like that. But we heard in the first panel a veteran 
who doesn't feel comfortable with that. So what accommodations 
can you make for folks who really aren't comfortable talking 
with their doctor over the computer system?
    Dr. Kearney. Yes, I think that is a really important 
concern. We want to make sure that each of our treatment plans 
that we work collaboratively with our veteran is something that 
they are comfortable with. So that is part, when they are 
having those initial discussions about plan of care, are they 
comfortable with tele-mental health services, would they prefer 
group or individual treatment, asking them these different 
things.
    Another option that we are also utilizing more is some of 
the different smart phone apps that are available now--PTSD 
Coach, for example. There is also a concussion app. There is 
cognitive behavioral therapy for insomnia, for example. Some of 
these things can walk them through treatment at home if they 
don't want to come in as frequently.
    We are also looking at our staffing levels at all of our 
CBOCs, as well as the medical centers, and trying to work with 
each facility who is maybe having difficulty recruiting and 
maintaining staffing there by having individual discussions 
with our VISN mental health leads and with our staff at central 
office to see are there other things that we can be doing to 
recruit providers to those hard-to-recruit locations.
    Mrs. Kirkpatrick. Thank you. I yield back my time.
    Mr. Coffman. Thank you.
    Congresswoman Sinema, you are now recognized.
    Ms. Sinema. Thank you, Mr. Chairman.
    Mr. Redlin, prior to my time serving in public office, I 
was a licensed clinical social worker. And during my time 
engaging in direct therapeutic relationships with consumers, I 
recognize how important it is to form that relationship with a 
client. Of course, equally important is the termination phase.
    But what we heard from a number of vets and vets' family 
members today was the additional trauma that they experienced 
when finding an unexpected interruption of service delivery 
with their trusted therapist or provider.
    What action does your office take--and perhaps Dr. Kearney 
can also answer, and Mr. Gardner as well. What steps are taken 
to help vets prepare for interruption of services or 
termination from their provider and transition to a new, 
appropriate provider?
    Mr. Redlin. Thank you, Congressman, and thank you for 
having me here today.
    At the Tucson Vet Center, what I can say as far as trying 
to keep that continuity of care when we have possibly a 
counselor retiring or taking another position is get a heads-up 
on it and try and recruit, especially within. Just recently I 
can give you an example where we actually did a very good job 
with this and were able to bring on a counselor two months 
before when we knew he was leaving. Unfortunately, that is not 
the case a lot of times, so clients are left feeling that they 
have no care or their care has been severely disrupted. But 
that is typically what we do at the Vet Center.
    Were there other parts of the question I missed?
    Ms. Sinema. No, thank you.
    Dr. Kearney. Thank you. One of the things that has been 
important that we have been rolling out across the VA is that 
every veteran within mental health would be assigned a mental 
health treatment coordinator, and that person, whether they 
were giving active treatment at that time or not, would be the 
person who makes sure that if they were transitioning, for 
example, to a substance use disorder treatment program, that 
they got in, they got started, things were not dropped.
    It also helps with the creation of that seamless plan of 
care with the veteran. That treatment coordinator is 
responsible for discussing those plans. So when a provider 
would announce they are retiring or they are transitioning to 
another job, to be able to have discussions with the mental 
health treatment coordinator on next steps, and also for the 
provider to be able to have those discussions.
    But another important thing that we are beginning to roll 
out within mental health is what we call behavioral health 
interdisciplinary programs, which is providing care by team, 
much like we do in our patient-centered medical home, the PACT, 
patient-aligned care teams, in which there are three to four 
people providing care to a patient. So they are all familiar 
with that patient so that the care is not going to be as much 
disrupted because that veteran may know the treatment team at 
hand. So we are hopeful that that will help address some of 
these different things that we have heard about this morning.
    But also important is that the mental health treatment 
coordinator should make sure that the veteran gets the care he 
or she needs after that person leaves.
    Ms. Sinema. Thank you.
    Dr. Scholten, you talked about the ability for a physician 
or perhaps a psychiatrist to prescribe a non-formulary drug, in 
particular a psychotropic drug, if the situation warrants. 
However, it appears from the testimony we heard from vets and 
Lance's father, Mr. Davison, that it is not perhaps the 
standard practice in many facilities.
    Can you help us understand why different facilities have 
different formularies when those of us in the mental health 
profession know that psychotropic drugs cannot be easily 
substituted one for another, like an allergy medicine could be? 
And how can the VA system more effectively help prescribing 
physicians and psychiatrists understand the procedures to go 
off of the formulary when a situation warrants it, as in the 
case of Lance Davison and some of the other testimony we heard 
today?
    Dr. Scholten. Thank you for the question, ma'am. You are 
correct in the fact that there are differences in formularies. 
I, unfortunately, can't speak to the rationale or the decision-
making process that is made between each medical center. That 
would be a question for our pharmacy benefits group.
    In regards to medications for mental health treatment, I 
would like to ask Dr. Kearney for some help with that.
    Dr. Kearney. Certainly. One of the things that we advertise 
quite a bit to our mental health psychiatrists and other 
prescribers is the clinical practice guidelines that are 
available within VA and DoD which provide guidance on what 
medications would be best for what particular diagnoses. So 
that is one particular area that we provide guidance through 
our individuals on.
    The other thing that we are beginning to roll out is the 
Psychotropic Drug Safety Initiative. We have heard concerns, 
and we are concerned as well and want to make sure that we are 
studying how these medications are prescribed, that we are 
helping prescribers get education as needed, that we are also 
helping to monitor improvements over time. So we are currently 
rolling this out across the nation to be able to better monitor 
at each facility how these medications are being utilized.
    Ms. Sinema. Thank you.
    Mr. Coffman. There will be a second round if anybody has 
any additional questions.
    Dr. Kearney, please describe the credentialing and 
licensing requirements under VA directors for psychologists and 
other clinicians responsible for administering C&P examinations 
that involve TBI determinations.
    Dr. Kearney. So, we do have a licensing requirement----
    Mr. Coffman. Can you speak more into the microphone, bring 
it a little closer to you?
    Dr. Kearney. Oh, I'm sorry. So, there are requirements for 
any provider hired within the VA by discipline. So for 
psychologists, psychiatrists, social workers, et cetera. For 
psychologists, that includes that they have obtained a Ph.D. or 
a Psy.D., a doctorate of psychology, from an accredited 
institution, and that they have also fulfilled a formalized 
training program thereafter. We require that they have two 
years of experience before becoming full licensed psychologists 
within the VA. We have credentialing boards that review these, 
along with our--this includes human resources. It would include 
local chiefs of psychology reviewing that they meet each of 
these particular standards. If not, they are not allowed to be 
hired within the VA.
    Mr. Coffman. So what happens if they are working with the 
VA and they lose their license, their state license?
    Dr. Kearney. They would no longer be able to be employed 
with the VA. The requirement for working at the VA is that they 
maintain their licensure.
    Mr. Coffman. That was certainly not the case in Montana.
    Dr. Kearney, is the Repeatable Battery for the Association 
of Neuropsychological Status, the RBANS that was discussed 
earlier, that assessment tool, how commonly is that used by the 
VA for TBI rating determinations?
    Dr. Kearney. That I could not answer. I would have to take 
that for the record, sir.
    Mr. Coffman. Okay. Are there any consequences for officials 
failing to properly manage and supervise C&P examinations 
involving TBI?
    Dr. Kearney. As with any concern that we have about an 
administrator or employee of our organization, we would be 
addressing that through our system of peer reviews, through 
reviews by our human resources department, et cetera. I can't 
speak specifically to C&P.
    Mr. Coffman. Is VA's MIND study considered trustworthy 
given the very small percentage of available veterans who 
participated?
    Dr. Kearney. I will defer to Dr. Scholten on that.
    Dr. Scholten. We can take that question for the record. I 
am familiar with the study. One of the study sites was actually 
at the Washington, DC, VA, but I would defer to our research 
colleagues to provide an analysis of the number of subjects and 
if that reached a statistical power to make those results 
generalizable.
    Mr. Coffman. Ranking Member Kirkpatrick, any follow-up 
questions?
    Mrs. Kirkpatrick. Just one quick question.
    Dr. Kearney, we heard from our first panel that out-
sourcing to the local communities would improve care. So my 
question is two parts. First of all, do you have the ability to 
out-source? And if so, how are the decisions made when and if 
to do that?
    Dr. Kearney. And, yes, we certainly can out-source. We have 
fee basis that we can do. We certainly do contracts with 
individuals and with the different organizations outside the 
VA. One of the examples of that is in response to the executive 
order. We had 24 community pilots with Health and Human 
Services in order to expand our services. So we are using that 
as models to expand to other areas as well in our rural 
communities.
    But certainly at each facility, an administrator can look 
into fee basis. It is not based on a geographical limitation. 
It is based on a number of different things, including is the 
service even available at the VA, is there wait time for that 
service, do we need to go ahead and refer that out to the 
community.
    So, yes, we are able to do this.
    Mrs. Kirkpatrick. Thank you.
    I yield back.
    Mr. Coffman. Congresswoman Sinema.
    Ms. Sinema. Thank you, Mr. Chair.
    In his testimony in the first panel, Mr. Boales described 
receiving health care for his service-related injuries but not 
receiving a benefit or designation from that service-related 
wound. My understanding based on conversations with other 
veterans is that this is kind of an isolated incident.
    In the cases in particular of military sexual trauma or 
military sexual assault in which the survivor often chooses not 
to report the incident at the time it occurs for reasons as we 
heard today from Mr. Boales, but for a variety of other 
reasons, what does the VA do or what can the VA do to ensure 
that the survivor does receive benefits at the time that he or 
she is able to report about that service-connected injury?
    Dr. Kearney. And we are very concerned about our veterans 
who have experienced military sexual trauma and want to ensure 
that they get timely treatment to care. I can't comment about 
VBA's decisions to give disability for any particular person 
overall. So, I'm sorry, I will have to take that for the 
record.
    Ms. Sinema. I yield back.
    Mr. Coffman. Thank you, Congresswoman Sinema.
    Our thanks to the panel. You are now excused.
    Today we have had the opportunity to hear from veterans and 
their families about the serious long-term consequences of 
traumatic brain injury. We heard about the continuing 
challenges veterans have in getting access to necessary 
services for TBI. We also heard from the VHA regarding the 
health care available to veterans with TBI. I expect the VA to 
use the discussions and issues heard today to improve upon 
services provided to our veterans.
    I ask unanimous consent that all members have 5 legislative 
days to revise and extend their remarks and include extraneous 
materials.
    Without objection, so ordered.
    Mr. Coffman. I would like to, once again, thank all of our 
witnesses and audience members for joining us in today's 
conversation.
    With that----
    Mrs. Kirkpatrick. Mr. Chairman, I ask that the statement of 
Mr. Barber and Ms. Sinema's full statement be submitted to the 
record.
    Mr. Coffman. So ordered.
    Mr. Coffman. I would like again to thank all the witnesses 
and audience members for joining us today.
    With that, this hearing is adjourned.
    [Whereupon, at 2:45 p.m., the subcommittee was adjourned.]
                                APPENDIX


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



                 Prepared Statement of Jerry Boales Jr.

    In 1989, I was stationed in the U.S. Army at Ft Riley, Kansas. 
During my time there, I was attacked by three male soldiers, grabbed 
and pulled in a room. I was forcibly held down by two of the males 
while one forcibly raped me. I was then raped by the second male. The 
third male did not do anything except hold me while this was going on. 
I was told that if I said anything I would be killed. I was in so much 
pain and shock that basically I was dragged to the stairs and was 
thrown down a flight of stairs (20 stairs) and left alone. I passed out 
and woke up by the cadre, I could not move so they sent me to the 
hospital on base. I became paralyzed emotionally, which I literally had 
to have a cattle prod taken pressed on my feet to bring me out of the 
paralyzed condition.
    At this time I was so ashamed about what happened that I did not 
report this incident and I even told my father that I had slipped down 
some stairs and broke my arm. In 1990 I was discharged from the army. 
So for the next 16 years I kept this to myself. I was married, had 
three children and one night because of a nightmare, something snapped 
within me. The nightmares became so bad, that I could not sleep and 
literally I was a walking zombie for not allowing myself to sleep. 
Finally after six years, I started seeing a nurse practitioner--
counselor at the Show low VA. I told her my story and after a year, she 
left and to see someone else, I would have to start all over again, 
which I just couldn't do. So after about a year and a half, my wife 
encouraged me to seek help. I was not really wanting to talk to a male 
doctor about my experiences, I wasn't getting any better, so I did go 
back to the VA , I saw a Physician ( Dr. Davis ), he could prescribe 
medications, so I continued to see Dr. Davis for almost two years. This 
was a one on one counseling visits. This time, I was recommended by Dr. 
Davis to submit for PTSD, Depression, unemployability which he 
documented and I can also add that in his notes he related the MST ( 
Male Sexual Trauma ). I was denied PTSD relating from the MST due to 
lack of evidence. However, I was service connected for depression (100% 
) temporary to be reevaluated after two years. I was originally denied 
social security disability twice which took over another two years to 
get that approved through the use of a lawyer. This was because I could 
not work and was already diagnosed as chronic depression by the 
Veterans Administration.
    I lost my family and found myself living in a cabin as a recluse in 
Show low almost two years. Before the cabin, I lived in a room in my 
ex-wife's home which I shut myself in and went out only after people 
were not around. I shopped at Walmart at 2 am so I did not have to see 
people. I would go fishing at daybreak before anyone would be there.
    In August of 2010, my son serving in the Army had been wounded in 
Afghanistan. I spent from August 2010 to November 2010 at Brooke Army 
Medical Center during his recovery. It was just me there for him. We 
had a lot of time to talk, but one of the last things he said to me 
during these conversations was, Dad, promise me that you go seek help, 
which I did after returning to Show low and contacted the Tucson VA. I 
requested to make arrangements to get into the inpatient substance 
abuse program. February 2011, was the quickest time that I could go 
there, which I did. I stayed inpatient for three months and was finally 
able to get into the MST inpatient group, which is a one year program. 
So after being inpatient for three months at the VA medical center, I 
then left and would live in Casa Grande. I would commute once a week to 
Tucson for my group sessions. I did this for nine months. The group 
counseling was very intense, starting with a group of eight male 
veterans ranging from the Korean War, Vietnam and current war. We ended 
with three finishing the program due to the intensity and having to 
relive the actual experiences.
    Currently, today I see a therapist at the VA CBOC Clinic in Casa 
Grande averaging every two weeks since October of 2013.I have submitted 
three times to the Veterans Administration for PTSD relating to the 
MST. I have been denied three times because of lack of evidence. I did 
not speak up when this rape occurred. I was too ashamed. I want to 
acknowledge the Veterans Administration for finally recognizing that 
Male Sexual Trauma is and has been an ongoing problem. However being 
recognized is one thing, not being service connected and compensated 
with benefits is another. This feels that it is a slap in the face like 
it never happened. If it is only being recognized for treatment, then 
the VA is only putting a band aide on the problem. I am speaking for 
all male veterans who are going through these difficult experiences of 
male sexual trauma. I realize that MST is very difficult for anyone to 
talk about. But more and more, we are now seeing these experiences come 
out in the limelight. What is needed now? We need fair evaluation of 
personal stressors and physician diagnoses to service connect and give 
our veterans benefits what they deserve and most important need.
    I would also like to comment on the Veteran Access to medical care 
especially in the rural area s based on my experiences. I first want to 
bring up that when I was in the MST program for that nine months in 
outpatient I had to drive 70 miles one way to attend sessions (Casa 
Grande to Tucson ), this is 140 miles roundtrip. Even today, to 
continue the MST individual or group counseling I would have to still 
drive that distance. The program is good, the distance is not for any 
veteran in this situation. I might add, even in Show low, if it was to 
see a specialist for my knee or shoulder, I would have to travel to 
Phoenix, which was almost 400 miles roundtrip. Living in a rural area, 
I would like to see more specialists and physicians that can do 
immediate care, not having veterans constantly trying to get 
appointments. I would like to see a fully staffed VA Clinic and 
maintain that VA staff to assure myself and all veterans quality health 
care in a reasonable time frame. I also recommend a VET Center in this 
area that veterans can go to and seek counseling for PTSD, TBI, Sexual 
trauma and concerns related. It is important to me and I know it is 
important to every veteran living in the Casa Grande Valley.
    Respectfully,
    Jerry Boales Jr. 
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    
                   Prepared Statement of Brad Hazell

    Thank you for this opportunity to testify to the House Committee on 
Veterans' Affairs Subcommittee on Oversight and Investigations 
regarding ``Access to Mental Health Care and Traumatic Brain Injury 
Services: Addressing the Challenges and Barriers for Veterans''. My 
name is Brad Hazell I served in the United States Marine Corps from 
November of 1999 to June 2005. During this time period I served two 
tours in Iraq. The first tour took place during the invasion in 2003 
where I was a Scout for the 1st Light Armored Reconnaissance Battalion. 
My second tour took place in 2004-2005 where I was an Infantry Squad 
Leader for 2nd Battalion 24th Marines. During the second tour my squad 
was hit by several IEDs, one of which killed one of my marines and 
wounded three (myself included).
    Upon returning to the states I resumed my life and returned to my 
civilian job. I had already started to struggle with PTSD Symptoms. 
Within a year of being home I had gotten to the point where I was self-
medicating with alcohol daily. Eventually I came to the conclusion that 
I could no longer deal with these issues myself and one night I called 
the Veterans' Crisis Line. The following day I went to the closest VA 
Clinic with was located in Alexandria Virginia. I was extremely 
fortunate, due to my desperation, a counselor at the clinic saw me that 
day even though I had not yet been enrolled in the VA Healthcare 
System.
    I began weekly sessions with a counselor and had monthly 
appointments with a psychiatrist. Eventually I agreed to be treated at 
an inpatient facility located in Martinsburg West Virginia. First I was 
treated for alcohol abuse, then for PTSD. Unfortunately due to the 
intense emotions that accompanied the PTSD program I withdrew myself 
from the program to return to work. Within a year I decided to return 
to my home state, Arizona. I was given a three month supply of 
medications with instructions to enroll in the VA Healthcare System in 
Arizona so that I could continue my treatment for PTSD.
    Upon arriving in Arizona I immediately began looking for work. I 
had two jobs, both of which last less than two months. I ran out of my 
medication and attempted to manage my PTSD on my own. After being 
without medications for over a month, I became emotionally distraught 
and finally enrolled in the Phoenix VA Healthcare System. When I 
attempted to make an appointment to be seen by a psychiatrist, so I 
could resume my medication, I was informed that I had to wait at least 
a month if not longer. I pleaded with the hospital to see if they could 
at least refill my prescriptions that I had been when I lived in the 
D.C. area. The Phoenix VA Hospital's solution was to treat me inpatient 
at their mental health ward. This only made matters worse. Within three 
days I demanded to be released and signed myself out of the hospital. 
The doctor refused to put me on the same medication stating the some of 
the medications were not on their formula.
    After leaving the mental health ward in Phoenix I moved in with my 
mother in Casa Grande. Living in Casa Grande, I was now in the 
jurisdiction of the Southern Arizona VA Healthcare System (SAVHCS). My 
experience was much better with SAVHCS. I was seen within two weeks by 
a psychiatrist at the Tucson VA Hospital and started therapy with a 
counselor at the Casa Grande CBOC. SAVHCS fell under yet another 
formula and they were able to put me on similar medications that I was 
on while living in the D.C. area. Over several years my medication was 
decreased and I vastly improved.
    Unfortunately PTSD hits in waves. I missed an anniversary date from 
an incident in Iraq during which several marines from my unit were 
killed. This sent me into a severe depressive episode. I canceled my 
appointments with my counselor and my psychiatrist. After several 
months of this depressive episode I eventually tried to take my own 
life by overdosing on a three month supply of sleeping pills. I awoke 
several days later in an intensive care unit and was then transferred 
to the Tucson VA Hospitals Mental Health Ward where I stayed for 
several weeks.
    Prior to discharge a safety plan was implemented and I was place on 
a ``High Risk'' list with the VA healthcare system. That being said 
when I called to make my first counseling appointment when I left the 
hospital the day after my discharge; I was told that it would be 
several weeks until I could be seen. When I informed the receptionist 
about my recent hospitalization, she saw the flag in the system and I 
was setup with an appointment within a couple of days. I remained on 
the high risk list for several months until my mental healthcare 
providers deemed that it was safe to take me off.
    Since that time I began working as a veterans' advocate helping 
veterans navigate the Veterans Benefits Administration. To this day I 
am still treated by the Southern Arizona VA Healthcare System.
    Respectfully, Brad Hazell

               Prepared Statement of Dr. Lisa K. Kearney

    Chairman Coffman, Ranking Member Kirkpatrick, and members of the 
Committee, thank you for the opportunity to appear before you today to 
discuss access to treatment for Veterans who have suffered from a 
Traumatic Brain Injury (TBI) or Posttraumatic Stress Disorder (PTSD) 
once they returned home. I am joined today by Dr. Joel Scholten, 
National Director of Special Projects, Physical Medicine and 
Rehabilitation Service, VHA, Mr. Jonathan H. Gardner, Medical Center, 
Director Southern Arizona VA Health Care System (SAVAHCS), Mr. Joshua 
Redlin, Team Leader, Tucson Vet Center, and Mr. Rod Sepulveda, Rural 
Health Program Manager Northern Arizona VA Health Care System.

VHA TBI Program

    VHA provides state-of-the-art comprehensive health care and support 
services for Veterans with both combat and civilian-related TBI, 
leveraging its nationwide resources through the Polytrauma System of 
Care (PSC). Through this program, the Department continues to advance 
the evaluation, treatment, and understanding of TBI in a variety of 
ways by developing and implementing best clinical practices for TBI; 
collaborating with strategic partners including Veterans Service 
Organizations, community rehabilitation providers, and academic 
affiliates; providing education and training in TBI-related care and 
rehabilitation; and conducting research and translating findings into 
improved clinical care. In fiscal year (FY) 2013, VA invested $231 
million in TBI care for Veterans. Of this amount, $49 million was for 
care of Veterans of Operation Enduring Freedom, Operation Iraqi 
Freedom, and Operation New Dawn (OEF/OIF/OND).
    All OEF/OIF/OND Veterans who receive health care within VA are 
screened for possible TBI, and from April 13, 2007, through December 
31, 2013, over 804,000 OEF/OIF/OND Veterans have been screened. More 
than 151,000 of these Veterans screened positive for possible TBI and 
were referred for comprehensive TBI evaluations by specialty teams; 
over 65,000 of these screened Veterans were diagnosed with sustained 
mild TBI (mTBI) and received appropriate follow-on care. Veterans, who 
were initially screened positive but were later determined not to have 
TBI, were referred for medical follow up as appropriate for their 
condition. Veterans with moderate to severe TBI receive initial 
diagnosis and treatment on inpatient hospital wards. Patients who were 
diagnosed as having sustained a TBI and continued to experience chronic 
problems requiring rehabilitation and treatment received an 
Individualized Rehabilitation and Community Reintegration Plan of Care 
to help coordinate services across episodes and sites of care. In this 
way, problems that may be related to TBI and polytrauma are addressed 
early on and proactively so they can be managed effectively before they 
become chronic disabilities.
    The PSC has a four-tier design that ensures access to the 
appropriate level of rehabilitation services based on the needs of the 
Veterans recovering from TBI and multiple, co-occurring injuries (i.e., 
polytrauma). This system of care includes:

         5 regional Polytrauma Rehabilitation Centers, that 
        serve as regional referral centers for acute medical and 
        rehabilitation care and as hubs for research and education;
         23 Polytrauma Network Sites (PNS), that coordinate 
        polytrauma services within the Veterans Integrated Service 
        Networks;
         87 Polytrauma Support Clinic Teams who provide 
        specialized evaluation, treatment, and community reintegration 
        services within their catchment areas; and
         39 Polytrauma Points of Contact who deliver a more 
        limited range of rehabilitation services and facilitate 
        referrals to the other PSC programs, as necessary.

    The tiered model of the PSC helps ensure that Veterans with TBI and 
polytrauma transition seamlessly between the Department of Defense 
(DoD) and VHA, and back to their home communities through the provision 
of evidenced-based rehabilitation services and care coordination.

VHA PTSD Treatment

    VA is one of the largest integrated health care systems in the 
United States that provides specialized mental health treatment for 
PTSD. In FY 2013, over 530,000 Veterans (including over 140,000 OEF/
OIF/OND) received treatment for PTSD in VA medical centers and clinics, 
up from just over 500,000 Veterans (including over 100,000 OEF/OIF/OND) 
in FY 2011. VA provides care for PTSD in a variety of settings 
including inpatient, residential, as well as specialty PTSD outpatient 
programs and general outpatient care.
    VA provides state-of-the-art care for Veterans with PTSD delivered 
by more than 5,200 VA mental health providers who have received 
training in Prolonged Exposure and/or Cognitive Processing Therapy, the 
most effective known therapies for PTSD. Medication treatments also are 
offered and may be especially helpful for specific symptoms of PTSD.
    VA operates a National Center for PTSD (NCPTSD) that provides 
research, consultation, and education to clinicians, Veterans, family 
members and researchers. The national PTSD Mentoring Program, which 
works with every specialty PTSD program across the country is designed 
to promote evidence-based practice within VA. NCPTSD's award winning 
PTSD Web site (www.ptsd.va.gov) provides research-based educational 
materials for Veterans and families, as well as for the providers who 
care for them. To help Veterans access needed care, AboutFace, which 
can be found at http://www.ptsd.va.gov/apps/AboutFace/ was added in 
2012, is an online video gallery dedicated to Veterans talking about 
how PTSD treatment turned their lives around. Each June, NCPTSD runs a 
national campaign to raise awareness about PTSD and its effective 
treatment during PTSD awareness month. NCPTSD's Consultation Program 
was established in 2011 to reach any VA provider who treats Veterans 
with PTSD, including those in VA PTSD specialty care, those in other 
areas of mental health, primary care providers, and case managers. The 
Consultation Program helps with questions about assessment and 
treatment services for Veterans with PTSD. By the end of FY 2013, there 
were over 650 consultations completed, over 550 for PTSD and over 75 
for Suicide Risk Management, a feature added this year to the 
Consultation Program.

Interdisciplinary Pain Management

    There has been an ongoing and broadening collaborative approach 
within the National Pain Management Program Office, Rehabilitation and 
Prosthetic Services (RPS), Primary Care Services, Mental Health 
Services, Specialty Care Services and Nursing Services to educate the 
field on the stepped-care model for pain management. On December 15, 
2010, the Under Secretary for Health chartered the Interdisciplinary 
Pain Management Workgroup to assist Veterans Integrated Service Network 
(VISN) Directors in establishing which specialty pain services will be 
available to all Veterans and how best to determine the need for 
tertiary pain care and pain rehabilitation services. The Pain Medicine 
Specialty Team Workgroup, chartered on January 26, 2012, is providing 
support to Patient Aligned Care Teams (PACT)/primary care and pain 
specialty care services through collaborative care models and 
participation in provider and team education through telehealth, e-
consults, and Specialty Care Access Network-Extension for Community 
Healthcare Outcomes (SCAN-ECHO). VA SCAN-ECHO experts provide didactics 
and case-based learning to PACT members using videoconferencing 
technologies to strengthen the competencies of providers in pain 
management.
    As of January 2014, VA has ten sites in seven VISNs with Commission 
on Accreditation of Rehabilitation Facilities-accredited pain programs. 
RPS has collaborated with the Employee Education System to provide a 
wide variety of TBI and pain- related training offerings to all VA 
clinicians at their desktop via VA's Talent Management System, 
including handouts, management algorithms, video lectures and 
workshops, and training courses. Other ongoing training venues 
available to primary care clinicians and nurses include:

         Conference calls and training
         Post-Deployment Integrated Care Initiative (PDICI) 
        Community of Practice (CoP)
         Pain PACT CoP (monthly)
         PSC/TBI System of Care
         Primary Care Mental Health Integration
         Health Services Research and Development (HSR&D) 
        ``Spotlight on Pain Management'' calls
         List serve Web sites (Physical Medicine and 
        Rehabilitation Program Office Web site, Pain Management Program 
        Office, PDICI Wiki on post-deployment care)
         SharePoint sites (Primary Care Staff Educational 
        Resources SharePoint for PACT, OEF/OIF/OND National SharePoint)
         Training applications for clinicians on smart phones 
        and tablets (TBI APP available 4th Quarter of 2013 and T2 mTBI 
        Pocket Guide)


SAVAHCS Mental Health Services

    SAVAHCS, in Tucson, Arizona, provides comprehensive mental health 
services to Veterans in the Tucson metropolitan areas and Southern 
Arizona. These services include Inpatient Psychiatry, the Evaluation 
and Brief Treatment of PTSD Unit (EBTPU), Inpatient Geropsychiatry, 
Primary Care-Mental Health Integration (PC-MHI), Opioid Replacement 
Treatment, Substance Use Disorder Treatment Programs (SUD-TP), 
Substance Abuse Residential Treatment Program (SARRTP), General 
Outpatient Mental Health, Outpatient Primary Care for Seriously 
Mentally Ill (SMI) Veterans, Homeless programs, Mental Health Intensive 
Case Management (MHICM), and Psychosocial Rehabilitation and Recovery 
Center (PRRC).
    SAVAHCS monitors access to mental health clinics and programs to 
enhance access for our Veterans. Access to mental health services is 
managed through PC-MHI. This program supports Primary Care PACT by 
providing a Mental Health psychiatrist and a team of social workers who 
are co-located in Primary Care Clinics. This team provides same day 
management of Veterans' mental health concerns thus reducing time and 
location barriers to access to care. In FY 2013, the SAVAHCS PC-MHI 
served 5,168 unique patients. This included 15,699 PC-MHI clinical 
encounters and 2,752 new PC-MHI patients. In FY 2013, PC-MHI exceeded 
all Mental Health Screening performance measures related to alcohol 
use, post-traumatic stress disorder, and depression. In FY 2013, the 
Mental Health Clinic at SAVAHCS provided 28,003 encounters and treated 
7,233 unique patients.
    SAVAHCS has established strong relationships with the community. On 
August 14, 2013, SAVAHCS hosted a Mental Health Summit which focused on 
coordination of care for homeless Veterans, and access to mental health 
services for Veterans and their families. Over 90 community 
participants attended this summit and provided valuable information 
about resources available to Veterans in the community. SAVAHCS will be 
hosting another Mental Health Summit in August 2014 with a focus on 
mental health access. In addition, SAVAHCS will be hosting a Homeless 
Summit in May 2014 which will bring together community partners and 
SAVAHCS staff who work with the homeless. This summit will provide an 
avenue for developing further outreach activities. SAVAHCS is also 
participating in the ``25 Cities Initiative'' which is a collaborative 
effort between local community leaders, SAVAHCS, VHA's Homeless Program 
Office, and our Federal partners, the Department of Housing and Urban 
Development and U.S. Interagency Council on Homelessness. The goal of 
this initiative is to identify and prioritize community resources and 
assist communities in removing barriers.
    Our Supportive Education for Returning Veterans (SERV) program 
provides credit-bearing courses for student Veterans utilizing their GI 
Bill benefits to increase retention and successful graduation rates at 
the University of Arizona. SAVAHCS' SERV program is a best practice, 
and this model has been adopted at colleges and universities throughout 
the country, including the Universities of South Dakota, New Mexico, 
and Mississippi State University. SAVAHCS staff are currently 
consulting with the Universities of Montana, South Carolina, Rhode 
Island, Rutgers University, and Massachusetts Institute of Technology 
to help with the development of SERV programs at these institutions.
    The EBTPU is a unique program in VA. It provides evidence-based 
treatment to cohorts of six Veterans struggling with combat-related 
PTSD. The program is administered over 4 weeks in an inpatient setting 
and accepts referrals from all over the country. Outcomes data have 
demonstrated sustained reductions in PTSD symptoms and high levels of 
Veteran satisfaction.

SAVAHCS' Polytrauma Network Site (PNS)

    SAVAHCS serves as the PNS in VISN 18 and coordinates key components 
of post-acute rehabilitation care for individuals with polytrauma and 
TBI across the VISN. Since 2010, VISN 18 has experienced a 47 percent 
growth in the number of Veterans treated in polytrauma clinics. The 
VISN has improved access to interdisciplinary teams of rehabilitation 
specialists, case management, and psychosocial support services. 
Rehabilitation services for TBI include screening, comprehensive 
evaluations, and interdisciplinary treatments that promote independence 
and community re-integration including various therapies, counseling, 
vocational rehabilitation, and prescription of prosthetic and adaptive 
devices.
    TBI frequently occurs in polytrauma patients combined with other 
disabling conditions, including depression, PTSD, and other mental 
health conditions. The hallmark of rehabilitation care provided at the 
PNS is the collaboration of specialists from different disciplines in 
the evaluation and treatment of symptoms related to TBI and polytrauma. 
Mental health professionals are key members of the interdisciplinary 
polytrauma teams (IDT) participating in the individualized assessment, 
planning, and implementation of the plan of care for Veterans served at 
the PNS.
    In order to expand the availability of specialty TBI services 
across VISN 18, we focused on provider education and on the use of 
telehealth technologies. The SAVAHCS PNS program has established mini-
residencies targeting provider education and training on TBI 
evaluation, treatment, and care coordination. Clinicians completing 
this training are mentored via additional telehealth observation until 
competencies in TBI evaluation and management are demonstrated. We also 
leveraged the increased availability of telehealth technologies to 
allow specialists from VA's larger medical centers to reach out and 
provide medical services and consultation to Community- Based 
Outpatient Clinics (CBOC) located in rural and highly rural areas. 
Since 2010, we have seen a 70 percent increase in TBI and polytrauma 
visits completed via telehealth. The number of telehealth consultations 
with Veterans residing in rural and highly-rural areas has also 
increased steadily to make up as much as 37 percent of the overall 
telerehabilitation workload in FY 2013.
    In addition to the leadership role in coordinating TBI 
rehabilitation services across VISN 18, the SAVAHCS PNS has implemented 
innovative programs that facilitate community re-integration of 
Veterans with TBI and polytrauma. Noteworthy among these are the series 
of group activities that provide injured Veterans with opportunities to 
learn new skills and to apply them in community-based environments. 
These programs have the added benefit of engaging Veterans' families 
and services outside VA to support Veterans in their community re-
integration efforts.
    Through SAVAHCS PNS outreach efforts, other VA programs and 
community partners have been brought together to develop 
multidimensional programs that address the complex needs of Veterans 
with TBI and polytrauma. Among the results of these efforts are the 
Adaptive Sports Programs, the VISN 18 program for managing Veterans 
with complex pain, a vision therapy clinic, and the headache management 
clinic. The SAVAHCS PNS also engages with the Arizona Governor's 
Council on Spinal and Head Injuries to link education, rehabilitation, 
and employment resources together to serve the vocational 
rehabilitation goals of injured Veterans. Other partners in this effort 
include VA Vocational Rehabilitation, the Arizona Coalition for 
Military Families, the University of Arizona, Pima Community College, 
and the Arizona Department of Economic Security, Rehabilitation 
Services Administration.

SAVAHCS' Relationship With Native American Community

    Native Americans serve in our Nation's military at the highest rate 
per capita of all ethnic groups. We, at SAVAHCS, honor their service 
through our programs and services for Native American Veterans, our 
relationships with Indian Health Service https://eop.skillport.com/
skillportfe/login.action (IHS) and other Native American community 
organizations, and cultural awareness training of our staff. In 
collaboration with IHS, SAVAHCS also honors and celebrates their 
service and sacrifices with an annual Gathering of American Indian 
Veterans event, which draws attendees from around the State of Arizona, 
to help American Indian Veterans learn more about the benefits they 
have earned.
    SAVAHCS respects the unique needs of our Native American Veterans 
by having a dedicated Native American Veteran Program. SAVAHCS is a 
place of healing for our Veterans, and through our Native American 
Veteran Program, we have learned invaluable lessons from Native 
Americans about the holistic healing process which we have incorporated 
into our programs. For example, SAVAHCS has a 24-day, inpatient EBTPU 
which helps Veterans who come from across the country. At graduation, 
the Veterans are blessed with a Native American cleansing ceremony. We 
also host weekly Native American Talking Circles.
    Our relationship with IHS provides a vital connection to the five 
local Native American tribes. To better identify the needs of our 
Native American Veterans, SAVAHCS has trained 250 IHS Benefits 
Coordinators concerning eligibility for VA health care services.
    Additionally, we have completed five (5) VA and IHS local 
implementation plans under the December 5, 2012, National Reimbursement 
Agreement between VA and IHS, under which VA reimburses IHS for direct 
care services provided to eligible American Indian/Alaska Native 
Veterans in IHS facilities. Under the National Reimbursement Agreement, 
approximately 700 SAVAHCS Native American Veterans are eligible to 
receive VA reimbursement to IHS for services provided by IHS.
    SAVAHCS is committed to our Native American Veterans and continues 
to build partnerships with organizations that can bring additional 
services to all Veterans. Our Rural Health Coordinators and Community 
Referral Center Case Managers routinely meet with our IHS partners to 
ensure that all health care needs are meet for the eligible Veterans. 
We want to be present in our community and actively engage in building 
a more Veteran-centric community. Since October 1, 2013, SAVAHCS 
Eligibility and Enrollment outreach staff have conducted 57 outreach 
events, connecting with over 4,800 Veterans and their family members; 
several of these events were specifically targeted to Native American 
Veterans.

Readjustment Counseling Service

    VA's Vet Centers present a unique service environment--a personally 
engaging setting that goes beyond the medical model--in which eligible, 
Veterans, Servicemembers, and their families can receive professional 
and confidential care in a convenient and safe community location. Vet 
Centers are community-based counseling centers, within Readjustment 
Counseling Service (RCS), that provide a wide range of social and 
psychological services including professional readjustment counseling 
to eligible Veterans, Servicemembers, and their families; military 
sexual trauma (MST) counseling for Veterans; and bereavement counseling 
for eligible family members who have experienced an active duty death. 
The Tucson Vet Center, like those throughout the country, also provides 
community outreach, education, and coordination of services with 
community agencies that link Veterans and Servicemembers with other 
needed VA and non-VA services. A core value of the Vet Center is to 
promote access to care by helping those who served and their families 
overcome barriers that may impede them from using those services. For 
example, all Vet Centers have scheduled evening and/or weekend hours to 
help accommodate the schedules of those seeking services.
    The Vet Center program was the first program in VA, or anywhere, to 
systematically address the psychological traumas of war in combat 
Veterans. The program was established a full year before the definition 
of PTSD was published in the Third Edition of the American Psychiatric 
Association Diagnostic and Statistical Manual (DSM III) in 1980.
    There are currently 300 Vet Centers located throughout the United 
States, Puerto Rico, Guam, and American Samoa. Vet Center staff provide 
a wide range of Veteran-centric psychotherapeutic and social services 
to eligible Veterans and their families in the effort to help these 
individuals make a successful transition to life after service in a 
combat zone or area of hostility. VA has a fleet of 70 Mobile Vet 
Centers that provide outreach and services to Veterans and families in 
areas geographically distant from existing VA services. These vehicles 
also are used to provide early access to Vet Center Services to 
Veterans newly returning from war via outreach to demobilization active 
military bases, National Guard, and Reserve locations nationally.
    These services include:

         Individual and group counseling for eligible 
        individuals and their families;
         Family counseling for military-related readjustment 
        issues;
         Bereavement counseling for families who experience an 
        active duty death;
         MST counseling and referral, if required;
         Educational classes on PTSD, Couples Communication, 
        Anger and Stress Management, Sleep Improvement, and Transition 
        Skills for Civilian Life;
         Substance abuse assessment and referral;
         Employment assessment and referral;
         Screening and referral for medical issues, including 
        mTBI, depression, etc.; and
         Referrals for Veterans Benefit Administration 
        benefits.

    Like Vet Centers throughout the country, the Tucson Vet Center is a 
small team of six staff members reminiscent of a military squad. The 
Tucson Vet Center is staffed by a team leader, three readjustment 
counselors, an office manager, and an outreach specialist. The staff 
also includes a qualified MST Counselor and a Family Counselor.
    The Vet Center's ability to rapidly and effectively respond to 
acute PTSD and other post-war readjustment difficulties makes it an 
integral asset within VA. As the community's first point of contact 
with many Veterans returning from combat, Vet Centers also serve as the 
front door for referring many individuals for other needed VA services. 
Vet Centers also promote collaborative partnerships with VA health care 
and mental health professionals to better serve Veterans requiring more 
complex care. In addition to maintaining a bi-directional referral 
process with local VHA facilities, Tucson Vet Center staff also 
participate in weekly care coordination meetings with VA medical center 
mental health clinicians to ensure that all shared Veteran clients are 
receiving the best possible care from VA.
    For individuals who are distant from the Tucson Vet Center, staff 
are bringing readjustment counseling to them through the creation of 
community access points in the communities in which they live. At these 
locations, counselors can provide services on a regularly-scheduled 
basis that are in line with the needs of that community. For example, 
the Tucson Vet Center maintains a community access point in Sierra 
Vista, Arizona and provides readjustment counseling twice a week to 
eligible local Veterans and Servicemembers stationed at Fort Huachuca.
    The Vet Center Program remains unique in the eyes of those who have 
served thanks to the ability of Vet Center Staff to personally engage 
the individual Veteran or Servicemember in a safe and confidential 
environment that minimizes bureaucratic formalities. Confidentiality 
with our Veterans and their families is of paramount importance. Vet 
Center staff respect the privacy of all Veterans and Servicemembers and 
hold in strictest confidence all information disclosed in the 
counseling process. No information will be communicated to any person 
or agency outside of RCS unless authorized by law.

Conclusion

    VHA provides comprehensive health care and support services for 
Veterans with both combat and civilian-related TBI through its 
nationwide Polytrauma System of Care. VHA also provides care for 
Veterans with PTSD through a variety of settings including inpatient, 
residential, specialty PTSD outpatient programs and general outpatient 
care. Care for PTSD is delivered by more than 5,200 VA mental health 
providers who have received training in Prolonged Exposure and/or 
Cognitive Processing Therapy, the most effective known therapies for 
PTSD. These TBI and PTSD programs enable timely access to treatment as 
part of the VA's efforts to deliver the high quality health care and 
support our Veterans have earned.
    Mr. Chairman, this concludes my testimony. Thank you for the 
opportunity to appear before you today. At this time, my colleagues and 
I would be pleased to respond to questions you or the other Members of 
the Subcommittee may have.

                                 

                             FOR THE RECORD

                       Statement of Tana Ostrowski

    Thank you for this opportunity to submit a written testimony on 
this most important topic. My name is Tana Ostrowski. For disclosure 
purposes, I am currently serving in my third term as Chair of the 
Governor's Traumatic Brain Injury Advisory Council for the state of 
Montana. I am also a direct care provider with a post acute brain 
injury rehabilitation program located in Missoula Montana. I am 
submitting this written testimony as a concerned citizen and not 
specifically representing either of the previously mentioned groups.
    As members of the committee are aware, combat related traumatic 
brain injury disabilities have increased among our Veterans. Traumatic 
brain injury has been recognized as a major public health issue for as 
long as I have worked in the field and I am now entering my 27th year 
providing rehabilitative services to survivors of TBI. Montana has a 
statistically high number of Veterans. The majority of our state is 
classified as rural and/or frontier. This is relevant as it emphasizes 
the barriers that citizens of Montana encounter when trying to access 
TBI related therapies, Veterans as well as civilian.
    I am writing today to support efforts that facilitate Veterans, 
their family members and care providers' access to skilled civilian 
providers within their geographic locations. There is significant 
evidence that indicates rehabilitation outcomes are improved when 
individuals are closer to their homes and support systems. In terms of 
resources, it is more cost effective to have a Montana Veteran receive 
TBI rehabilitation within the state of Montana vs. sending them to 
Colorado or other out of state facility. What is even more important is 
that TBI affects each individual differently. Service providers who 
specialize in TBI rehabilitation understand the unique needs of the 
person served. Cognitive changes, whether they are related to basic 
functions such as attention, memory or information processing, or 
executive skills like self monitoring/self regulation, organization, 
mental flexibility etc. all impact an individual's day to day function. 
The rehabilitation process does not end in the clinic. Allowing 
Veterans to access skilled civilian providers will allow for improved 
rehabilitation outcomes, significantly improved continuum of care and 
follow up, reduce stress and is certainly more cost effective.
    It is truly a disservice to our returning Veterans and their family 
members, to not provide them with the most effective traumatic brain 
injury rehabilitation available.
    Respectfully,
    Tana Ostrowski, OTA/L, CBIS

    Addendum: I feel that it is important to note the following: In 
2011 the Community Bridges post acute brain injury rehabilitation 
program of the Rehabilitation Institute of Montana applied for and 
received a contract with the VA. At that time, the Bridges program had 
three components to the program, Residential, Day Treatment and 
traditional Outpatient BI rehabilitation. The contract was part of a 
pilot program with the VA and was awarded based on the Bridges 
program's continuum of care. In the Residential program, an individual 
with TBI reside in apartments within a community setting. The residence 
is staffed and in addition to traditional therapies individuals learn 
how to become skilled at implementing their compensatory strategies 
post TBI in real life situations. All aspects of recovery are addressed 
including behavior regulation. As of 2013 no referrals had been 
received from the VA. In late 2013 the Residential program was closed, 
limiting access to this highly successful rehabilitation environment.
    An additional concern is the funding cuts to the Yellow Ribbon 
program. The Governor's TBI Advisory Council was success in obtaining 
two $50,000 one time funding during the last legislative session, in 
effort to provide direct outreach and training to rural Montanan's with 
an emphasis on Veterans and their family members. For months the 
Council committee worked in collaboration with a member of the National 
Guard, developed a plan to divide Montana into 10 geographical regions. 
The plan includes but was not limited to travel to the designated 
locations to provide education related to the long term effects of TBI, 
but most importantly provide training to participants to better manage 
difficult issues that may persist post TBI. Providing family members, 
Veterans and when needed, care providers, (most often family members 
and/or spouses), with tools that they can effectively implement on a 
day to day basis on extremely important. This would have been at no 
cost to Veterans and their families. I believe that having education, 
understanding why one is experiencing what they are experiencing and 
how it impacts their goals and IADLs is fundamentally important for 
successful management of persistent post TBI symptoms. I also believe 
that these tools could have a direct impact on reducing the number of 
suicides among our returning Veterans. It was extremely disappointing 
when the DoD cut the funding to the Yellow Ribbon program. The Council 
committee will follow through with outreach, education and training. It 
is important to note however that without the direct involvement of the 
VA, National Guard or other direct Service organization participation 
from Veteran's and their family members and/or care providers will be 
significantly reduced.

                                 

                Statement of Congresswoma Kyrsten Sinema

    Thank you Chairman Coffman and Ranking Member Kirkpatrick for 
allowing me to participate today and for holding this hearing in 
Arizona.
    Chairman Coffman, thank you for coming to our state. We have a 
proud military tradition here and this issue is very important to us.
    Congresswoman Kirkpatrick, you are a great champion for Arizona's 
veterans and I am glad you brought the Veterans Affairs Committee to 
Arizona to hear directly from our veterans.
    Thank you for holding a hearing on this important topic: Veterans' 
access to mental health care and traumatic brain injury services.
    Finally, thank you to our panelists. Thank you for your service to 
our country, your sacrifice and for your advocacy for our nation's 
veterans.
    Our state has a proud history of military service and it is 
critical that our returning veterans have access to appropriate care.
    Traumatic brain injury and mental health wounds are the signature 
wounds of the wars in Afghanistan and Iraq, but previous generations of 
veterans also have these wounds.
    Ensuring access to care is critical, but while resources and 
attention are now more focused, too many of our veterans our not 
getting the support they need.
    Tragically, 22 veterans lose their lives to suicide every day. This 
is unacceptable.
    I am also disturbed and concerned by the allegations at the Phoenix 
VA Medical Center that delays in care may have caused the deaths of 
Arizona veterans. We need to get to the bottom of this and hold 
accountable those responsible.
    This battle cannot be one that is fought by our veterans alone, or 
by their families or by the VA.
    We have to work together as a community and as a country to end 
this tragedy.
    No veteran should feel they have no place to turn and no family 
should lose their loved one after he or she returns home.
    Again, thank you Chairman Coffman and Ranking Member Kirkpatrick 
for holding this hearing and for your leadership.
    And thank you to our panelists for sharing your very personal 
stories and for working to help other veterans and military families.

                       Rep. Ron Barber (D-AZ-02)

    I am sorry that I cannot be with you. I am in Yuma today for the 
dedication of the John Roll United States Courthouse.
    Our nation owes each of our veterans a debt greater than gratitude. 
I will continue working in Congress with my colleagues, like 
Congresswomen Kirkpatrick and Congressman Coffman, to ensure that each 
of our veterans and their families receive the care, the benefits and 
the opportunities they have earned and deserve.
    We need to do all we can as a Congress, a community and a country 
to guarantee care for those who've served and sacrificed for our 
nation.
    Thank you for coming to Southern Arizona to explore the critical 
issues of mental health care and traumatic brain injury services for 
our veterans.