[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]


    
                     CARE COORDINATION: ASSESSING VETERANS
                      NEEDS AND IMPROVING OUTCOMES

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                         TUESDAY, JUNE 13, 2023

                               __________

                           Serial No. 118-19

                               __________

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


                    Available via http://govinfo.gov
                    
                               __________

                   U.S. GOVERNMENT PUBLISHING OFFICE                    
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-----------------------------------------------------------------------------------     
                    
                     COMMITTEE ON VETERANS' AFFAIRS

                     MIKE BOST, Illinois, Chairman

AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking 
    American Samoa, Vice-Chairwoman      Member
JACK BERGMAN, Michigan               JULIA BROWNLEY, California
NANCY MACE, South Carolina           MIKE LEVIN, California
MATTHEW M. ROSENDALE, SR., Montana   CHRIS PAPPAS, New Hampshire
MARIANNETTE MILLER-MEEKS, Iowa       FRANK J. MRVAN, Indiana
GREGORY F. MURPHY, North Carolina    SHEILA CHERFILUS-MCCORMICK, 
C. SCOTT FRANKLIN, Florida               Florida
DERRICK VAN ORDEN, Wisconsin         CHRISTOPHER R. DELUZIO, 
MORGAN LUTTRELL, Texas                   Pennsylvania
JUAN CISCOMANI, Arizona              MORGAN MCGARVEY, Kentucky
ELIJAH CRANE, Arizona                DELIA C. RAMIREZ, Illinois
KEITH SELF, Texas                    GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia        NIKKI BUDZINSKI, Illinois

                       Jon Clark, Staff Director
                  Matt Reel, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

               MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman

AUMUA AMATA COLEMAN RADEWAGEN,       JULIA BROWNLEY, California, 
    American Samoa                       Ranking Member
JACK BERGMAN, Michigan               MIKE LEVIN, California
GREGORY F. MURPHY, North Carolina    CHRISTOPHER R. DELUZIO, 
DERRICK VAN ORDEN, Wisconsin             Pennsylvania
MORGAN LUTTRELL, Texas               GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia        NIKKI BUDZINSKI, Illinois

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

                              ----------                              

                         TUESDAY, JUNE 13, 2023

                                                                   Page

                           OPENING STATEMENTS

The Honorable Mariannette Miller-Meeks, Chairwoman...............     1
The Honorable Christopher R. Deluzio, Acting Ranking Member......     2

                               WITNESSES
                                Panel 1

Dr. M. Christopher Saslo, Ph.D, Assistant Under Secretary for 
  Health/Chief Nursing Officer, Office of Patient Care Services, 
  Veterans Health Administration, U.S. Department of Veterans 
  Affairs........................................................     3

        Accompanied by:

    Dr. Sachin Yende, MD, Chief Medical Officer, Office of 
        Integrated Veteran Care, Veterans Health Administration, 
        U.S. Department of Veterans Affairs

    Dr. Jennifer Strawn, Ph.D, Deputy Chief Nursing Officer/
        Executive Director, Office of Nursing Service, Veterans 
        Health Administration, U.S. Department of Veterans 
        Affairs

    Ms. Jill Debord, Executive Director, Office of Care 
        Management and Social Work Services, Veterans Health 
        Administration, U.S. Department of Veterans Affairs

Dr. Julie Kroviak, MD, Principal Deputy Assistant Inspector 
  General, Healthcare Inspections, Office of the Inspector 
  General, U.S. Department of Veterans Affairs...................     5

                                Panel 2

Ms. Andrea Sawyer, Advocacy Director, Quality of Life Foundation.    16

Mr. Matt Brady, Director, Complex Case Coordinator Program, 
  Wounded Warrior Project........................................    18

Mr. Roscoe Butler, Senior Health Policy Advisor, Paralyzed 
  Veterans of America............................................    20

                                APPENDIX
                    Prepared Statements Of Witnesses

Dr. M. Christopher Saslo, Ph.D Prepared Statement................    33
Dr. Julie Kroviak, MD Prepared Statement.........................    38
Ms. Andrea Sawyer Prepared Statement.............................    46
Mr. Matt Brady Prepared Statement................................    50
Mr. Roscoe Butler Prepared Statement.............................    57

 
                 CARE COORDINATION: ASSESSING VETERANS
                      NEEDS AND IMPROVING OUTCOMES

                              ----------                              


                         TUESDAY, JUNE 13, 2023

             U.S. House of Representatives,
                            Subcommittee on Health,
                            Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The subcommittee met, pursuant to notice, at 1 p.m., in 
room 360, Cannon House Office Building, Hon. Mariannette 
Miller-Meeks [chairwoman of the subcommittee] presiding.
    Present: Representatives Miller-Meeks, Radewagen, Van 
Orden, Luttrell, Kiggans, Brownley, Deluzio, Landsman, and 
Budzinski.

   OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN

    Ms. Miller-Meeks. Come to order.
    As a 24-year veteran and a physician who has worked with 
the VA, I have seen first-hand how important coordination is to 
providing timely, quality care, especially for veterans with 
complex health needs. It is one of my top priorities in 
Congress to ensure veterans have access to care where they need 
it and when they need it.
    VA's care coordination programs should help veterans 
navigate the complex world of healthcare both within the VA and 
with VA's community partners. VA's Patient Aligned Care Team, 
or PACT, model provides, or should provide, personalized, 
patient driven care and positively can impact a veterans 
experience in the primary care setting. However, high need, 
high risk veterans often lack support for their complex 
clinical and psychosocial needs beyond that setting. This is 
not due to a lack of compassionate coordinators and social 
workers within the VAs, but rather due to poorly defined roles 
and jurisdictions for these advocates. Veterans who receive 
care across multiple locations are at the greatest risk for 
lapses in care, especially when their medical records are 
either not returned to the VA or the VA does not correctly 
input vital medical information. Communication between the VA 
and its provider partners could be greatly enhanced with 
coordinators who are empowered to work across clinical and 
arbitrary bureaucratic lines.
    As we will hear from the Veteran's Affairs Office of 
Inspector General (VA OIG) and from our second panel of veteran 
advocates, veterans with complex cases who do not receive 
proper care coordination more often than not experience 
detrimental health outcomes. Some of their stories are 
heartbreaking. The Quality of Life Foundation, Wounded Warrior 
Project, and Paralyzed Veterans of America have managed to 
establish programs that cross multiple disciplines to 
effectively manage the care for some of our most complex, 
injured, and ill veterans. VA can and must do better.
    I look forward to hearing how we can better coordinate the 
coordinators and ensure that no veteran falls through the 
cracks.
    With that, I yield to the ranking member and her 
substitute.

  OPENING STATEMENT OF CHRISTOPHER R. DELUZIO, ACTING RANKING 
                             MEMBER

    Mr. Deluzio. Thank you, Madam Chairwoman. Of course, I am 
sitting in for Ms. Brownley today, who is still in 
Transportation and Infrastucture (T&I) markup, I am sure, will 
join us when she can.
    As the largest integrated healthcare system in this 
country, the Veterans Health Administration is perhaps one of 
the most well positioned to effectively coordinate patients 
care. Given the patient population it serves, my fellow 
veterans care coordination is critical. As compared to their 
non-veteran peers, veterans have a greater number of medical 
comorbidities, and psychosocial needs that need to be 
considered and well-coordinated when delivering healthcare. 
However, as we will hear from some of our witnesses today, 
there are many ways in which the Veterans Health 
Administration, VHA, needs to improve its coordination of 
veterans care to ensure veterans receive the soonest and best 
care possible, whether directly from the VA or from fee for 
service or community care providers.
    As defined by the Federal Agency for Healthcare Research 
and Quality, care coordination entails deliberately organizing 
patient care activities and sharing information among all of 
the participants concerned with the patient's care to achieve 
safer and more effective care. Despite the existence of 
numerous care coordination and case management programs across 
VHA, the committee regularly hears about instances where 
veterans with complex care needs have not received the help, 
they need to navigate VHA's direct care system or fee for 
service or community care, experiencing delays or serious gaps 
in care. There are too many instances where veterans fall 
through the cracks and do not receive the care they need, when 
and where they need it. In the most serious cases, like those 
we will hear about from our Office of Inspector General 
witness, lapses in care coordination can lead to poor patient 
outcomes and patient harm.
    I hope today's hearing will help us examine ways VHA can 
address some of the root causes of care coordination 
breakdowns. At the outset, I see at least three areas to be 
addressed.
    First, care coordination programs within VHA tend to be 
fragmented or siloed within certain program offices or clinical 
service lines. They generally target specific categories of 
patients diagnoses or clinical specialties, leading veterans to 
be passed off from one care coordinator to another. This 
heightens the risk of care coordination breakdowns as veterans 
transition from one coordinator or one setting of care to 
another accomplishing the exact opposite of the goals these 
programs are intended to meet.
    Second, information technology limitations also present 
barriers to care coordination. We are still years away from 
having integrated electronic health record at VA and Department 
of Defense (DoD). Meanwhile, VA's legacy system makes it such 
that veterans traveling to or relocating from one VA facility 
to another have to be registered at their new facility before 
providers at that facility can access their VA electronic 
medical record. VA's ability to electronically access and 
receive medical records from non-VA community providers is 
still very limited. This means that VA staff often have to 
request paper copies of medical records from non-VA providers, 
leading to delays and gaps information from fee for service or 
community care encounters.
    Third, and last, a lack of strong oversight across VA 
medical facilities and gaps in existing policies lead to 
inconsistent patient care experiences for veterans. Some care 
coordination programs are only available at VA medical 
facilities that have chosen to offer them, and even in care 
coordination programs that all facilities are required to 
offer, caseloads and patients experiences can vary 
considerably.
    Certainly, much for us to examine today and many 
opportunities for VHA to improve. I would add that with the 
ongoing implementation of the The Sergeant First Class Heath 
Robinson Honoring our Promise to Address Comprehensive Toxics 
(PACT) Act, thousands of veterans with complex cancers and 
respiratory illnesses will be entering the VA healthcare system 
in the coming years. It is therefore an opportune time for this 
committee and VHA to consider ways to strengthen care 
coordination frameworks and ensure VHA will be prepared to 
serve this cohort of veterans and their caregivers.
    Madam Chair, thank you again for organizing this hearing. I 
look forward to it and I yield back.
    Ms. Miller-Meeks. Thank you, Mr. Deluzio.
    I just wanted to have a point of information, and that is 
most of you know that votes will be coming up shortly, so we 
will take a recess for votes. At this time, I would like to 
introduce the witnesses today and I would like to thank you for 
joining us.
    Joining us from the Department of Veterans Affairs is Mr. 
Christopher Saslo, who is the assistant undersecretary for 
Patient Care Services and the chief nursing officer. 
Accompanying Dr. Saslo today is Dr. Sachin Yende, the chief 
medical officer in the Office of Integrated Care. If I 
mispronounce anybody's name, I do apologize. Ms. Jennifer 
Strawn, the executive director, Office of Nursing Services and 
deputy chief nursing officer, and Ms. Jill Debord, executive 
director of Care Management and Social Work Services. We also 
have Dr. Julie Kroviak, the principal deputy assistant 
inspector general of healthcare inspections in the office of 
the Inspector General.
    Dr. Saslo, you are now recognized for 5 minutes to deliver 
your opening statement.

               STATEMENT OF M. CHRISTOPHER SASLO

    Mr. Saslo. Thank you. Good afternoon, Chairwoman Miller-
Meeks and ranking members and distinguished members of the 
subcommittee.
    Thank you for the opportunity today to discuss VHA's 
various care coordination programs within VA, community 
providers and emergency services. Accompanying me today, as 
mentioned, is Dr. Sachin Yende, chief medical officer for the 
Office of Integrated Veterans Care, Dr. Jennifer Strawn, 
executive director for the Office of Nursing Service and our 
deputy chief nursing officer, and Ms. Jill Debord, executive 
director for Care Management and Social Work services.
    Care Coordination and Integrated Case Management (CCICM) is 
a practical approach rather than a program with a framework 
that promotes care coordination stratification across the 
entire care continuum. It focuses on the complex and high to 
moderate veterans who have complex care coordination needs. 
Preliminary data illustrates that our CCICM model provides 
positive impacts to care outcomes and increasing veteran trust 
scores.
    To illustrate this, I would like to share one of our many 
care coordination integrated care management success stories. A 
veteran with multiple complex comorbidities has been utilizing 
community emergency rooms to address all of their medical 
needs. The veteran has found to have 16 ER visits in a 2 month 
period of time. The lead coordinator assigned to this veteran 
was able to build a rapport and gain the veteran's trust while 
assessing for global needs. The urgent consults were scheduled, 
and follow up was obtained while connecting the veteran three 
to five times a week via phone. The coordinator assisted the 
veteran with support using therapeutic listening and 
motivational interviewing to empower the veteran to feel 
confident about their healthcare decisions. The coordinator 
also assisted with obtaining an emotional support animal for 
the veteran, which made a positive impact in their mental 
health and coping abilities.
    As a result, since being assigned a lead coordinator, the 
veteran has had zero visits to any urgent care or emergency 
department. The veteran expressed confidence in the care team 
and in control of their health and wellness. The veteran is now 
able to proactively manage care and enlist the lead coordinator 
with urgent requests on an as needed basis.
    While this story highlights positive outcomes, we also know 
that there are opportunities to enhance and improve that care 
coordination within our system. With the number of veterans 
using VA care as it grows and the veteran patient population 
typically having more complex medical and social needs than any 
other population, that care coordination is critical. To meet 
these needs, VA provides a broad array of services.
    VHA is developing a long-term strategy to ensure all 
veterans across their continuum of care receive the soonest and 
best care possible, both within the VA and in the community. It 
is imperative that VHA optimizes and integrates its care 
coordination and services and its resources. VHA's strategy 
must address the current navigational and access to care 
challenges. Without intervention to better coordinate the care, 
veterans will continue to have higher rates of emergency 
department visits, hospital admissions, and substantial 
increases in healthcare costs. When fully implemented, the new 
coordinating care will benefit thousands of veterans and their 
qualified family members, increasing their access to care and 
improving health outcomes.
    Last year, VHA leadership assembled an interdisciplinary 
integrated project team, or IPT, bringing together the offices 
in patient care services, such as nursing service and care 
management and social work services, and our integrated 
veterans care team to address these challenges and serve as the 
team's resource and planning framework. This initiative aims to 
decrease navigational and fragmented care challenges through 
proactive identification of veterans with complex care 
coordination needs. The objective is to enhance and align 
resources to organizational needs to support stabilization of 
our workforce and drive innovation.
    Finally, under the framework for CCICM, veterans will have 
high quality, coordinated care that is delivered in a 
consistent manner across all care settings. We are serving 
record numbers of veterans both in the VA and in the community, 
with significant progress toward our timeliness goals. I will--
was going to say Chairwoman Miller-Meeks, but you have 
changed----
    Mr. Van Orden. [Presiding] I appreciate that.
    Mr. Saslo [continuing]. and ranking member, we appreciate 
your continued support and look forward to answering your 
questions.

    [The Prepared Statement Of M. Christopher Saslo Appears In 
The Appendix]

    Mr. Van Orden. Thank you, Dr. Saslo.
    The chair now recognizes Dr. Kroviak for 5 minutes.

                   STATEMENT OF JULIE KROVIAK

    Dr. Kroviak. Thank you. I appreciate the opportunity to 
discuss the OIG's oversight of VHA care coordination.
    The OIG's Office of Healthcare Inspections reviews the 
quality and safety of healthcare provided across VHA, and our 
reviews frequently highlight challenges associated with 
coordinating veteran care across multiple service lines and a 
wide variety of healthcare settings.
    My written testimony highlights some of the many issues and 
breakdowns that providers and patients have faced in navigating 
the complexities of care coordination, from enrolling in VA to 
receiving care at the VA and then receiving care in the 
community. Gaps in any of these steps of care transition 
compromise patient safety and fracture confidence in the 
system. Unfortunately, it is during these transitions of care 
that the most vulnerable patients face the greatest risks.
    Transitioning from DoD to VA can introduce new stressors to 
service members and their families, and the reintegration 
challenges can be magnified for a veteran with traumatic brain 
injury, Post Traumatic Stress Disorder (PTSD), or substance use 
disorder. Gaps in care coordination for those members diagnosed 
with high-risk mental health or substance use issues can be 
fatal during this period.
    The OIG is finalizing a national review evaluating the 
risks for service members with documented opioid use disorder, 
or OUD, as they transition their care from DoD to VHA. We found 
that VHA providers are not consistently placing critical 
information regarding the OUD diagnosis in the veterans VA 
medical record. Failure to identify and document a patient's 
known OUD history may decrease the likelihood of a patient 
receiving timely VA care and support.
    These care coordination challenges continue for VHA 
patients, with many of our reports finding failures involving 
VHA clinical and administrative leadership, and frontline 
staff. Our reports have substantiated unreasonable delays in 
responding to critically ill veterans needing emergent care, 
dangerous errors in discharge planning for high-risk veterans, 
and failures in coordinating end-of-life care for a terminally 
ill veteran transferring between levels of care within VA. We 
have also seen failed coordination between the Veterans Crisis 
Line, local suicide prevention teams, and emergency department 
staff, as well as failures with vet center staff coordinating 
with local VA medical centers to ensure that clients deemed 
high risk for suicide receive appropriate clinical support.
    The expansion of VHA's partnership with community providers 
has further challenged care coordination. Once a veteran and 
their VHA provider agree on a need for a community care 
referral, a variety of VHA clinical and administrative staff 
enter into a complex process to complete a simple goal 
scheduling an appointment for a veteran. We reviewed VA's 
implementation of the Referral Coordination Initiative, which 
is designed to improve timeliness of scheduling community care 
appointments. Despite a goal of complete implementation 2 years 
ago, full implementation has yet to be achieved.
    The challenges of community care coordination continue 
beyond timely scheduling. Our reports have highlighted 
deficiencies for veterans receiving care in the community, 
including delays in diagnosis and treatment, lack of or 
miscommunication between providers, and quality of care 
concerns. We are in the final stages of developing a community 
care cyclical review, and the initial phases of data analysis 
support many of the issues identified in our publications. We 
are hopeful that these reviews will support VHA leaders efforts 
to introduce efficiencies and reduce the risks associated with 
community care. From a quality of care standpoint, until timely 
clinical information sharing between the community and VHA is 
ensured with each care encounter, VHA has no reasonable 
assurance that veterans are getting the care they need. Reviews 
from our Office of Healthcare Inspections as well as from our 
Office of Audits and Evaluations confirm current processes put 
veterans at risk.
    We do appreciate VHA staff's exhaustive efforts to 
coordinate safe care across multiple venues for millions of 
veterans. The complexity and scale of that work will only 
increase as more veterans engage with the community and VA 
healthcare services expand in response to the PACT Act. The OIG 
will continue to enhance and adapt our work to support VA 
leaders and frontline staff with meaningful and impactful 
oversight, with a shared goal of increasing efficiencies and 
processes and assuring high quality care delivery.
    This concludes my statement. I would be happy to answer any 
questions.

    [The Prepared Statement Of Julie Kroviak Appears In The 
Appendix]

    Mr. Van Orden. Thank you, Dr. Kroviak. I appreciate that.
    I now recognize myself for 5 minutes.
    Dr. Kroviak, I got to tell you, I read all your testimony, 
I reread the testimony from last time you were here, and I 
appreciate it greatly. I found this particular set, or this 
testimony fascinating. It was terrifying. It was fascinating 
because it was like watching a slow moving train wreck and it 
was terrifying because I find it interesting that someone as 
brilliant as you are, and you are, could not identify the root 
problem that you alluded to. It is so obvious. It is the fact 
that there is no accountability. There is no accountability 
across any of these levels.
    I had my staff, which are awesome, they did the word 
search. A lot of people say accountable--accountable, 
accountability, right. There are zero instances in anybody's 
testimony from this panel or the next of the word fired, 
censured, referred for discipline, nothing.
    You have a veteran in southwestern Nevada who committed 
suicide because they were essentially blown off. They had all 
these problems, everybody knew about it, and they were not 
treated appropriately, and they committed suicide.
    I come from a naval background, as does my friend Morgan, 
as does my colleague, Mr. Deluzio. When a ship's captain is 
asleep in their cabin at night and the ship runs aground, the 
captain is held ruthlessly accountable. They are fired 
immediately even though they are asleep. I did not find any 
testimony of a single instance of anyone being fired, referred 
for discipline, or censured, and we have dead veterans.
    I would like to make a suggestion for you. When these 
instances happen, I think every single person that is involved 
in that chain of custody, for lack of a better term for these 
veterans, should write a personal letter to the widow or the 
widower or the mother or the father and the children of these 
dead veterans and apologize to them for their lack of care. I 
think every single person from the Veterans Administration in 
that chain of custody for a veteran that is responsible for 
these suicides needs to go to all of these funerals. I would be 
more than happy to submit an amendment. I am sure everybody 
would sign on it. We will pay for that. We will pay for your 
travel costs. As soon as your folks at the Department of 
Veterans Affairs start going to some of these funerals, like we 
have gone to God, I do not know how many of my friends, you 
will change. Until that happens, nothing will. If you have no 
accountability, do not have an organization, you have a paid 
mob.
    Can you, with a piece of paper and a pencil, could you 
possibly draw me a line and block chart of all of these various 
coordinators that currently exist and are being paid for by the 
American taxpayers that have been failing our veterans for 
decades?
    Dr. Kroviak. Sir, I can certainly appreciate-the disdain 
you feel--our reports hold VHA accountable to their policies 
and practices, and we assign recommendations to whom is 
ultimately responsible for correcting those actions. We have no 
authority to manage or punish VHA staff in our oversight 
position.
    Mr. Van Orden. Does anybody?
    Dr. Kroviak. That would be from VA.
    Mr. Van Orden. Okay, so check me out. I represent Tomah. It 
is where the whole candy doctor guy opioid thing blew up. Had a 
veteran commit suicide from that. We had 900 veterans being 
seen by a single lady that did not appropriately rate them, 600 
of the 900, 2/3s have been determined that she did that 
incorrectly. She got fired. I was there with Denis, the 
Secretary of Veterans Affairs--fired. I want you to tell me how 
we can make sure that your reports--because they do not hold 
anybody accountable, they do not. It is a harshly worded, 
email--I want you to tell us how we can help you to empower you 
to make sure that these people are actually held accountable. 
By that, I mean the door hitting them in the behind as they are 
leaving the institution permanently.
    Can you help me with that?
    Dr. Kroviak. I believe I can definitely help with that.
    Mr. Van Orden. Thank you.
    Dr. Kroviak. We are always thrilled to provide briefs of 
our reports to congressional staff, and we take their 
interest--the local interest, and the authority they have to 
hold local leaders accountable for their recommendations and 
action plans that are put into place.
    Mr. Van Orden. Thank you, ma'am. My time has expired.
    I am frustrated, but my brothers and sisters are dead.
    With that, I yield back.
    I recognize Mr. Deluzio for 5 minutes.
    Mr. Deluzio. Thank you, Mr. Van Orden. I will echo your 
very good and correct point that the consequence here is 
people's lives. I think it is a good reminder of what is at 
stake when there are mistakes in the lack of coordination. 
Those are the stakes. They are serious ones.
    I guess my question -I will start with Dr. Saslo and then 
Dr. Kroviak, love to hear from you as well, from the OIG 
perspective.
    I am thinking about, first, coordination of care or the 
lack thereof, that happens on the community care fee for 
service side. My understanding is many providers--well, there 
is not a requirement to submit records to VA in an electronic 
form, for instance, and some do not do it in a timely manner or 
at all. I am wondering what the ways in which those lapses in 
coordination are impacting veterans who are serving in the VA?
    Mr. Saslo. Thank you for the question.
    One of the things I think is important to acknowledge is 
that we recognize that the challenges in getting the medical 
records back in a timely manner and being able to integrate 
them into the veterans record is extremely important for that 
continuity of care. One of the reasons for the Care 
Coordination Integrated Case Management Project itself is 
because of the gaps that we have identified both within VA and 
within the community care itself. Our goal is to actually be 
able to identify for those complex needs, or moderate to 
complex needs, that we have one individual who is that lead 
coordinator who will not only be able to work with the veteran, 
but also working with the different care teams across the 
continuum so that the information that we receive is not only 
provided in a timely manner, but also handed off to the correct 
individual that will then continue that care within the VA if 
it is necessary, or managing the care within the community.
    Mr. Deluzio. Dr. Saslo.
    Mr. Saslo. Yes, sir.
    Mr. Deluzio. I am sorry to interrupt, but just for the sake 
of time, I am curious, if a provider does not provide any 
records at all, or they do it in a very untimely fashion, what 
is the consequence for them?
    Mr. Saslo. Dr. Yende.
    Dr. Yende. I can take that question, Congressman.
    Previously we used to link claims reimbursement for 
community care providers with receipt of medical records. That 
means we need to confirm that they have sent the medical 
records. As you rightly pointed out, the fax system is very 
challenging to work with. We had instances where the provider 
said that they had sent the records, we could not verify on the 
VA side, and we had delays with claims processing. I believe we 
had several congressional inquiries asking why those claims 
processing were delayed. In order to make sure that our 
veterans were getting timely access, we decided to waive it.
    You ask a very important point, and we realize that there 
are challenges getting medical records back. I totally 
understand that care coordination cannot be done without it. We 
have two or three approaches we are pursuing.
    Number one, VA is one of the five Federal agencies that 
participates in health information exchanges. That is a 
mechanism where we can get those records electronically. Those 
Health Information Exchanges (HIEs) account for about 70 plus 
percent of HIEs locally. Through those we get those records, 
but they are not complete in most instances.
    Number two, we have worked out processes with our Third 
Party Administration (TPA) partners where if we feel that a 
provider is not providing records consistently, which is what 
you alluded to, we will work with their TPA partners to make 
sure that they send those records to us.
    Finally, as you said, really, technology is a solution out 
here. Trying to work through faxes, trying to make sure those 
faxes get into our medical records, is a very laborious 
process. We are really exploring some technology solutions out 
here, and we hope to brief you in the near future.
    Mr. Deluzio. Thank you.
    Dr. Kroviak, I am going to give you the remainder of my 
time. My question is the same. One, how bad is this problem 
where providers outside the VA are not turning in records at 
all or in a timely fashion, and is there any real consequence, 
and is the lack thereof hurting care for veterans?
    Dr. Kroviak. It is absolutely impacting care for veterans. 
It is not getting better from our work. I do believe technology 
is the solution, but I do not believe we are anywhere near 
making that solution a reality.
    Mr. Deluzio. Thank you.
    Mr. Van Orden, I yield back.
    Mr. Van Orden. Thank you, Mr. Deluzio.
    The chair now recognizes Mr. Luttrell for 5 minutes.
    Mr. Luttrell. Thank you, Mr. Chairman.
    Good morning, Ms. Kroviak. Your one year anniversary in 
this position, correct? Last year?
    Dr. Kroviak. In this position, it might be August, but I 
was the deputy prior to that, so it is been several years.
    Mr. Luttrell. How many Inspector General (IG) reports have 
you presented on these topics?
    Dr. Kroviak. On community care?
    Mr. Luttrell. Mm-hmm.
    Dr. Kroviak. I cannot count, but I suspect almost every 
report we published in the Office of Healthcare Inspections 
touches on aspects of care coordination.
    Mr. Luttrell. Is there a repetitive nature to these 
reports?
    Dr. Kroviak. Yes.
    Mr. Luttrell. Very similar to the ones that you just read 
for us today?
    Dr. Kroviak. Yes.
    Mr. Luttrell. Is there anyone sitting on this panel with 
you today responsible for any of the issues that you listed 
directly?
    Dr. Kroviak. Directly? I would have to assume not. I think 
we are talking with leaders at the table. In terms of 
individuals at facility levels...
    Mr. Luttrell. Is there anybody that directly reports to 
anybody sitting on this panel?
    Dr. Kroviak. From any of our reports? I could not say, but 
I am not 100 percent sure, but I would not--they would probably 
be----
    Mr. Luttrell. If you are following my line of questioning 
here, and you can see how this panel is unified on these 
issues--we are done. I want names. I do not want any more IG 
reports that get lost in the sauce and hung on the shelf or the 
Department does not take it seriously. You have repeatedly done 
your job. Well done. It has obviously fallen through the cracks 
because these issues are the same issues that we keep hearing 
over and over again.
    Mr. Saslo, do you have any response at all to the IG report 
and how we can course correct this ship that is continually 
sinking?
    Mr. Saslo. Yes. I believe, as I started earlier, the entire 
integrated project team that we have put together really has 
looked at a number of those failures that does not ensure that 
the veterans timely access to care or their care coordination 
is being addressed.
    I will ask Dr. Strawn or Ms. Debord to address it a little 
bit further, but from an awareness standpoint, we have two 
different professions that really help to coordinate the care 
within VHA, our nursing partners as well as our social work 
partners. Coming together and working with our integrated 
veterans care team, we have actually identified several 
different mechanisms that are going to help to minimize any of 
the fragmentation in care and hopefully over the course of the 
roll out to make sure that we do not have those veterans 
falling through the cracks, making sure that we----
    Mr. Luttrell. How long have you been in this position?
    Mr. Saslo. I have been in my position as an assistant 
undersecretary since October. I have been with the VA for 27 
years.
    Mr. Luttrell. Twenty seven years--so you are familiar with 
these issues?
    Mr. Saslo. Yes, sir, I am.
    Mr. Luttrell. What are we doing wrong?
    Mr. Saslo. We are----
    Mr. Luttrell. That is rhetorical. How do we fix the 
problem?
    Mr. Saslo. We are looking at being able to do----
    Mr. Luttrell. No more looking. We are done looking.
    Mr. Saslo. I apologize for the verb. We are in the process 
of addressing that through the CC&ICM framework, which will 
allow us to help make sure that that complex care that our 
veterans are sometimes losing is going to be addressed by lead 
coordinators, by making sure that the teams are actually 
effectively engaged, so that it is not just you are going to go 
to the mental health clinic or you are going to go for your 
orthopedic clinic, how do we have that continuity of care to 
make sure that one person helps to mitigate many of those 
issues.
    I will ask Dr. Strawn or Ms. Debord to go ahead and add to 
that.
    Dr. Strawn. What Dr. Saslo has described is what we are 
calling--it is a framework. It is a care coordination and 
integrated case management framework.
    Within VA, there are multiple programs, and there are care 
coordinators within each program. A veteran who may suffer from 
medical chronic conditions, may have mental health issues, may 
have social determinants of health issues, those patients or 
veterans may have multiple case managers. What we have found is 
that there is siloing and fragmentation. With the new CCICM 
framework, a veteran who needs moderate or complex care 
coordination will have an assigned lead coordinator, and that 
coordinator will assist them, internal and external to VA to 
navigate the healthcare system.
    Mr. Luttrell. Ms. Strawn, real quick, I am running out of 
time here, how long have you been with the VA?
    Dr. Strawn. I have almost been with the VA 30 years.
    Mr. Luttrell. Thirty, years twenty six years. Mr. Yende?
    Dr. Yende. About a decade.
    Mr. Luttrell. Ten years. Ms. Debord.
    Ms. Debord. Thirty years.
    Mr. Luttrell. Thirty years. How many of those reports have 
you read from the IG? Every one of them? Collectively, you are 
over 100 and some odd years of experience in the VA, and the 
report has not changed in decades.
    I think we need to take a hard look in the mirror. I hate 
to be brash, but as a veteran, I am being brutally honest. 
Understand.
    Ms. Kroviak, will you get me those names? I want everybody 
that is responsible for this IG, the reporting officer, whether 
it is the secretary or whomever. Enough is enough. Deal.
    Thank you.
    Mr. Chairman, I yield.
    Mr. Van Orden. Thank you, Mr. Luttrell.
    I just like to sum something up. You guys, the four of you 
have over 100 years of experience in the Veterans 
Administration, and nothing is going to change until one of you 
get fired.
    I now yield to Ms. Budzinski for 5 minutes.
    Ms. Budzinski. Thank you, Mr. Chairman. Thank you to the 
witnesses.
    In Dr. Kroviak's testimony, she mentioned the VA OIG 
encouraged VHA leaders to broadly disseminate findings from the 
OIG's oversight publications to all facilities to alert them of 
the potential risks and to promote processes that would prevent 
or correct similar deficiencies at other facilities.
    My question is really for any of the witnesses right now, 
to what extent is the VHA doing this now? There are many 
lessons to be learned just from the reports of the OIG findings 
reported. I am just curious, any reaction to that?
    Ms. Debord. Are you asking, representative, how often we 
disseminate the information across the workforce?
    Ms. Budzinski. Yes.
    Ms. Debord. When it has to do with something that is in my 
area, care management and social work and the programs that I 
have oversight for, we review the OIG reports, we work with 
those facilities that are managing those, those chiefs and 
execs, because we take this incredibly seriously. In my 30 
years, I have done care coordination across the spectrum. We 
can do this better, and we really believe we can.
    The integrated case management program, the Care 
Coordination and Integrated case management program, which we 
are just starting to work on as a framework with Integrated 
Veteran Care (IVC), we really do believe that we have some 
immature data that suggests that this will have an impact on 
veterans' trust, on some of the things that impact their 
health. It is new. We began this process in December. We are 
going to be deploying this to 12 sites across the country no 
later than September. They have been selected. We really 
believe that we can start to see the needle move.
    We take our own responsibility incredibly seriously.
    Ms. Budzinski. Could I just follow up with Dr. Kroviak? Do 
you have--would you want to add anything in addition?
    Dr. Kroviak. It is challenging, and I appreciate the 
frustration that hundreds of reports are published. The reality 
is when we go into sites, though we find dedicated skilled 
staff, we do have repeat findings onsite specific to individual 
facilities. Certainly, we can go onsite to one facility and 
find similar findings at others. I do not have as much 
confidence that these reports are being disseminated or studied 
as a true risk assessment tool that we would hope for.
    Ms. Budzinski. Mm-hmm. Okay. Okay.
    I have a question for Dr. Saslo. The OIG also shared their 
assessment of VA Video Connect, VVC. VVC is a crucial tool for 
older veterans, those with mobility issues, and vets living in 
rural areas like the district I represent. The OIG found that 
VHA would not--was not able to support the increased demand for 
VVC despite having created emergency preparation plans for 
disaster scenarios prior, plans created prior to the pandemic.
    Dr. Saslo, I think we can all agree no one--no one 
anticipated obviously a pandemic like the one that we just 
experienced, and VHA was doing their best to care for our 
veterans. Now that the pandemic is over, what improvements has 
VHA made to the VVC program and is there a plan in place for 
future emergencies?
    Mr. Saslo. Thank you for the question.
    One of the things that I think is really relevant is the 
fact that VVC, as it rolled out, was something that we did as a 
reflex to the pandemic whereby it was already established 
earlier on, just not to the degree. What we learned as a result 
of the project itself, or the program, is that we have a lot of 
opportunity to improve and also increase the way that we expand 
it.
    We partner with our Office of Rural Health, which is 
looking at different modalities in which we can expand that 
connection piece to our most vulnerable patients. Within VHA 
itself, we have multiple program offices that are working in 
tandem with the Office of Connected Care in order to make sure 
that VVC is actually more robust than it ever has been before.
    We are also using our opportunities with Integrated 
Veterans Care so that those veterans that need the care 
consistently and are at risk for not being able to do it in 
person have a consistent process that we use in order to engage 
them.
    I do not know if you want to add anything else to that.
    Ms. Budzinski. Yes, and I think just a follow-up question. 
In rural communities in particular, when you are looking at 
coordination and unique challenges that they face, could you 
speak a little bit more to, like, what those are and how you 
are working through those challenges?
    Mr. Saslo. One of the things that is probably the most 
challenging at times is bandwidth, in making sure that our 
veterans, who may have the opportunity to have a connected 
device, which we have the opportunity to provide for, does not 
always necessarily have the necessary bandwidth in their area 
in order to make those connection pieces the most stable or 
consistent. Our Office of Connected Care is working with a lot 
of the different community providers, Verizon, T Mobile, et 
cetera, to try to find ways that we can enhance and expand that 
bandwidth itself. That is definitely one of the biggest 
challenges I think we have seen in our successful expansion of 
the VVC program.
    Ms. Budzinski. Okay, thank you.
    I think I am out of time.
    I will yield back, chairwoman.
    Ms. Miller-Meeks. Thank you, Ms. Budzinski.
    The chair now recognizes Representative Radewagen.
    Ms. Radewagen. Thank you, Chairwoman Miller-Meeks and 
Ranking Member Brownley, for holding this hearing today. Thank 
you to the witnesses as well for your testimony.
    Dr. Saslo, in your testimony you discuss VA's efforts to 
simplify veteran referrals to community care via the Referral 
Coordination Initiative, or RCI. This initiative has been in 
the work since before the pandemic, yet VA OIG states in their 
testimony that no VA facility has fully implemented RCI. They 
also state that there are no clear staffing models or 
mechanisms in place to evaluate whether staff are meeting 
goals.
    Community care is VA care. What is VA doing to ensure that 
veterans do have the access and care coordination they deserve? 
I think this is kind of following a little bit along Eli 
Crane's questioning.
    Mr. Saslo. Thank you for the question.
    I am going to defer to Dr. Yende because I think the 
Integrated Veterans Care Program really can touch on some of 
the opportunities that we are addressing.
    Dr. Yende. Thank you for that question, Congresswoman. A 
couple of questions there. I will try to answer all of them.
    Number one, you are right, RCI was an initiative started to 
help veterans understand their options for direct care and 
community care. At sites where it has been implemented, we have 
seen reduction in access times. You are absolutely right, we 
need to do a better job in terms of implementing RCI across the 
enterprise and making sure that we give some guidance in terms 
of staffing.
    Number two, you asked a question about how we are trying to 
improve care coordination for community care. We started a 
community care program--Patient Community Care (PC3) and Choice 
were present prior to it, but we really started a community 
care program in 2018 through community care networks. Since 
then, we have seen a huge increase in utilization of community 
care.
    When we implemented policies, we have very clear guidance 
to the field that there would be care coordinators in our 
community care offices. These care coordinators look at the 
request for community care, they do a risk stratification, 
which is standard care coordination process. Consider a veteran 
who needs to go and see an orthopedic surgeon. Let us say the 
veteran does not have transportation. It is the role of the 
community care Registered Nurse (RN) care coordinator to help 
the veteran make sure that there is transportation in place so 
that they can get to the appointment. That is an expectation 
from that office.
    As OIG and several of you have pointed out, our care 
coordinators are currently siloed. We have care coordinators on 
the direct care side as well as we have care coordinators on 
the community care side. What we are trying to do with the 
CCICM framework, and as part of this IPT, we started last fall, 
is really trying to bring all the care coordinators together, 
identify who would be the lead and help the veteran. Now, in a 
given scenario where the veteran is going out to the community, 
let us say they are trying to get orthopedic care, the best 
person to coordinate that care could be the community care, 
care coordinator, but in some cases, it might be the PAC clinic 
care coordinator. We are trying to work out those processes as 
to who could serve as the care coordinator for those complex 
veterans and can help with that care coordination process.
    Ms. Radewagen. Thank you.
    Dr. Saslo, in your testimony you note the importance of a 
strong care coordination between VA and community providers. 
However, we often hear from veterans that are either wrongfully 
denied community care or their community care referral is 
delayed. In your opinion, what can be done to streamline 
community care referrals? How do care coordinators fit into 
this process anyway?
    Ms. Radewagen. Thank you for the question.
    I think it is important to recognize that the framework 
that we are talking about is not building a whole new set of 
case management or care coordination. What it is doing is 
trying to identify how best to serve that veteran's needs and 
if those needs happen to be for community care referral, 
identifying, as Dr. Yende said, the individual who has the most 
effective ability to ensure the veteran's care would be the 
person that is identified as that lead coordinator.
    In turn, that lead coordinator then works with either the 
community partners directly or with the hospital, if the 
patient is going into the hospital for the orthopedic surgery, 
coming back, what those needs might be for the patient in order 
to be able to go home safely and effectively in order to get 
the kind of care that they need. That lead coordinator is 
really going to be the piece that we are hoping will help to 
reduce the silos that we have had in place related to the 
different areas where care coordination and case management 
already occur. Having a lead coordinator will help us to be 
sure that we have got one person who is identified and within 
the patient's record who is easily recognized for helping to 
coordinate that care.
    Ms. Radewagen. Thank you, Chairwoman Miller-Meeks.
    I yield back.
    Ms. Miller-Meeks. Thank you, Representative Radewagen.
    It sounds as if we have too many care coordinators and not 
enough care coordination.
    I am just going to ask that question of both Dr. Yende and 
Mr. Saslo. Does the VA have too many siloed care coordinators? 
Maybe that is the appropriate question.
    Mr. Saslo. I think the fair answer to that is we do not 
have enough individuals working for care coordination or case 
management. What we have is a lack of someone being identified 
to be able to coordinate the multiple layers that oftentimes go 
with a veteran's complex care. Many of our veterans, as you are 
aware, have multitudes or have numerous care issues, whether it 
be behavioral health, medical, psychosocial, and so having one 
person identified as that lead will help to break down those 
silos working with those care coordinators or those case 
managers within the other arena so that the care is now 
identified as a responsible process and that we can have 
communication that is going to be a lot more effective.
    Dr. Yende.
    Ms. Miller-Meeks. Dr. Yende.
    Dr. Yende. Yes, and if I may give an example. You rightly 
pointed out we have silos, but let us take a veteran--I think 
one of the panelists are going to describe a veteran who had 
PTSD, who had issues with cancer care, which was going out into 
the community, and had other issues that they had to address. 
Care coordination is a fairly sort of sophisticated function. 
People need to have an understanding in terms of care 
coordination in that particular area. Imagine that veteran who 
needs care coordination for their mental health and needs care 
coordination when they go out in the community. Both these 
skills will not be available in that same one individual. We 
need to have care coordinators in these individual areas within 
VHA. What you have rightly pointed out is assuming that these 
care coordinators are providing the support to the veteran, how 
does all this get coordinated? That is exactly what we are 
trying to do with CCICM.
    Also, please understand that care coordination is not a 
static function. A veteran on a given day might need help with 
oncology care, and the oncology navigator or care coordinator 
may have to step in and guide the veteran. Three months from 
now, the mental health issues may become more predominant, at 
which point the mental health coordinator who has the necessary 
expertise in that area needs to step in. We really are trying 
to design a system that can accommodate the veterans dynamic 
needs, rather than saying there is one person who is always 
going to coordinate all of your care throughout your lifetime. 
That is really what we are trying to achieve here.
    Ms. Miller-Meeks. Our witnesses on the second panel 
recommend that the VA establish essentially a coordinator for 
the coordination, either at the facility or the Veterans 
Integrated Services Network (VISN) level. Maybe what is 
required is that there is one coordinator assigned to the 
veteran instead of a facility coordinator who then coordinates 
only a specific medical entity or a specific problem.
    One of today's witnesses referenced the Federal Recovery 
Care, FRC, Coordinator program and its utility during the surge 
of complex injuries post 9/11. Why did the VA move away from 
this program, and how is your latest care coordination IPT 
using any lessons learned from this joint DoD VA program?
    Mr. Saslo.
    Mr. Saslo. I am going to ask Ms. Debord to go ahead and 
take that.
    Ms. Debord. Yes, ma'am.
    What I would say, representative, is that as far as the 
FRCs, they were really very critical right in the wake of the 
Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/
Operation New Dawn (OND) conflict. We were really intensively 
elevating everything that was happening on for care 
coordination very high and just hitting it hot. I would say 
today what we are doing with CCICM, which I am talking with our 
Quality of Life Foundation and Wounded Warrior Project 
colleagues, is that we have an opportunity to take CCICM, this 
lead coordinator, and elevate that person's authority, their 
knowledge base of all systems, so that that person really can 
do a similar job as what they did in the FRC.
    I think what we are hoping to do, and again, it is new, we 
recognize that we are in the infancy, but as we continue to 
roll this out, that the training allows these people an 
elevated status, that they know multiple systems, they speak 
multiple different languages, DoD, community care, VA, and are 
able to help the veterans navigate those systems and feel the 
authority to elevate things when things are not getting through 
that need to happen.
    Ms. Miller-Meeks. [Audio malfunction] program that was 
working. It is not the status that is required, it is that the 
coordination is given.
    With that, I am going to thank our witnesses on the behalf 
of the subcommittee for their testimony for presenting to us 
today. You are now excused.
    We will resume with the second panel after we go vote. We 
will resume after votes.
    [Recess]
    Ms. Miller-Meeks. Welcome everyone and thank you for your 
participation today.
    On our second panel, we have Ms. Andrea Sawyer, advocacy 
director with the Quality of Life Foundation, Mr. Matt Brady, 
director of Complex Case Coordination Program with the Wounded 
Warrior Project, and Mr. Roscoe Butler, senior health policy 
advisor with Paralyzed Veterans of America (PVA).
    Ms. Sawyer, you are now recognized for 5 minutes to deliver 
your opening statement.

                   STATEMENT OF ANDREA SAWYER

    Ms. Sawyer. Good afternoon, Madam Chairwoman, and members 
of the subcommittee. My name is Andrea Sawyer, and I am the 
advocacy director for the Quality of Life Foundation, a 
national nonprofit organization founded to address the unmet 
needs of caregivers and the Nation's most seriously wounded, 
ill, and injured veterans.
    We have evolved directly to work with veterans and 
caregivers as they attempt to apply for and navigate the 
Program of Comprehensive Assistance for Family Caregivers and 
other clinical support programs within the Department of 
Veterans Affairs. Serving all generations and focusing the 
majority of our time on those with significant wounds, 
illnesses or injuries, we often assist those with complex 
clinical needs.
    Additionally, I am the wife of a seriously injured 
medically, retired and medically complex combat injured 
veteran, and I have been managing his care since his return in 
2007.
    As one of the few organizations working exclusively with 
the Veterans Health Administration, Quality of Life Foundation 
has had a front row seat to witness and help others utilize 
many of the programs and services available within the VA. 
While we do not provide clinical recommendations of any kind, 
our role is to ensure that veterans and caregivers are prepared 
for the Program of Comprehensive Assistance for Family 
Caregivers (PCAFC) process, assist in the drafting of clinical 
appeals to ensure the VA is following its own regulations and 
directives, and we assist veterans and caregivers in navigating 
other programs and supports available to them within and 
outside of the VA, specifically the Veterans Health 
Administration.
    Through our work directly with veterans and their 
caregivers, done so, by reviewing the medical record, we help 
advocate for the population we serve within all VHA programs. 
Many of the cases that come to us have a lack of whole health 
coordination and management. Many have some basic care 
coordination, better known as a primary care treatment plan, 
some have care managers who resolve simple issues or referrals 
through low level intervention. However, many of our veterans 
have multiple complex care needs and no one to create a case 
coordination and case management plan. VA is severely lacking 
in case management services. Case management is a time 
intensive level of care management that looks at a veteran 
holistically to document and manage all the veteran's 
conditions and any social/environmental issues that develop as 
a result of the care needs of the veteran.
    As such, Quality of Life Foundation makes the following 
recommendations: number one, create a cadre of specially 
trained case managers similar to the Federal Recovery Care 
Coordination Program as envisioned by the Dole-Shalala 
Commission, who can manage the most complex cases by developing 
comprehensive treatment plans for each need that a veteran has. 
These case managers should have a VISN level lead. Second, ease 
the process of obtaining a case manager. Per our written 
testimony, it is hard to ask for what one does not know about. 
Third, review the current community care network and outside 
provider records' integration process. Fourth, review the 
actual caseloads of different care and case management and 
social work teams across the VA and ensure that different roles 
are being filled as individual jobs and not as collateral 
duties. Fifth, establish a ``pathway to advocacy'' for outside 
organizations to officially assist veterans and caregivers 
within VHA so that all veteran service organizations and non-
profit organizations are able to effectively advocate within 
VHA.
    In conclusion, Quality of Life Foundation believes VA needs 
to simply realign their resources and bring back older, more 
robust models of case management for those most severely 
impacted veterans. These program models have existed in the 
past, but then case management was siloed, and veterans 
suffered. The original veteran driven case management plans, 
not current vet centric plans, should allow the veterans 
treatment goals to be the focus of the plan. Allowing Veterans 
Service Organizations (VSOs) and nonprofit organizations to 
advocate for care that exists within the system would also help 
veterans and facilities focus on the needs of veterans. 
Veterans would get more timely appropriate care with the help 
of a holistic full-time case manager with authority to cut 
through VA red tape. Veterans with lesser care needs would then 
have access to lower-level care managers available to them.
    Overall, VA would save money if veterans are able to get 
timely appropriate care that is managed across the spectrum of 
the medical community, and veterans would have better health 
outcomes and quality of life.
    Thank you for your time, and I look forward to answering 
any questions you may have, especially about the Federal 
Recovery Care Coordination Program. Thank you.

    [The Prepared Statement Of Andrea Sawyer Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Ms. Sawyer.
    Mr. Brady, you are now recognized for 5 minutes to deliver 
your opening statement.

                    STATEMENT OF MATT BRADY

    Mr. Brady. Thank you, Chairwoman Miller-Meeks, ranking 
member, and distinguished members of the Health Subcommittee 
for this opportunity to speak about care coordination at the 
VA.
    As you know, effective care coordination not only produces 
better outcomes, but gives the veteran confidence in their 
system of health. To frame the issue of today's hearing from 
Wounded Warrior Project's perspective, our goal is to help 
warriors receive the appropriate care in a timely manner in the 
setting they want. We provide care coordination as part of 
three programs.
    The first is our Complex Case Coordination Program, which 
helps veterans with complex cases that are multifaceted and 
need urgent action to address mental and physical healthcare 
needs utilizing high quality VA or community-based services.
    The second is our Independence Program, which helps 
veterans with moderate to severe brain injury, paralysis, and 
neurological conditions live more independently with a better 
quality of life.
    The final is Warrior Care Network, which aims to reduce 
gaps and inefficiencies in mental healthcare delivery through 
innovation and collaboration.
    Based on these programs, we have a number of 
recommendations for Congress to consider, all of which are 
outlined in our written statement. Today, I want to point out 
three specific bills and discuss some targeted ideas that may 
inspire future bills for the subcommittee.
    The first bill is H.R. 3520, the Veteran Care Improvement 
Act, specifically section 2, which would codify an access to 
care standard for the VA's mental health Residential 
Rehabilitation Treatment Programs (RRTPs). If somebody today 
decides to turn their life around, ask for help with substance 
or mental healthcare, why would we allow them to wait 30 days 
to get that care? If this was your family member, you would not 
find this acceptable. We can do better. I know we can do better 
also. Additionally, we can do a better job communicating of 
records between the VA and the community residential care 
facilities, address follow on care, and medication needs.
    The second bill that I will highlight is H.R. 452, 
Elizabeth Dole Home Care Act. A key provision would instruct 
the VA to provide informal geriatric and extended care program 
assessment tools to give options to the eligible veteran and 
caregiver, letting them decide which programs are appropriate 
for them. If a caregiver is denied or discharged from the 
caregiver program, the VA needs to help find and enroll them in 
other VA provided home based care and support.
    Last, I will note our support for S. 1792, the Care Act. 
Section 3 has the potential to transform how organizations like 
ours advocate for veterans and their family members in 
navigating VHA programs and services.
    Our organization has been delivering this kind of help for 
thousands of veterans, and we know the life changing impact 
that an advocate can have when people need help.
    To that end, I would like to close by speaking to our 
interest in seeing the VA create a system that helps centralize 
care coordination and patient advocacy, particularly for those 
with complex needs. There are several pilot programs across VHA 
that are currently exploring how we can improve integrated case 
management, but the fact is, veterans need consistent, 
coordinated care no. We understand the VA, like many 
organizations, continue to experience staff shortages in 
critical areas. We appreciate everyone who chooses to work to 
make veterans lives better.
    Our recommendation can be instituted rather quickly. 
Designate a lead social worker, your best social worker--you 
know who they are--at each VA medical center. Have them serve 
as the lead for advocates to address critical coordination 
issues, serve as the organization's subject matter expert, and 
most importantly, having the authority to cross service lines 
and facilitate immediate assistance.
    Care coordination is only part of the solution. We must 
also empower veterans and advocates with the knowledge about 
the access to care standards and their options in care, help 
them actively participate in their care pipe, providing them 
with information, resources, and education, allowing the 
veteran to make informed decisions, effectively communicate 
their needs, and take ownership of their health.
    Thank you again for the opportunity to testify. I look 
forward to your questions.

    [The Prepared Statement Of Matt Brady Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Mr. Brady.
    Mr. Butler, you are now recognized for 5 minutes to deliver 
your opening statement.

                   STATEMENT OF ROSCOE BUTLER

    Mr. Butler. Chairwoman Miller-Meeks, Ranking Member 
Brownley, and members of the subcommittee, Paralyzed Veterans 
of America (PVA) would like to thank you for the opportunity to 
submit our views on VA's efforts to coordinate veterans care.
    Veterans with complex healthcare conditions, like spinal 
cord injuries or disorders, receive care from various 
healthcare professionals to include primary care physicians, a 
wide range of specialists, visiting nurses, and caregivers, 
many of whom are family members. This care is provided through 
a number of service points. It may be provided at one of VA's 
25 Spinal Cord Injury and Disease (SCID) centers, through VA's 
6 long-term care centers, or at other VA facilities. Care may 
also be provided through community care providers, in state 
veterans or community nursing homes, or in veterans residents. 
This often poses a difficult challenge to the many dedicated 
professionals who are working tirelessly to ensure that the 
delivery of high quality acute and long-term care is 
administered by the right providers in order to achieve optimum 
care outcomes for veterans.
    However, when coordinating care outside of the Department, 
VA's ability to coordinate care drops dramatically because most 
civilian facilities and agencies are not knowledgeable or 
equipped or properly staffed to handle SCID patients' acute and 
long-term care needs. PVA is concerned about VA's current lack 
of long-term care beds, which is severely impairing its ability 
to coordinate care for veterans with SCIDs. More than half of 
the veterans on VA's SCID registry are over the age of 65, and 
the number of veterans needing this level of care is increasing 
rapidly. Nationwide, there are very few long-term care 
facilities capable of approximately serving veterans with SCID, 
and only one of VA's six specialized long-term care facilities 
lies west of the Mississippi River.
    Today, VA care coordinators spend a tremendous amount of 
their time attempting to locate providers, facilities, or 
agencies in the private sector to meet SCID veterans' long-term 
care needs. To be clear, these were scarce prior to COVID, and 
VA SCID care coordinators tell us they are getting scarcer. 
Nursing home and home health agencies often pursue contacts 
with VA, but do not maintain them long enough once they find 
they lack the necessary training to perform the critical tasks, 
like bowel and bladder care, that some veterans with SCID need. 
Facilities lacking proper staffing are often unwilling to 
procure additional personnel for SCID veterans whose greater 
care needs consume a larger than anticipated share of their 
existing workforce time. Even if they are willing to hire 
additional personnel, nationwide provider and nursing shortages 
will often preclude them from finding the personnel that they 
need. These starts and stops are frustrating to veterans and 
those who coordinate their care.
    The 65 percent statutory cap on what VA can pay for home 
care can almost impact care coordination because it limits care 
options which may contribute to unfortunate results.
    In light of the limited access to VA facility, long-term 
care, and the desire of many veterans with SCID to receive 
noninstitutional long-term care, VA must expand access to home 
and community based services to meet the growing demand for 
long-term care services and supports. Facility based long-term 
care services are expensive, with institutional cares exceeding 
costs of Home and Community Based Services (HCBS). Studies have 
shown that expanding HCBS entails a short-term increase in 
spending followed by a slower rate of institutional spending 
and overall long-term care cost containment. Reduction in costs 
can be achieved by transitioning and diverting veterans from 
nursing home care to HCBS if they prefer it and the care 
provided meets their needs. Passage of H.R. 542, the Elizabeth 
Dole Home and Community Based Services for Veterans and 
Caregiver Act, would address many of these barriers to care. I 
cannot stress enough how important it is for Congress to pass 
this important legislation sooner rather than later.
    PVA appreciates the subcommittee's interest in this 
critical area, and I would be happy to answer any questions you 
may have.

    [The Prepared Statement Of Roscoe Butler Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Mr. Butler.
    I will defer my questions until the end so that other 
members can address the panel. I now recognize Ranking Member 
Brownley for any questions she may have.
    Ms. Brownley. Thank you, Madam Chair. I am sorry that I was 
not able to be here for the panel one discussion, but I did 
read the testimony.
    This question really is for any of you. We heard today from 
the VA and their testimony about they are rolling out a new 
care coordination framework and management system to have one 
point of contact within a patient's primary care team to help 
ensure veterans needs are met. Based on what you heard today, 
and this is are you confused as I am? `Cause and I am curious 
to know if you have heard of this program before today because 
for me, it was the first time I had ever--I mean, I read the 
testimony, but it was the first time I became aware that this 
was -this was underway. Do any of you think that this is going 
to solve the problem?
    Ms. Sawyer. I am going to put on two hats here. I am the 
advocacy director at Quality of Life Foundation, but I am also 
a caregiver for a warrior who returned in 2007 and was severely 
injured with multiple conditions that we had to manage.
    I would tell you that CC&ICM with lead coordinator has 
existed probably since the dawn of time. What we used to call 
it was you needed a case manager for your case managers. For 
those of us who had warriors coming back at the beginning of 
the war, 2006, 2007, I had a bazillion case managers on the DoD 
side and transitioning over to VA, I just add more to the 
layers. Everybody was talking past each other. Originally the 
person managing those was me until we met up with the person, 
who at that time, was head of the newly stood up Federal 
Recovery Care Coordination Program. I managed to get a case 
manager for my case managers. That person had Federal level 
authority across DoD, VA, Medicare, and could work in Social 
Security programs.
    For my warrior, and for many others that had that same 
level of case management need, that program was there. If we 
were only within the VA, the person that would have handled 
care would have been OIF/OEF, which is now the Post 9/11 
military2VA (M2VA) Office or potentially a polytrauma case 
manager.
    Those models have changed through the years. Basically, the 
FRC program rolled down into kind of a consultant basis, but 
then a consultant on just the VA employee/facility side. A VA 
facility consults the FRC program, you no longer have 
interaction with the warrior. As organizations we can refer 
people to the program. They look through the record, and then 
they can contact the facility which, if they have a difficult 
case, can engage the program. Basically, if you do not know 
they exist--and there are, I believe, only ten, I think, within 
the VA now, where there used to be, I think, a robust program 
of 75 or more across the country. That number may be a little 
elevated. They just do not exist like they did anymore. There 
is certainly not that level of case management at any facility.
    Do I know that CC&ICM is rolling out again? Yes. Do I think 
it is something we had before? Yes. Was it adequate? No. That 
is why Dole-Shalala stood up the FRC program.
    When I was listening to the VA testify and they said that 
we came in hot and heavy and we kind of triaged folks and took 
care of them. What I would like to say to the VA as the 
caregiver of one of those warriors is just because you changed 
your model of case management did not mean that my veteran did 
not have the same needs. Basically, they took away our--not in 
our case, because I fought like the devil to keep our FRC--but 
in a lot of cases, they just took away these case managers and 
left caregivers to navigate the system on our own. As a 
caregiver, while I am good at that, that is not my intended 
role. It is to provide that daily support and supervision; it 
is not to medically case manage them.
    I had to go to Veteran's Affairs Central Office (VACO) and 
fight very hard to get a coordinated treatment care plan that 
still exists today for my warrior and in a lot of cases, for 
advocacy. I am so sorry. That is what I advocate for some of 
our most seriously injured or impacted cases and what their 
caregivers do for their warriors also. We talk about how we get 
it done, how to get it done.
    Ms. Brownley. Well, thank you for that. Your warrior was 
very lucky to have you.
    I yield back.
    Ms. Miller-Meeks. Thank you, Ranking Member Brownley.
    I now recognize Representative Van Orden for any questions 
he may have.
    Mr. Van Orden. Thank you, Madam Chairwoman.
    Ms. Sawyer, I read your testimony. It was gut wrenching. I 
want to know, is that veteran in Arkansas?
    Ms. Sawyer. Yes, sir?
    Mr. Van Orden. Who is their congressperson?
    Ms. Sawyer. I cannot tell you who their congressperson is 
on the House side. I am so sorry.
    Mr. Van Orden. Will you do me a favor?
    Ms. Sawyer. I will find that. We work with Senator Boozman 
a lot.
    Mr. Van Orden. Okay. Please do. I would like to speak to 
him or her personally about this.
    Ms. Sawyer. Yes.
    Mr. Van Orden. I want to make sure that this issue is 
resolved. In that spirit, I would like the name of every single 
person that that veteran has come in contact with, because I 
will be holding them directly accountable.
    Ms. Sawyer. Well, I appreciate that.
    Mr. Van Orden. Okay.
    Ms. Sawyer. I will say your staff has been involved in that 
case with me since 2016, and the staff on this committee has 
been wonderful to work with.
    Mr. Van Orden. They are awesome.
    Ms. Sawyer. Yes, they are.
    Mr. Van Orden. Okay.
    In the break, I did not just vote, I had my crack graphics 
team develop something to help the Veterans Administration 
figure some stuff out. That is a wheel. It has been invented 
long time ago. I will give this to you if you would like. You 
can take it home, put it on your desk. You are reinventing the 
wheel, and the ranking member, boom, spot on. You have got 
institutional knowledge of the Veterans' Affairs Committee. If 
she does not know that it is going on and our chairwoman, 
nobody does.
    Command Sergeant Major, you put in here that a lot of 
veterans in this population remain confused by the number and 
types of VA services, employees roles, their delivery and 
eligibility criteria. Okay. You wrote that. I got, I do not 
know, 300, 400 Facebook messages and emails and phone calls. I 
know that Congresswoman Kiggans did also because the Veterans 
Administration was capable of pumping out some ludicrously 
political garbage on their website, terrifying our veterans. 
Everybody knew about that. It was a lie. The Veterans 
Administration lied for political purposes to our veterans, 
terrified them, and that went out like on a coconut wire, dude. 
Our veterans do not know the services that are available to 
them, and that is shameful. We are waiting for a public apology 
from the Department of Veterans Affairs and waiting for them to 
use their public affairs officers to get out the word, the 
truth, to tell people the services that are available, because 
they are available. The Veterans Administration, they work so 
hard. I am incredibly proud of our VA. I get all of my 
healthcare through the VA. I am 100 percent service-connected, 
disabled veteran, and I go to Tomah, and I am proud of them. I 
was just there last week. I told them I am proud of them.
    Ms. Sawyer, I am going to have to disagree with part of 
your testimony here.
    Ms. Sawyer. Okay.
    Mr. Van Orden. This is why--you are good. The establishment 
of a cadre of specially trained case managers. No. The 
Veterans' Affairs Committee has not done what the command 
sergeant major would call troop to task. They got plenty of 
people sitting around, and they are working, and they are 
qualified, and they are dedicated, but they need to do troop to 
task, command sergeant major. They need to be able to draw a 
line and block chart where I can put my finger on it and say, 
this person is directly responsible for this veteran's care. If 
that veteran winds up committing suicide, that person, not a 
system----
    Ms. Sawyer. Right.
    Mr. Van Orden.--of a series of things. The system is not 
responsible, an individual is responsible. That is what you 
guys need to do. I will be frank with you, the only thing 
missing from the word salad testimony that you guys gave today 
was a bucket of ranch dressing. It is unacceptable. Use 50,000 
words to say nothing. We are not taking this anymore. I will 
not allow our veterans to be disabused or ignored or commit 
suicide because a bunch of bureaucrats cannot get their act 
together.
    Mrs Sawyer, you are doing God's work, Command Sergeant 
Major, you are too, Mr. Butler, you have my undying support. 
Thank you very much for what you are doing.
    With that, I yield back.
    Ms. Miller-Meeks. Thank you, Representative Van Orden.
    I now recognize Representative Kiggans for any questions 
she may have for 5 minutes.
    Ms. Kiggans. Thank you very much, Madam Chair.
    I do not necessarily have any questions, just a couple of 
comments to piggyback off of Mr. Van Orden's remarks.
    I was geriatric primary care nurse practitioner. For me and 
having to coordinate care with the Veteran Administration on a 
civilian side, I know we are doing some good work with 
community care and really trying to incorporate them. Half the 
battle, maybe it is in charting. I know we are working through 
some of the charting systems with the VA. I hope that is a step 
in the right direction. Having patients that receive just VA 
healthcare, I would almost throw up my hands. Getting the 
charts, the diagnosis, the med list from VA was next to 
impossible. We would just kind of write it off if he got care 
at the VA, and the caregiver would then--it would be their 
responsibility to try to communicate with the civilian provider 
what happened to the VA and vice versa. We can do so much 
better.
    I know Mr. Van Orden hit on the fact that when we had that 
little political stunt about Republicans taking away veteran 
benefits, which again fabricated lie, but I too received 
multiple hundreds, like you said, of comments and emails 
saying, why are you taking away my healthcare. The VA has the 
capability to get that word out to veterans. Use it in a 
constructive, good manner, not for political games, which we 
hate. That is I know why I ran for office, to not do those 
things and to advocate for our veterans, for our military men 
and women.
    We need to prioritize. I know that so many of us on this 
committee today are willing to work to do that, especially 
those of us who are veterans, who are healthcare providers. I 
think we understand that language. We are going to work 
together to make sure the word gets to our veterans.
    I am having to hold an event in my district to inform 
veterans what resources are out there. I am having to put that 
event together. The VA should be doing these types of things 
and educating. I know as a primary care provider, it was so 
hard for me to understand what resources were available to 
veterans, to caregivers, and their families. It should not be 
that hard. I do not know, the VA should be educating providers, 
primary care providers especially. We can do so much better. We 
are going to work together and get that job done for you all.
    Thank you for your advocacy and work as well.
    I yield back.
    Mr. Van Orden. We will do a second round of questioning and 
I would like to recognize our ranking member for 5 minutes.
    Ms. Brownley. Thank you, Mr. Chair. I appreciate it very 
much.
    Ms. Sawyer, going back to your conversation on my first 
question.
    Ms. Sawyer. Sure.
    Ms. Brownley. You are recommending, you know, a case 
management social work lead operation. Sounds more like going 
back to the good old days where it was working better, correct?
    Ms. Sawyer. Yes, ma'am.
    Ms. Brownley. More or less. You are suggesting that the 
point that this should happen at the VISN level. Let me just 
say, I think for some of us who have served on this committee 
for a while, and I am one of those, we get really nervous when 
the VISN has control of something that we believe is very 
important and critical to the health outcomes for our veterans. 
Because the VISN has medical centers, VISNs, they have their 
autonomy and kind of - kind of do things the way they want to 
do things.
    Ms. Sawyer. Right.
    Ms. Brownley. I get very frustrated because we have got - 
we have got a gazillion people with coordinator titles out 
there, but some of them have, you know, a tenth of an Full-time 
Equivalency (FTE) or, you know, whatever.
    Ms. Sawyer. Right.
    Ms. Brownley. Tell me why that is where you want to start.
    Ms. Sawyer. I actually want to start in the facility 
levels. Okay. That is a little bit of a--I think in the oral 
statements it gets a little lost. I want to start at the local 
facility levels. It is not that I think there are tons of care 
coordinators out there and care managers, which are--care 
managers are really defined by single disease or injury or 
condition. I want at the local level some of those folks, 
instead of being siloed in their care management roles, to be 
trained for full holistic case management of the veteran. Right 
now, at the VISN level, there is no person for a case manager 
to go to. I would like that there is like the VACO level should 
exist at the facility level but does not and there is no layer 
in between. There is no authority of that case manager to do 
anything. That would be the reason to add a level at an 
intermediate level at the VISN to give that case manager some 
authority.
    Also going back to another part of that plan, when we 
talked about those Federal individual recovery plans, that is 
what an FRC put together, it was a veteran led plan where the 
veteran said what he wanted his care management goals to be. 
Currently, VA leads a vet centric model where the veteran is at 
the center and the VA tells the veteran what they are going to 
give them. We want it to be the other way around.
    Really, the third thing we would like to do is for VA to 
have some more centralized authority as far as case management 
is concerned. Right now, what we see is standardized authority 
throughout the VA, which allows every single medical facility 
and every single VISN, as you said, to kind of look at what the 
standard is and then apply it as they see fit. There is no, as 
we said, again and again, accountability because everybody can 
say, oh, well, it was standardized, it is not centralized 
authority, it is just standardized. It is a suggestion that I 
just have to fulfill. We want it to be a more centralized 
authority so that there is someone to hold accountable. Here is 
your model, here is what you are required to do, and should you 
fail to do that and should there be a medical consequence for 
this patient, there is someone to hold accountable when, God 
forbid, somebody winds up in the hospital because their care 
was not coordinated, and then they have an infection that is 
bad enough that they lose their leg, which is what is looking 
like it is going to happen in our case in Ohio.
    Ms. Brownley. Thank you for that.
    Mr. Brady and Mr. Butler both, thank you for mentioning the 
Elizabeth Dole bill. I appreciate that very much.
    I wanted to ask you, Mr. Brady, you talked about the -you 
talked about I guess it is a nomenclature problem that you 
talked about in terms of younger veterans and the way we 
recognize some of the long-term care services, geriatrics, and 
so forth, that can be pretty confusing and may stigmatize, et 
cetera. Do you have some suggestions around destigmatizing and 
improving outreach efforts for younger veterans who may need 
the long-term care services?
    Mr. Brady. Rank member, thank you.
    Yes, absolutely. The first easiest thing to do is to not 
have every picture of geriatric care being somebody over the 
age of 70. That is the first easiest thing. We had a meeting 
with Health and Human Services to talk about where there was 
potentially some overlap in services that they could be giving. 
The conversation centered around everybody in the room looking 
at every picture, every website, and there is no way that 
warriors see, veterans see themselves as that. I still feel I 
am 34. My wife tells me, no, you are not. When I look at those 
pictures, I do not see myself in there.
    Ms. Brownley. Yes.
    Mr. Brady. We need to get veterans that are closer to that 
age, right and then discuss geriatric in a different light with 
them, right. Advanced care, advanced age, advanced veteran, and 
stay away from geriatric.
    Ms. Brady. That would be my suggestion.
    Ms. Brownley. Very good. Yes, very good. Thank you very 
much.
    I yield back, Madam Chair.
    Ms. Miller-Meeks. Thank you.
    Mr. Butler, thank you very much for your testimony. In my 
younger years as a nurse in the Army, I was on the neurosurgery 
floor on Walter Reed on Ward 10 and turned a number of striker 
frames and worked with spinal cord injured veterans quite a 
bit, as did my husband, who is a nurse.
    In your testimony you mentioned the importance of 
coordinated care in this population, the SCID community, and 
what strengths in the hub and spoke model of care could work in 
other areas of VA care, and should the VA focus more on complex 
populations like your membership, rather than investing in 
numerous coordinators who try to manage a more basic general 
population?
    Mr. Butler. Thank you, Chairwoman Miller-Meeks, for that 
question.
    VA has an excellent model, VA's spinal cord injury system 
of care. One thing that they could do is examine that model and 
why is that model so superior to the coordination of care 
throughout the SCID program in comparison to care outside of 
that system? They may find that there is some uniqueness in the 
way the SCID care is delivered throughout that system that they 
can use throughout the entire VA healthcare system to gain some 
leverage in the coordination of care outside the SCID system of 
care.
    Ms. Miller-Meeks. As a template, then?
    Mr. Butler. Yes.
    Ms. Miller-Meeks. Ms. Sawyer, in your testimony--you and 
Mr. Brady both mentioned the Federal Recovery Coordinator 
program. As you heard me in the last panel--and I thank the 
previous panel for still being here--you heard me say the old 
adage, if it ain't broke, don't fix it. It sounds like we 
developed an FRC program in order to fix the deficits after 9/
11 in coordination of care, and it seemed to be working.
    What were the strengths in that program that should be 
continued and what were the barriers that proved to limit 
continued implementation today?
    Mr. Brady. Sure, I will go. Chairwoman, great question.
    When it was in full implementation, the FRC had great 
latitude in which to really execute, right, the plan for the 
warrior to execute where it was going to go, not just in the 
DoD, but the VA, the benefits, the Social Security 
Administration. This incredible amount of latitude in which to 
work really centered on the injured veteran. I think the 
problem with that is we got away from that and now we are at a 
level where there is not the direct interaction, there is not 
the direct care with developing the care plan with the veteran.
    There is a level of ownership I think when you are an 
advocate, when you are somebody in a Federal Recovery 
Coordinator, there is some ownership in the people you deal 
with and how you treat them and where you see them going. I 
think that we have gotten to a point where there is much fewer, 
they are farther in between. This may have been the consequence 
of obviously a drop in the amount of wounded veterans coming 
back.
    That is what I would say.
    Ms. Miller-Meeks. It sounds like what you are saying is 
that we are going from a program that worked but had less 
wounded veterans coming back from war to now a bureaucracy 
centered coordinator rather than a veteran centered coordinator 
or case manager.
    Ms. Sawyer, you talk about seeing veterans with case care 
managers who typically manage one clinic or one specific 
disease program, which is what I mentioned earlier. That seems 
to align with what the committee sees as multiple layers of 
coordinators, advocates, and champions that have little overlap 
in function and limited ability to extend past their respective 
silos. I know I am running out of time, but what does the VA 
need to do to truly provide care coordination with veterans 
with complex needs? Then in writing, if the three of you could 
submit to the committee, are there any organizations outside of 
the VA--outside of the VA, any health systems that you think do 
case management and care coordination especially well? If you 
could refer that to us.
    Ms. Sawyer. I will be glad to do that. There are several of 
that are out there.
    One of the things I wanted to respond to with that and with 
your question, we do see these very siloed case managers. One 
of the reasons I said a specially trained cadre is not because 
I think VA needs to add more employees. I do not. I think we 
need to realign the employees we have. I do agree with the VA 
when they stated that care managers are very single, focused, 
and siloed, but what you need is a person who is trained to be 
able to look at all of those clinical needs together, and it is 
simply just a--so when I said a specially trained cadre, I 
simply mean that you take some of those people who are 
individually siloed and train them to be an across the board 
case manager, to look at all of these individual care plans 
that each specialist puts in place, see where they overlap, see 
where they are contra indicated, and be able to weave those 
things out, give your family a single point of contact, and be 
accountable to see that each one of these plans and needs that 
the warrior has can do that--or they can be accountable for 
that and for helping manage that.
    I also think it is important that that person be 
responsible for portraying to the VA what the veteran wants. I 
feel like in this system a lot of times as a caregiver with a 
veteran and with the cases that I work also, is that I have the 
VA telling me a lot of the times what we are going to do, and 
it does not fit in with what we want to do. That is not 
something in the civilian medical model that we deal with.
    Sorry.
    Ms. Miller-Meeks. Thank you.
    I know all of you would want to answer that question. I 
have already gone over my time.
    Ranking Member Brownley, would you like to make any closing 
remarks?
    Ms. Brownley. Thank you, Madam Chair.
    I will just say that I think this is a really, really 
important discussion, and we have not even touched upon some 
other care coordinators in the VA. For example, for women 
veterans, all of their, if they become pregnant, all of their 
healthcare needs are outside of the VA. There is a coordinator 
for that to make sure, but you know, they do not even have the 
chance, really, except for their primary caregiver, not even 
have a chance within the VA that somebody might pick them up 
and advocate for them in terms of services they need. They 
are--they are lost on the outside.
    I have spent some time going to other medical centers 
across the country. We made a lot of trips, I think, 2 years 
ago, but spent a lot of time in Texas and Oklahoma. I mean, 
every medical center that we went to, the maternity coordinator 
was well way overworked, way, way, way overworked. No way that 
she or he could possibly manage the caseload that they had.
    I think this is an important conversation to have. I think 
we have to even dig deeper, and I think we need to watch 
carefully what the VA is doing in terms of a solution and say 
our piece.
    With that, I will yield back.
    Ms. Miller-Meeks. Thank you, Ranking Member Brownley.
    I would like to thank everyone for their participation in 
today's hearing and for the productive conversation. It is one 
of my priorities, and I know the same goes for my colleagues on 
both sides of the aisle, to take care of all veterans and to 
ensure that care is being properly coordinated to meet both the 
patient's needs, the family's needs, and improve health 
outcomes. No veteran should be left in the dark about their 
ongoing medical care or the coordination of that care.
    I look forward to working on these issues and many more 
with the Department, the stakeholders, and my colleagues on 
this subcommittee.
    The complete written statements of today's witnesses will 
be entered into the hearing record.
    I ask unanimous consent that all members have 5 legislative 
days to revise and extend their remarks and include extraneous 
material.
    Again, I would ask our panelists to provide for us any 
medical care healthcare systems that you think does an 
exemplary job of case management care coordination hearing.
    Hearing no objections, so ordered.
    I thank the members and the witnesses for their attendance 
and participation today. This hearing is now adjourned.
    [Whereupon, at 3:17 p.m., the subcommittee was adjourned.]

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                         A  P  P  E  N  D  I  X

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                    Prepared Statement of Witnesses

                              ----------                              


               Prepared Statement of M. Christopher Saslo

    Good morning, Chairman Miller-Meeks, Ranking Member Brownley and 
distinguished Members of the Subcommittee. Thank you for the 
opportunity today to discuss VHA's various care coordination programs 
within VA, community providers and emergency services. Accompanying me 
today is Dr. Sachin Yende, Chief Medical Officer, Office of Integrated 
Veteran Care (IVC), Dr. Jennifer A. Strawn, DNP, RN, NEA-BC, Executive 
Director, Office of Nursing Services/Deputy Chief Nursing Officer, and 
Ms. Jill DeBord, LCSW, Executive Director Care Management & Social Work 
Services.

Overview

    The number of Veterans using VA care over the past 5 years has 
grown 6 percent and, generally, the Veteran patient population who 
utilizes VA has more complex medical and social needs than the general 
population. VA provides a broad array of services that must be 
coordinated across the VA network to meet the unique needs of the 
Veterans we serve. Care coordination is a system-wide approach to the 
deliberate organization of all Veteran care activities to facilitate 
the appropriate delivery of health care services across all settings. 
Care coordination exists within the individual programs, including 
primary, specialty, mental health, and emergency care as well as long-
term, and social work services and what we have learned is Veterans 
move across these different programs. In addition, as use of community 
care increases, care coordination of services within VHA and the 
community is increasingly more complex and common.
    VHA is deploying an overarching framework called Care Coordination 
and Integrated Case Management (CCICM), which coordinates the work 
between various programs within the enterprise, so Veterans have one 
point of contact to assist with their care needs. In December 2022, VHA 
established an integrated project team (IPT) between CCICM and the 
Office of Integrated Veteran Care (IVC). The IPT aimed to enhance 
operations between CCICM and IVC to increase VHA's ability to offer 
collaborative, coordinated and seamless care experience(s) for 
Veterans. The goal is to expand and leverage pre-existing CCICM 
processes, procedures, and reporting throughout the health care 
continuum to include Referral Coordination (RCI) and IVC initiatives to 
further enhance VHA's ability to offer collaborative and coordinated 
care for Veterans. VHA will start implementing recommended IPT 
enhancements this fiscal year across the enterprise for the most 
vulnerable Veterans who require moderate to complex care coordination.
    A Patient Aligned Care Team (PACT) involves a team of health care 
professionals working together with each individual veteran, to plan 
for life-long health and wellness that addresses the whole person. A 
PACT achieves coordinated care through deliberate collaboration. Team 
members meet often to talk with Veterans and each other, discussing the 
patient's health care goals and the progress toward achieving them. 
They coordinate all aspects of the Veteran's health care within the 
PACT and with other care teams outside the primary care system, as 
needed.
    PACT members coordinate the Veteran's care from the primary care 
team to specialists and other health care professionals who are part of 
the Veteran's health care plan. If needed, the care team coordinates 
the transition during emergency room services, inpatient stays, or dual 
care with non-VA clinicians. In addition, they work with the Veteran on 
private sector referrals and arrange for community resources when 
needed. The focus is on building trusted, personal relationships that 
promote open communication and sharing of information. The goals 
include improved quality of care and patient safety.

Enhancing Collaboration Between VA and Community Providers

    Strong care coordination between VA and community providers ensures 
Veterans receive timely and high-quality care regardless of where that 
care is provided. VA's care coordination model is a Veteran-centered, 
team-based approach, which involves receiving the request for community 
care, assessing the Veteran's needs, developing and implementing a care 
coordination plan, and ensuring appropriate follow-up.
    With the Community Embedded Staff Program, one or more VA staff 
members are physically or virtually stationed at community facilities 
within their respective markets. Within this program, an embedded nurse 
or community liaison collaborates with community hospitals to improve 
care coordination and Veterans' experiences. This team of nurses, 
social workers, care coordinators, or a combination thereof, works to 
coordinate care for Veterans who present to a community hospital, 
including working closely with those providers to create an integrated 
care plan for the Veteran, attempting transfer to the appropriate level 
of care (nursing home, VA hospital, rehabilitation clinic), or 
connecting with a VA PACT provider.
    Another such example is the VA Liaison Program which has integrated 
VA Liaisons for Healthcare, who are VA social workers and nurses, with 
public-private partnership (P3) sites to coordinate an individualized 
transition into VA health care for Veterans who receive specialized 
treatment at a P3 site. VA Liaisons for Healthcare are assigned to each 
site in Wounded Warrior Project's Warrior Care Network, which consists 
of four academic medical centers that specialize in posttraumatic 
stress disorder, and six Avalon Action Alliance sites that offer an 
intensive outpatient program to treat brain injuries.

Referral Coordination Initiative

    VA is continuing our efforts to simplify a provider's referral of a 
Veteran to another provider. The Referral Coordination Initiative (RCI) 
aims to ensure Veterans have comprehensive information about their care 
options at the time of scheduling. Referral coordination teams include 
local staff with administrative and clinical expertise who talk with 
Veterans about their available care options with a VA provider, in-
person or virtually, or when eligible, through the Veterans Community 
Care Program.
    In August 2022, we released a systemwide update that allows 
clinicians to capture the clinically appropriate care options for these 
referrals. Additionally, the staff scheduling the requested care can 
document discussions with Veterans regarding the full range of care 
options and the outcome of that conversation. As of December 2022, we 
have seen a 24 percent improvement in scheduling internal consults for 
key RCI specialties across VHA, with average times decreasing from 10.4 
days to 7.9 days. We continue to improve and standardize documentation 
and discussion notes, as well as roles and responsibilities for the 
referral coordination teams. Additional guidance will be included in 
the new Consult Management policy expected later this year.

Ensuring Coordination for Mental Health and Emergency Services

    Section 201 of the Veterans COMPACT Act of 2020 (Public Law 116-
214) expanded eligibility for emergent suicide care for Veterans (as 
defined in 38 U.S.C.Sec.  101) and former Service members described in 
38 U.S.C. Sec.  1720I(b), in acute suicidal crisis. Care can be 
provided in VA and non-VA facilities for medical and mental health 
needs associated with the acute suicidal crisis for a period of up to 
30 days for inpatient or crisis residential care and up to 90 days for 
outpatient care.
    To optimize acute suicidal crisis care while ensuring Veterans' 
care is optimally delivered, VA is piloting a program to establish a 
network of dedicated Care Coordinators at VA medical centers. 
Leveraging the CCICM team structure, the pilot will fund five VHA 
facilities with acute psychiatric admissions and five VHA facilities 
with no acute psychiatric unit. This effort will ensure optimal 
coordination across potential medical and mental health services, 
ensure efficient navigation through both the VA and non-VA systems, 
provide Veterans or other individuals with a single resource to ensure 
optimal resolution of the suicidal crisis event, and provide VA with 
invaluable information on best practice models for expansion.

Care Coordination for Specific Veteran Populations

Rural and Elderly Veterans

    VA employs close to 19,000 clinical social workers. These dedicated 
employees provide clinical assessment and interventions that include 
care coordination and case management across all areas of programming, 
including for Veterans residing in rural and highly rural areas, and 
elderly Veterans.
    In FY 2019, Veteran Health Administration (VHA) enrollees ages 65 
and older accounted for 48 percent of all VHA enrollees, 57 percent of 
all VHA rural health enrollees, 64 percent of all VHA acute care 
hospital admissions, and 59 percent of all VHA expenditures. VHA 
enrollee projects between FY 2019 and FY 2039 include projected 38 
percent increase in the number of VHA enrollees ages 85 and older and 
278 percent increase in women VHA enrollees ages 85 and older.
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    VA social workers provide clinical interventions for Veterans in 
rural and highly rural areas through primary care. The Social Work in 
Patient Aligned Care Team (PACT) Staffing Program increases access to 
clinical social work services for this population. Over 142 social 
workers have been initially funded by the Office of Rural Health (ORH) 
to provide high quality social work interventions across 41 rural 
sites. This approach has led to positive outcomes in health and 
wellness for Veterans through proactive outreach and intervention. 
Since 2016, VA PACT social workers in funded or sustainment phases of 
the program, have served over 100,000 unique Veterans (64.27 percent 
rural).
    The Intensive Community Mental Health Recovery program serving 
rural Veterans with serious mental illnesses is called Rural Access 
Network for Growth Enhancement (RANGE). An adaptation of this program - 
Enhanced RANGE (E-RANGE) - more specifically addresses the needs of 
homeless Veterans with serious mental illness diagnoses who live in 
rural areas. RANGE and E-RANGE teams across VHA have been initially 
funded by ORH and provide mental health treatment and care coordination 
for this special population of Veterans with more than 90 teams 
covering more than 130 rural locations across the Nation.
    VA Social Workers also provide clinical assessment and inventions, 
including care coordination and case management, for elderly Veterans. 
Social workers are embedded within Geriatric and Extended Care programs 
focused on supporting elderly Veterans and routinely assist with 
coordinating care both internal and external to VA. Programs include 
Medical Foster Home, Home Based Primary Care, Community Living Center, 
Adult Day Health Care, Home Maker & Home Health Aide, Community Nursing 
Home, Veteran-Directed Care, Hospice & Palliative Care. These programs 
touch Veterans across the system, including those in rural and highly 
rural areas. ORH partners with Care Management and Social Work Services 
to integrate rural social workers into the Patient Aligned Care Team 
model to improve care coordination for rural Veterans and their 
interdisciplinary care teams.

Women Veterans

    The number of women Veterans using VHA services has nearly tripled 
since 2001, growing from 159,810 to over 600,000 today. Women Veteran 
care coordination and management creates, enhances, and expands care 
coordination in areas of maternity care, mammography, cervical cancer 
screening, breast cancer care, and infertility treatment. ORH and 
Women's Health collaborate to expand access to these services to rural 
areas.

Maternity Care Coordination

    VA has a robust Maternity Care Coordination (MCC) Program to 
support pregnant Veterans through every stage of pregnancy and after 
delivery. As of May 2023, over 150 Maternity Care Coordinators, 
including at least one at every VA medical center, communicate and 
connect with Veterans, collaborate with VA and community clinicians, 
monitor the delivery of care, and track outcomes. MCCs contact, 
educate, and support Veterans at regular intervals throughout pregnancy 
and postpartum. MCCs connect pregnant and postpartum Veterans to 
appropriate resources and needed services both within VA and within the 
local community. MCCs also ensure Veterans are scheduled for an 
appointment with their PACT within 12 weeks after the pregnancy ends.

Fertility/In Vitro Fertilization Services

    VA continues to develop care coordination for Veterans and VA 
beneficiaries eligible for fertility care, those who are enrolled in 
the medical benefits package and recognizes the importance of 
coordinating that care. Most highly specialized infertility care is 
authorized by VA for provision in the community by reproductive 
endocrinologists. Care coordination is essential to the provision of 
high-quality, time-sensitive fertility services for Veterans and VA 
beneficiaries. Between fiscal years (FY) 2017 and 2021, over 26,000 
Veterans and or their beneficiaries received fertility counseling and 
treatment through a VA facility.
    In September 2016, Congress passed the Continuing Appropriations 
and Military Construction, Veterans Affairs and Related Agencies 
Appropriations Act, 2017 and Zika Response and Preparedness Act (PL 
114-223, Div. A, Sec.  260) which authorized VA to provide Assisted 
Reproductive Technologies (ART), including In-Vitro Fertilization 
(IVF), to certain eligible Veterans and their spouses. Pursuant to 38 
CFR Sec. Sec.  17.380 and 17.412, VA has furnished care for over 300 
Veterans and their spouses with a service-connected disability 
resulting in infertility between FY 2017 and FY 2021.
    In 2019, VA established Fertility/In Vitro Fertilization 
Interdisciplinary Teams (IVF-IDT) in each Veterans Integrated Service 
Network to coordinate care for fertility services. The Fertility/IVF-
IDT meets regularly to discuss and review Veterans' requests for 
fertility care and services, ensuring Veterans and VA beneficiaries 
meet eligibility requirements set forth in law and outlined in VHA 
Directive 1332, Fertility Evaluation and Treatment, and VHA Directive 
1334, In Vitro Fertilization Counseling and Services Available to 
Certain Eligible Veterans and Their Spouses.
    A key role of members of the Fertility/IVF-IDTs is to ensure 
Veterans have access to information about available fertility and 
family building services through VA. Members ensure information on 
fertility benefits are readily available to Veterans and VA facility 
staff. The IDT ensures the existence of a transparent process that is 
efficient and effective in the timely management of fertility consults. 
In addition, Fertility/IVF-IDT members ensure Veterans and VA 
beneficiaries are receiving appropriate fertility care. They monitor 
authorized fertility care and cryopreservation through record review to 
track fertility treatments and ensure fertility services do not exceed 
authorized limits.
    Interdisciplinary members communicate with Veterans and VA 
beneficiaries about fertility eligibility and services while providing 
resources and support. If it is determined a Veteran is ineligible for 
VA fertility services, the Fertility IVF-IDT provides written 
notification of ineligibility with an explanation where eligibility 
criteria were not met for fertility services authorized by VA and 
notice of how to appeal this decision.

Cervical Cancer and Breast Cancer Screening

    Screening for cervical cancer through Pap tests and/or Human 
Papilloma virus screening and screening for breast cancer with 
mammograms is critical to identifying cancerous or precancerous 
conditions. These screening tests require precise tracking of 
timelines, results, and referral orders to ensure that all eligible 
Veterans are followed. Often, a return visit or advanced evaluation is 
recommended. Women's health care coordinators ensure timely scheduling 
of initial screening, follow up, and community provider scheduling, and 
they then finalize all required documentation. Care coordinators have 
proved to be critical in executing accurate and reliable screening 
across the system.
    In 2022, 90 percent of VA sites had full-or part-time breast cancer 
screening coordinators, and 78 percent had full-or part-time cervical 
cancer screening coordinators. State-of-the-art information technology 
assistance is available through national electronic health record 
clinical reminders, the System for Mammography Results Tracking, and 
the Breast Care Registry. To enhance the availability of Women's Health 
Coordinators at all sites, VA has funded over 170 Women's Health Care 
Coordinators through the Women's Health Innovations and Staffing 
Enhancements (WHISE) program. Through ORH's Rural Health Initiative, 40 
VA medical facilities received funding to recruit and hire 53 care 
coordination personnel in the areas of mammography and cervical cancer 
screening, maternity care, and breast cancer care. This allowed 
facilities that serve mainly rural women Veterans to create, enhance, 
and expand women's health care coordination and management for rural 
women Veterans.
    VA follows the United States Preventive Services Task Force 
Recommendations for Cervical Cancer Screening and the American Cancer 
Society Guidelines for Breast Cancer Screening in average risk women. 
In response to the Dr. Kate Hendricks Thomas SERVICE Act (SERVICE Act; 
Public Law 117-133), VA has expanded access to ensure that eligible 
Veterans who were deployed in support of a contingency operation in 
certain locations and during certain time periods can receive a breast 
cancer risk assessment and clinically appropriate mammography 
screening. Beginning in March 2023, providers began offering breast 
cancer and toxic exposure screenings to Veterans identified through the 
SERVICE Act. In addition to ensuring timely scheduling of initial 
screening, follow up, and community provider scheduling, breast and 
cervical cancer care coordinators would generally transition care 
coordination over to Oncology or necessary specialty care after a 
diagnosis.

Conclusion

    Veterans have more options than ever before to receive timely and 
coordinated care. We are serving record numbers of Veterans both in VA 
facilities and through community care with significant progress toward 
our timeliness goals. Within VA, the goal of care coordination is to 
improve patient experience and health outcomes through effectively 
organized health care and sharing of information with Veterans, their 
care teams, and caregivers.
    Chairman Miller-Meeks and Ranking Member Brownley, we appreciate 
your continued support and look forward to answering your questions.
                                 ______
                                 

                  Prepared Statement of Julie Kroviak

    Chairwoman Miller-Meeks, Ranking Member Brownley, and Subcommittee 
Members, thank you for the opportunity to discuss the Office of 
Inspector General's (OIG) oversight of how the Veterans Health 
Administration (VHA) coordinates the delivery of veterans' health care. 
The OIG's Office of Healthcare Inspections routinely reviews and 
publicly reports on the quality of health care provided across VHA and 
on risks to patient safety.
    Coordination of health care defines a series of activities that 
must occur for a patient to achieve the most desirable outcomes of 
their treatment. There is nothing passive about these activities; the 
choreography of delivering care is often a complex interchange of 
clinical and administrative activities that must always be precise. 
From aligning appropriate specialty teams to ensuring essential 
medications and equipment are in place, providers must also work to 
anticipate the patient's future needs as well as potential 
complications. This complex coordination often occurs, as many of the 
OIG reports discussed below show, for patients facing serious 
illnesses. These patients rely on a comprehensive assessment of not 
only their specific condition but the supports in place to ensure their 
recovery, such as the safety and appropriateness of a patient's 
discharge environment, clear education and instructions to the patient 
and their caregivers, and reliable processes that ensure all 
participants have all relevant information. When there are breakdowns 
at any point in coordination, the safety of the patient is compromised 
and the trust placed in the system responsible for providing that care 
is lost.
    This testimony highlights some of the many issues that care 
providers and patients have faced in navigating the complexities of 
care coordination. These reports recognize that VHA personnel often 
have to overcome inefficient and ineffective processes or system 
limitations to ensure safe transitions and quality care both within VHA 
and with outside care providers. The discussion that follows focuses on 
(1) the transition from the Department of Defense (DoD) to VA care, (2) 
barriers to care coordination within VA, and (3) breakdowns that can 
occur when engaging community care providers. Ultimately, effective 
care coordination is dependent on dedicated and skilled staff 
consistently adhering to sound clinical and administrative policies and 
practices that result in desired outcomes for patients and their 
caregivers and families.
    Although the specific OIG reports highlighted below detail 
deficiencies at various points of coordination or at a particular 
facility, the findings and recommendations should be considered by VHA 
leaders and staff participating in patient care across the Nation.

CARE COORDINATION CHALLENGES DURING THE TRANSITION FROM THE DEPARTMENT 
OF DEFENSE TO VA

    Many challenges can occur within the first 12 months of discharge 
from DoD associated with leaving active duty and transitioning to 
civilian life, such as homelessness, family reintegration, employment, 
posttraumatic stress disorder, and substance misuse, which can increase 
the risk for suicide.\1\ While improvements have been made in the 
interoperability of VA and DoD electronic health record (EHR) systems, 
significant risks remain when VA providers find DoD records are not 
complete or accessible, or when VA providers have not thoroughly 
reviewed and evaluated those records during former service member's 
earliest encounters in VA.
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    \1\ VA, Executive Order 13822 Fact Sheet, accessed June 1, 2023.
---------------------------------------------------------------------------
    The OIG is finalizing a national review in which a team evaluated 
the transition of clinical care for service members with opioid use 
disorder (OUD) from DoD to VHA.\2\ Failure to identify and document a 
patient's known OUD history and related treatment during this critical 
transition period may decrease the likelihood of a patient receiving 
timely VA care and support. Of particular concern, veterans have been 
found to be ``twice as likely to die from accidental overdose compared 
to non-veterans.'' \3\
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    \2\ VA/DoD Clinical Practice Guideline for the Management of 
Substance Use Disorders, Version 4.0, 2021. Care transition refers to 
the transition of healthcare from DoD to VHA for a service member upon 
separation from the military; Diagnostic and Statistical Manual of 
Mental Disorders Fifth Edition, Text Revision (DSM-5-TR), ``Substance 
Related and Addictive Disorders,'' accessed December 15, 2022. OUD is 
defined as a ``problematic pattern of opioid use leading to clinically 
significant impairment or distress'' as manifested by at least two 
symptoms from a list of psychological, physical, occupational, 
interpersonal, or recreational consequences, within a 12-month period.
    \3\ Elizabeth M. Oliva et al., ``Saving Lives: The Veterans Health 
Administration (VHA) Rapid Naloxone Initiative,'' The Joint Commission 
Journal on Quality and Patient Safety 47-8, (August 2021): 469-80.
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    The OIG reviewed a sample of discharged service members with a DoD-
originated OUD diagnosis. The team then reviewed the patients' VHA 
electronic health records for evidence that care providers were aware 
of the OUD diagnosis and treatment. The OIG team found concerning gaps 
in the records review with a significant percentage of the VHA 
providers not recording the OUD diagnosis in VHA records, thus 
potentially hampering future medical decisions.\4\ Additionally, the 
OIG found providers perceived barriers to documenting OUD diagnoses 
during the transition of clinical care, and the OIG determined that 
while there was evidence of the use of risk-mitigation strategies, such 
as dispensing opioid reversal agents, improvements could be made.
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    \4\  Currently, this report is in draft, but, consistent with OIG 
practices, has been reviewed by VA. This allows VA offices to comment 
on OIG findings and recommendations, as well as to provide responsive 
action plans. OIG staff is integrating that feedback into the final 
report. While it is not the OIG's routine practice to testify regarding 
pending reports, due to the timing of this hearing and VA having had 
the chance to review the report, the findings are discussed in general 
terms today.
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    Veterans who are referred by VA to a DoD medical facility also may 
experience coordination problems due to limitations in the 
interoperability between the DoD and VA electronic healthcare records 
(EHR), such as the lack of full accessibility offered by the Joint 
Longitudinal Viewer (formerly known as Janus and the Joint Legacy 
Viewer). The OIG has released 14 oversight reports on the deficiencies 
with the new EHR system that is meant to provide a seamless health 
record for veterans between DoD and VA.\5\ Despite progress, there is 
still significant work to be done.
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    \5\ VA OIG, Statement of Deputy Inspector General David Case--
Hearing on ``VA's Electronic Health Record Modernization: An Update on 
Rollout, Cost, and Schedule'', September 21, 2022.
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    Staff from several OIG divisions worked on a joint project led by 
the DoD Office of Inspector General that was released in 2022.\6\ The 
project assessed internal controls and compliance with legal 
requirements, as well as actions by DoD, VA, and their joint Federal 
Electronic Health Record Modernization (FEHRM) program office to help 
ensure that healthcare providers serving veterans can access a complete 
healthcare record. The joint audit found that while the agencies took 
some actions to achieve the level of interoperability between DoD, VA, 
and external care providers specified by Congress in the National 
Defense Authorization Act (NDAA) of 2020, challenges remain. The audit 
found that VA and DoD did not consistently migrate patient healthcare 
information into the new EHR to create a single, complete patient 
health record, because DoD and VA have separate processes for bringing 
information into the new EHR. To access clinical information that 
hasn't been migrated to the new system, users have been instructed to 
use the Joint Longitudinal Viewer. This work-around does not meet NDAA 
requirements that healthcare providers access and exchange patient 
healthcare information without additional intervention. Second, the DoD 
and VA did not develop interfaces from all medical devices to the new 
EHR so that patient information will automatically upload to the 
system. For example, some medical devices, such as some blood pressure 
cuffs and IV pumps, did not have set national healthcare data standards 
and still require the departments to develop effective interfaces. One 
contributing factor to interoperability problems was the failure of 
FEHRM program office officials to develop and implement a plan to 
achieve all NDAA requirements and actively manage the program's 
success, as authorized by the FEHRM's charter. Because the FEHRM 
program office limited its role, DoD and VA took separate actions to 
migrate patient healthcare information and develop interfaces. These 
issues remain unresolved.
---------------------------------------------------------------------------
    \6\ DoD OIG and VA OIG, Joint Audit of the Department of Defense 
and the Department of Veterans Affairs Efforts to Achieve Electronic 
Health Record System Interoperability, May 5, 2022.
---------------------------------------------------------------------------
    As part of the OIG's oversight of VA's development and 
implementation of the new EHR system, reports have been issued on care 
coordination concerns affecting patients at VA facilities that have 
transitioned to the new system.\7\ The OIG found several areas of 
unresolved issues that create barriers to various aspects of care 
delivery, such as appointment scheduling, laboratory orders, prescribed 
medications, and the utility of high-risk-for-suicide and behavioral 
patient record flags.
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    \7\ VA OIG, Care Coordination Deficiencies after the New Electronic 
Health Record Go-Live at the Mann-Grandstaff VA Medical Center in 
Spokane, Washington, March 17, 2022.

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CARE COORDINATION CHALLENGES FOR VETERANS RECEIVING CARE WITHIN VHA

    After veterans are enrolled and established in VHA, issues related 
to care coordination can arise in both acute and long-term care 
settings. For example, the OIG has repeatedly identified clinical 
failures caused by unclear or inadequate processes or in the oversight 
of personnel tasked with ensuring a safe transition for patients.

        Facility Personnel Did Not Follow VA Processes or Failed to 
        Properly Coordinate Care within a Facility or Clinic

    Many OIG reports focus on personnel within medical facilities 
either not following policy and procedure or failing to properly 
communicate to other providers and clinical staff.
    For example, the OIG has reported on the death of a veteran who was 
wrongly denied care at a VA emergency department. Despite being told of 
the veteran's serious condition and provided with identifying 
information, nurses and an administrative staffer wasted critical time 
analyzing the veteran's eligibility status, later having the veteran 
transported to a community hospital. In the end, it was determined the 
patient in fact was a veteran and proper policies had not been 
followed.\8\ Similarly, a veteran residing in a VA community living 
center was found deceased after a nurse failed to initiate that 
resident's transfer to an emergency department following the 
recommendation of the on-call resident.\9\
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    \8\ VA OIG, Delay in a Patient's Emergency Department Care at the 
Malcom Randall VA Medical Center in Gainesville, Florida, June 3, 2021. 
Further, the OIG has numerous reports that describe issues associated 
with coordinating the after care for patients who visited emergency 
departments. VA OIG, Quality of Care Concerns and Leadership Response 
at the Amarillo VA Health Care System in Texas, April 14, 2022; VA OIG, 
Poor Emergency Department Care of a Patient, January 25, 2023. The OIG 
also reported on an emergency department physician whose delay in 
recognizing the need to transfer a patient to a facility that could 
provide needed life-saving treatment led to the patient's death. VA 
OIG, Mismanagement of Emergency Department Care of a Patient with Acute 
Coronary Syndrome at the Robert J. Dole VA Medical Center in Wichita, 
Kansas, September 23, 2020.
    \9\ VA OIG, Failure to Communicate and Coordinate Care for a 
Community Living Center Resident at the VA Greater Los Angeles Health 
Care System in California, August 17, 2022.

        Failures in Coordinating Discharge from Facility Care Place 
---------------------------------------------------------------------------
        Veterans at Risk

    Careful and thorough discharge planning is critical to support safe 
outcomes as patients move between providers and various care settings, 
especially when transitioning back to their homes.
    During an inspection at the VA Southern Nevada Healthcare System's 
inpatient mental health unit, the OIG found serious gaps in discharge 
planning for a patient who died by suicide the same day as being 
released.\10\ The patient had been treated by various VHA facilities 
for significant mental health conditions for many years before this 
inpatient stay. The OIG found inadequate care by both inpatient and 
outpatient staff, a failure to reconcile critical clinical treatment 
and discharge plan information, delayed assignment of a required mental 
health treatment coordinator, and ineffective responses to the 
patient's complaints and requests. For example, staff did not request 
substance use disorder assessments despite a positive drug test; failed 
to understand the patient's suicide risk factors, like access to lethal 
means; and did not identify coping strategies among other aspects of 
unsatisfactory safety planning. These lapses placed this patient at 
significant risk during their transition to home. Even after the 
suicide event, the OIG found facility leaders did not properly handle 
institutional disclosure processes by failing to alert the veteran's 
next of kin to the deficiencies. The OIG made 10 recommendations, now 
closed, for corrective action focused on improving patient care 
coordination and mental healthcare delivery.
---------------------------------------------------------------------------
    \10\ VA OIG, Deficiencies in the Mental Health Care of a Patient 
who Died by Suicide and Failure to Complete an Institutional 
Disclosure, VA Southern Nevada Healthcare System in Las Vegas, July 15, 
2021.
---------------------------------------------------------------------------
    As part of a review of allegations that an elderly patient suffered 
verbal abuse and physical harm at the hands of facility staff at the VA 
community living center (CLC) in Miles City, Montana, after being 
discharged from an inpatient stay at the Fort Harrison VA Medical 
Center, the OIG found the patient experienced deficient care 
coordination and discharge planning.\11\ Because Miles City CLC did not 
have a designated screening process for reviewing the appropriateness 
of admissions from a VA medical center, opportunities were lost in 
determining whether the CLC could support the veteran's clinical needs. 
Further complicating the tragic events surrounding his abuse, care 
providers in the CLC failed to ensure the patient received necessary 
imaging that would have revealed a terminal diagnosis. While the 
horrific events of patient abuse are inexcusable, recognizing that 
failures in inpatient discharge planning contributed to this same 
veteran being denied timely access to end-of-life care is devasting.
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    \11\  VA OIG, Mistreatment and Care Concerns for a Patient at the 
VA Montana Healthcare System in Miles City and Fort Harrison, January 
26, 2023.

        Failures with Coordination of Care in Non-Facility VHA Settings 
---------------------------------------------------------------------------
        Can Result in Patient Harm

    Veterans engage with VHA outside of traditional medical facility 
settings, often seeking additional or complementary services, 
particularly in support of mental health treatment. Similar to care 
coordination provided in VHA clinic and inpatient settings, prompt and 
clear communication is imperative to ensuring a patient's needs are met 
when engaging with crisis hotline personnel, community-based vet 
centers that provide counseling, and VA-directed home-based mental 
health care.

        Veterans Crisis Line

    Since its establishment in 2007, the Veterans Crisis Line (VCL) has 
answered millions of calls from veterans in crisis. VCL responders are 
required to initiate emergency rescue services for those veterans 
identified as being in immediate danger to themselves or others. In 
addition, coordination activities for callers not in need of immediate 
rescue are critical to ensuring appropriate care. For example, in 2021, 
a VCL staff person told the veteran it was urgent that they go to a VHA 
emergency department in Augusta, Georgia, after the veteran expressed 
suicidal ideation.\12\ The VCL staffer notified an emergency department 
nurse that the patient was directed there. The patient reported to the 
emergency department as directed; however, the nurse did not document 
for the emergency department physician evaluating the patient that this 
was due to a VCL referral because of suicidal ideation, and there was 
no evidence the physician was ever notified. On arrival, the patient 
reported a chief complaint of pain and denied suicidal ideation during 
a routine screening. Without knowledge of the VCL referral, the 
physician did not have a complete understanding of the patient's 
current condition and therefore did not ensure the patient's follow up 
with mental health clinicians. Additionally, the facility's suicide 
prevention staff, despite being made aware by VCL staff of the 
veteran's contact with VCL, did not contact the veteran to schedule 
follow-on care as required.\13\ Approximately two months later, the 
veteran was found deceased from a self-inflicted gunshot wound in the 
parking lot of the Aiken, South Carolina, Community Based Outpatient 
Clinic. The OIG made nine recommendations to the Augusta facility in 
May 2023, including several focused on managing referrals and care 
coordination.
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    \12\ VA OIG, Deficient Care of a Patient Who Died by Suicide and 
Facility Leaders' Response at the Charlie Norwood VA Medical Center in 
Augusta, Georgia, May 10, 2023.
    \13\ In a different OIG healthcare inspection, emergency department 
staff failed to inform suicide prevention staff of a patient in crisis, 
and the patient died by suicide six days later. VA OIG, Inadequate 
Emergency Department Care and Physician Misconduct at the Washington DC 
VA Medical Center, July 28, 2020.

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        Vet Centers

    Vet centers are community-based clinics that provide a wide range 
of psychosocial services to clients that include eligible veterans and 
current service members. Vet center counselors communicate with local 
VA medical facilities to coordinate care for shared clients, most 
importantly, those who are high risk for suicide. The counselors are 
required to provide timely notification to VA medical facility suicide 
prevention coordinators when shared clients have a significant safety 
risk. They must follow confidentiality requirements when communicating 
with local VA medical facilities to coordinate care. Since 2021, the 
OIG has published findings from its vet center inspection program, 
which provides a focused evaluation of key aspects of the quality of 
care delivered at vet centers. The OIG has consistently found in the 
sites reviewed that vet center staff across the country have not 
consistently complied with these requirements.\14\ For example, the OIG 
found that of the 30 client records reviewed in vet centers in district 
1 zone 3, 18 records had documented coordinated care with the 
supporting VA medical facilities as required, and only three of the 18 
followed confidentiality requirements.\15\ The OIG also found most 
records did not reflect mandatory notifications to VA staff were made 
for patients with significant safety risks.
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    \14\ VA OIG, Vet Center Inspection of Pacific District 5 Zone 2 and 
Selected Vet Centers, December 20, 2021; Vet Center Inspection of 
Midwest District 3 Zone 1 and Selected Vet Centers, January 19, 2023.
    \15\ Locations visited included City Center and Northeast 
Philadelphia, Pennsylvania; Scranton, Pennsylvania; and Huntington, 
West Virginia. VA OIG, Vet Center Inspection of North Atlantic District 
1 Zone 3 and Selected Vet Centers, May 25, 2023. While a veteran using 
a vet center may be referred to a VHA medical facility when in crisis, 
VHA facility staff must ensure they coordinate care with vet center 
staff when appropriate. For example, the OIG substantiated that a 
patient died by suicide within three days of discharge from an 
inpatient mental health unit in the VA OIG report, Deficiencies in 
Inpatient Mental Health Care Coordination and Processes Prior to a 
Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital 
in Columbia, Missouri, issued on January 5, 2021. While the patient 
received medication and discharge instructions that included suicide 
prevention materials, the OIG identified care coordination and 
discharge planning deficiencies that included the failure to coordinate 
the patient's mental health treatment or include vet center staff in 
the discharge planning. The vet center could have helped to facilitate 
the patient's engagement with outpatient resources and timely follow-
up.

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        Home-Based Mental Health Care

    To coordinate the complex care of veterans with serious mental 
illness and to mitigate negative outcomes, VHA utilizes Intensive 
Community Mental Health Recovery programs (ICMHR). ICMHR provides case 
management to veterans diagnosed with serious mental illness who are 
deemed able to live in the community with the frequent support of a 
multidisciplinary team coordinating the clinical and social services of 
each veteran. To reduce the burden on the veteran, these visits occur 
in the veteran's home and, as required during the pandemic, can be 
supported when necessary via the use of telehealth.\16\ The OIG 
reviewed ICMHR programs from 2019 to 2021 and found they did not meet 
VHA's required visit frequency for high-intensity services. Without 
meeting the evidence-based number of visits to support veterans and 
ultimately reduce their risk of being in crisis, opportunities for 
early and less intensive interventions are lost. Realizing that these 
patients also often require long-acting injectable antipsychotic 
medications, the OIG reviewed ICMHR-specific contingency plans for 
emergency situations such as a pandemic, when injectable medications 
may be challenging to secure. The OIG found the majority of VHA 
healthcare systems did not have ICMHR-specific contingency plans for 
ensuring veterans' access to needed medication.
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    \16\ VA OIG, Improvements Recommended in Visit Frequency and 
Contingency Planning for Emergencies in Intensive Community Mental 
Health Recovery Programs, January 31, 2023.

        Opportunities Exist to Support Care for Veterans Who Face 
---------------------------------------------------------------------------
        Challenges in Accessing Care

    Care coordination between care providers and their patients can be 
challenging for veterans who experience obstacles in getting to any 
healthcare facility. In particular, accessing in-person care can be a 
formidable task for older veterans, those with mobility issues, and 
individuals living in rural areas.
    One way that VA has been working to reduce barriers to care is by 
increasing the use of telehealth. Because providing telehealth services 
is not without obstacles, the OIG recently assessed the implementation 
and use of VA Video Connect (VVC) prior to and during the pandemic.\17\ 
VVC provides a secure environment for patients and providers to carry 
out video telehealth visits, regardless of where the veteran and 
provider are located. Specifically, the review team explored factors 
affecting why primary and specialty care providers used telephone 
communication more frequently than VVC at the onset of the pandemic and 
in lieu of in-person encounters, and how VHA resolved technology 
issues. The OIG also examined VHA provider experience with VVC prior to 
and during the pandemic to identify the benefits of and barriers to VVC 
use. When the pandemic started, VHA was not readily able to support the 
increased demand of VVC use, leading providers to provide patient care 
by telephone. This occurred despite VHA having developed telehealth 
strategic plans, which focused on improving technology to support VVC, 
increasing provider capability, and identifying emergency preparations 
for disaster scenarios.
---------------------------------------------------------------------------
    \17\ VA OIG, Review of Access to Telehealth and Provider Experience 
in VHA Prior to and During the COVID-19 Pandemic, April 26, 2023.
---------------------------------------------------------------------------
    Notably, the VHA Office of Connected Care's chief officer said 
video visits increased from 2,000 to 40,000 per day and emphasized 
that, ``the technical infrastructure was not scaled to that kind of . . 
. unexpected and unplannable [sic] for growth.'' As the pandemic 
continued, providers continued to use VVC, recognizing its value in 
increasing access to care and enabling more comprehensive evaluations 
than telephone encounters could offer. There were identifiable 
barriers, however, including patient difficulties with technology, lack 
of clinical and administrative support during the encounters, and 
challenges with scheduling VVC appointments. VHA concurred with the 
OIG's three recommendations to address those barriers that were issued 
in April 2023.

OIG REPORTS HAVE FOUND CONCERNS WITH COMMUNITY CARE COORDINATION

    Coordinating medical care between VHA and community providers 
remains a tremendous challenge, particularly for managing patients with 
complex health needs. The OIG has identified persistent administrative 
and communication errors or failures among VHA, its third-party 
administrators, and community care providers, as well as between the 
care providers and their patients. These deficiencies, often a result 
of personnel errors or policy implementation, undermine the 
considerable efforts of VHA personnel to ensure a seamless experience 
for veterans. VA has made considerable efforts to increase the use of 
technologies that enable better information sharing with the community. 
As one example, VA's participation in health information exchanges 
advances the sharing of veterans' information outside VA, whether 
through the community care program or not. Many OIG reports have 
described the frustrations and various risks experienced by patients 
referred to the community.

        Administrative Failures Challenge the Coordination of 
        Healthcare Services

    VHA has detailed numerous steps in the process to obtain healthcare 
services for a veteran through its community care programs. This 
process requires staff from clinical service lines and administrative 
support offices in the medical facility to work with the veteran or 
caregiver, the VA's third-party administrator, and the community 
provider. The OIG reviewed VA's implementation of the Referral 
Coordination Initiative (RCI) that sought to facilitate consult 
(referral) scheduling for specialty care within VHA facilities and in 
the community for eligible veterans.\18\ RCI was designed to improve 
veterans' timely access to care, empower patients to make informed care 
decisions, reduce providers' administrative burden and increase their 
time on patient care, and enhance access to community care for veterans 
eligible under the MISSION Act of 2018.\19\
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    \18\ VA OIG, Additional Actions Needed to Fully Implement and 
Assess Impact of the Patient Referral Coordination Initiative, October 
27, 2022.
    \19\  The OIG reported in 2020 on the community care consult 
process, with an audit team finding patients experienced community care 
appointment delays in Veterans Integrated Service Network 8 due to the 
facilities' insufficient staffing and consult-processing structure at 
community care departments that review, authorize, and schedule 
community care. There was insufficient staffing for administrative 
functions such as contacting patients and coordinating appointments. 
Also, merging the consult authorization and scheduling tasks within 
community care departments could allow scheduling to begin promptly. 
The OIG's five recommendations focused on key process improvements. VA 
OIG, Improvements Are Needed in the Community Care Consult Process at 
VISN 8 Facilities, January 16, 2020.
---------------------------------------------------------------------------
    Under the non-RCI consult referral process, a provider first 
determines whether a patient requires a specialist and then assesses 
whether the patient is eligible for community care provided by a non-VA 
practitioner. If the patient is eligible for care in the community, the 
healthcare provider submits a referral to the facility's community care 
department staff to confirm eligibility and to call the patient to 
discuss appointment preferences (including provider and location). 
Then, the community care staff either help schedule the appointment or 
provide the patient with the information to do so.
    Under the RCI process, after a facility provider (usually a primary 
care physician) enters a consult for a patient requiring specialty 
services, a Referral Coordination Team (RCT) determines the veteran's 
eligibility for community care.\20\ A clinical RCT member, typically a 
triage nurse, determines the available care options for the patient 
(in-house, in another VA facility, or in the community); assigns the 
consult a priority level indicating how urgently the patient needs to 
be seen; determines whether any medical tests are needed; and contacts 
the patient to discuss care options.
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    \20\  VHA, Referral Coordination Initiative Implementation 
Guidebook, December 2021. The guidebook states that the RCT is a 
multidisciplinary team of clinical and administrative staff, which 
includes doctors, physician assistants, licensed nurse practitioners, 
registered nurses, and schedulers.
---------------------------------------------------------------------------
    In 2019, VHA began implementing the RCI at 139 VA medical 
facilities, with expected completion across all facilities and all 
specialty services by June 30, 2021. VHA staff generally agreed the RCI 
had the potential to achieve its stated goals. However, facilities 
struggled with implementation for several reasons, including 
insufficient staffing and resources, unreliable data (such as a lack of 
accurate wait times for community care), and a lack of required 
training. The RCI describes two implementation models, centralized and 
decentralized, but facility staff were sometimes confused about which 
model to apply and noted slow responses from VHA to questions. Without 
clear direction on staffing models, some facilities tested different 
implementation methods. Given the staffing strain, initiative leaders 
from one facility said they were planning to roll out the initiative to 
only two services every month; at this time, completion may still take 
several years.
    The Office of Integrated Veteran Care (IVC) predecessor, the 
program office responsible for overseeing the RCI, also lacked the 
ability to monitor progress due to insufficient data. Because of these 
deficiencies, no VA facility had fully implemented the RCI almost a 
full year after VA's own June 2021 deadline, and facilities are 
currently working to fully implement the process. IVC had not developed 
a mechanism for facilities to evaluate whether staff were meeting the 
initiative's goals. VHA did not have data to measure whether the 
initiative reduced the average time to schedule appointments--one of 
its key goals. Also, VHA lacked measures to evaluate whether veterans 
received key information to inform care decisions, a second key goal. 
The review team identified instances when facility staff did not 
provide patients with key information--for example, there was a 
provider who said he generally decides what is best for patients and 
does not usually give them an option. Similarly, IVC had not evaluated 
if the initiative reduced administrative burdens on providers, a third 
key goal, and none of the four facilities the review team visited had 
conducted this type of analysis.
    The under secretary for health concurred with the OIG's seven 
recommendations issued in October 2022 to improve RCI implementation by 
better assigning responsibilities and roles, improving training, 
establishing local procedures for sharing community care data to more 
fully inform patients, sharing best practices among all facilities, 
ensuring accurate tracking of RCI consults, and developing measures of 
how well facilities meet the initiative's requirements. Five 
recommendations remain open at this time.
    After a veteran receives services from a community care provider, 
VHA has contracted for those providers to return the treatment records 
to VA. These records from non-VA care settings enable continuity of 
care by VHA providers and inform treatment decisions. An OIG audit team 
found in a June 2021 report that staff at six of the seven VA medical 
facilities reviewed did not always index or categorize these records 
accurately.\21\ Inaccurate indexing of medical records poses a risk to 
veteran care and increases the burden on the VHA staff who locate and 
correct the errors, reducing their time for other tasks. Errors 
included using ambiguous or incorrect document titles, indexing records 
for non-VA care to the wrong referral or veteran, and entering 
duplicate records. These errors occurred, in part, due to inadequate 
procedures, training, quality checks, and quality assurance monitoring, 
as well as a lack of local facility-level policies. The OIG recommended 
the under secretary for health improve non-VA medical records scanning 
and indexing by ensuring VHA facilities create and fully implement 
standard operating procedures. Besides clearly defining 
responsibilities and procedures for accurately scanning, importing, and 
indexing non-VA medical records, the OIG also made recommendations 
related to training and oversight of facility community care staff 
responsible for medical record management.
---------------------------------------------------------------------------
    \21\ VA OIG, Improvements Needed in Adding Non-VA Medical Records 
to Veterans' Electronic Health Records, June 17, 2021.
---------------------------------------------------------------------------
    In addition to errors while indexing returned medical documents, 
the OIG has also examined the impact of the backlogs at VA facilities 
in scanning these documents.\22\ Beyond the continuity of care risks, 
backlogs can lead to delays or denials of veterans' claims for 
reimbursement of non-VA emergency care and the expiration of checks 
sent to VA for payments, as the OIG reported after reviewing the 
contents of unopened mail at the Atlanta VA Healthcare System.\23\ The 
OIG has repeatedly found VHA staff did not enter documents into EHRs in 
a timely manner, nor did they perform appropriate reviews and 
monitoring to assess the overall quality and legibility of scanned 
documents. The OIG also found leaders' poor communication and follow-
through, as well as staffing shortages, contributed to these backlogs.
---------------------------------------------------------------------------
    \22\ VA OIG, Health Information Management Medical Documentation 
Backlog, August 21, 2019.
    \23\  VA OIG, Atlanta VA Health Care System's Unopened Mail Backlog 
with Patient Health Information and Community Care Provider Claims, 
April 27, 2022.

        Veterans Have Experienced Poor Outcomes When Care Was Not 
---------------------------------------------------------------------------
        Coordinated with Community Care Providers

    In a March 2021 report on the deficiencies found in the care and 
administrative processes for a patient who died by suicide, the OIG 
review team found that numerous administrative errors and confusion in 
the Phoenix VA healthcare facility's community referral process delayed 
a patient's specialized psychological testing. VA's third-party 
administrator (the contractor that manages the community provider 
network and appointment scheduling) incorrectly scheduled the veteran 
for therapy, not testing. The patient died by suicide not having 
received the appropriate testing and resulting treatment.\24\
---------------------------------------------------------------------------
    \24\ VA OIG, Deficiencies in Care and Administrative Processes for 
a Patient Who Died by Suicide, Phoenix VA Health Care System, Arizona, 
March 31, 2021.
---------------------------------------------------------------------------
    Another oversight report focused on a patient who ultimately died 
by suicide after not receiving several authorized community care 
counseling sessions. This was due to deficiencies in the coordination 
of the patient's care among the Memphis VA facility's community care 
staff, providers in the community, and the third-party 
administrator.\25\ The patient also suffered from hyperthyroidism, a 
condition that can aggravate anxiety. The patient declined a referral 
to endocrinology at the facility, due to the distance from home, but 
was never offered a referral to the community. In addition, a September 
2022 OIG healthcare inspection examined the failure of a facility's 
community care staff to adequately convey the seriousness of a 
patient's cancer diagnosis to VHA and community health providers.\26\ 
Due to bureaucratic issues and a lack of standard guidance, the 
facility incorrectly denied the patient's initial radiation therapy 
request.
---------------------------------------------------------------------------
    \25\  VA OIG, Deficiencies in Care, Care Coordination, and Facility 
Response to a Patient Who Died by Suicide, Memphis VA Medical Center in 
Tennessee, September 3, 2020.
    \26\ VA OIG, Community Care Coordination Delays for a Patient with 
Oral Cancer at the Veterans Health Care System of the Ozarks in 
Fayetteville, Arkansas, September 12, 2022.
---------------------------------------------------------------------------
    Managing care for veterans who have been seen in the community and 
are coming back into VHA facilities for treatment presents similar 
coordination risks. The OIG examined concerns related to a lack of care 
coordination for patients receiving ketamine for treatment-resistant 
depression (depression that has failed to respond to multiple attempts 
of more conventional treatments) in the community after authorizations 
for the care lapsed in September 2019 at the VA San Diego Healthcare 
System in California.\27\ The OIG substantiated that the facility ended 
authorizations for community care for patients receiving ketamine in 
October 2019 and again in March 2020, negatively affecting 35 patients. 
The OIG also identified deficiencies in facility processes. The OIG 
concluded that risks for negative patient outcomes increased due to 
communication and care coordination deficits, terminating community 
care authorizations, accelerating timelines for care transition, and 
uncertainties from suddenly changing treatment for complex patients. 
Four recommendations were made to the facility director related to 
community care processes for coordination of non-VA care and ensuring 
coordinated, clinically informed plans for transitioning remaining 
patients to care at the facility.
---------------------------------------------------------------------------
    \27\ VA OIG, Deficiencies in Coordination of Care for Patients with 
Treatment-Resistant Depression at the VA San Diego Healthcare System in 
California, August 24, 2021. In a separate report discussing the 
administration of ketamine for treatment-resistant depressions, the OIG 
found VHA-internal care coordination failures, including inconsistent 
prescribing practices. VA OIG, Deficiencies in the Implementation and 
Leadership Oversight of Ketamine at the Eastern Oklahoma VA Health Care 
System in Muskogee, March 9, 2023.

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VHA MUST DO BETTER AT TRACKING AND RESOLVING HEALTHCARE COMPLAINTS

    It is imperative that veterans and their caregivers have a voice in 
their care and an avenue for redress when mistakes have been made. The 
Patient Advocacy Program is VHA's effort to improve customer service, 
support veterans' access to quality care, and provide a mechanism to 
resolve healthcare delivery or coordination issues. When a veteran 
submits a complaint at a VA medical facility regarding care delivered 
within VHA or through a community partner, a patient advocate begins 
the process of documenting the concern, communicating a resolution, and 
providing follow up and feedback. Patient advocates also are expected 
to identify trends to signal potential opportunities for medical 
facility improvements. However, a March 2022 report found that VHA did 
not effectively issue and implement adequate policy, monitor complaint 
practices, and provide guidance to medical facility directors 
responsible for local program management.\28\ The OIG also found that 
patient advocates were not entering complaints into their tracking 
system or the documentation to show how complaints were being resolved. 
Further, coordinators, managers, and VHA-level Office of Patient 
Advocate staff were not monitoring and reviewing patient advocate 
activities. In addition to quality concerns, this leads to missed 
opportunities to improve veterans' experiences because facility leaders 
may not fully understand the scope of problems that veterans encounter. 
The three recommendations made to VHA to update policy, implement 
controls, and fulfill oversight duties of the program all remain open.
---------------------------------------------------------------------------
    \28\ VA OIG, Improved Governance Would Help Patient Advocates 
Better Manage Veterans' Healthcare Complaints, March 24, 2022.

---------------------------------------------------------------------------
CONCLUSION

    High-quality care demands that patients receive the necessary care 
provided by qualified clinicians in a timely manner. The reports 
highlighted in this testimony call attention to the risks introduced 
when care is not coordinated properly, whether due to clinical or 
administrative problems. The OIG is committed to ongoing and meaningful 
oversight of these issues. As VA continues to purchase an increased 
amount of community care, it must redouble its efforts to make care 
coordination efforts more efficient, and it must refocus attention on 
patients transitioning between care providers and venues. Without an 
efficient strategy to consistently monitor the access to and quality of 
care provided to veterans in the community, VHA and other 
stakeholders--and most importantly, veterans and their caregivers--can 
have no assurance of the quality or safety of that care.
    Almost every report published by the OIG's Office of Healthcare 
Inspections details aspects of care coordination, whether it is a 
hotline inspection detailing missteps or failures in that coordination, 
or the cyclical reviews that provide VHA leaders with a risk assessment 
of their medical facilities' current practices. The OIG encourages VHA 
leaders to broadly distribute these healthcare oversight publications 
to alert all facilities of potential risks and to promote the robust 
exchange of local success stories in preventing or correcting them. The 
OIG will continue to enhance our proactive tools, while revealing the 
complex findings of our inspections in responding to allegations of 
substandard care. Additionally, teams across the OIG will continue 
their efforts to assess the various VHA program offices' operations and 
monitor the issues raised in this testimony.
    Chairwoman Miller-Meeks, Ranking Member Brownley, and members of 
the Subcommittee, this concludes my statement. I would be happy to 
answer any questions you may have.
                                 ______
                                 

                  Prepared Statement of Andrea Sawyer

    Madame Chairwoman, Members of the Subcommittee, my name is Andrea 
Sawyer, and I am the Advocacy Director for the Quality of Life 
Foundation (QoLF), a national non-profit organization founded in 2008 
to address the unmet needs of caregivers, children and family members 
of those who have been wounded, ill, or injured serving this Nation. 
Since then, we evolved and now work directly with veterans and 
caregivers as they attempt to apply for and navigate the Program of 
Comprehensive Assistance for Family Caregivers (PCAFC) and other 
clinical support programs within the Department of Veterans Affairs. 
Serving all generations and focusing mostly on those with significant 
wounds, illnesses, or injuries, we often assist those with the most 
complex needs.
    As one of the few organizations working exclusively within the 
Veterans Health Administration, and as a caregiver to a Post 9/11 
veteran myself, we have had a front row seat to witness and help others 
utilize many of the programs and services available within the VA. 
While we do NOT provide clinical recommendations of any kind, our role 
is to ensure that veterans and caregivers are prepared for the PCAFC 
process, assist in the drafting of clinical appeals to ensure the VA is 
following its own regulations and directives, and assist veterans and 
caregivers in navigating other programs and supports available to them.
    In that role, we see the positive things that can happen when 
veterans and caregivers are connected by caring and passionate 
providers and social workers to the programs and services that enhance 
their care and their quality of life. PCAFC, Respite, Veteran Directed 
Care, and the Homemaker Home Health programs are just some of the 
programs that support veterans in their homes and can serve as a 
lifeline for veterans in need. Unfortunately, we also see what can 
happen when those especially vulnerable veterans are not connected to 
those resources, and, more often than not, poor or a complete lack of 
care or case management is at the root of the problem.
    In order to understand the problem, it is important to understand a 
little bit of the history and terminology involved in this process. 
After the Walter Reed scandal, the Department of Defense and the VA 
stood up unprecedented levels of case management for injured veterans. 
At one point, it was not uncommon to hear family caregivers say that we 
needed a case manager for our case managers, ultimately resulting in 
the creation and implementation of the Federal Recovery Care 
Coordination program for those with multiple severe injuries and 
complex needs. FRC's were Masters Level GS-15's nurses or social 
workers reporting to the Deputy Secretary with broad referential 
authority and, in the best of cases, the ability to created integrated 
care plans and cut across program and agency lines to resolve issues 
for the most vulnerable warriors and their caregivers.
    Since the winding down of operations in Iraq and Afghanistan and 
even before then, however, the case management programs seem to have 
been minimized with some being removed, some being revamped, and still 
others being renamed. Unfortunately, the case managers seem to have all 
again been siloed in their efforts. While FRC's still exist, there are 
very few of them and they have been relegated further down into VHA and 
do not interact with veterans directly. Instead, they serve as 
consultants upon request of the facility, when and if the facility 
knows to call them--leaving those with the most complex needs, a 
population that includes severe mental health issues, PACT act eligible 
veterans, and those with long-term complex injuries and conditions with 
no known case manager who can help them navigate resources across the 
VA, access the Community Care Network, and develop a workable 
coordinated care plan.
    Every veteran in the VA is entitled to care coordination; this is 
basic care coordination through the Primary Care Manager and a basic 
treatment plan that the veteran is responsible for carrying out.
    In our experience at QoLF, we see many veterans with care 
managers--people who usually manage one clinical support or disease 
specific program--but no overall case manager. A care manager does not 
necessarily look at overlapping needs or outside the clinic in which 
they are operating.
    Care objectives in disease specific treatment plans may be 
contradictory OR multiple disease/injury specific care plans may create 
an overall higher burden on the veteran and caregiver for management. 
With no higher oversight on the part of individual care managers, 
veterans and caregivers have multiple plans to try to navigate and 
multiple points of contact individual to each disease, injury, or 
intervention.
    Many of the veterans that QoLF serves have complex care needs. They 
are in need of case managers. Case managers are trained to evaluate the 
multiple care plans that a veteran has for each injury or condition, 
look at the veteran's whole health needs--including environmental and 
social needs, and develop a coordinated care plan. The coordinated care 
plan will take into account each condition, set goals or targets for 
each condition, list who is responsible for those goals/conditions, and 
set target dates for completion. This gives the veteran and caregiver 
ONE point of contact for issues that arise. Cases that need case 
management are time-intensive, require coordination of care both inside 
and outside the VA, and usually have psychosocial and environmental 
needs as well.
    In Ohio, we were contacted by an elderly veteran who had been 
removed from the Caregiver Support Program. The veteran had been in 
Home Based Primary Care, the Caregiver Support Program, and was 
receiving support from Geriatrics and Extended Care. The caregiver was 
using her stipend to pay for in home physical therapy, occupational 
therapy, and extra homemaker home health aide hours. When it was time 
to review the veteran, the caregiver was removed from the Caregiver 
Support Program because the Caregiver Eligibility Assessment Team felt 
that by removing the caregiver from the program, then the caregiver 
could be given many more hours of support by Geriatrics and Extended 
Care, something that is prevented by a case matrix tool that exists 
between GEC and PCAFC.
    However, and this is where case management would have been helpful, 
upon the removal of the caregiver from the stipended portion of the VA 
Caregiver Support Program, there were no steps put in place to 
immediately increase the veteran's hours of care through Geriatrics and 
Extended Care. Nor did VA send or coordinate more physical therapy or 
wound care therapy at the home of the veteran which had been being paid 
for by the caregiver from her stipend. The caregiver began calling the 
local non-emergency line to help change and bathe the veteran after no 
home health care workers were initially added to assist the caregiver. 
Additionally, the caregiver suffered an increasing level of exhaustion, 
as the VA contracted workers failed to show up for more than half the 
hours for which they were contracted and the workers were a revolving 
door of workers, some of whom did not speak any English in an only 
English speaking home.
    Once we asked for a higher level of case management to engage with 
the VA, there were a higher number of hours that were granted for 
homemaker home health aide hours, but they still were not filled. The 
issue became that GEC said it was the agency's responsibility, and the 
caregiver was supposed to take it up with the agency; the agency said 
they did not have workers to fulfill it, and no one was able to support 
the caregiver and veteran in their ever declining state.
    When we first got the family, the veteran and caregiver needed more 
support, but due to a lack of coordination between PCAFC's dismissal 
and GEC's ability to actually get the necessary about of services into 
the home that had been being provided by private care with the 
caregiver stipend, the people who paid the price were the veteran and 
caregiver. Unfortunately, while the hours were raised, they were still 
unable to be met, and now the veteran is in the hospital. Had VA 
coordinated the proper order of resource stand up and withdrawal, this 
case may have had a better outcome. This is where an overall case 
manager would have been helpful in aligning the order of how resources 
could have been added and removed.
    Additionally, no one is assisting the veteran to navigate Community 
Care Network referrals and records management. This falls to the 
veteran and caregiver, and those with these complex needs often cannot 
do it because it involves multiple behind the scenes VA processes and 
offices. Being a veteran with complex needs or an overwhelmed caregiver 
often leads to complications in the veteran and caregiver's social, 
emotional, and financial well-being. Having holistic long-term case 
management and a case coordination plan allows an extra level of 
support and management to improve the whole health of the veteran and 
caregiver so that they can focus on simply getting through treatment 
and recovery when possible.
    In Arkansas, we have a 34 year old veteran with a cancer that has 
necessitated the removal of is colon and rectum, severe PTSD that has 
resulted in a behavioral flag being placed for outbursts, and a recent 
diagnosis of sarcoidosis of the heart, lungs, and intestinal tract. The 
veteran has additional complications of a severe allergy that permeates 
his diet, nutritional and medicinal absorption issues due to his 
missing colon and rectum, and social and environmental factors that 
include a distrust of the medical system. The veteran has five children 
aged 16 to 1. Complicating the care management, is that the veteran has 
had 15 VA PCMs in the six-years that Quality of Life Foundation has had 
this case. He has multiple outside providers, some Community Care 
Network appointments and some providers that he uses his Medicare to 
see, because often VA does not have a timely appointment and referral 
process for him. His wife has never been accepted into the VA Caregiver 
Support Program, and she works from home full time. Up until recently, 
the family had had no case manager.
    After attempted conversations with the facility and then with VACO, 
a case manager was appointed through the M2VA office. Unfortunately, 
the case manager is more a care manager. He is not used to working 
complex case management that involves multiple conditions. The case 
manager is hampered by the delay in CCN notes being returned to the VA. 
The case manager is also assigned this veterans care on top of a very 
large population that he serves simply for care coordination and care 
management. When seeking answers about referrals or pieces of 
information, or trying to get two doctors to have a discussion about a 
patient, he has no authority to do so.
    We have attempted to engage, through VACO and this committee for 
multiple years, a complete care coordination and case management plan. 
That has yet to happen. In fact on multiple occasions, my staff member 
has been told that the case manager, assigned by VACO at the local 
level, does not know how to do such a detailed case plan. As a result, 
the veteran's care lags, referrals fall through the cracks, the 
veteran's health declines, and an overall sense of dissatisfaction with 
VA healthcare and anger over feeling discarded permeates his life. The 
caregiver is angered that she has a management of the case manager that 
has to occur when she already has such a heightened responsibility. 
Overall the LACK of case management on a continued basis has caused the 
VA to fail this patient.
    We understand that the VA is implementing a new process to appoint 
a ``lead coordinator,'' and as part of this initiative is specifically 
looking at sites to further enhance the coordination of care through 
the Community Care Network. While we have some concerns that the lead 
coordinator role would not alone be sufficient to address these most 
complex cases, it will be helpful to have a named individual who is 
accountable for the provision of services. Our most pressing concern is 
that the lead coordinator position becomes a collateral duty on top of 
an already heavy case load. As the ``lead coordinator'' process 
develops, QoLF recommends that the Subcommittee and the VA consider the 
following:

    The establishment of a cadre of specially trained case managers, 
similar to the FRC program and potentially linked to the lead 
coordinator who can take on the most difficult cases would benefit the 
individual veteran as well as free up the care managers and other case 
managers to serve more veterans. While most veterans can be 
accommodated by a simple phone call to a social worker or care manager, 
those with the most complex needs often need an individual with the 
training, competency, desire and authority to request waivers, explore 
options, and develop integrated care plans.

    The establishment of a case management and social work lead at the 
VISN level who could help to coordinate training, standardization of 
services, and serve as a point of contact when challenges arise.

    Ease the process of obtaining a case manager. While we have 
hopefully made a good case for having a case manager for those who need 
it, the fact remains that it is difficult to obtain one and very little 
public information exists to educate the patient. For example, the 
Richmond, Virginia VAMC homepage only mentions case management once as 
a subheading for Post 9/11 M2VA Care. There is no mention of co-morbid 
complex care case management or of disease specific case management. If 
you click on Post 9/11 M2VA case management, the description is not 
about multiple disease/condition/injury care, but more a description of 
transitioning back into civilian life after serving in the military. 
For those veterans that entered Afghanistan in 2001 or Iraq in 2003, 
should they look for case management services for multiple complex care 
needs, the description would not be one that would likely cause them to 
connect with the M2VA program or case managers. For any other veteran, 
not post 9/11, there is no mention of case or care management programs 
on the front page for that facility. So how exactly does a veteran know 
that these programs exist, know to ask for them, and know how to find 
them?

    Review the current process for entering records from outside 
providers (CCN, TRICARE, Medicare, other private providers) and how it 
impacts the ability to provide appropriate care and care management. 
(This should occur system wide as the process varies facility to 
facility and VISN to VISN.) While reimbursement for care is an issue, 
the lack of a transparent process, including identifying who is 
responsible for obtaining the records and the methods by which those 
records are or are not uploaded into the VA system, delays care and 
frustrates both doctors and veterans. This lack of record input and 
management impacts patient care, eligibility for programs, and the care 
manager's ability to effectively manage the case.

    Review the current actual caseloads of the different care 
management and social work teams across the VA to ensure proper 
staffing and allow for incentives to fill needed vacant roles. In 
addition, identify collateral duties that do not have a designated full 
time employee (FTE).

    Establish a ``Pathway to Advocacy'' for outside organizations to 
officially assist veterans and caregivers within VHA. QoLF strongly 
supports the recent Senate introduction of the CARE Act of 2023 which 
includes a provision requiring the Secretary to develop a process to 
train and recognize non-profit organizations to assist in the 
navigation of programs and services within the Veterans Health 
Administration. While QoLF currently uses Releases of Information to 
advocate on behalf veterans and caregivers, such a process would allow 
certified organizations to work more effectively WITH social workers 
and care managers to better support the population we all serve.
    In conclusion, Quality of Life foundation believes VA needs to 
simply re-align their resources and bring back older, more robust 
models of case management for those most severely impacted veterans. 
These program models have existed in the past, and for some reason were 
changed as the more recent conflicts wound down. As a result, care 
management was siloed and veterans suffered. Correctly modeling, 
training, and assigning case managers to complex cases would save time, 
money, and resources. Allowing VSO's and NPO's to advocate for care 
that exists within the system would also help veterans and facilities. 
Veterans would get more timely appropriate care with the help of a 
holistic full-time case manager with authority to cut through VA red 
tape. Overall, this would save VA money if the veteran is able to get 
timely, appropriate care that is managed across the spectrum of the 
medical community; and veterans would have better health outcomes and 
quality of life.
                                 ______
                                 

                    Prepared Statement of Matt Brady

    Chairwoman Miller-Meeks, Ranking Member Brownley, and distinguished 
members of the House Committee on Veterans' Affairs Subcommittee on 
Health - thank you for inviting Wounded Warrior Project (WWP) to submit 
this written statement for the record of today's hearing on care 
coordination at the U.S. Department of Veterans Affairs (VA). Care 
coordination is critically important to those who rely on VA for health 
care, particularly for those with multiple conditions and providers, 
and those who receive care within VA and its network of community-based 
providers. We appreciate your attention to this topic and are pleased 
to share our perspective.
    Wounded Warrior Project was founded to connect, serve, and empower 
our nation's wounded, ill, and injured veterans, Service members, and 
their families and caregivers. We are fulfilling this mission by 
providing more than 20 life-changing programs and services to over 
190,000 registered post-9/11 warriors and 48,000 of their registered 
family members. As our programs have evolved alongside those we support 
over the past 20 years, filling gaps in government-provided services 
has been an enduring focus that has fostered close familiarity with 
VA's ability to coordinate care for veterans.
    To be clear, there is no shortage of VA programs to support 
veterans and their families. However, in that abundance, many in this 
population remain confused by the number and types of VA services, 
employee roles in their delivery, and eligibility criteria. As such, 
WWP has often filled a void by assisting warriors and their families 
with navigating the VA system to help better ensure positive outcomes 
and coordination. This support- which can be provided through different 
WWP programs - is particularly important for the specific population of 
veterans that WWP serves.
    Based on data from our 2022 Annual Warrior Survey, nearly four in 
five WWP warriors have a VA disability rating of 70 percent or higher. 
Typically, our warriors have multiple cooccurring diagnoses (94 
percent), with the most common being sleep problems, post-traumatic 
stress disorder (PTSD), anxiety, and depression. Over 90 percent of 
warriors report having health care coverage through VA and nearly 60 
percent use VA-only providers to receive their primary care. 55 percent 
of those warriors who use VA providers for their primary care report 
that VA was either extremely helpful or very helpful in coordinating 
their primary care. Nearly 45 percent of warriors who use VA providers 
for their primary care report that VA was either somewhat helpful or 
not at all helpful in coordinating their primary care.
    With these warriors in mind, WWP has purposefully set out to build 
and maintain a series of programs to help increase the quality of 
interactions with the VA health system and ensure the best results for 
those we serve. Three of those programs stand out in particular.

Independence Program: Helping veterans live more independently and with 
better quality of life in consideration of moderate to severe brain 
injury, paralysis, or neurological/neurodegenerative conditions.

    The Independence Program is a partnership between WWP, the warrior, 
and his or her family or caregiver, and is uniquely structured to adapt 
to their ever-changing needs. This program pairs warriors who rely on 
their families and/or caregivers with a specialized case management 
team, paid for by WWP, to develop a personalized plan to restore 
meaningful levels of activity, purpose, and independence into their 
daily lives. These teams focus on increasing access to community 
services, empowering warriors to achieve goals of living a more 
independent life, and continuing rehabilitation through alternative 
therapies.
    Services are highly individualized and supplement VA care, 
including: case management, in-home care, transportation, life skills 
coaching, traditional therapies (physical, occupational, speech, etc.), 
alternative therapies (art, music, equine, etc.), and community 
volunteer opportunities. These services are provided for free and 
augment or complement what our warriors receive from VA. For many, this 
is an opportunity to participate in the types of daily tasks and 
meaningful activities others take for granted. It also provides 
anecdotal evidence to indicate that veterans fitting this profile may 
require more consistent care coordination service:

      WWP assisted an Army veteran who, because of his 
injuries, was honorably discharged after two deployments to Iraq. He 
now requires supervision and assistance with his activities of daily 
living, as well as instrumental activities of daily living due to a 
severe neurological disorder. His caregiving situation became unstable 
with his previous spouse not being able to provide care to him or their 
children. The family moved in order to get support from the veteran's 
mother, who is now the primary caregiver. Without the support from the 
caregiver, the veteran would be at significant risk for 
institutionalization. The Independence Program assisted the veteran 
with transferring care to the new VA facility and implementing some 
community support services so he can engage in meaningful activities at 
home. Unfortunately, the veteran and his family became homeless after 
they were evicted from their home. The Independence Program stepped in 
to provide financial assistance and temporary housing for the family. 
Additionally, the Independence Program staff contracted a local case 
manager to assist the veteran with identifying primary care and mental 
health providers at the local VA; supported the veteran with enrolling 
his kids into school; placed mental health counseling referrals for the 
kids; referred the veteran to a financial counseling program; and 
assisted with application process for a new apartment. After a year in 
the Independence Program, veteran is attending all medical appointments 
at the VA, making timely payments on his bills, obtained his driver's 
license, purchased a car, and is working with a community support 
specialist to build structure and consistency at home.

      WWP has also helped a 23-year-old Army veteran who was 
injured in a fall resulting in a spinal cord injury, paraplegia and 
traumatic brain injury (TBI). The soldier was residing in an ADA 
accessible Barrick at the Soldier Recovery Unit in San Antonio, Texas 
when the Independence Program connected with him. He required 
assistance with activities of daily living including transfers and 
bowel/bladder care. He also had undetermined cognitive deficits as a 
neuropsychological evaluation had not yet been completed. He did not 
have access to transportation and could not get to appointments, 
grocery shop, or access his community independently. At the time of 
discharge, he did not have a comprehensive discharge plan, ADA 
accessible housing, or an identified caregiver. This veteran was at 
significant risk of homelessness, institutionalization or further 
injury without supervision and supports put in place. The Independence 
Program connected this veteran to a community-based case manager who 
supported the veteran in securing ADA housing, setting up VA Homemaker 
and Home Health Aide (HHA) in-home supports, and Community Support 
Specialists to assist the veteran in scheduling and attending medical 
appointments. The veteran also engaged in recreational therapy to 
address his reintegration into his community and participated in 
financial counseling. WWP also collaborated with the veteran's VA 
social worker to ensure physical therapy was conducted in his home, 
that he was provided a shower chair, had access to VA transportation 
and ensured a neuropsychological evaluation was scheduled with his 
local VA. His community-based case manager, provided by WWP, continues 
to work with the VA to ensure these in home supports are managed by the 
VA moving forward.

    In addition to these specific case studies, WWP also surveyed our 
veteran and caregiver population to gather insight about how care and 
services might be better coordinated at VA, specifically with the VA's 
Program of Comprehensive Assistance for Family Caregivers (PCAFC). In 
May 2022, WWP surveyed a subset of veterans and caregivers (13,000) who 
previously indicated: a need for aid & attendance services, being 
housebound, requiring instrumental support or currently participating 
in WWP's Independence Program. Data from this survey strongly supports 
the idea that veterans and caregivers benefit from enhanced care 
coordination and that more effective communication about VA's 
programmatic offerings is needed.
    Over half of respondents reported they never participated in PCAFC 
(51.2 percent) or were denied (11.3 percent). For those that never 
participated in PCAFC, 67 percent were not aware of PCAFC and their 
potential eligibility. Nearly 24 percent were ineligible under the 
previous PCAFC rules. The lack of awareness about PCAFC eligibility in 
our sample population, despite disclosing a disability rating of 70 
percent or higher, where a significant majority reported a need for 50 
hours per week of caregiver assistance due to physical injury and/or 
mental injury, is concerning. Additionally, we surveyed our 
constituents about utilization of other VA entitlement programs that 
can support aid & attendance, such as VA special monthly compensation 
(SMC). SMC is a benefit paid directly to veterans that specifically 
supports aid & attendance. Despite the high disability rating, the 
requirement for aid & attendance, and the reliance of our population on 
a caregiver, 71.8 percent do not receive SMC. In sum, we believe these 
findings suggest improved care coordination and commitment to raising 
awareness of programs for more severely wounded, ill, or injured 
veterans would result in better utilization among those who would 
qualify for them.
    Based on the experience of our Independence Program, we have the 
following calls to action for the subcommittee to consider:

      Ensure that policies are in place to increase awareness 
and accessibility of programs for those with heightened needs. WWP 
supports the Elizabeth Dole Home Care Act (H.R. 452, S. 141), 
particularly key provisions that would instruct VA to provide informal 
Geriatrics and Extended Care (GEC) program assessment tools to help 
veterans and caregivers identify expanded services they are eligible 
for, and assist caregivers denied or discharged from PCAFC into other 
VA-provided home-cased care and support. Such support can also be found 
in the community and advanced through measures like Section 2 of the 
Caregiver Application and Appeals Reform Act of 2023 (S. 1792), which 
WWP also supports. Improving veteran and caregiver knowledge of VA 
program intricacies and providing clearer direction of how they can be 
used is a less formal variety of care coordination that should help 
many.
        Additionally, WWP has found that establishing treatment and 
        support programs may simply not be enough. Overlapping 
        resources and nonuniform availability of federal, state, and 
        local resources require a broad community effort to connect 
        those in need with the services created for them. For this 
        younger generation, VA's nomenclature has an impact. The word 
        ``Geriatric'' - in reference to VA's GEC program office - can 
        be a source of confusion or deterrence for both the veteran and 
        their case manager or social worker to seek services even as 
        veterans under the age of 65 already represent 27 percent of 
        those served by VA's long term support services.\1\
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    \1\ U.S. DEP'T OF VET. AFFAIRS, FISCAL YEAR 2024 BUDGET SUBMISSION, 
Medical Programs and Information Technology Programs at VHA-198, 
https://department.va.gov/administrations-and-offices/management/
budget/ (last visited June 9, 2023).
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        To overcome even this most basic barrier as well as others, a 
        menu of available program options tailored to the veteran/
        family and based on his or her needs and eligibility would 
        maximize the use and impact of those services. In addition, 
        younger veterans with long term care needs and their caregivers 
        are often overlooked for programs like Veteran Directed Care 
        and Home-Based Primary Care because they are a small - but 
        vulnerable - portion of the eligible population. In many cases, 
        they are in desperate need of these services but simply are not 
        aware they exist. Because this population is relatively small 
        and geographically diverse, increased training to identify 
        younger veterans in need of long-term support services may be 
        needed.

      Continue to foster VA collaboration with community-based 
non-profit organizations, and State and local governments to increase 
the availability of care coordination services in the community. WWP 
was pleased to advocate for passage of the Commander John Scott Hannon 
Veterans Mental Health Care Improvement Act (P.L. 116-171) that signed 
into law in 2019. Section 201, the Staff Sergeant Parker Gordon Fox 
Suicide Prevention Grant Program, established a 3-year grant program to 
provide grants for upstream community-based suicide prevention efforts. 
These grants are awarded to organizations working to provide or 
coordinate suicide prevention efforts within their communities, 
including by providing case management services. WWP supports these 
ongoing efforts and encourages continued collaboration between VA, 
community organizations, and state and local governments to collaborate 
and provide additional case management services to veterans.
        While the Fox Grant Program is focused on suicide prevention 
        services and expressly includes case management service as a 
        (see Hannon Act, Sect. 201 (q)(11)(A)(v)), this model of 
        collaboration between VA and community may also find success in 
        a program dedicated specifically to care coordination.

Complex Case Coordination: Helping veterans in need of immediate mental 
or physical health care access high quality VA or community-based 
services as soon as possible.

    Wounded Warrior Project's Complex Case Coordination (C3) team 
serves warriors with complex challenges that are often multi-faceted 
and require urgent action. They connect warriors to internal and 
external resources and treatment options to provide them with immediate 
assistance. When working with warriors, the C3 team assesses each of 
their unique needs and works with them to develop an individualized 
plan. They work to identify the resources that will best meet the 
warrior's needs and often act as a liaison between VA, the Department 
of Defense (DoD), and private community resources throughout the course 
of the warrior's treatment.
    The C3 team works a case in three phases. First, they work to 
ensure the warrior is safe and stable, conducting an assessment and 
determining their needs. The second is to maintain the situation while 
they work to build an action plan, mobilize resources, and advocate for 
the warrior's needs. The third is the transition, where the team 
coordinates wrap around services and conducts follow-up.
    As VA is one of our most critical partners, C3 has a strong record 
of collaborating with VA's Central Office (VACO), every Veteran 
Integrated Service Network (VISN), and nearly every VA Medical Center 
(VAMC). The C3 team works with VA providers and social workers to not 
only coordinate care, but to facilitate the resolution of complex 
needs, including housing insecurity, justice involvement, military 
sexual trauma (MST), substance use, and mental health, or cognitive 
challenges. With over 1,200 cases over the last four years, we have 
seen the impact and efficacy of case coordination result in improved 
outcomes and often, a restored confidence for the veteran in VA 
healthcare.
    When working a case, the C3 team assesses what VA resources may be 
available to immediately address a warrior's needs. Whether it's a 
mental health social worker, Military2VA Case Manager, MST, or U.S. 
Department of Housing and Urban Development-VA Supportive Housing 
(HUDVASH) program lead, these dedicated VA employees work in 
coordination with WWP to assist warriors. In some extremely complex 
cases, C3 will enlist assistance from VISN Chief Mental Health Officers 
or even VACO when clinical care needs are not being met, there is 
inconsistent policy execution, or care plan execution is unable to be 
resolved. In the past, they have been extremely helpful in elevating 
these issues and working with WWP to find a quick resolution.
    Based on our experience of helping wounded veterans through C3 and 
the associated perspectives of working with VA to advocate for their 
needs, we have the following recommendations for the subcommittee:

      Create a system that helps centralize care coordination 
and patient advocacy - particularly for those with complex needs. 
Wounded Warrior Project supports the creation of a system to help 
centralize care coordination and patient advocacy, especially for those 
veterans with the most complex needs. This approach should include a 
mechanism to help identify those most in need of assistance with care 
coordination, through screening during enrollment, identification by 
providers and social workers of current enrollees, and a process for 
veterans and caregivers to self-identify as in need of these services. 
Additional elements should include a central hub for coordinating care 
across different healthcare settings to ensure that all providers 
involved in the veteran's care have access to the necessary information 
and can collaborate effectively, as well as the ability for health 
advocates (like WWP) to intervene and assist with necessary appeals.
        WWP would also recommend the designation of a VA social worker, 
        at each VAMC, with enhanced authority to serve as the subject 
        matter expert for the facility. This social worker would 
        provide mentorship, oversight, and assistance to other social 
        workers executing care coordination at the service level and 
        would have the authority to expedite needed care across all 
        service areas while facilitating communication between 
        different providers, and helping veterans navigate the 
        healthcare system. An additional consideration may be for 
        training and accreditation for veteran service organizations 
        (VSOs) to be able to engage directly with this designated 
        social worker on behalf of a veteran. It is also essential that 
        we empower veterans (or their designated advocates) to actively 
        participate in their care by providing them with adequate 
        information, resources, and education about their health 
        conditions, treatment options, and available support services. 
        This allows veterans to make informed decisions, effectively 
        communicate their needs, and take ownership of their health.
        Inspiration for additional improvements to case management, 
        especially for those with more complex needs, can be found in 
        the Federal Recovery Coordination Program (FRCP) that 
        previously assigned recovering Service members with recovery 
        care coordinators responsible for overseeing and assisting the 
        Service members through their entire spectrum of care, 
        management, transition, and rehabilitation services available 
        from the federal government. This model which developed a 
        holistic care plan for the veteran, with the authority to see 
        it through, was more effective in our experience, than the 
        current model of indirect liaisons.
        Given how often veterans receive care outside of VA facilities, 
        it is also necessary to ensure that medical information is 
        appropriately communicated, and that care coordination exists 
        between all primary, specialty, and residential care providers. 
        Care plans, treatments, and the availability for continuing 
        pharmaceutical support of treatments must be communicated 
        effectively to those provider teams involved in an individual's 
        care, whether inside or outside of VA.

      Establish a consistent access standard for VA's Mental 
Health Residential Rehabilitation Programs. Another way to address care 
coordination at VA is by establishing a consistent access standard for 
VA's Mental Health Residential Rehabilitation Programs (MH RRTPs). 
Currently, the access standards established by the VA MISSION Act (P.L. 
115-182 Sec.  104) and memorialized in the Code of Federal Regulations 
(38 C.F.R. Sec.  17.4040) do not, in practice, extend to mental or 
substance use disorder (SUD) care provided in a residential setting. VA 
has maintained adherence to access standards for this type of care 
through Veterans Health Administration (VHA) Directive 1162.02, which 
establishes a priority admission standard of 72 hours and, for all 
other cases, 30 days before a veteran must be offered (not necessarily 
provided) alternative residential treatment or another level of care 
that meets the veteran's needs and preferences at the time of 
screening.
        Unfortunately, this policy has not been uniformly applied 
        across the VA system and WWP has seen many examples of veterans 
        forced to wait longer than 30 days for residential treatment, 
        and not being offered care in the community as required. 
        Interim care offerings have included telehealth and virtual 
        intensive outpatient programs that are less than what the 
        veteran ultimately needs and desires. These care options tend 
        to be less intensive, less effective, and have poorer outcomes 
        than the residential care options they are intended to 
        supplant. Other issues WWP has seen involving care within MH 
        RRTPs includes poor communication of records between VA and 
        community residential care, lack of appointment follow-up, and 
        prescription updates.
        We believe by establishing a consistent access standard for MH 
        RRTPs, veterans will not only receive more standardized, 
        quality, and timely care, but we will also see an improvement 
        in some of these other issues currently associated with RRTP 
        care more generally. To that end, WWP appreciates and supports 
        Section 2 of the Veteran Care Improvement Act (H.R. 3520), 
        which would codify an access standard for RRTP programs. 
        However, we would also recommend expanding the terms of that 
        section to include other varieties of RRTP care like its 
        specialty tracks for PTSD, MST, and severe mental illness.

Warrior Care Network: Helping reduce gaps and inefficiencies in mental 
health care delivery through innovation and collaboration.

    Wounded Warrior Project's Warrior Care Network (WCN) is a two-week 
intensive outpatient program where warriors learn how to minimize the 
interference of mental health issues in their everyday lives. WWP 
partners with four academic medical centers across the country to 
provide this treatment to help warriors manage their PTSD, traumatic 
brain injury (TBI), SUDs, and other mental health conditions.
    WCN academic medical center (AMC) partners provide veteran-centric 
comprehensive care, share data and best practices, and coordinate care 
in an unprecedented manner. This program's partnership with VA has 
helped create a broad continuum of support that is critical to 
successful outcomes for veterans. In 2016, the VA and WWP created a 
first-of-its-kind partnership, signing a Memorandum of Understanding 
(MOU) aimed at ensuring continuity of care and successful discharge 
planning for Warriors receiving treatment from both WCN and VA. This 
partnership included providing VA staff to assist part time at each AMC 
facilitating coordination of care and integrating the AMC care team.
    The MOU and partnership were expanded and enhanced in 2018, 
establishing four full time VA Liaison positions, embedded at each AMC. 
The VA Liaisons are responsible for ensuring that medical records are 
seamlessly shared between VA and WCN, that warriors are fully 
registered with VA, and that they get follow-up care appointments after 
WCN graduation at the VA. In 2022, the VA renewed the MOU for a third 
time, continuing to fund one VA Liaison at each AMC site. Each VA 
liaison facilitates national referrals throughout the VA system as 
indicated for mental health or other needs. During 2022 alone, VA 
Liaisons served 708 warriors. Over the FY 18-22 period (beginning when 
VA Liaisons were assigned):

      88 percent of veterans served by Warrior Care Network 
took advantage of connecting with a VA Liaison.

      More than 3,000 referrals for VA care were opened. Among 
the most requested appointments were mental health care, VA benefits, 
and primary care.

      More than 19,000 hours of collaborative hours between VA 
Liaisons and academic medical center employees and veterans.

    In sum, Warrior Care Network results and collaboration with VA has 
validated our belief that community-based, veteran-centric, intensive 
mental health and substance use care can lead to exceptional health 
improvements and increased engagement between veterans and VA when 
properly structured and managed. While we realize that this level of VA 
interaction and embedding with community care providers may not be 
reproducible at large scale, we remain committed to the following calls 
to action:

      Leverage innovation programs and investments to explore 
long term solutions for improved care coordination. One approach could 
be to elevate VA's commitment to exploring innovative programming 
approaches by elevating the Center for Care and Payment Innovation 
(CCPI) to the Secretary's office rather than an entity within VHA, as 
outlined in Section 206 of S. 1315, the Veterans' Health Empowerment, 
Access, Leadership, and Transparency for our Heroes Act. The bill would 
also require CCPI to establish pilot programs for the development of 
innovative approaches to testing payment and service delivery models, 
expand CCPI's mandate to include pilot programs that increase 
productivity and modernization, and accelerate CCPI's operational 
tempo. Strengthening CCPI may allow for VA to transform and improve 
veteran care, while reducing costs and administrative burdens.

Additional Calls to Action that can Improve Care Coordination

    Continue Drive Toward Electronic Health Record Modernization (EHRM)

    As DoD and VA continue push toward interoperability, we cannot lose 
sight of the goal of widespread and efficient adoption of electronic 
health record (EHR) systems. This will ultimately allow for seamless 
sharing of medical information, treatment plans, and progress updates. 
It also mitigates the risk of fragmented care. We believe a successful 
deployment of a fully integrated and user-friendly EHR will create 
efficiencies and result in better quality of care, improved 
identification of high-risk patients, an overall higher quality of life 
for veterans, and most significant to today's discussion, improved care 
coordination.
    Wounded Warrior Project continues to share the larger communities' 
concerns with the ongoing delays and issues surrounding the EHRM 
efforts. WWP was pleased to see the recent announcement that VA 
renegotiated their EHR contract with Oracle Cerner to include 
additional performance metrics and accountability measures. We are 
encouraged to see Congress playing a larger role in oversight and 
believe all stakeholders must be held accountable to ensure high levels 
of interoperability and data accessibility between VA, DoD, and 
commercial health partners.
    As the EHRM process continues to play out, WWP encourages Congress 
to look at the lessons learned from the DoD implementation of MHS 
GENESIS. The DoD MHS GENESIS electronic health record will provide 
DoD's 9.6 million beneficiaries and over 200,000 medical providers with 
a single, common record of medical and dental information. It is 
deploying in 23 ``waves'' and is currently 81 percent complete with 
full deployment expected by the end of 2023. While the initial 
deployment was not without its challenges, it is now expected to fully 
deploy within budget and on time. One aspect of the deployment that 
proved successful for DoD throughout this process was a system 
integrator approach. This approach involves using a government 
contractor to coordinate the integration and implementation of the 
single, common record. We encourage Congress to evaluate the 
differences in these implementation efforts and consider additional 
models, including this system integrator approach.

Continue to Leverage Telehealth

    Wounded Warrior Project continues to believe in the importance of 
telehealth and asks that you continue to leverage its benefits for the 
veteran community. Telehealth and telemedicine services should be 
expanded to improve access to care, especially for veterans in remote 
areas. Telehealth enables virtual consultations, remote monitoring, and 
the delivery of healthcare services, reducing the need for veterans to 
travel long distances for appointments.
    While telehealth has been critical to expanding access to health 
care services; telehealth cannot simply replace in-person service 
delivery. Consumers, in consultation with their providers, must be able 
to choose whether telehealth or in-person services are most appropriate 
for their needs. Some plans have implemented strategies to limit 
consumers' options by offering ``telehealth only'' or ``telehealth 
first'' coverage, which bars or limits access to in-person care. For 
individuals who need a higher level of outpatient care, residential 
care, or inpatient care to treat their MH/SUD condition(s), a 
``telehealth only'' option can negatively impact treatment options, 
further delay an appropriate level of care, and can be a significant 
financial barrier if individuals find they must pay out-of-pocket for 
additional services.
    We support telehealth provisions in S. 1315, the Veterans Health 
Empowerment, Access, Leadership, and Transparency for our Heroes Act of 
2023, and H.R. 3520, the Veteran Care Improvement Act of 2023. Both 
bills include measures that would require VA to discuss telehealth 
options for care, both at VA and in the community, if telehealth is 
available, appropriate, and acceptable to the veteran. We ask that 
Congress continue to work with VA and other stakeholders to ensure that 
the necessary balance is found between the efficiencies of telehealth 
and veteran preference.

Stabilize the Clinical Care Workforce

    WWP has been encouraged by recent efforts to address the workforce 
shortage and high turnover rates at VA. In the first five months of 
fiscal year 2023, nearly 10,000 new employees were hired at VHA and as 
of March, they were 44 percent of the way toward their goal of hiring 
52,000 new employees \2\. However, we continue to be concerned by 
reports of high numbers of vacancies, often resulting in long wait 
times and disjointed care for veterans. We believe that more can be 
done to help recruit and retain the best talent to ensure veterans are 
receiving timely and quality care.
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    \2\ Eric Katz, VA Is Hiring at a Record Rate. Employees Say It's 
Still Not Enough, GOVERNMENT EXECUTIVE (March 21, 2023), available at 
https://www.govexec.com/workforce/2023/03/va-hiring-record-rate-
employees-say-its-still-not-enough/384257/.
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    Congress can address some of these issues by passing S. 10, the VA 
CAREERS Act. This bill would set higher base pay caps for VA 
physicians, podiatrists, optometrists, and dentists, making VA a more 
competitive option for providers. The bill would also improve VA's 
ability to hire at rural VA facilities by providing them with the 
ability to buy out the contracts of some private-sector health care 
professionals in exchange for employment at rural facilities. 
Additionally, it would allow VA to pay for licensure exam costs for 
future clinicians participating in VA scholarship programs and expand 
eligibility for health care staff to be reimbursed for professional 
education costs.
    To ensure veterans are receiving the best possible care, with 
minimal interruptions, WWP believes it is essential that VA be given 
the resources necessary to adequately recruit and retain top talent to 
care for veterans. We encourage Congress to monitor this issue and 
ensure VA has the resources they need to achieve this goal.

Focus on PACT Act-related Care Needs

    For two decades, Service members who were deployed to post-9/11 
battlefields were exposed to dangerous fumes from burn pits and other 
toxic chemicals. After the 117th Congress passed the Sergeant First 
Class Heath Robinson Honoring our Promise to Address Comprehensive 
Toxics (PACT) Act of 2022 (P.L. 117-168), many veterans now suffering 
from respiratory conditions, cancers, and other serious illnesses have 
access to VA care for those disorders. Under the PACT Act, recently 
discharged combat veterans now have a 10-year enhanced enrollment 
period (up from 5 years), and veterans who were discharged more than 10 
years ago have a limited one-year period to enroll for care (October 1, 
2022, to September 30, 2023). Even more may now seek care for 
conditions that are now more likely to be service connected.
    While VA deserves praise for all of its implementation efforts, 
expansion of health care under the PACT Act has highlighted gaps in 
care coordination for cancer care. As noted in a recent Government 
Accountability Office report and experienced by WWP's C3 team, VHA does 
not have a policy that addresses cancer surveillance or assign 
responsibility for cancer care coordination.\3\ Given the success that 
VA has had using social workers in fields like traumatic brain injury 
and spinal cord injury to coordinate ancillary care for patients, we 
believe a similar policy should be in place for oncology patients.
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    \3\ OFF. OF INSP. GENERAL, U.S. DEP'T OF VET. AFFAIRS, INADEQUATE 
COORDINATION OF CARE FOR A PATIENT AT THE WEST PALM BEACH VA HEALTH 
CARE SYSTEM IN FLORIDA iii (Mar. 2023).

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CONCLUSION

    Wounded Warrior Project thanks the Subcommittee on Health and its 
distinguished members for inviting our organization to submit this 
statement. We are grateful for your attention and efforts to ensure 
that veterans receive the best possible care and outcomes through the 
Veterans Health Administration, particularly through well-coordinated 
care. We look forward to continuing to work with you on these issues 
and are standing by to assist in any way we can toward our shared goal 
of serving those that have served this country.
                                 ______
                                 

                  Prepared Statement of Roscoe Butler

    Chairwoman Miller-Meeks, Ranking Member Brownley, and members of 
the Subcommittee, Paralyzed Veterans of America (PVA) would like to 
thank you for the opportunity to submit our views on the Department of 
Veterans Affairs' (VA) efforts to coordinate veterans' care. No group 
of veterans better understands the importance of having timely access 
to a full continuum of coordinated health care than PVA members--
veterans who have incurred a spinal cord injury or disorder (SCI/D).
    Veterans with complex healthcare conditions like SCI/Ds receive 
care from primary care physicians, a wide range of specialists, 
visiting nurses, and caregivers--many of whom are family members. 
Additionally, this care is provided through a number of service points. 
It may be provided at one of VA's 25 SCI/D centers, through VA's six 
long-term care centers, or at other VA facilities. It may also be 
provided through community care providers, in state veterans or 
community nursing homes, or in the veteran's residence. This often 
poses a Herculean challenge to the many dedicated professionals who are 
working tirelessly to ensure that the delivery of high-quality acute 
and long-term care is administered by the right providers in order to 
achieve optimum care outcomes for veterans.
    Veterans with SCI/D who are enrolled in and using VA care generally 
have an easier time with care coordination than those individuals who 
are receiving care solely outside the VA system. Appendix D of Veterans 
Health Administration (VHA) Directive 1176(2) on the SCI/D system of 
care lists the wide range of doctors, nurses, social workers, 
psychologists, therapists, and other specialists that serve as part of 
the interdisciplinary team for each SCI/D center. They include the 
members of the Patient Aligned Care Team (PACT) who are responsible for 
care coordination within VA, including at SCI/D spoke sites; in long-
term care settings (e.g., VA Community Living Centers and community 
nursing homes); outreach; and virtual care. Ensuring they have the 
appropriate staff on their payroll allows VA to more quickly and 
completely coordinate its care for SCI/D veterans. An example of this 
coordinated care is a PVA member from Maryland who receives much of his 
care through his local VA Medical Center, but also utilizes VA's 
community care network and the Department of Defense's TRICARE program. 
Since a spinal cord injury in 2006, his VA care team has managed 
hundreds of dermatology, gastroenterology, hematology, immunology, 
neurology, occupational and physical therapy, oncology, primary care, 
pulmonology, rheumatology, and surgical visits both in and out of VA 
facilities. This veteran and many others like him are thriving because 
proper coordination of care ensures they are able to receive the right 
care at the right time and in the right place.
    Within the VA's SCI/D system of care, knowing how to care for a 
veteran with these injuries or illnesses isn't optional, it's a 
requirement. Unfortunately, a serious knowledge deficit about SCI/D 
care exists in the private sector. Civilian facilities are simply not 
equipped or properly staffed to handle SCI/D patients' acute and long-
term care needs, so most will not accept them. That number is growing 
as facilities and agencies decide to drop this capability as staffing 
shortages persist. Outside of VA, the ability to coordinate care drops 
dramatically for several reasons.
    Caring for veterans with SCI/D requires sharp assessment, time-and 
labor-intensive physical skills, and genuine empathy. Nurses who work 
in SCI/D must possess unique attributes and specialized education. All 
medical providers, Registered Nurses, Licensed Practical Nurses, 
Certified Nursing Assistants, and Nurse Practitioners working with the 
SCI/D population are required to have increased education and knowledge 
focused on health promotion and prevention of complications related to 
SCI/D. This includes the prevention and treatment of pressure injuries, 
aspiration pneumonia, urinary tract infections, bowel impactions, 
sepsis, and limb contractures. Unlike VA, few facilities in the private 
sector have the highly trained personnel on staff to properly care for 
SCI/D patients.
    Partly due to the lack of proper education and training, many 
private sector hospitals, agencies, and nursing homes are not able to 
properly care for veterans with SCI/D. As a result, SCI/D care 
coordinators must spend a considerable amount of time searching for 
ones that do. Sometimes SCI/Ds interrupt communication between the 
brain and the nerves in the spinal cord that control bladder and bowel 
function. This can cause bladder and bowel dysfunction known as 
neurogenic bladder or neurogenic bowel. Other veterans may have 
tracheotomies that allow air to flow in and out of the windpipe. Some 
veterans may need a feeding tube due to difficulty swallowing, an 
eating disorder, or other feeding issues. Each of these conditions 
require close management and regular physical interventions that 
private sector facilities often cannot adequately provide. Most private 
sector facilities cannot provide long-term care for the same reasons. A 
few private sector health care facilities do a good job of providing 
acute SCI/D recovery care, but only VA is able to provide the full, 
lifelong continuum of services for veterans with SCI/D that can 
increase their lifespan by decades. That is why PVA places tremendous 
emphasis on preserving and strengthening VA's specialized systems of 
care.
    Although VA is able to best provide care for veterans with SCI/D, 
there are still challenges. These challenges include difficulties in 
coordinating with other VA services and lack of resources to assist 
special populations of SCI/D veterans. Also, the lack of facility-based 
long-term care in VA and in the community causes significant issues in 
care coordination.

Challenges in Coordinating with Other VA Services

Prosthetics

    VA's SCI/D centers and their spoke sites are intentionally designed 
and staffed so the coordinated, lifelong continuum of services that 
SCI/D veterans need are readily available. Prosthetics is often cited 
as one area within VA where coordinating individual veterans' needs can 
be difficult. Here, timeliness is often an issue as requests for 
equipment move slowly within the system. Sometimes orders are not 
placed or they are dropped without any apparent cause. Unfortunately, 
accountability for these systemic failures is lacking. Supply shortages 
can aggravate matters further. The inability to receive needed 
prosthetics in a timely manner frequently prevents veterans from 
returning home quickly and stimulates preventable increased workloads 
when VA's care coordination team must do multiple follow ups just to 
ensure a veteran receives the devices or other equipment they need.
    A wheelchair is an extension of the body of a veteran with an SCI/
D. Thus, they can typically tell when a part is wearing out or is 
broken. Sometimes a part is visibly in need of repair or replacement, 
but even if veterans report these types of problems, some facilities 
make them wait until a vendor is dispatched to their residence and 
confirms its broken before initiating repairs. In these instances, 
veterans are not being well served by an antiquated process that could 
hold them hostage for several days or weeks. It also increases the VA 
care coordination team's workload as they are forced to intervene on 
behalf of frustrated veterans.
    At a small number of VA facilities (2-3), support for prosthetics 
is essentially ``available on demand.'' Unfortunately, these locations 
can be described as ``unicorns'' because that level of support is 
rarely available in most other facilities. The VA should study the 
policies and process at the locations were access to prosthetics is 
working well, and have them implemented system-wide.

Care for Special Populations

    Determining if a veteran can return home is usually the starting 
point for the care coordination team and accommodating the needs of 
homeless SCI/D veterans can be particularly challenging. Occasionally, 
homeless veterans with SCI/D receive treatment at one of VA's acute 
SCI/D centers and once they are stabilized there is nowhere to send 
them because they have no residence. Finding affordable, accessible 
housing in the veteran's community often proves to be difficult for 
VA's SCI/D care coordinators. Resolving these types of cases are very 
labor intensive and can take months to resolve. There does not appear 
to be formal guidance to handle these types of situations and their 
resolution is often the result of the ingenuity and skill of the SCI/D 
care coordination team. Congress should examine VA's existing policies 
and ability to care and house such veterans.
    The population of veterans with SCI/D has undergone substantial 
changes over the last 50 years. Increasing numbers of women have been 
serving in the military and they now represent about 5 percent of the 
veteran SCI/D population. Additional considerations when coordinating 
their care usually include the use of a single patient room and the 
availability of gender-specific care in properly staffed and fully 
accessible buildings. These qualifications are rarely found in tandem 
in the private sector. Additionally, in-resident care of SCI/D veterans 
with substance use disorders (SUD) is virtually nonexistent within VA 
and the private sector. They may be able to receive counseling but at 
the end of each day return to home where the potential for a relapse is 
high. These individuals are not normally housed in acute care centers 
until the SUD is resolved due to security and safety concerns. Until VA 
gains the ability to provide this level of care, these veterans will be 
trapped in a vicious cycle that threatens their health and well-being. 
We hope that this Subcommittee will work with VA to determine how the 
Department can better serve these cohorts of veterans.

Limited Long-Term Care Services

    VA's lack of long-term care beds is severely impairing its ability 
to coordinate care for veterans with SCI/Ds. More than half of the 
veterans on VA's SCI/D registry are over the age of 65 and most of 
their caregivers are aging as well. As indicated previously, 
nationwide, very few long-term care facilities are capable of 
appropriately serving veterans with SCI/D. VA operates just six SCI/D 
long-term care facilities; only one of which lies west of the 
Mississippi River.
    According to VHA Directive 1176(2), the VA is required to operate 
at least 181 of its 198 authorized long-term care beds at SCI/D 
centers. Recently, only 168 beds were either available for or in use. 
This number fluctuates depending on several variables like staffing, 
women residents, isolation precautions, and deaths. When averaged 
across the country, that equates to about 3.4 beds available per state.
    In 2012, VA's own research \1\ warned that a wave of elderly 
veterans with SCI was coming and the Department should prepare for 
them. At the time, aging veterans, new cases of SCI from recent 
conflicts, and increasing numbers of women veterans were dramatically 
changing the profile of VHA's SCI/D population. If the Department 
heeded its own warning back then and increased its SCI/D long-term care 
capability, we might not be in the dire situation we are today.
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    \1\ ``Who are the women and men in Veterans Health Administration's 
current spinal cord injury population?'' https://
www.rehab.research.va.gov/jour/2012/493/pdf/page351.pdf.
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    A pair construction projects will add roughly 50 more SCI/D long 
term care beds to VA's inventory in the next few years. Other projects 
have been identified but need funding allocated in order to progress. 
Until then, a high number of aging veterans with SCI/D who need long-
term care services will be occupying acute care SCI/D center beds or be 
forced to reside in nursing care facilities outside of VA that are not 
designed, equipped, or staffed to properly serve veterans with SCI/D. 
Others will remain in precarious situations in their homes and VA care 
coordinators will continue its struggle to find appropriate agencies or 
individuals to deliver their care. PVA strongly supports H.R. 3225, the 
Build, Utilize, Invest, Learn and Deliver (BUILD) for Veterans Act of 
2023, which seeks to improve staffing to manage construction of VA 
assets and ensure that there are concrete plans to improve the 
planning, management, and budgeting of VA construction and capital 
asset programs.
    The lack of capacity to provide long-term care for SCI/D veterans 
within VA and the private sector mean VA care coordinators spend a 
tremendous amount of their time attempting to locate providers, 
facilities, or agencies in the private sector to meet SCI/D veteran's 
long-term care needs. Truth be told, access to long-term care was 
extremely scarce prior to COVID, and VA's SCI/D care coordinators worry 
that it is getting scarcer. We understand that nursing homes and home 
health agencies often pursue contracts with VA, but many don't maintain 
them long. Most lack, and are unwilling to achieve, the necessary 
training to perform the critical tasks like bowel and bladder care or 
tracheostomy care that some veterans with SCI/D need. Facilities 
lacking proper staffing are often unwilling to procure additional 
personnel for SCI/D veterans whose greater care needs consume a larger 
than anticipated share of their existing workforce's time. Even if they 
are willing to hire additional personnel, nationwide provider and 
nursing shortages will often preclude them from finding the personnel 
that they need. These ``starts and stops'' are frustrating to veterans 
and those who coordinate their care.
    Most veterans with Amyotrophic Lateral Sclerosis (ALS) and some 
with a spinal cord injury will eventually require ventilator care. VA 
has an extremely limited number of vent-capable beds for SCI/D veterans 
and they are often maxed out with patients. In most states, this level 
of care for SCI/D patients does not exist outside of the VA; thus, it 
is a daily occurrence that care coordinators are combing the country 
looking for an available bed. We work regularly with VA to assess its 
SCI/D system of care and those we speak with during our annual visit to 
each SCI/D center agree that the Department desperately needs to expand 
its ventilator capability.
    The 65 percent statutory cap on what VA can pay for home care can 
also impact care coordination because it limits care options which may 
contribute to unfortunate results. Recently, a PVA member in Texas with 
ALS whose home care was limited by the VA cap developed a problem with 
his gallbladder bag. Since he wasn't receiving the much-needed 
assistance from VA at home, the family sought help from the local 
private sector medical system because they believed VA had already 
demonstrated an inability to meet his needs. While there, the veteran 
developed complications due to an undiagnosed pneumonia which led to 
him being intubated. Mentally and physically, his condition 
deteriorated rapidly, and the veteran passed away.
    In light of the limited access to VA facility-based long-term care 
and the desire of many veterans with SCI/D to receive non-institutional 
long-term care, VA must expand access to home and community-based 
services (HCBS) to meet the growing demand for long-term services and 
supports. Facility-based long-term care services are expensive, with 
institutional care costs exceeding costs for HCBS. Studies have shown 
that expanding HCBS entails a short-term increase in spending followed 
by a slower rate of institutional spending and overall long-term care 
cost containment.\2\ Reductions in cost can be achieved by 
transitioning and diverting veterans from nursing home care to HCBS, if 
they prefer it, and the care provided meets their needs.
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    \2\ Do noninstitutional long-term care services reduce Medicaid 
spending?
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    Passage of H.R. 542, the Elizabeth Dole Home and Community Based 
Services for Veterans and Caregivers Act, would improve care 
coordination for SCI/D veterans by making critically needed 
improvements to VA HCBS including raising the cap on non-institutional 
care, expanding the Veteran Directed Care program, creating a pilot 
program to address direct care worker shortages, and improving family 
caregiver supports. We cannot stress enough how important it is for 
Congress to pass this important legislation sooner rather than later.
    PVA appreciates the Subcommittee's interest in this critical area, 
and I would be happy to answer any questions you may have.

  Information Required by Rule XI 2(g) of the House of Representatives

    Pursuant to Rule XI 2(g) of the House of Representatives, the 
following information is provided regarding federal grants and 
contracts.

                            Fiscal Year 2023

    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events----Grant to support rehabilitation sports 
activities--$479,000.

                            Fiscal Year 2022

    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events----Grant to support rehabilitation sports 
activities--$ 437,745.

                            Fiscal Year 2021

    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events----Grant to support rehabilitation sports 
activities--$455,700.

                     Disclosure of Foreign Payments

    Paralyzed Veterans of America is largely supported by donations 
from the general public. However, in some very rare cases we receive 
direct donations from foreign nationals. In addition, we receive 
funding from corporations and foundations which in some cases are U.S. 
subsidiaries of non-U.S. companies.
                                       
                                       [all]