[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
SERVICEMEMBERS' SEAMLESS TRANSITION
INTO CIVILIAN LIFE--THE HEROES RETURN
=======================================================================
HEARING
before the
SUBCOMMITTEE ON OVERSIGHT AND
INVESTIGATIONS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
MARCH 8, 2007
__________
Serial No. 110-7
__________
Printed for the use of the Committee on Veterans' Affairs
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34-309 PDF WASHINGTON DC: 2007
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine DAN BURTON, Indiana
STEPHANIE HERSETH, South Dakota JERRY MORAN, Kansas
HARRY E. MITCHELL, Arizona RICHARD H. BAKER, Louisiana
JOHN J. HALL, New York HENRY E. BROWN, JR., South
PHIL HARE, Illinois Carolina
MICHAEL F. DOYLE, Pennsylvania JEFF MILLER, Florida
SHELLEY BERKLEY, Nevada JOHN BOOZMAN, Arkansas
JOHN T. SALAZAR, Colorado GINNY BROWN-WAITE, Florida
CIRO D. RODRIGUEZ, Texas MICHAEL R. TURNER, Ohio
JOE DONNELLY, Indiana BRIAN P. BILBRAY, California
JERRY McNERNEY, California DOUG LAMBORN, Colorado
ZACHARY T. SPACE, Ohio GUS M. BILIRAKIS, Florida
TIMOTHY J. WALZ, Minnesota
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
HARRY E. MITCHELL, Arizona, Chairman
ZACHARY T. SPACE, Ohio GINNY BROWN-WAITE, Florida,
TIMOTHY J. WALZ, Minnesota Ranking
CIRO D. RODRIGUEZ, Texas CLIFF STEARNS, Florida
BRIAN P. BILBRAY, California
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
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further refined.
C O N T E N T S
__________
March 8, 2007
Page
Servicemembers' Seamless Transition into Civilian Life--The
Heroes Return.................................................. 1
OPENING STATEMENTS
Hon. Harry E. Mitchell, Chairman................................. 1
Prepared statement of Chairman Mitchell...................... 55
Hon. Ginny Brown-Waite, Ranking Republican Member................ 2
Prepared statement of Congresswoman Brown-Waite.............. 55
SUBMISSION FOR THE RECORD
Hon. Cliff Stearns, a Representative in Congress from the State
of Florida, statement.......................................... 56
WITNESSES
U.S. Department of Veterans Affairs:
Michael J. Kussman, MD, MS, MACP, Acting Under Secretary for
Health, Veterans Health Administration..................... 4
Prepared statement of Dr. Kussman........................ 57
Shane McNamee, MD, Director, Hunter Holmes McGuire Richmond
Veterans Affairs Medical Center, Richmond, VA.............. 25
Prepared statement of Dr. McNamee........................ 65
Steven G. Scott, MD, Medical Director, Tampa Polytrauma
Rehabilitation Center, James A. Haley Veterans' Hospital,
Tampa, FL.................................................. 27
Prepared statement of Dr. Scott.......................... 67
William F. Feeley, MSW, FACHE, Deputy Under Secretary for
Health for Operations and Management, Veterans Health
Administration............................................. 41
Prepared statement of Mr. Feeley......................... 69
Edward C. Huycke, MD, Chief Department of Defense
Coordination Officer, Veterans Health Administration....... 43
Prepared statement of Dr. Huycke......................... 70
Ira R. Katz, MD, PhD, Deputy Chief Patient Care Services
Officer for Mental Health, Veterans Health Administration.. 45
Prepared statement of Dr. Katz........................... 72
U.S. Government Accountability Office, Cynthia A. Bascetta,
Director, Health Care.......................................... 10
Prepared statement of Ms. Bascetta........................... 59
______
Lain, Kimberly, Millersville, MD................................. 33
Pearce, Kathy, Mesa, AZ.......................................... 46
Sullivan, Paul, Cedar Park, TX................................... 30
Walter Reed Medical Center/Bethesda Naval Hospital:
Kathy Dinegar, Social Worker Liaison for Seamless Transition. 34
Sherry Edmonds-Clemons, Social Worker Liaison for Seamless
Transition................................................. 35
MATERIAL SUBMITTED FOR THE RECORD
Letter dated March 7, 2007, from U.S. Department of Veterans
Affairs Secretary Nicholson to Congresswoman Ginny Brown-Waite,
regarding the ability of DOD and VA to provide world-class
health care to servicemembers and veterans..................... 73
U.S. Government Accountability Office Letter dated June 30, 2007,
from Cynthia A. Bascetta, Director, Health Care, to Congressman
Michael Bilirakis, regarding Transition of Care for OEF and OIF
Servicemembers (GAO-06-79R).................................... 78
U.S. Government Accountability Office Report entitled,
``Vocational Rehabilitation--More VA and DOD Collaboration
Needed to Expedite Services for Seriously Injured
Servicemembers,'' dated January 2005 (GAO-05-167).............. 94
POST-HEARING QUESTIONS FOR THE RECORD
Response to Questions for the Record from Paul Sullivan, Cedar
Park, TX, and former Project Manager for the U.S. Department of
Veterans Affairs, dated March 27, 2007 [The exhibits submitted
by Mr. Sullivan are being retained in the Committee files]..... 111
SERVICEMEMBERS' SEAMLESS TRANSITION
INTO CIVILIAN LIFE--THE HEROES RETURN
----------
THURSDAY, MARCH 8, 2007
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Oversight and Investigations,
Washington, DC.
The Subcommittee met, pursuant to notice, at 3:43 p.m., in
Room 334, Cannon House Office Building, Hon. Harry E. Mitchell
[Chairman of the Subcommittee] presiding.
Present: Representatives Mitchell, Space, Walz, Rodriguez,
and Brown-Waite.
Also Present: Representatives Filner, Hare, Buyer,
Bilirakis, and Lamborn.
OPENING STATEMENT OF CHAIRMAN MITCHELL
Mr. Mitchell. Welcome to the Oversight and Investigations
Subcommittee of the Committee on Veterans' Affairs March 8,
2007, hearing entitled, Servicemembers' Seamless Transition
into Civilian Life--The Heroes Return. I want to thank everyone
for being here today. Two weeks ago, the American people
learned that some of the most seriously wounded warriors were
recovering in dilapidated conditions at the Walter Reed Medical
Center, supposedly the Army's premier medical facility.
These conditions are absolutely unacceptable and the
American people are rightly outraged. Sadly, it appears the
buildings are just the tip of the iceberg. Reports have been
filtering in about a labyrinth of bureaucratic red tape our
returning soldiers are having to navigate to get the basic
health care benefits they need and deserve. These problems have
a direct impact on these men and women as they transition from
the military's health care system to the VA. We have a
responsibility to investigate how issues at the Department of
Defense affect soldiers as they become veterans. We have a
responsibility to make sure that the Department of Veterans
Affairs is doing its job to make the transition as easy as
possible.
I am not convinced that the U.S. Department of Veterans
Affairs (VA) is doing its part. Last night, ABC News reported
that a proposal to keep seriously wounded vets from falling
through the cracks of the bureaucracy was shelved in 2005 when
Jim Nicholson took over as VA Secretary. I am deeply troubled
when wounded soldiers say in news reports that the VA has made
them feel horrible. That is unacceptable and embarrassing and
the American people deserve answers. Today, we hope to get to
some of them. In today's hearing, we will hear from witnesses
who have seen and experienced firsthand the difficulties
veterans face when they transition from the DOD health care
system to the VA. Their stories are compelling, and I am eager
to learn how the VA is responding to their concerns as well as
the health care needs of their fellow veterans who have taken
time to come to observe our hearings.
In particular, I would like to recognize Specialist Greg
Williams, Corporal Noel Santos, Sergeant Frank Valentine, Staff
Sergeant Danny Vega. We are honored to welcome these young
heroes here today. At this time, I ask unanimous consent that
Mr. Filner, Mr. Buyer, Mr. Hare, Mr. Lamborn, and Mr. Bilirakis
be invited to sit at the dais for the Subcommittee hearing
today. Hearing no objections, so ordered.
[The prepared statement of Chairman Mitchell appears on pg.
55.]
Mr. Mitchell. Before I recognize the ranking Republican
Member for her remarks, I would like to swear in all of our
witnesses. And at this time, if you would please stand, we will
swear you in.
[Witnesses sworn.]
Mr. Mitchell. Thank you. Now I would like to recognize Ms.
Brown-Waite for her opening remarks.
OPENING STATEMENT OF HON. GINNY BROWN-WAITE
Ms. Brown-Waite. I thank the Chairman. And I apologize both
to the Chairman and to the Members for my tardiness. It was an
issue relating to a sexual predator in my district who was
found guilty yesterday, and I was speaking to the family and to
some Members of the press about it. And I thank the gentleman
for yielding. The Committee on Veterans' Affairs has been
conducting oversight reviews of the seamless transition issue
for our Nation's servicemembers for the past several
Congresses.
In the last Congress alone, the Committee and its
Subcommittee held 10 hearings on the transition of our
servicemembers. I believe that I speak for all of us when I say
that this is a top priority issue, that despite our best
efforts has not always been entirely resolved. Congress
codified the concept of DOD-VA sharing, now known as seamless
transition, in 1982, with the passage of the Veterans
Administration and the Department of Defense Health Resources
Sharing an Emergency Operation Act. This Act created the VA
Care Committee to supervise and manage opportunities to share
medical resources. Now, 25 years later, we are still discussing
this issue. Some progress has been made in the area of
transitioning servicemembers back to the workforce.
Last Congress, Public Law 109-461 was enacted which
included various transition assistance initiatives ranging from
health care needs to education and employment needs. During the
last Congress, Members and staff from the Committee conducted
numerous field and site visits at the VA and military treatment
facilities and military bases to review efforts on the seamless
transition, and held oversight hearings in May and September of
2005. The transition and integration back into civilian life
should be transparent and effortless for our servicemembers.
However, this apparently does not always seem to be the
case. More often than not, the handoffs have been fumbles. In a
GAO report prepared for this Subcommittee on June 30, 2006, it
was found that the VA has taken many aggressive actions to
provide timely information to OEF and OIF servicemembers and
their families, especially in their critical time of need. The
report also noted the positive steps taken to increase the
awareness training and sensitivity of staff and medical
providers on the needs of OIF and OEF servicemembers and
veterans. The report also found the VA continues to have
problems assessing real-time medical information from DOD
treatment facilities. Mr. Chairman, I ask unanimous consent
that a copy of this report be inserted in the official hearing
record, and I will be happy to hand that to you.
Mr. Mitchell. So ordered.
[The referenced GAO Report entitled, ``Vocational
Rehabilitation--More VA and DOD Collaboration Needed to
Expedite Services for Seriously Injured Servicemembers,'' (GAO-
06-79R), appears on pg. 78.]
Ms. Brown-Waite. I appreciate that.
We know that we have witnesses from Walter Reed Army
Medical Center, and I want to make it clear that today's
hearing is not about the conditions at Walter Reed, but about
the transition of our servicemembers and how they are making it
from DOD to VA care, how the process works, are there any gaps
in care, and is VA getting the information that it needs from
DOD in a timely manner to ensure the continuity of care for
these new veterans, so that waiting periods for care do not
extend for months after separation from active duty. And why to
this day is information on DOD personnel being cared for at the
VA's polytrauma centers still not being electronically
transmitted? Is there a difference between DOD electrons and VA
electrons? Again, Mr. Chairman, I thank you and I yield back
the balance of my time.
[The statement of Congresswoman Brown-Waite appears on pg.
55.]
Mr. Mitchell. Thank you. At this time, I am asking Members
to submit their opening statements. We have 13 people on three
panels that we are going to hear today. So it will take quite a
while. If you could submit them for the record, I would
appreciate that.
We will now proceed to panel one, we are pleased to welcome
Dr. Michael Kussman, the acting Under Secretary of Health for
VA. Dr. Kussman has had a long and distinguished military
career beginning with his service in the 7th Infantry Division
in Korea. He has held leading medical positions at multiple
facilities while on active duty, such as serving as commander
of the Walter Reed health care system.
As the Director of Health care at the GAO, Ms. Cynthia
Bascetta provides our Subcommittee with a major service not
only in her ability to provide independent assessment of VA
program performance, but also to place the performance of VA's
seamless transition programs in a historical context. As many
of you are aware, last night, Mr. Paul Sullivan appeared on ABC
News to discuss a data tracking system, which would have made
the seamless transition of new veterans much more efficient. We
are pleased to welcome him here today to answer questions and
share his knowledge and experience on this issue.
Finally, Private First Class Kimberly Lain who has recently
gone through the transition process to the VA from the Walter
Reed Medical Center is here to share her experiences with us.
STATEMENTS OF MICHAEL J. KUSSMAN, MD, MS, MACP, ACTING UNDER
SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; AND CYNTHIA A. BASCETTA,
DIRECTOR, HEALTH CARE, U.S. GOVERNMENT ACCOUNTABILITY OFFICE
Mr. Mitchell. Dr. Kussman, if you would please. If everyone
could please, in front of you is a little clock with a green
light, a yellow light and a red. And if we could keep that,
keep it in line with that, I would appreciate it. Dr. Kussman?
STATEMENT OF MICHAEL J. KUSSMAN
Dr. Kussman. Good afternoon Mr. Chairman and Members of the
Subcommittee. I would like to submit the written record for the
record if that is okay, Mr. Chairman. Thank you for this
opportunity to comment on VHA's seamless transition efforts.
Before I begin, however, let me address an issue with which was
discussed in the news media last night. In 2003, VA developed a
contingency tracking system to meet the Veterans Benefits
Administration, not the VHA's immediate need to track their
benefits, assistance activities in support of seriously injured
servicemembers as they transition from MTFs to our health care
facilities.
The VA employees who worked on the system hoped that it
would evolve to meet the VHA. Unfortunately, it could not meet
VHA's needs or even all of VBA's needs without additional
development costs, and in February 2005, our Department decided
to consider other ways to accomplish this task.
Because VHA's case management needs were not met by the
system, we developed our own tracking system which is known as
the MTFs to VA. Last summer, we were briefed on DOD's joint
patient tracking application, or JPTA system, which provides a
great deal of information on the progress of seriously injured
veterans through DOD's health care system.
Together, DOD and VA realized that enhancing DOD system was
our best option, providing both departments with a much better
tool to track case management issues. DOD provided us with the
capability to look at their records toward the end of last
year, and earlier this month, we developed the ability to
enhance the system to enable VA case managers to add their own
notes and information about phone calls they have made to
patients.
Our vision is to create a continuous clinical record of
transfers and case management activities for all seriously
injured patients as they progress through both DOD and VA
systems of care. VHA will continue to use the MTF to VA system
until JPTA can create such a record for seriously injured
patients.
One other thing, before I leave this subject, contrary to
what was erroneously reported last evening, the decision to use
one system which was felt better met our needs over another one
was made appropriately at the administrative level. This was a
programmatic decision and not one made by the Secretary. VHA's
efforts to create a seamless transition for men and women as
they leave the service and take up the honored title of veteran
begins early on. Our outreach network ensures that returning
servicemembers receive full information about VA benefits and
services.
In each of our medical centers and benefits offices now has
a point of contact designed to work with veterans returning
from service in Operation Enduring Freedom and Operation Iraqi
Freedom. VHA has coordinated the transfer of other 6,800
injured or ill active duty servicemembers and veterans from the
Department of Defense to the VA.
Our highest priority is to ensure that those returning from
the global war on terror who transition directly from DOD
military treatment facilities or MTFs to VA medical centers
continue to receive the best possible care available anywhere.
This month, we are attempting to call each of these severely
injured servicemembers and veterans to see if they need
additional support. And we are directing facilities to provide
OIF/OEF care coordinators at each facility.
VA social workers benefits counselors and outreach
coordinators advise and explain the full array of VA services
and benefits to servicemembers while they are still being cared
for by DOD. These employees assist active duty servicemembers
as they transfer to VA medical facilities from MTFs.
In addition, our social workers help newly wounded
soldiers, sailors, airmen, and marines and their families plan
a future course of treatment for their injuries after they
return home. Currently, VA social work and benefits counselors
are located at 10 military treatment facilities. One important
aspect of coordination between DOD and VA to a patient's
transfer to VA's access to clinical information. The Bi-
Directional Health Information and Exchange, BHIE, allows VA
and DOD clinicians to share text space clinical data in a
number of sites, including Walter Reed and National Naval
Medical Center and the two military treatment facilities that
refer them, they are the two military treatment facilities that
refer the majority of polytrauma patients to the VA.
Mr. Chairman, case management for our patients begins at
the time of transition from the military treatment facility and
continues as their medical and psychological needs dictate.
Patients suffering severe injuries or those with complex needs
receive ongoing case management at the VA facility where they
receive most of their care. VHA has recently determined that
every medical center will have a full-time case manager for
OIF/OEF veterans needs and we are in the process of hiring a
hundred new OIF/OEF veterans to serve as ombudsmen to support
severely wounded veterans and their families.
Each VA NC also has a designated point of contact to
coordinate activities locally for OIF/OEF veterans and to
ensure the health care and benefits needs of the returning
servicemember and veterans are fully met. VA has distributed
specific guidance to field staff to ensure that the roles and
functions of the points of the contact and case manager are
fully understood and that proper coordination of benefits and
services occur at the local level. To ensure that all eligible
veterans are aware of the services they are entitled to, VA's
developed a vigorous outreach education and awareness program
for our returning veterans and their families.
To allow us to provide coordinated transition services and
benefits for National Guard and Reservists, a memorandum of
agreement was signed with the National Guard in May 2005.
Similar memorandums are under development with the United
States Reserve and the United States Marine Corps. These new
partnerships will increase awareness of and access to VA
services and benefits during the demobilization process as
former servicemembers return to their local communities.
VA is also reaching out to returning veterans whose wounds
may be less apparent. VA's a participant in the DOD's post-
deployment health risks and assessment program. We provide
information about VA care and benefits, enroll interested
Reservists and Guardsmen in the VA health care system and
arrange appointments for referred servicemembers.
As of December 2006, an estimated 68,800 servicemembers
were screened under the provisions of this program resulting in
more than 17,000 referrals to the VA. Finally, VA provides
outreach to our newest veterans through our readjustment
counseling service, commonly known to veterans as the Vet
Centers Program. Vet centers were created by Congress as the
outreach element in VA's health administration. The approximate
number of OIF/OEF combat veterans served by vet centers today
is 180,000. Vet centers have provided bereavement services to
the families of over 900 fallen warriors. VA plans to expand
the Vet Center Program. We will open 15 new vet centers and
eight new vet center outstations at locations throughout the
Nation by the end of 2008. At that time vet centers will total
232.
We also expect to add staff to 61 existing facilities to
augment the services they provide. Seven of the 23 new centers
will be opened during calendar year 2007. Mr. Chairman, this
concludes my presentation. At this time I would be pleased to
answer any questions that you may have. Thank you.
Mr. Mitchell. Thank you, Dr. Kussman, for your
presentation.
[The statement of Dr. Kussman appears on pg. 57.]
Mr. Mitchell. The others are here just for questions. We
will not have an opening statement. But I do have some
questions I would like to ask of you to start with. I am going
to ask about the complaint system that is in place that the VA
has. When a patient approaches the VA with a complaint about
treatment they have received, how is that complaint handled?
Dr. Kussman. Sir, there would be multiple ways. We have
patient advocates at every facility. There are signs up that
tell the patients that if they are unsatisfied with what they
have they can go to the patient advocate. They could call the
IG, they could call our Office of Medical Inspection. They
could go directly to the hospital director or they could send
an e-mail directly to me, which people do, as well as the
Secretary.
Mr. Mitchell. And is there someone who follows up with this
after they have made a complaint?
Dr. Kussman. Yes, sir. Personally, if it is to me.
Mr. Mitchell. And to follow up with this, the follow-up,
who follows up with the facility to make sure that they correct
whatever is wrong? Does anybody follow up? Because it seemed to
me, you know, when we hear about Building 18 and some other
buildings out there--I am sorry, that was Walter Reed, not
under your control. But let's say that there was a facility
that someone complained about, is there anybody who follows up
with the facility?
Dr. Kussman. Yes, sir. Our assistant, I mean, our Deputy
Under Secretary for Operations and Maintenance, Mr. Bill
Feeley, is responsible for the upkeep and the services at all
the facilities and through him and the hospital directors we
would be sure that things were corrected. We also have a lot of
inspection teams that come and visit us. If there was an issue
like that, not only the joint commission, but we have what we
call our own supports, there are a mini joint commission that
we do on ourselves. The IG comes and reviews us with their CAP
reports. We have other outside agencies that review, CARF which
reviews rehabilitation centers. So there is a lot of review and
follow up if there is identified a deficiency in any of our
facilities.
Mr. Mitchell. What kind of records do you keep on patients'
complaints?
Dr. Kussman. Again, I think that would be at the facility
level. But we also have very elaborate patient satisfaction
surveys that are done when patients come in, they fill out a
form, and those are reviewed and kept that, I believe at the
facility. They are tracked at the facility as part of the
performance measures for the leaders of the facilities to be
sure, but we also have the University of Michigan do a consumer
satisfaction review service every year, and thank goodness
every year that we have done very well on that is a customer
satisfaction, and have actually been 10 points higher than
civilian facilities.
Mr. Mitchell. What is the process you use for taking valid
complaints and taking corrective action?
Dr. Kussman. Well, as I said, sir, hopefully that would be
handled at the facility level, that if somebody raised a
complaint about something, that through the patient advocate or
anybody else who took the complaint, the facility director and
associate directors would act on that. If the patient doesn't
get satisfaction, it could be raised through the division level
or to the central office through an 800 hotline call to the
Secretary, the IG, or the Office of Medical Inspection.
Mr. Mitchell. How often do you review these surveys or
these complaints? Are they done every day? Once a month? Every
3 months? How often do you review these complaints or these
satisfaction surveys? Once a year?
Dr. Kussman. The survey, the large survey, as I mentioned
from the University of Michigan, is done once a year, but other
surveys are done on a rotating basis. The IG does--rotates
through our facilities.
Mr. Mitchell. Besides surveys about satisfaction, what
about complaints about service or the care they are getting?
How often are those reviewed and are there records of those?
Dr. Kussman. Well, as I said, I think it depends on whether
the complaint got up to the central office or not, but the
complaints are generally handled at the local level if they can
be handled. If the individual doesn't get satisfaction, it
would bubble up, but that is an ongoing thing. They review
those complaints and see if there is any pattern.
Mr. Mitchell. If a patient doesn't feel they have gotten
satisfactory compliance or haven't had their complaint
satisfactorily answered, what happens then?
Dr. Kussman. Well, I would encourage them and they would be
encouraged to take it to the higher level. They can come to the
division or they can come to the central offices if they don't
get satisfaction. That is our job, to take care of veterans and
if they are not satisfied with what they want, we would
encourage them to call us.
Mr. Mitchell. Do you have any idea about how many
complaints you might get a month?
Dr. Kussman. No, sir, but I can go back and ask and get it
to you.
Mr. Mitchell. All right. Thank you. I yield my time.
Mr. Buyer. Mr. Chairman, I ask for a parliamentary inquiry.
Mr. Mitchell. Yes.
Mr. Buyer. My inquiry is that the witnesses sitting with
the Acting Under Secretary, the individuals sitting there, are
they witnesses or are they sitting there in an individual
capacity?
Mr. Mitchell. Mr. Buyer, they were sworn in. So they are
here to answer questions as we try to further this.
Mr. Buyer. Further parliamentary inquiry. Is it the
intention of the Chairman to follow rule XI of the House Rules
when it comes to the rules and procedures of the Committee?
Second, Mr. Chairman, in the 15 years I have been here in
Congress, I have never seen a Committee or a Subcommittee ever
treat an official of the administration without respect and
dignity of their position and station. And I have been here
through Republican and Democratic administrations. This is a
very curious manner in which you are treating the Under
Secretary of Health for the VA. So I, again, ask you, is it the
intention of the Chairman to follow the rules and protocols of
the House under rule XI?
Mr. Mitchell. We will take a five-minute recess on that.
[Recess.]
Mr. Mitchell. We will reconvene. Mr. Buyer recommends that
having Mr. Sullivan and Ms. Lain appear with Dr. Kussman on the
panel does not show proper respect. So, we will ask Ms. Lain
and Mr. Sullivan if they would step down and join the second
panel. If you would do that, please.
Mr. Sullivan. Yes, Mr. Chairman.
Mr. Mitchell. That's the only way I guess we can get proper
respect. Thank you.
Mr. Buyer. I thank the Chairman.
Mr. Mitchell. Ms. Brown-Waite?
Ms. Brown-Waite. I would address this to Dr. Kussman. Today
I received a letter from Secretary Nicholson addressing what
the VA has done and what they are doing, and what they're going
to do in the future to ensure that the wounded veterans receive
everything that they need as a transition from DOD medical
facilities to the VA. If you would please talk about that, I'm
sure that you were involved in that letter. Is that correct?
Okay. If you would just please discuss that, and I think
that every Member here does plan, you know, holding the
Secretary's feet to the fire to make sure that those promises
made in the letter, and I think everyone received one, I think
the Chairman received a letter today, that that really does
take place. I think regardless of the party affiliation, every
Member here wants to make sure that our veterans are well taken
care of, and in response to the Chairman's question about what
happens when the number of complaints pile up, I can just tell
the Chairman that I'm aware of at least one hospital
administrator who was removed from that post in my district,
and I am sure that the freshman Members here will learn and
that we will be also contacted when the VA is not responsive.
The families and/or the veterans and military people won't
hesitate to also let us know. So if you would just elaborate a
little bit on that letter, I would appreciate that very much.
Dr. Kussman. Congresswoman, I don't have the letter right
in front of me, so I didn't have it memorized, but obviously I
am aware of the content of the letter. We believe very strongly
in our responsibility to veterans and their families for care,
and I believe that we have done that, as mentioned with the
satisfaction surveys that we have. But I believe this was just
another way of energizing and reminding our people and our
facilities of our obligation to do the things that we need to
do. We are hoping we will accept responsibility when things
don't go well, and we pledge to fix them when they're not, and
so we want to be sure that we've assessed everything that we
are doing, and be sure that we can raise the bar as
appropriate.
Ms. Brown-Waite. You know, when I first ran for office, I
thought it was a really good idea to virtually have the
veterans be able to go to non-VA hospitals. I really thought
that was a good idea until I really got to know the veterans
population both in my district and the organizations that are
represented up here. And I learned what a very high
satisfaction level that the clear majority of veterans have and
also the very good survey results that the virtual--the
customer satisfaction survey that takes place. I know I don't
have a VA hospital in my district.
I have three great ones around me, and we're going to hear
later from the head of the polytrauma unit there. But I get
great results and the veterans who aren't happy also contact
us, you know, I would be interested in the number of
complaints. I think maybe we should--every Member should have
that information available, and how many of them were resolved.
You know, so that we can also assure the veterans that if they
do have a question, or a complaint, that their complaint is
taken seriously, and is resolved.
Dr. Kussman. Yes, ma'am.
Ms. Brown-Waite. Mr. Chairman, I would also request that
Secretary Nicholson's March 7 letter addressed to me and to you
regarding the VA's efforts to ensure the seamless transition
into the VA system from DOD, that that can be also submitted
for the record.
Mr. Mitchell. Without objection, so ordered.
[The March 7, 2007, letter from Secretary Nicholson appears
on pg. 73.]
Ms. Brown-Waite. I appreciate that. In the letter it also
said that every VA medical center now has specialty PTSD
treatment capability. Would you elaborate a little bit on that?
And how recent is it that the PTSD treatment availability has
been available?
Dr. Kussman. Thank you for the question. The VA, as you
know, has been the leader in the treatment evaluation and
research of PTSD ever since the diagnosis was first used in
1980, and we have a national center in White River Junction and
other research sites that are seen as international resources
for the treatment research and evaluation of PTSD. We, in 2004,
developed a very thorough and elaborate mental health strategic
plan to look at where we were at the time and what are the
things that we could do better. And one of those things we
realized that we could do better was to be sure there was PTSD
treatment teams at all our facilities and there are over 200 of
them and that is more than just our facilities, because as you
know, we have about 155 hospitals. We've also put PTSD
treatment teams in large clinics as well to meet the needs of
people who have PTSD or are being looked at for PTSD. And so
this is really part of our mental health strategic plan to
enhance the services available.
Ms. Brown-Waite. I thank the Doctor, and I yield back the
balance of my time.
Mr. Mitchell. Thank you, and just one follow-up question
real quick. What is the waiting time for a person to receive
treatment in these centers?
Dr. Kussman. Sir, obviously our goal, first of all, if
anybody has urgent or emergent care, they get in right away.
Our goal is that if it is not urgent or emergent the person
should be seen within 30 days of the request.
Mr. Mitchell. How long?
Dr. Kussman. 30 days.
Mr. Mitchell. Thank you. Mr. Space?
Mr. Space. Thank you, Mr. Chairman. I understand that Ms.
Bascetta is available for questioning?
Mr. Mitchell. Right.
Mr. Space. I hope I have pronounced your name correctly.
Ms. Bascetta. Bascetta.
Mr. Space. Thank you. And I apologize.
Ms. Bascetta. That's okay.
Mr. Space. Ms. Bascetta, you, in your work for the GAO,
obviously have invested many hours in researching, in
documenting matters concerning seamless transition. My question
is to what extent--I am assuming you have made recommendations.
And I am curious to what extent those recommendations have been
followed, and if there have been matters that you have
recommended, issues that you have suggested that have been
ignored.
STATEMENT OF CYNTHIA A. BASCETTA
Ms. Bascetta. I wouldn't say that the VA has ignored any of
our recommendations in this regard. I can't say, however, that
the two departments working together have followed our
recommendations so far to the extent that we'd want them to.
And the one that I'm most concerned about is that VA and DOD do
a better job collaborating on rehabilitation so that veterans
or servicemembers, for that matter, who need services get them
as early as possible. Our work has shown that if there is a
delay in getting rehabilitation, there can oftentimes be
deficits that can't be made up. And one of our most significant
concerns is that, of course, all veterans start in the DOD
system. And if they don't work together early, meaning that DOD
at times would have to let VA in early, it could happen that
when VA has a veteran arrive for care in their system, you
know, there could be deficits that VA can't make up.
I'd also say that with regard to the seamless transition,
it remains a work in progress rather than a fully implemented
reality, but I think that because of the complexity of the
process, there will always be room for continuous improvement.
When we reported on it in 2006 to this Committee, we did not
make recommendations because in the course of our work when we
found problems to VA's credit, they corrected them while we
were completing our work. Most of those were problems with
regard to individual patients. So we would have to do more work
at this time to look systematically to reassess how well it is
working.
[The statement of Ms. Bascetta appears on pg. 59.]
Mr. Space. Thank you. Have you made specific
recommendations concerning the fashion in which these delays
can be eliminated, specifically with respect to rehabilitation?
And if so, can you provide us with a copy of those specific
recommendations?
Ms. Bascetta. I can submit our report for the record. The
recommendation was a conceptual one that the two departments
collaborate to come up with a plan and an agreement as to when
it would be appropriate for VA to have data about
servicemembers. And that through the course of them working out
the details early intervention could become a reality.
[The GAO report (GAO-05-167) reference by Ms. Bascetta
appears on pg. 94.]
Mr. Space. Thank you. I yield back the balance of my time.
Mr. Mitchell. Thank you. Mr. Buyer?
Mr. Buyer. Mr. Chairman, I will follow the protocols of the
Committee and I will go at the end of the sitting Members of
the Committee for questions. Thank you.
Mr. Mitchell. Thank you. Mr. Walz.
Mr. Walz. Thank you, Mr. Chairman. And thank you, Dr.
Kussman, for being here. Ms. Bascetta, I appreciate the
opportunity to speak with you, and I want to thank you for the
work you've done for our veterans. I said I do think that is
critically important that we keep that in mind, and having
spent a lot of time in our polytrauma center in Minneapolis, I
know the quality of care and the professionalism there is
something that I am very proud of.
My constituents demand that we get this right and we're
here today to question and to look ahead and I think that is a
healthy exercise, I think it is one we need to do and we can
get this right. We must get it right. I would associate myself
with the Ranking Member Ms. Brown-Waite when she said, that
this is a priority. This is one that we have to get right. I
feel it is a moral imperative to take care of our wounded
warriors when they return home, but I also think that it is a
national security issue.
We need to make sure this is part of what we're doing so
soldiers know they're being taken care of. Results matter in
this, and it is one of these situations that I think we have to
shoot for. You're right, it is always going to be a continuing
process. But this is a zero sum proposition. One mistake is too
many in this. One soldier left untreated is too many.
And I think all of us agree with that, and the goal is to
try to get it to zero. If we ever get there, we must continue
to try. So just a couple of questions, Mr. Kussman. How long
have you been with the VA--I'm not sure if I got that--have you
been working in your current position, sir?
Dr. Kussman. In my current position? Since 12 August 2006.
Mr. Walz. How long have you been with the VA in general,
Dr. Kussman.
Dr. Kussman. I first came to the VA on 24 September 2000.
Mr. Walz. Very good. My first question on this is do you
believe there were substantial changes made or substantial
preparations made starting in about March of 2003 when this
current conflict in Iraq got started? Were there preparations
made for the influx of wounded veterans that we would see?
Dr. Kussman. We always, sir, are ready to take whatever we
need. I think that the thing that surprised everybody was the
type of injuries that we were seeing, not necessarily the
volume, although no one could predict how long the war was
going to go on, and that is a different issue. But what we have
seen is that there are certain signature injuries of this war.
One is PTSD, particularly for the National Guard and Reserves
because I am not trying to minimize the active component, but
they do have a cocoon around them, and in my previous life I
appreciated that. But what do you do with the people who then,
when they get discharged, don't have that same type of cocoon?
The other thing is because of the body armor and the far-
forward surgical care, servicemembers are surviving with much
more complicated wounds. So that was one of the things that
drove us very quickly to build on our four TBI centers that we
have in Palo Alto, Minneapolis, Tampa and Richmond. And we have
two of the directors here that will be on a follow-up panel. We
put in place there, the full multidisciplinary approach for
things, not just TBI. But TBI is another signature injury that
is occurring, partly because I think when we went into the war,
we thought that we would see the more traditional types of
casualties, gunshot wounds, shrapnel, the usual thing.
The enemy is taking a different tact in using IEDs and car
bombs that create blast injuries, and one of the blast injuries
among others is the traumatic brain injury which is--not to
minimize it, it is head rattle that occurs inside the helmet,
the brain floats and things in the brain, it is not locked in.
So there is a whole spectrum of mild to moderate traumatic
brain injuries to severe traumatic brain injuries.
Mr. Walz. And just using the last bit of my time, do you
feel like we're prepared for the large number that are going to
be diagnosed as we start to check everyone now the traumatic
brain injury? Sometimes it's not so visible, vision, different
things like that, and PTSD. Do you feel like we're prepared?
And you are absolutely right, in my former life, it was 24
years in the National Guard. And I know when they go out to
rural Minnesota, it is a lot different than when we're on an
active military base. Are we prepared for these soldiers today,
tomorrow and 5 years and 50 years down the road?
Dr. Kussman. Sir, as you know, I can't read a crystal ball,
but I think right now we put in place the procedures and
processes that we can take care of this group of patients. As
you know, of the 613,000 servicemembers that have transitioned
out of the active component since the OIF/OEF started, some are
active component people who have left, others are transitioned
back to the National Guard or Reserve or just get out of that
as well. We've seen 205,000 of those people with a myriad of
differing complaints. We see--we project that number--that was
out at the end of FY 06. We project that number in FY 08 to be
263,000.
We project that we will see 5.8 million veterans. So it is
a relatively small number of our total force, but they have
certain needs, and we believe with our four polytrauma centers,
our 17 additional level two centers and teams and all our
facilities, we are ideally poised to be able to take care of
the patients as they transition out.
Mr. Walz. Thank you. And I yield back, Mr. Chairman.
Mr. Mitchell. Mr. Rodriguez?
Ms. Bascetta. Mr. Chairman, may I add something? I'm sorry.
Mr. Mitchell. Go ahead, ma'am.
Ms. Bascetta. I would just like to elaborate a little bit
on what Dr. Kussman said. And that is, we did some budget work
for this Committee last year and reported in September 2006
that one of the factors that caused one of the problems in VA's
budget estimation was underestimating the cost of serving
veterans returning from Iraq and Afghanistan. And part of that
was due to the fact that their data largely predated the
conflict. But the other part was--and I can't make this point
too strongly--that they have had trouble getting data from DOD
that they need for planning purposes. So it is another example
of the need for these two agencies to work together.
Mr. Mitchell. Thank you. Mr. Rodriguez?
Mr. Rodriguez. Thank you very much. I wanted to follow up
with the GAO. And you answered one of my questions because I
recall some time back, we pushed an effort in terms of trying
to get both the active-duty soldier and the VA working together
more and it seems based on the GAO report that there are still
some serious problems in communication and, in fact, some even
questioning the part of the DOD about the fact that they have
concerns that they might even provide services to them while
they're still in the military. And I was wondering, why would
they be concerned about that?
Ms. Bascetta. They told us--and this was about a year and a
half ago now--that they were concerned about their retention
goals.
Mr. Rodriguez. They were concerned about their retention
goals?
Ms. Bascetta. Yes.
Mr. Rodriguez. And not necessarily concerned about their
health, I gather.
Ms. Bascetta. They didn't say that.
Mr. Rodriguez. They didn't say that.
Ms. Bascetta. They were worried about VA coming in too
early and giving servicemembers the idea that they might want
to leave the military. And our concern was that these
servicemembers needed rehabilitation from VA, from DOD, from
the private----
Mr. Rodriguez. Whoever can provide it, I agree.
Ms. Bascetta. So they could fully recover both medically
and vocationally and have the option to, you know, work to
their fullest potential, either in the military or in the
private sector, in the civilian sector and many of them, I
think, might have opted to stay in the military and many are
because it is their career, and they're dedicated to it. Others
have told us that they don't want to leave the military because
their families need health care, health insurance.
Mr. Rodriguez. And I know that doesn't have anything to do
with VA, but you also, in the GAO report, talk about our
military soldiers having difficulty paying, or when creditors
go after them, when they're unable to get their loans, unable
to buy a car, and mainly, because they're being harassed by
credit agencies and going after them for fees?
Ms. Bascetta. Yes, sir. There are long-standing problems
with the military pay system that have not been fixed. And it
aggravates an already antiquated system. If I might add too,
there are other problems that we noted in the course of the
seamless transition work. It was done for the VA Committee. So
we didn't report these findings in the report, and we didn't
make recommendations to DOD because they weren't within the
scope of our reporting. But some of them had to do with other
bureaucratic problems that the family members and the
servicemembers get caught up in.
For example, in one case, a disabled servicemember was to
be discharged from a PRC to a VA nursing home. And DOD refused
to pay to have the wheelchair transported. It didn't fit in the
ambulance, and they refused to have it transported separately
until a cost analysis could be done. They told the VA social
worker that would take several weeks. The VA social worker, to
her credit, found donated post funds, not appropriated funds,
and used them to have the wheelchair shipped to the nursing
home so the servicemember would not be confined to his bed.
Mr. Rodriguez. My God. You know, and I know that, you know,
I had left for 2 years from Congress, but I remember prior to
leaving, we were working hard at trying to establish a system
where the soldier automatically leaves the military and can be
picked up as quickly as possible. Now you also mention that the
VA is still having difficulty getting the prognosis and
diagnosis, and the medical history, because it isn't
electronically done?
Ms. Bascetta. That's correct.
Mr. Rodriguez. What can we do from the VA perspective in
terms of trying--because that is part of--you know, and the
other part, and I know you have only been there a short time
and I know the responsibility falls with all of us. I don't
like the idea of coming down--this I am referring to the
administration--firing the commander at Walter Reed who has
only been there for 6 months when in all honesty, that
responsibility falls with all of us in ensuring that they have
the resources that are needed, and I know that we haven't
provided that, and I know that with a large number, some 23,000
soldiers that are coming back seriously injured, we need to
beef up on funding. I was pleased to see on the CR, that $3.6
million, and I want to get your feedback on it, and we're
hoping to add some additional supplemental funding, but not
only to the VA, but also to the active soldier.
And in saying that, we had talked about seeing how we can,
you know--and maybe you can guide us from the VA perspective.
What do we need to do to make sure that we accomplish that goal
that when that soldier leaves the military and the VA picks him
up, how can we make sure we don't have to reduplicate
everything and retest everything in terms of the soldier?
Dr. Kussman. Sir, is that a question to me?
Mr. Rodriguez. Yes, sir.
Dr. Kussman. We are working very closely with DOD,
particularly with the more seriously injured people. And let me
just add to what Ms. Bascetta said. The two health care
systems, by their nature, have been complementary, that the VA
does some things and DOD does others. I mean, we don't do
pediatrics and things of that sort. She is exactly right, that
when people have multidisciplinary problems, you need to get at
them all quickly because you can then lose some momentum with
one thing if you are only focused on one. So we have moved to
put a blind rehabilitation specialist into Walter Reed, a
spinal cord specialist coming out of the Washington VA, because
those are the two things that----
Mr. Rodriguez. If I can, what else do we need to do to try
to correct some of those things that were mentioned by the GAO
from the VA perspective?
Dr. Kussman. Well, I think that we have done a lot of the
things that the GAO mentioned, and Ms. Bascetta said that. What
we did is we realized that we have those four wonderful centers
that we have, and I think they're state of the art and
multidisciplinary, but people leave those centers. They don't
live near there, so we put 17 additional--there are really 21
level II sites, one for each of our divisions. But the 17 are
additional. The four that we already have in VISNs, we didn't
see any reason to duplicate on top of the level I. So there is
a total 17 new, but a total of 21 centers as well as putting
resources at our facilities to try to provide the full depth
and breadth of services close as we could.
Mr. Rodriguez. Did I hear you saying that we don't need to
do anything else, that you have established the things that are
there in order for us to--for the service person to be able to
be picked up? Is that what I am hearing?
Dr. Kussman. We can always do better. We appreciate your
assistance.
Mr. Rodriguez. The question is how can we do better? What
do we need to do to help to you do better? Because apparently
we're not doing----
Mr. Mitchell. Mr. Rodriguez, your time has expired.
Mr. Rodriguez. Thank you.
Mr. Mitchell. Thank you. Mr. Buyer?
Mr. Buyer. Thank you very much. Ms. Bascetta, I was sitting
here trying to think how many years we have been on this issue.
I can't even remember. It has to go back 12 or 13 years. It is
not nice to talk about age with a lady, but it has been a long
time. I can't even begin to count the number of GAO studies
you've done and supervised over the years. You know, this is
20-plus years in the making, trying to get DOD and VA to
coordinate and cooperate.
And Dr. Kussman, I've got history with you too, even back
when I was on the Armed Services Committee and you were a
commander at Walter Reed, which a lot of people may not even
realize, back in the nineties. And you know what--pardon?
Mr. Filner. Now we know who is responsible.
Mr. Buyer. Well, if you want to know who is responsible,
let's go back and do a little history. I remember--let's do
this, Dr. Kussman, because you were a senior officer then in
the medical corps. In the nineties, we would come out of two
rounds of base closures, back then the defense budgets were
about $270 billion, and we were doing everything we could to
try to downsize everything from wings and ships and divisions,
and were trying to make it work, and then that is when I had
the supervision over the military to help the delivery system.
So what was the response? The response was that if we had
less dollars, we'd create centers of excellence. Remember? So
we created Brooke, Bethesda, and Walter Reed as centers of
excellence because there weren't enough dollars to go around
out of those budget years to fund all of those hospitals at all
the ports or all of the bases and forts. So we create the three
centers of excellence. And we had this belief coming out of the
first gulf war that, gee, we weren't going to have as many
wounded, we wouldn't be in a continuous war for a long period
of time. It was challenging for me when Walter Reed came out on
the BRAC. I was pretty surprised by that. I knew it was an
aging facility. But at a time of war, for us to put one of our
centers of excellence on the BRAC was bothersome to me.
Now I no longer had served on the Armed Services Committee,
so I have a void in my background in intellect here as to
exactly what happened and transpired over the last 5 years. But
even to say we're going to transition it all over to Bethesda
is a pretty heavy burden. So as we had a surge of wounded and
other than hospitals were not able to accept those capacities,
we had a problem.
And I also, then, add to this Congress, GAO, and Inspectors
General have put a lot of pressure on commanders of bases that
have been BRAC'ed about what moneys you are going to spend on
facilities that are about to be closed. And so, what an
untenable and difficult position we put a commander in at
Walter Reed by squeezing him from both ends. We're going to
maintain the standard and quality of care, and at the same
time, by golly, you'd better be careful what dollar you spend,
and the worst, horrible things that happened is, I can almost
see an individual thought they would make a well-intentioned
decision by saying, let's keep these unmarried soldiers in
close proximity to the care giver and they made a bad judgment
by putting them in an unhealthy building.
So when they talk about who is responsible, well, Congress
is on the list. Because what did we do BRAC'ing one of our
centers of excellence during a time of war? So I'm going to
turn it over to you. I have a lot of history with you, General,
and Dr. Kussman, and I would, from a historical perspective, be
interested in your comments on mine.
Dr. Kussman. Well, sir, I think--thank you for the
question. And Mr. Filner said maybe I am responsible for what
happened. It was 10 years ago, Mr. Filner. So thank you. But
having been a commander of other facilities when they were
targeted to be closed, it wasn't when I was at Walter Reed, but
I've been there at other times. It is a big challenge because
psychologically, the place closes very quickly with the ability
to do the nonrecurring maintenance, the other things that you
would like to have done as well as maintaining an adequate work
force, because if people look ahead and they know there is a
good chance that they will not have a job 2, 3 years from now,
the real good ones in particular start looking for new things.
So it is a great challenge to be in charge of a facility that
has been earmarked to close.
Mr. Buyer. So with the personnel challenge, then what
commanders have to do is do contracting, try to fill in the
gaps or holes where they can. And now we have soldiers waiting
on their disability ratings and therein lies the tremendous
challenge that we have for them, as that begins to back up and
now that they gain rehab and convalescent care. Well, thank you
very much. Thank you, Mr. Chairman.
Mr. Mitchell. Thank you. Mr. Filner?
Mr. Filner. Thank you, Mr. Chairman. And thank you for
allowing those of us who are not on this Subcommittee to visit
with you today. It is a very important issue, and I appreciate
your leadership on this, and I appreciate the job you are
doing. I apologize, Dr. Kussman. I did not hear your opening
statement, but I did hear answers to some questions. What I was
surprised about when Mr. Walz asked are you prepared? I think
it was in the context of the traumatic brain injury. But I
probably enlarged that to PTSD also. And you said, we are
ideally poised. Those were your words.
I find that, that kind of--I don't know, misplaced optimism
or defense of where we are to be at the cause of a lot of
things we are hearing today, whether it was at Walter Reed,
whether--if you read the cover story from Newsweek on veterans
falling through the cracks, to see the situation that Bob
Woodruff portrayed on ABC, I don't believe we're ideally
poised. I don't think we're handling what we're doing now, let
alone the tens of thousands, maybe several hundred thousand
returning vets. This injury, as you, I assume, pointed out is
not always recognizable at the beginning. You said that. So, we
got probably thousands of kids coming back that have brain
injuries that we don't know about, they don't know about, that
it is our obligation to follow as long as they are alive. The
stress on this system right now is very tough.
I mean, we are not handling the veterans who get out today
and who have been out. We have a 600,000 claim backlog. Does
that mean we're ideally poised? We have got veterans waiting
weeks and weeks, if not months, for their first appointment. Is
that ideally poised? We have people sitting in waiting rooms
for hours because there is not enough doctors or there is not
enough nurses. Is that ideally poised? Come on. Let's be frank
and candid about the situation. The VA is being stressed to the
limits. I'm not blaming you.
I'm blaming you for the defensiveness and the cheery
optimism you have instead of telling us the truth. Because we
are asking you to do more and more with fewer and fewer
resources. It is our job to give you the resources, but if you
say you don't need them, I mean, that is ridiculous. I will
tell you, by the way, by the work of the people from Mr.
Mitchell and Mr. Space, Mr. Walz, Mr. Rodriguez, and Mr. Hare
and myself, and a couple people who aren't here, we convinced
our leadership to add in the supplemental that is coming to the
floor, $3.5 billion of additional resources, primarily aimed at
traumatic brain injury and PTSD. That is going to be a big
item.
But you will probably give it back because you are so
ideally poised to deal with these issues. Listen, we have an
incredible obligation here. We have an incredible obligation.
There are so many with brain injuries, there are so many with
PTSD, we are not diagnosing them. Kids want to get home.
They're not checking anything. Marines say if you check
anything, that is a weakness. The American public doesn't
understand PTSD, doesn't understand traumatic brain injury. We
got a lot of work to do.
You guys had the nerve last year, when there were sudden
upticks of diagnoses of PTSD, you had the nerve to say--instead
of saying to Congress, we need more resources to handle all
these diagnoses, you said, let's investigate these doctors and
why they're giving out this diagnosis so freely. That is the
problem. You guys keep not saying what--that we have an
extensive situation. We have got to take--our obligation, these
kids have done everything we've asked them to do. It is our job
to treat them with the--to extent worthy of the sacrifices they
have made. And I will tell you, we're not doing it, Dr.
Kussman. And you are not doing us any good with this cheery
optimism saying that, ``we can handle it.'' We are not handling
it today. You tell me how we are handling it if a young Marine
goes to one of your facilities in Minnesota who says he thinks
he has PTSD and he has suicidal thoughts and they tell him he
is 26th on the waiting list. Come back in a few months and he
goes home and commits suicide. Are we ideally poised, Dr.
Kussman?
Dr. Kussman. Sir, can I respond to that particular case?
Mr. Filner. No. Respond to the whole thing.
Dr. Kussman. No one is more committed than I am of taking
care of veterans. I am a veteran and a retiree and I am very
proud of it. So I wasn't trying to be glib when I said ideally
suited. I meant from a clinical perspective, when we have the
resources, we are looking at TBI. No one really knows how
common mild to moderate TBI is. We put in a screen that we are
going to evaluate everybody who comes in, and we do that same
thing with PTSD, our outreaches.
Mr. Filner. You tell me you are diagnosing every single
returnee with PTSD and TBI? You are telling me you are doing
that right now? You are not doing it. Let these guys tell me if
they are doing it. They check a questionnaire, and that is what
the thing is.
Dr. Kussman. That is not what I am talking about, sir. I am
talking about when somebody comes to the VA not some screen
that is being done someplace. This is part of when----
Mr. Filner. Oh, they have to come in first. Well make that
clear.
Dr. Kussman. When they come in to the VA for whatever their
problem is, they get screened for PTSD and now we're screening
for TBI as well.
Mr. Filner. Thank you.
Mr. Mitchell. Thank you. Mr. Bilirakis.
Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it.
Dr. Kussman, GAO testimony last Monday at the Walter Reed field
hearing indicated medical information of patients being
transferred to the VA is less than adequate. I want to know why
there is no transfer electronically. It requires a very time-
consuming process of multiple phone calls and faxes. Doesn't
this become a safety issue, a serious safety issue?
Dr. Kussman. I think there is more progress that needs to
be done, obviously in the transfer of information. We are
working together, our IT people, to develop that seamless flow
of information. As you are probably aware of, it recently was
announced last month that we are going to move toward a single
inpatient electronic health record that would be the same in
DOD and VA.
Mr. Bilirakis. Okay. Thank you. Ms. Bascetta, TBI patients
and their families at the polytrauma centers complained that
while they were on lengthy administrative hold, awaiting
military disability process up to 6 months, no brain
rehabilitation was given until they arrived at the VA. I
understand early intervention would help, most definitely. Can
you comment on this, please?
Ms. Bascetta. Absolutely. That is one of our biggest
concerns. I should emphasize, we don't have work on the DOD
rehabilitation side of the story, medical or vocational. But we
have heard this repeatedly, and, you know, it is great that VA
is going to start screening for PTSD and brain injury, but it
has to start earlier. It has to start at DOD. And that
information has to be shared with VA as early as possible.
Otherwise, I don't understand how servicemembers or veterans
will get the care that they need when they need it.
Mr. Bilirakis. Thank you. I yield back.
Mr. Mitchell. Thank you. Mr. Hare?
Mr. Hare. Thank you, Mr. Chairman. I don't know really
where to begin here. I share Congressman Filner's anger and
frustration. I have been sitting here during this hearing. I
look out and I see those brave people sitting there, and for
the life of me, I cannot understand why we cannot get two
agencies to talk to each other to do something that makes some
sense to help these people out. And I know that might be
oversimplification on my part. But you know, this is another VA
hearing that I sit in, and I listen to testimony about things
that have been going on for years, and I'm not blaming the
witnesses even for this.
I am talking--I think this problem is just built in,
inherent, and I don't see any movement on it or I see
discussions on it, and I see a lot of rhetoric. But you know,
it is like the old commercial, ``Where's the Beef?'' There has
to come a time, it seems to me, where we have to make treating
these people, our finest, in the finest possible fashion that
we can. I am just so incredibly tired of what I consider to be
lip service.
I think the hammer has got to be dropped, and I think this
Walter Reed thing is just systemic. I think we fight like--
sometimes like children on a playground to figure out if we're
going to have funds, to be able to give the kind of care that
we have while we spend $11 million an hour on a war, and we're
not nearly prepared for the people that are coming back, not
nearly prepared to take care of them.
And we shrug our shoulders and wonder, well, we hope we can
get some continuity and some cooperation between DOD and the
VA, and in the meantime, while that goes on, we have people
going home that are hurt, people, you know, I don't even know--
I'm beyond the point of being angry about this.
And just when you think it gets bad, it keeps getting
worse. I think we have to put our money where our mouth is. I'm
glad that we got the additional funds, but I share this
frustration. I have a vet center two blocks from my district
office. They do a wonderful job and you're right, we need more
of them. And we need to do everything we can, and we have to
back up what we're doing with a lot more--I think--I think
maybe you folks ought to be angry, if you are not already
there, maybe a little bit more.
Maybe we have to figure this out because what we've been
doing hasn't been working, quite candidly. I said this before,
I'm the new kid on the block. I'm a veteran and a freshman on
this Committee, but you know, I don't get it. And perhaps maybe
you folks can enlighten me at another point. I just wanted to
say a couple things. Why is it the case that servicemembers who
are transitioning to veteran status still have to make hard
copies, if that is the case, of the medical records and hand-
deliver them to the VA? Is that still the practice? Do they
still have to do that?
Dr. Kussman. I believe for the benefits, that is true, sir.
Mr. Hare. Okay. How long do you folks see an integration of
these two systems so that we can put an end to this once and
for all? And from your perspective, what can we do? What can I
do or what can this Committee do or what can this Congress do
to move this along and put an end to this once and for all to
put an end to it and to do what needs to be done from your
perspective, I would be very interested in hearing what you
think.
Dr. Kussman. I think there are several things that are
being done, as I hope you know that we have VA personnel full
time in the military facilities. We have military people in the
VA facilities. I think Congressman Filner and the Secretary
just visited north Chicago as an example of partnering. We hope
to be able to do more things like that in a more integrated
system. There are a lot more things to be done.
Mr. Hare. Can you maybe describe what actions are being
done to improve the sharing the medical records between the VA
and the DOD. I think you did. I apologize if I didn't get it.
Ms. Bascetta. We characterize it really as a work in
progress. They clearly are better off at the polytrauma centers
than elsewhere because they do have some access to the
electronic records. DOD actually installed computers in the VA.
They're not VA computers that have access to DOD computers.
What bothers us is that, you know, a year ago when we showed up
in one of the PRCs to make sure that the electronic access was
working, it wasn't.
As recently as 3 weeks ago DOD unilaterally cut off the
access of the physicians in one of the PRCs because the two
bureaucracies had failed again to reach a data sharing
agreement. That is inexcusable. And the potential adverse
effect on patient care could have been a significant problem.
In a larger sense, sometimes I think that if the servicemembers
on medical hold were not discouraged and were getting the kinds
of rehabilitation services that they needed, maybe the mold in
Building 18 wouldn't have caused as much of a problem.
And where I've seen VA and DOD sharing work the best it has
been when the two departments or the people in the departments
at the local level have taken the approach of focusing on the
patient, not their own bureaucratic rules and regulations.
Mr. Hare. Hopefully that is--I know my time is up, and I
thank you, but hopefully that is something we can all improve
on and get that cooperation. So that the men and women that are
sitting here are the beneficiaries of that cooperation. I yield
back. Thank you.
Mr. Mitchell. Thank you. I would like to ask Dr. Kussman
just a couple of other questions. Are you familiar with the
contingency tracking system that has been talked about?
Dr. Kussman. Yes, sir.
Mr. Mitchell. And one of the purposes of that tracking
system was to supposedly track the status of wounded soldiers
throughout their medical treatment in Defense and VA
facilities. In your view, why was this canceled?
Dr. Kussman. It is my understanding, sir, that when the
program was developed it was tried to be used. It didn't meet
the needs of particularly the VHA. It was a system that was
localized to a military treatment facility, and the input would
have had to be done at the military treatment facility. It
didn't integrate itself with the CPRS Vista or the DOD system,
and it was felt it wouldn't meet the needs of particularly VHA
in the longitudinal following of patients, because when they
transferred out of the MTF, the data didn't go anywhere.
Mr. Mitchell. Okay. One last question. Did social workers
who are liaisons at Walter Reed, did they ever report any
concerns about the conditions that the servicemembers were
living under at Walter Reed?
Dr. Kussman. Are you talking specifically, sir, about
Building 18?
Mr. Mitchell. That or any other buildings, any of your
social workers.
Dr. Kussman. They didn't report that to us. Actually when I
heard about it, I called them over to have a meeting of what
was their assessment of what was going on. You know, they don't
have the visibility of the actual physical plant. They're
working generally in the hospital with servicemembers who are
transitioning.
Mr. Mitchell. They were not working with those who were
outpatients, for example?
Dr. Kussman. Well, the individuals, as they're working
through the disability process in the military, they would be
talking to them as needed to be sure that if they chose to use
the VA when they left then some of them are direct transfers,
others would be patient that are going back home and we would
get them enrolled in appointments at a local VA but we're not
involved the MEB/PEB process that is going on in the military.
Mr. Mitchell. So if you know that someone who is a multiple
amputee is obviously not going to be in the military very long,
and will be transitioned into your service, you don't do
anything with them until they report back home to the hospital?
Dr. Kussman. No, sir. The people who are entering into the
disability process, someone like you just described, we then
approach them and work with them to determine what their
benefits might be and where they would like to get their health
care. As you know, someone who is leaving the military,
particularly if they're being medically discharged have
basically three options of their care. They can come to the VA
if they choose and we would encourage them to do so and have
them seen. They can use TRICARE or they can use the military
treatment facility. The more severely injured ones, as you go
from Walter Reed to Bethesda or Brooke to one of our four
polytrauma centers.
Mr. Mitchell. Thank you. Yes, Ms. Brown-Waite?
Ms. Brown-Waite. Thank you Mr. Chairman. I have another
question for Ms. Bascetta and I know also that Mr. Buyer has a
question also.
Ms. Bascetta, were you able to ascertain why the joint
patient tracking application system was turned off so that the
VA did not have information about the patients?
Ms. Bascetta. My understanding is that a decision was made
at TMA and DOD by their attorneys that the data sharing
agreement had not been signed, and that is why the access was
cut off.
Ms. Brown-Waite. Are you aware if any efforts are ongoing
to resolve any issues so that that access can be turned on so
that there can be continuity of care and information sharing?
Ms. Bascetta. I don't know what was done systemically, and
I am not current on whether they have a data sharing agreement
at this point. But I know that the access was restored. I think
it was cut off on a Friday and it was restored that Saturday
morning.
Ms. Brown-Waite. Doctor, could you respond?
Dr. Kussman. Yes. There is a data sharing agreement, and it
was restored.
Ms. Brown-Waite. So it has been fully restored?
Dr. Kussman. Yes, ma'am.
Ms. Brown-Waite. Thank you.
Mr. Mitchell. Thank you. Mr. Buyer, you had a question?
Mr. Buyer. Yes. Thank you, Mr. Chairman. What I realize
quickly is that, you know, many soldiers, Dr. Kussman, they
will be very complimentary of their care for the military
treatment facilities or the actual medical care at the VA. But
they have real challenges when they're facing the discharge.
Over the years, we talked about this in doing the Benefits
Delivery at Discharge (BDD), identified the 142 sites. Ms.
Bascetta, you went out there and visited some of those a couple
of years ago, you identified 20, went to 10 I think. And so, as
we try to do this, one physical that will apply to that VA
disability, Dr. Kussman, right there is the sandpaper to the
skin. I think that is the beginning of a lot of irritation for
soldiers in ``how my government is treating me, do they
appreciate my sacrifice, am I being fairly treated with regard
to my rating,'' and it just rips them from the inside of their
gut.
And I think that is where this one really begins to
identify itself. And so, if there is a weakness that I see in
our system in the total chain of mercy, it is right here. And
so let me ask now, Ms. Bascetta, whether or not you have looked
at this. Since you looked at it 2 years ago, have you had any
advance look with regard to the BDD and the sites and whether
or not we've improved ourselves?
Ms. Bascetta. No. Unfortunately we don't have updated work
on that, but we have overall work on modernizing disability,
which is at a much higher level than you were talking about,
but I think it speaks volumes that if soldiers are feeling as
though they're discouraged, they don't really want to be
boarded out, and the system becomes more adversarial than it's
intended. It's not surprising we have these kinds of outcomes.
And the systems are geared in VA, DOD, Social Security, you
name it, the Federal disability programs are cash benefit
programs. And the incentive is to minimize the payments, and
that is part of what creates the adversarial atmosphere.
Our view is that a better system would focus on
rehabilitation first because it is in the interest of the
government, if not the servicemembers, to get everybody
rehabilitated so that they can work either in the military or
in the civilian labor force to their fullest potential. If we
had a system that focused on rehabilitation, what people can do
instead of what they can't do, and compensated them afterward
for their residual impairments, it could really help reduce a
lot of the animosity.
Mr. Buyer. Dr. Kussman, your thoughts?
Dr. Kussman. Sir, I am aware--we've had this discussion
before. Right now, we have two types of seamless transition.
There is the little seamless transition that we've been talking
about about patients who are severely injured or going from one
facility to another. The large--what I call big seamless
transition, is the average servicemember who is getting out
through the BDD process. And we have, as you know, worked for a
long time to focus on a single physical exam. I think the thing
that we've learned is that it is really a comp and pen exam
because routine discharge physicals are not actually done in
the military.
And so what we have to do is be sure that we start with
this process at these 144 sites up to 6 months before if
somebody is getting out to help them work through the process,
encourage them if they have a problem to request a CMP exam,
and the whole idea is to get that done expeditiously so that
when they do separate, because as you know, we can't provide
anything for anybody until they get a DD-214 from a disability
perspective, that we would be prepared to provide them that
disability for whatever it is determined to be.
Mr. Buyer. All right. Thank you, Dr. Kussman. Thank you for
your courtesy, Mr. Chairman. Okay.
Mr. Mitchell. If there are no other questions, we want to
move to the second panel. Thank you for coming today. We
appreciate you answering questions and your statements. Thank
you.
Ms. Bascetta. Thank you.
Dr. Kussman. Thank you, sir.
Mr. Mitchell. At this time we'll take a 5-minute recess.
And let me just mention that I will read the panel as they get
their name tags up there. Go ahead. Thank you.
[Recess.]
Mr. Mitchell. If everyone will be seated, we can get
started. If those witnesses that were not sworn in at the very
beginning, if they would please rise and raise their right
hand.
[Witnesses sworn.]
Mr. Mitchell. Let me just very quickly introduce this
panel, and I will reintroduce two that were on the last panel.
As many of you may be aware, last night, Mr. Paul Sullivan
appeared on ABC News to discuss a data tracking system which
would have made the seamless transition of new veterans much
more efficient, and we're pleased to welcome him here today to
answer questions. He shares his knowledge and experience on
this issue. Also Private First Class Kimberley Lain who has
recently gone through the transition process to the VA from
Walter Reed Medical Center is here to share her experience with
us.
We also have Ms. Kathy Dinega and Ms. Sherry Edmonds-
Clemons, who are VA social work liaisons to Walter Reed Medical
Center and Bethesda Naval Hospital. We have asked Mr. Dinegar
and Ms. Edmonds-Clemons and what the options are once they
transition into the system at the local level. Dr. McNamee is
the director of VA Polytrauma Center in Richmond, Virginia, and
we welcome his input on the challenges facing the VA as it
attempts to move seriously wounded servicemembers into these
facilities. At this time--let me--I want to defer to Ms. Brown-
Waite and ask her to introduce Dr. Scott, and let me do that
now. I'm sorry.
Ms. Brown-Waite. I thank the Chairman very much. It is my
very distinct pleasure to introduce Dr. Steven Scott. Dr. Scott
heads up the polytrauma unit at Haley Hospital, and there is
something we didn't know until today when I actually had time
to fully read his resume, and that is, he is graduate of
Springfield College from Springfield, Massachusetts, where he
got his original bachelor's degree, and I taught at
Springfield, but at the Tampa campus. And he went on to
Pennsylvania State University, did his graduate school of
medicine at Mayo Clinic in Rochester, Minnesota with a
residency in physical medicine.
He also was recently nominated to be the VA employee of the
year. We don't know yet, the votes aren't counted, but that
certainly is a great honor for him to be nominated. And I visit
the hospital regularly, and talk to the family members, and
also to some of the patients and let me just tell you that Dr.
Scott is held in very high esteem. He is passionate about
quality care for those who need the polytrauma rehabilitation
center. And I thank the gentleman for allowing me to introduce
him.
STATEMENTS OF SHANE McNAMEE, MD, DIRECTOR, HUNTER HOLMES
MCGUIRE RICHMOND VETERANS AFFAIRS MEDICAL CENTER, RICHMOND, VA;
STEVEN G. SCOTT, MD, MEDICAL DIRECTOR, TAMPA POLYTRAUMA
REHABILITATION CENTER, JAMES A. HALEY VETERANS' HOSPITAL,
TAMPA, FL; PAUL SULLIVAN, CEDAR PARK, TX (FORMER PROJECT
MANAGER, U.S. DEPARTMENT OF VETERANS AFFAIRS); AND PRIVATE
FIRST CLASS KIMBERLY LAIN, MILLERSVILLE, MD (RECENTLY
TRANSITIONED VETERAN FROM WALTER REED AND DISABLED AMERICAN
VETERAN)
Mr. Mitchell. Thank you. We're going to have two
statements, five minutes each. Dr. McNamee, is that how you
pronounce it?
Dr. McNamee. It is McNamee, sir.
Mr. Mitchell. Thank you. And if you would start, I would
appreciate it.
STATEMENT OF SHANE McNAMEE
Dr. McNamee. Good afternoon, Mr. Chairman and Members of
the Committee. Thank you for the opportunity to discuss the
transition of our wounded heroes with the Veterans and Health
Administration. My name is Dr. Shane McNamee, and I will be
testifying from the perspective of a clinician as well as in my
role as the medical director of the Richmond polytrauma
program. To frame the issue appropriately, I will describe the
typical transition process of severely wounded heroes and their
family Members in the military treatment facilities through our
programs and into their communities. It is my firm belief that
this highly coordinated effective system is unparalleled in
this Nation's medical system for those who have suffered a
traumatic brain injury.
The key concepts of seamless transition I will be
discussing are as follows: Number one, the significance of
medical record access, the continuum of care; number two, the
importance of relationship-based medicine; and number three,
the recognition of the family as part of the injury complex and
the integration of families into the therapeutic plan of care.
Our four polytrauma rehabilitation centers are consulted by the
military treatment facilities when a wounded hero screens
positive for a traumatic brain injury. The referrals that come
to Richmond are processed by our nursing admissions
coordinator. Following collection and analysis of clinical and
family information, we provide the military treatment facility
a decision on the referral within 24 hours of the DOD's
original request for this referral.
At the earliest possible time, the family Members of the
severely wounded are contacted by myself, the nursing
admissions coordinator, and the social worker assigned to the
case. This step has proved essential for several reasons. For
the family, the transition of a wounded hero between medical
facilities creates anxiety due to the unknown. Importantly,
this contact provides an early opportunity to build a
relationship with key family Members. This relationship with
the patient and the family Members forms the basis of a
successful rehabilitation plan. The family also serves as an
invaluable resource in the recognition of personality and
cognitive changes that are common after a traumatic brain
injury. Numerous systems are used to develop an individualized
plan of care prior to admission to our polytrauma
rehabilitation center. Medical records are obtained through our
direct access of Walter Reed Army Medical Center and Bethesda
national Naval Medical Center.
Up-to-date information about medications, laboratory
studies, results of imaging and daily progress notes are
reviewed to determine the individual case parameters. We access
the Web-based joint patient tracking application to gain
further understanding of the patient's clinical status,
specifically the field notes from Balad, Iraq, and follow up at
Landstuhl, Germany, are indispensable in determining severity
of TBI and associated injuries.
Our nursing admissions coordinator also takes specific
documentation through the DOD liaison personnel stationed at
both Walter Reed Army Medical Center and Bethesda national
Naval Medical Center. As medical director, I contact referring
physicians and discuss the particulars of the case. Our
facilities have scheduled video teleconferences to discuss the
referral and to meet the wounded hero and family Members face
to face. These are essential in developing intensive
individualized rehabilitation medicine plan for each wounded
hero before admission. This also includes coordination of
resources necessary for the family including housing,
transportation, meals and psychosocial supports. Upon admission
to our facility, each Member of our rehabilitation team
individually evaluates the wounded hero within 24 hours and
pays particular attention to the functional needs.
Our team meets three times weekly to discuss each patient
and continually adjust the therapeutic plan of care. Each
patient undergoes 3 to 6 hours of therapy a day tailored
specifically to their functional and cognitive needs, we
actively work to reinstitute the roles that previously defined
our wounded heroes. As mentioned earlier, it is not just an
individual who suffers a traumatic brain injury, rather, the
entire family's structure is affected and requires attention.
The literature relating to TBI is very clear on the fact that
those individuals with strong psychosocial supports are more
successful over time.
Our support is multi-modal and includes health information
through site specific literature, informal education sessions,
formalized lecture series and intensive discharge planning. We
also provide professional support, emotional support,
logistical support, involvement in the care processes, and the
support of a military liaison officer.
To further support the families, we have instituted a pager
and cell phone system that are covered 24 hours a day by
Members of our social work team. This allows yet another level
of support for our families. And importantly, in a very real
sense, the family Members become an integral part of our team.
This program serves to educate families, decrease their anxiety
of the unknown and prepare them to care for their loved one. In
recognition of this, we have developed the model of care
appropriately referred to as relationship-based medicine.
We have found that it is this relationship with those
involved in the continuum of care that drives our success.
Initially, we intensively worked with the families and patients
to gain their trust and instill recognition that we are on
their side indeed. Once this level of trust has been
established, we can develop an effective treatment plan and
approach. It is important to point out that this relationship
does not end once discharged from our facility. Patients are
followed at regular intervals by the social work case manager
along with the physiatrist.
Intensive discharge planning is the cornerstone of any
successful rehabilitation plan. Our discharge plans are
initiated the moment a patient is admitted to our facility. On
a weekly basis, we discuss the discharge needs and timelines
necessary for success. These are communicated with the family
and aligned with their needs. Once a disposition is provided by
the family, we begin to contact necessary resources in the
community. Based upon location, a consult is opened either with
one of the polytrauma network sites or----
Mr. Mitchell. Doctor, could you summarize very quickly?
Dr. McNamee. The integrated transition plan of care from
the military treatment facility to the PRC into the community
is paramount to the success of our wounded heroes and families.
The systems set up throughout the VA is world-class and has no
equal for those suffering from traumatic brain injury. Across
the system, we continually monitor and incorporate
improvements. I am proud to be a part of an exceptional
rehabilitation staff who are fully dedicated in their mission
to serve those who sacrifice so much. Thank you, Mr. Chairman
and members of the Subcommittee for your time.
[The statement of Dr. McNamee appears on pg. 65.]
Mr. Mitchell. Thank you. Dr. Scott?
STATEMENT OF STEVEN G. SCOTT
Dr. Scott. Mr. Chairman and Members of the Subcommittee,
thank you for the opportunity to discuss our experience as it
relates to the Servicemember's Seamless Transition Into
Civilian Life, Our Heroes Return. My name is Dr. Steven Scott,
and I have been a specialist in physical medicine
rehabilitation since 1980. I have been employed at the James A.
Haley Veterans Hospital in Tampa, Florida, since 1990 and have
directed both the spinal cord and traumatic brain injury
programs.
I would like to provide you with a brief history of the
development of polytrauma rehabilitation care. In the summer of
2003, we began to receive these unique patients who had been
evacuated from the battlefield following improvised explosive
devices blasts and injuries.
Due to tremendous advancement in military care, we now have
the opportunity to rehabilitate young men and women who in
years past would not have survived. These patients are
medically complex and have sustained numerous injuries which
are complicated by serious TBI or traumatic brain injury. The
primary focus of the polytrauma system of care has been to
provide rehabilitation care to the most seriously injured. A
typical patient has traumatic brain injury, vision or hearing
loss, pain, wounds, burns, orthopedic problems including
amputations. We deal with extended families in crisis including
spouses, children of all ages, parents and siblings, as well as
care givers.
The stress and the sacrifice of these families frequently
takes its toll, sometimes resulting in conflict and serious
marital issues.
The complexity of injuries of these combat veterans wasn't
like those seen previously. The unique needs of these patients
required rapid realignment of our delivery of health care
systems to routinely include such things as our
multidisciplinary team of medical specialists. In addition to
our team of physiatrists or rehabilitation doctors, specialists
in the areas of surgery, neurosurgery, internal medicine,
psychiatry, infectious disease, prosthetics, orthotics, and
spinal cord injury are a part of the day to day planning and
patient care treatment program. The physiatrist or rehab doctor
also runs the interdisciplinary team which is quite large and
includes speech therapists, kinesiotherapists, vocational
therapists, social workers, neuropsychologists, psychologists,
advanced nurse practitioners, wound care nurses, respiratory
therapists, recreational therapists, rehabilitation counselors,
military liaisons, chaplains, blind occupational therapy case
managers, physical therapists amputation case managers, social
worker case managers, educational specialists, and veteran
benefit specialists.
Each one of these medical specialists and health care
disciplines have a specialized expertise in caring for the
polytrauma patient and their family and are essential to be
sure that their comprehensive care results in excellent
outcomes.
As we developed the program it became quite apparent that
we needed to establish a mechanism to exchange medical
information. Initially we established physician to physician
phone conferences to the National Naval Medical Center in
Bethesda and the Walter Reed Army Medical Center in Washington.
Videoconferencing with the patient and family in attendance was
established with Brooke Army in San Antonio, National Naval and
Walter Reed. A military treatment referral form was completed
by the military and sent to our onsite case manager DOD VA
military liaison social worker.
This form initiates the referral to the polytrauma system
of care. Medical records and exchanges occur between the Tampa
VA and the military treatment facilities.
This practice was new to us, and we have progressively
improved this practice over the years. We continue to work on
improvements in the transfer of radiological images and
microbiology lab results. The VA polytrauma rehabilitation
centers have been an active participant in videoconferencing
with the DOD Trauma of Continuing Care that has been
established to improve practices in care and transportation of
trauma patients.
In addition, we've been able to connect and actually
participate with the joint patient tracking system that allows
us to get more detailed medical information.
Most polytrauma patients remain on active duty during the
entire stay at the Tampa Polytrauma Center. Therefore, ongoing
sharing of information between the VA and DOD is necessary. The
military liaisons assigned to our center assist the patient and
family with military issues and assist with maintenance of
nonmedical orders for the family.
Patients are frequently referred back to the military
treatment facilities from the VA for follow-up surgery and
placement in medical hold.
When the individual comes to Tampa, a military greeting
team and case manager meets the patient and their family.
Community volunteers arrange free housing and transportation
for families through the Haley House Fund. Our 7-day a week
program for both patients and families always has the emphasis
of community re-entry as our primary goal. Our staff and
volunteers provide family educational classes, family support
groups, planned family activities such as spouses day out,
trips to NASA and to the space shuttle, and others. Our
Internet Cafe provides activities outside our structured
therapy program and recreational therapy provides community re-
entry such as shopping and recreational activities. As the
patients and families advance in rehab, they go to day passes,
then overnight passes to practice their independent living
skills. We also have----
Mr. Mitchell. Dr. Scott, could you wrap it up?
Dr. Scott. I will wrap it up for you. In summary, basically
we work on a continuing care to get the individual home, that
is our goal. And it is in my conclusion that I am honored to
serve these courageous young men and women and their families.
And I look forward to working with DOD, Congress, our VA
leaders, advocacy groups and private citizens to continue to
provide the excellent care and improve the function of their
future lives throughout the lifespan of the American wounded
heroes. Thank you.
[The statement of Dr. Scott appears on pg. 67.]
Mr. Mitchell. Thank you very much. I have a couple
questions. First to Dr. Scott. It has been reported recently in
the news that VA physicians have been cut off from relevant DOD
data on injured patients and the VA inspector general, the GAO
have reported that there have been incomplete transfers of
medical records when soldiers are transferred from DOD to the
VA medical centers. Do you currently have any reliable access
to relevant DOD medical records for the OIF and the OEF
veterans and active duty men and women who are in your wards?
Dr. Scott. Presently this morning in Tampa we have access
to Bethesda, Walter Reed, as well as Brooke Army and also have
access with the Joint Patient Tracking System. The only system
that was down that I am aware of is the Patient Joint Tracking
System. When I became aware of it I called the help line and
within 12 hours--I think 24 hours that was back online. So that
was the only down time that I experienced during this time.
The record system itself is cumbersome in the military, to
get into those cumbersome records, but we can do it on a
regular basis, we have done it, and it is working at the
present time.
Mr. Mitchell. Dr. Scott, you were reading all of the
different kinds of therapists and the specialists. There is a
whole list of them. Do you have a proper mix of all of these
specialties?
Dr. Scott. Presently based on our outcomes it appears that
we have a proper mix. But as the injuries change and as
individuals and new things come up, we may need different and
newer specialists in the future. This is an ongoing change. As
we follow the war, the injury patterns sometimes change. We
have seen where the injuries were first fairly minor and then
more complex. We saw mild burns, now there are major burns.
So sometimes our team management has to change according to
the needs of the patient. All this program is and all this team
structure is, is focused to meet the needs of those injured
from the war. Whatever those needs are, we try to meet them
directly with the highest quality of care.
Mr. Mitchell. One follow-up. Have you had to turn anybody
away because you just didn't have the space or the beds?
Dr. Scott. In my 16 years at the James A. Haley Veterans
Hospital I have never turned a patient away, and I never will
in the future. I will always find space for that individual,
wherever that might be. And with these returning individuals I
will also find space wherever that might be within our
facility.
Mr. Mitchell. Thank you. I have a question for Mr.
Sullivan. Could you please explain to us your role in the
Seamless Transition Task Force? Not only your role but what did
you do on the task force and what data did you brief your
supervisors on while you were at the VA?
STATEMENT OF PAUL SULLIVAN
Mr. Sullivan. Yes, Mr. Chairman. Thank you for having me
here today. My role on the Seamless Transition Task Force
created by Secretary Anthony Principi in 2003 was as staff
support to one of the full Members of the Committee. That was
my Assistant Director, Susan Perez.
I attended the task force meetings with her and when we
were requested to create the contingency tracking system, I
became the project manager for that system. There was a person
also for a while who was the project manager on this before me.
He was deployed to Afghanistan. That is the other reason why I
picked up the project. That was my role with the Seamless
Transition Task Force.
What did I report to my supervisors regarding what was
going on and what was I seeing with the data? I can tell you,
Mr. Chairman, that one of my other responsibilities at the
Veterans Benefits Administration was to monitor the claims,
health care and counseling use of gulf war veterans and thus I
was asked to monitor the claims activity of the new Iraq and
Afghanistan war veterans.
So what I did is designed along with the team of computer
programmers and analysts a method to use the Pentagon data to
see how many Iraq and Afghan war veterans had filed claims.
Then we would take that information and sort it. We would sort
it and see how many of those claims were still pending, how
many were approved, and how many were denied. Then I would
prepare reports and I would brief my supervisor, the Assistant
Director, as well as other executives within VBA about our
findings.
I can tell you that starting in March of 2005, we started
to notice some very significant events and if you would like I
can actually read you some of the e-mails that I sent issuing
what I thought were warnings that there would be a surge in
disability compensation claims among the Iraq and Afghanistan
war veterans. I made those concerns known several times in
several briefings.
[The additional information from Mr. Sullivan was supplied
in a March 27, 2007, letter, and the attachments are being
retained in the Committee files.]
Mr. Mitchell. My time has expired. Maybe somebody else will
follow up on that.
Ms. Brown-Waite.
Ms. Brown-Waite. I would encourage Mr. Sullivan to submit
the information to the Subcommittee so that we could all have
it. I think that would be appropriate, Mr. Chairman.
Dr. Scott, I know from talking to so many families that the
reputation that James Haley Polytrauma Unit has is superior,
and Dr. McNamee, I am sure it is the same with your facility. I
just have a little more familiarity with the facility in Tampa.
I would like to know what else can we do here, including
appropriating more money, to make your job a little bit easier
when you see the young people coming back with these traumatic
brain injuries and I know the great work that is done, the
great rehab work that is done. Tell us what we can do. I know
last year, Dr. Scott, for the Haley Hospital I think we
provided more money for spinal cord injury, and are you going
to be--so that they could expand. Are you going to get some
more beds also when that expansion takes place? I know the
funding was there but it takes a while for that construction to
take place.
Dr. Scott. Presently we do have a space problem on our
polytrauma unit. The VA leadership is trying to do its best to
create more space for our unit at the present time as well as
expand the bed situation too. Our space problem is serious. I
would have to say this because I have a strong compassion to
those who come back. We basically put them in rooms 10 by 10,
about 100, 110 square feet. That is just not--we should not do
that. We need to change that, and I think we will change that
very shortly and with the support of our leadership.
But we also probably need to expand more beds than we
currently have because of the increased amount of attention,
awareness of traumatic brain injury. We are not sure exactly
what numbers they are, we are not sure exactly how many are out
there. We know this is an invisible, hidden type of wound. We
know that by creating more attention and more awareness this is
going to create more individuals referring not only the active
duty individuals but also our veteran population who also
sustained TBI or have had previous TBIs in the past. I might
add there is an unknown population group that we haven't
really----
Ms. Brown-Waite. Doctor, I am confused. When the Chairman
asked you, you said that you never turned anybody away, and I
believe that because I have been there. But is the issue that
you don't turn anybody away in a response to the Chairman, but
you are telling me that they are in inadequate rooms for the
equipment that is needed. That is question number one. And
question number two is: Making room for somebody, and, Dr.
McNamee, you probably have exactly the same problem and I would
like to hear from you too, making room for somebody and making
sure that the room is adequate are really two different things.
So, Dr. Scott, could you just clarify that?
Dr. Scott. We do make room, it may not be adequate, as you
mentioned. One of the lessons learned is that our whole
hospital is involved in the polytrauma system and so we use all
the hospital beds in our facility, and so when we run out of
rehab beds we will use medical/surgical beds.
Another one of the lessons learned, we also have done, is
we admit people right on our medical/surgical floors directly
and make sure that they are medically and surgically stabilized
before we move them to rehab. If we don't have rehab beds at
that time, we keep them off-floor and we start the rehab off-
floor. That allows us to again keep that open door and be able
to serve those in need.
Ms. Brown-Waite. How many in Haley are not on the
polytrauma unit floor, but rather are elsewhere in the
hospital?
Dr. Scott. We usually have several over in the spinal cord
unit that we use and we may have one or two in our intensive
cares or even off-floor because of the nature of these complex
injuries. So when we make our multi-disciplinary rounds, it is
almost like hospital rounds because we are all over the
hospital. And that is why we do it in a multi-service type
fashion, not just one service. We have all the services
involved because we basically cover most areas of the hospital.
Ms. Brown-Waite. I thank the doctor.
Mr. Mitchell. Thank you. Mr. Walz.
Mr. Walz. Thanks, Mr. Chairman. I would say I am lucky
enough in Minnesota, we have one of the four polytrauma centers
in Minneapolis and in my district the Mayo Clinic. I would
argue that we have two of the finest medical facilities in the
world. So I am very familiar with the polytrauma centers.
The work that has been done there has been nothing less
than stellar. That is verifiable, that is not anecdotal. We are
seeing some incredibly impressive work being done there. So,
see, I do applaud you on that and we are here to be proactively
preparing for the needs of our returning veterans to make sure
that we are carrying forward lessons learned maybe over at
Walter Reed and the DOD system and making sure we are getting
them into the VA system.
I want to make very clear especially to the two directors
the work you are doing is absolutely stellar in that regard. We
need to make sure the work that Congress is doing in oversight
is equally stellar in preparing for that. That is part of our
leadership responsibility.
I have two questions, the first one was to Mr. Sullivan, I
know you are going to submit it to the record, about this data
you are providing to the VA. I want to know a bit about it if
you could summarize that quickly and when you were giving that
to the VA, what you knew about what was coming.
Mr. Sullivan. Here is a briefing from August 2005 and it is
just a couple of sentences of summary: In summary, these
analyses that I gave provide a strong warning of a current and
future increase in the surge of claims activity among global
war on terror veterans. VBA is now beginning to observe the
initial yet tremendous and sustained impact of more than 1.1
million recent war servicemembers discharging from the military
and promptly filing substantial numbers of complex multi-issue
disability compensation claims. The risk of an increased claim
workload and delays in processing claims based on the
continuing surge in VBA claims activity among new war veterans
can be mitigated with immediate and proper staffing, training
and funding at central office and at regional offices.
That is my summary.
Mr. Walz. That is what we are here to do. What was done
with this data as far as you know?
Mr. Sullivan. I am not aware of anything that was done.
Mr. Walz. Is it possible, do you think this data is solid
enough that you could extrapolate and project needs into the
future that we would have then an idea of what we could see on
maybe a yearly basis or specifically a monthly basis? Is that
possible?
Mr. Sullivan. Yes, Congressman. I was fortunate enough to
use the Freedom of Information Act to get this information and
provide it to Harvard Professor Linda Bilmes, who prepared and
delivered a report that estimated the number of patients and
the cost of the war. She was estimating hundreds of thousands
of claims and patients and she estimated between $350 billion
and $700 billion in costs for VA for the war for the next 40
years.
Mr. Walz. In your mind, Mr. Sullivan, how was the VA making
these projections if they are not using quantifiable data? How
are they making projections on needs when the President tells
us how much he needs in the future? How are they doing it?
Mr. Sullivan. That wasn't done in my office, Congressman.
You would have to ask the Department of Veterans Affairs
actuary. You may want to ask the former chief actuary, Mr.
Steven Meskan, about what he was trying to do at VA to make
those kinds of projections, sir.
Mr. Walz. Because their projections are quite a bit lower
than what you are projecting and what the Harvard study is
projecting.
Mr. Sullivan. That is correct.
Mr. Walz. We will look at those, you can rest assured. My
last question is to PFC Lain. First, I would say as a retired
enlisted soldier I know they moved you off that first panel; I
would proudly sit with you on that panel. So there was no
disrespect there sitting with a PFC in a military uniform.
I would ask as comfortable as you are, I know these are
private matters, if you could summarize just briefly from your
impact in your wound to where you are at today, how would you
summarize your care?
STATEMENT OF KIMBERLY LAIN
Ms. Lain. Actually, I just joined the military back in July
of 2005 and I was injured in basic. I ended up here at Walter
Reed in September of 2005 and the care--the doctors are great.
There's awesome doctors there. When I was finally discharged
from the hospital and sent on my way, I grew up in Baltimore so
I knew the area, I ended up at home with family, and when I
finally ended up back for checkups and everything, I really--
there was no direction on where to go from the doctor to med
hold. I eventually did find my way to med hold and then from
there it was one appointment after the other until eventually
they said okay, we are going to discharge you, and then once I
was told that, I had to start the MEB process.
The MEB process was--I wasn't very involved in it, it was
basically give your documents to your counselor, they will get
them to where they need to go. The problem with the documents
is we are moving into a paperless society. There is no physical
documents unless you ask your doctor for them, and a lot of the
soldiers aren't told that so they go back and ask for these
documents that the doctor can't access any more because they
have been filed and gone wherever they need to go.
Once I finally did get my MEB back I was given 3 days to
look over it and decide whether or not I agreed with the
findings or wanted to submit something else. Actually, I agreed
with mine and I submitted them to the PEB as they were and once
they finally made it over to the PEB I was given a rating
according to their standards, and it came back and I was told
that I then had 10 days to decide whether I agreed with the PEB
findings of what they were going to discharge me with, either
medical separation or medical retirement, depending on the
severity of what they felt my injuries were.
Once I had decided that I didn't agree with what they had
rated, they had rated a condition that I didn't have, that
there was a mix up somewhere in paperwork, and so I submitted
an appeal for that. When I first decided to submit my appeal, I
had no idea how to go about doing it. I didn't know who to go
to.
Luckily, in my platoon I had been hearing the phrase DAV
being thrown around and I finally was put in contact with the
DAV. There's one person on post operating from the DAV, and he
submitted my appeal, he started my VA claim. Actually, he's
helped me through the entire process of the PEB. Actually, I
signed it this morning for a medical retirement. And I have
already--with his help submitting my information to the VA I
have already seen all of the initial doctors I need to see for
the VA. They just have to wait for my orders to finally get me
completely into the VA system to be discharged from the
military.
Mr. Walz. Thank you.
Mr. Mitchell. Mr. Rodriguez.
Mr. Rodriguez. We have large caseloads of veterans that we
do the casework for because the VA doesn't have sufficient
workers to help them out in the process of doing the casework
that is needed. I know we have handled a large number of VA
requests, and it is unfortunate.
Let me ask the two social workers, do you all have the
tools that are necessary, and the staffing that is required to
handle the so-called surge or the injuries that I know has got
to be there because there have been some 23,000 soldiers that
have been seriously injured that have been coming in and I
wanted to see if you could react to that.
Ms. Dinegar. I think so. Our program has really grown. We
started with one VA at Walter Reed.
Mr. Rodriguez. One?
Ms. Dinegar. We started with one back in August of 2003. We
now have two full time at Walter Reed, one full time at
Bethesda, and I think it is 12 VA social work liaisons at 10
MTFs across the country. So the resources have been given to us
to grow and try and meet the need of the servicemembers who are
returning and getting off of active duty.
Mr. Rodriguez. What's your caseload?
Ms. Dinegar. We have transferred out of--well, I can speak
to Walter Reed and Bethesda, we have transferred, transitions
health care, about 11,000 referrals out of Walter Reed and I
believe Bethesda's number is somewhere around 500, just
transitioning of health care from those two facilities. I know
Dr. Kussman had some more numbers about how many nationwide we
have transitioned through our social work liaisons at the MTFs.
Mr. Rodriguez. The most common problems that you see coming
toward you, and the question is to both of you, the most common
problems that you see coming to you in terms of from the
soldiers. Do you want to react?
Ms. Dinegar. In terms of injuries and illnesses?
Mr. Rodriguez. Yes.
Ms. Dinegar. Sir, that varies from a broken foot, an injury
in basic training, to your most severe traumatic brain injury,
to your triple amputee. We see all ranges of severity of
illnesses and injuries.
Mr. Rodriguez. Now you heard the comments by the soldier in
terms of her difficulty. As social workers do you have a
responsibility there?
Ms. Edmonds-Clemons. Can you repeat that, sir?
Mr. Rodriguez. You heard the soldier talk about her
difficulties in terms of trying to figure out what you needed
to do next and where she was going to get access to services
and those kind of things. Is that part of the role of the
social worker in terms of helping out?
Ms. Edmonds-Clemons. Yes. We become involved with the
soldiers at the point that they are referred to us from their
treatment team, and that would be their teams at, say, Walter
Reed or Bethesda. The part that she was involved in with the
MEBs, we generally are not directly involved in that until
which time the case manager or one of the treatment team
Members refers the soldier to the VA.
Mr. Rodriguez. Do you know what kind of caseloads the case
managers might have? No?
Go ahead, ma'am.
Ms. Lain. The case managers that we have, in the active
duty med hold side, we have one case manager per platoon and
the platoons usually have 55 to 60 soldiers in the platoon and
that one case manager is responsible for coordinating all their
doctors visits, their meetings with their PEBLO counselors, any
other kind of meeting they have. The case manager keeps track
of them and it is their responsibility to make sure the soldier
gets there.
I know with the med holdover, which is the Reserve/National
Guard component, the med holdover side, which is Reserve/
National Guard component they--I believe they have six--they
have six platoons and their six platoons have anywhere between
30 to 40 soldiers. The Active duty side has eight platoons.
Mr. Rodriguez. I guess on the VA side in terms of casework
I know that as a Member of Congress we have a large number of
veterans that come to see us when they have difficulty getting
access either because of the waiting list or because of a
variety of different decisions are made. Is there any attempt
in terms of the VA maybe taking on the responsibility? Of
course they are always welcome to run to their Congressman, but
is there an effort in terms of beefing up on the case managers?
I am talking to the two directors of the hospitals.
Dr. McNamee. Sir, are you specifically speaking about the
case managers on the Department of Defense side or on the
Veterans Affairs side?
Mr. Rodriguez. Am I making a mistake on this? DOD then?
Dr. McNamee. With Veterans Affairs.
Mr. Rodriguez. I apologize. Because we do get the ones----
Mr. Mitchell. Mr. Rodriguez, your time has expired. Thank
you. Mr. Bilirakis.
Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it.
Dr. Scott, I know you worked very well with my father,
Congressman Bilirakis, in the 109th Congress when he Chaired
the Oversight Subcommittee. I look forward to working with you
as well and I will see you next week at Haley. I have a couple
questions here. Are you still having problems receiving
complete medical records from military treatment facilities?
Dr. Scott. We receive them, and I think I can say from our
facility it is always an effort to get everything because we
have to make sure with this complex injury that every
microbiology report, every x-ray, ever--we can't miss one
thing. And I think that is what makes this very complex and why
the medical records system has to be a perfect system almost
because if anything is lost in that exchange it could affect
the outcome of that individual, and it has affected the outcome
of the individual. And so we are able to get them; it takes a
lot of effort. It has improved and it is going to continue to
improve as we all continue to work together to make it better.
Mr. Bilirakis. So it is improving and you are receiving
them in a timely manner?
Dr. Scott. I think we are like Richmond, too; we try to get
a response back once the individual is referred within about a
day, if possible. If we have all the medical information, we
can make that response. If it's anything longer than that, then
we have to get updated medical records because that morning or
that last 4 hours it may change completely, the medical status.
That is why it is important that we do things in a very timely,
orderly way.
Mr. Bilirakis. Dr. McNamee, do you want to comment on that?
Dr. McNamee. We definitely get full records from our DOD
facilities and, as Dr. Scott and I both had mentioned, we get
them in multiple different fashions. We get them through our
direct access, we get them through the incredible work of our
VA-DOD liaisons, we get them through the joint patient tracking
application, and go figure, you can pick up a phone and call
someone as well. That to me has been the piece that is probably
the most appropriate because even when you look at a hospital-
to-hospital transfer and if you have someone coming from one
floor to another, typically the most appropriate way to
understand a case and to transfer a case is for the two
clinicians to sit down and discuss the complexities of the case
and work it through.
As I had mentioned earlier, the term relationship-based
medicine that we preach, that isn't just with the families and
the patient, but that is with our referers and the clinicians
on the other end.
In my cell phone in my bag I have the phone numbers of two
of the major referers from Walter Reed and Bethesda and we talk
on a very frequent basis. This on its own has really led to a
tremendous level of care and handoff and even more so the
ability to plan care over time for these individuals. So yes, I
do believe we get access to the data and we get it from a lot
of different ways. Sometimes it takes some effort but I don't
think people are being in any way cut out from the highest
quality of medical care because of it.
Mr. Bilirakis. Thank you very much. I yield back the
balance.
Mr. Mitchell. Thank you. Mr. Filner.
Mr. Filner. Thank you, Mr. Chairman. Thank you all for
being here and helping us understand this issue. To the two
medical directors, thank you for providing a good survey of
what you are doing and the passion which you bring to the job.
I have questioned the VA bureaucracy and their seeming lack of
passion for the veterans because it comes through that way
sometimes. So we appreciate your passion.
On the medical records, you say you are able to get them,
but the two systems electronically can't communicate with each
other, is that correct?
Dr. Scott. Yes, they do not connect. Actually, there is a
two-step approach, the other one takes three different steps to
go through.
Mr. Filner. You have to go through each system to get those
records. That is the kind of thing we need you to point out to
us. Is there a plan to bring them into one system as far as you
know?
Dr. Scott. My understanding from the previous testimony and
my reading is there is a plan to have one medical records
system. That is I think the long-term plan.
Mr. Filner. That is very long-term, unfortunately. It is
probably not going to help any of your patients in the next 10
years. It's a question of programming and software, and if we
put the resources into it we could do it. It is not
conceptually a difficult problem. I was at North Chicago, as
one of the witnesses said, and there the military clinic and
the VA are trying to figure this out and they are making some
progress. But even bringing this together is difficult.
Again, I think you would be helped tremendously by having
that access, and it's not just at Walter Reed; it's also what's
happened on the battlefield in Iraq. In the most advanced
society in the world, we can't get these two systems to
communicate. It's beyond my comprehension. But it takes
resources to do it. How many actual patients do you have right
now, sir?
Dr. McNamee. We currently have 11 on our unit, in our
active unit.
Mr. Filner. How many would you deal with in a year?
Dr. McNamee. In the last year the number of specifically
OIF/OEF injured on our last count was 56 for fiscal year 2006.
Mr. Filner. Similar or more?
Dr. Scott. We have 11 now, we had over 100 this past year.
Mr. Filner. In four polytrauma centers, 44 people we are
treating right now. You have painted an incredibly good picture
but we are doing only a couple hundred, maybe 350 a year
compared to the needs that we are going to have. It seems to me
that we are so far from where we need to be. You don't turn
anybody away, but are there a lot more cases out there that
would profit from being at your polytrauma center?
Dr. McNamee. Sir, the numbers that we quoted are the
individuals who are on the inpatient unit, and they are the
most severely wounded of the polytraumatic injuries. The large
numbers that we will see will be the mild to moderate injuries
that will not need intensive neuro-cognitive and behavioral
training on an inpatient unit.
Mr. Filner. Based on what you know at this moment. Three
years from now, they may.
Dr. McNamee. It is from the knowledge that we have gained
in the last 30 years with traumatic brain injury
rehabilitation.
Mr. Filner. If you have mild brain injuries that do not
need that kind of care, they may need it in a decade.
Dr. McNamee. The care we provide is in the outpatient
setting. Currently, at Richmond, the outpatient caseload for
these individuals is 75 and growing rapidly every month as we
are beginning to screen these individuals. So this care----
Mr. Filner. Are you in charge of the outpatient, too?
Dr. McNamee. I have a large hand in the outpatient setting.
Mr. Filner. It seems at Walter Reed the problem was in the
outpatient situation, not necessarily in the hospital. It looks
like to me we have much greater needs. You are doing a great
job with the 11 you have, but we've got hundreds of thousands
coming back and, Paul, you told me what percentage might have
brain injuries?
Mr. Sullivan. According to a document from the Defense and
Veterans Brain Injury Center, it was about 10 to 12 percent. So
if you do the math on 1-1/2 million servicemembers deployed,
that could be about 150,000. And most of those overwhelmingly
are going to be in the mild, is that right, Doctor?
Dr. Scott. If you compare the report, A Mild Head Injury in
2003, and that would be a good one for everyone to review,
about 75 percent of all head injuries in this country are mild
head injuries. So if you just multiply basically what we have
for moderate to severe and then multiply it by again times
four, you can probably get just a rough estimate.
Mr. Filner. What's the estimated number of polytrauma
centers we need or will need next year? Probably dozens I would
think, offhand. We've got four.
Dr. Scott. We just don't really know what the number is out
there. We could estimate, we could draw some things here and
there, but what we do know is that our troops over there are
under a lot of these IED blasts and they are being redeployed
multiple times. So they are going to have increased chances of
having these injuries.
Mr. Filner. One last question if I may, did you watch the
Bob Woodruff interview? It seemed to me, that one of the main
problems there was in the discharge to the local home area,
where there was not the same expertise that you have.
Is that a legitimate concern, and how do we deal with it?
Woodruff showed several people who went backward in their
movement toward health because there was just not the expertise
and the records got lost.
Dr. McNamee. What we are doing at this point in this, and
obviously there are 21 outpatient polytrauma network sites, and
to develop a system of care that crosses the country for
traumatic brain injury has never been done in the history of
this society and what we are doing with that is to provide the
appropriate levels of education, support and direction. We have
the video teleconferencing abilities with all these sites, we
have frequent conferences. There is a system-awide TBI
initiative to cover this as well. We are all here to cover each
other, and I don't think anyone would say that any system is
anywhere near perfect, particularly with one that is this wide
ranging and this large, but we are doing our best to make sure
that all of these individuals receive the highest level of care
that we have.
That issue that you talk about is true with any system of
care within this country for any specific injury. It is about
building the appropriate system.
Mr. Filner. You are ready for a promotion to the
bureaucratic staff if you look at what you just said. Instead
we need answers of how we are going to prepare for all these
people. I need numbers of centers, number of beds, what you're
telling me is not going to help in getting the job done. You
have to be more simple with us.
Mr. Mitchell. Thank you. Mr. Hare.
Mr. Hare. I am going to ask a quick question, then yield my
time to Mr. Filner.
What measures and accountability practices are you
implementing when you work with the Department of Defense to
ensure that the rehabilitation of TBI patients is initiated
when it's clinically indicated?
Dr. Scott. We have our own outcome and quality management
that we do on every individual that enters our program. It is
based on an outcome-based program. It's very comparable to the
private sector, too. It is based on functional gains,
accessibility, amount of disability, amount of impairment, and
we can follow that individual within the hospital and also on
follow-up, too, in that fashion and we roll up those data on a
regular consistent basis with what we call performance
improvement plan, and with that we then look at that and see
which areas we can improve upon and from that improvement we
can advance forward.
I am also a principal investigator of the Defense and
Veterans Head Injury Program and we have regular contact every
other week. We have phone conferences in which we bring up key
issues on head injury management between DOD and VA, and from
that we can problem solve and identify certain key areas that
we can contribute and improve upon.
Also the international trauma continual care, that we
actually follow the individuals. This is a V-Tel that goes from
the battlefield all the way over. We also are an active
participant in which we can contribute information back to
those at the warfront or back to those that actually can
improve and identify head injuries or problems that we see at
our end that they can help at the other end, and that also
improves the quality of care, too.
Mr. Hare. Let me just if I can, Mr. Filner, would you
like--I am going to yield the balance of my time to Mr. Filner.
Mr. Filner. Again, we need some help. And you are on the
front lines. There is a disconnect, and it's especially
pronounced when you're in the bureaucratic hierarchy here, as
you saw with the previous panel. From your perspective, you are
doing everything really well with what you have and the people
you have to see.
Ms. Lain, did I get that right? Ms. Lain's testimony was
the frustration felt from the patient end. There is a
disconnect here. You are doing great work, yet we have
hundreds, if not thousands, of people feeling very frustrated
with the system. You have to help us bridge that and you have
to be honest with us and straightforward, and if you said, ``I
have 11 beds but if I had 50 I could really do something,'' or
``their caseload is 1,600,'' and I don't know how many social
workers have to handle those 1,600 referrals. It's not just the
two of you, is it?
Ms. Dinegar. There are three of us that have transitioned
1,600. They are not all currently active.
Mr. Filner. That is a big load. We need people to say, if I
had half I could really help people. So we need to hear that.
Apparently the upper bureaucrats don't want us to hear. They
are instructed not to tell us.
We want to help you. We are all committed on both sides of
this Committee to helping you serve our veterans better, but
we've got to know what's going on. Paul has been sort of the
designated guy on some of the TV shows where he's telling us
what's going on. That's been very helpful watching you, Mr.
Sullivan. I really appreciate what you have been saying.
But we all have to be honest and straightforward. We need
to know what you want because we control the money. Help us
help you because you are doing a great job with what you have.
But we are going to have thousands, if not tens of thousands
more to deal with.
So I'll leave it open. Anything that you would like us to
know right now about what you need in the current budget?
Dr. McNamee. I think one of the initiatives that the VA is
working on right now, which is tremendously important, is the
transitional care and the transitional living care piece for
those individuals with traumatic brain injuries. These are
individuals again with moderate to severe brain injuries. The
things that we look at that are the greatest success for these
individuals is to transition back into a community setting and
potentially transition back into a work setting.
There has been a model of this developed in the community;
however, there is a bit of disconnect with it over time.
Mr. Filner. You mentioned 21 centers; what was that 21?
Dr. McNamee. 21 polytrauma networks. These transitional
care units will be developed at the polytrauma rehabilitation
centers and will be set up to transition these individuals back
into active duty to re-establish those roles I talked about or
back to home with their family.
Mr. Filner. What would you tell the veteran on the Bob
Woodruff show in some rural town that didn't have access? What
do they do?
Dr. McNamee. We need to continue to case manage these
individuals and allow them every opportunity to get back into
our system and work with them and deliver the kind of care that
they absolutely deserve. We are responsible for that and we are
responsible to deliver that care to those individuals and
responsible to develop programs to support these individuals.
Mr. Filner. Thank you, Mr. Chairman.
Ms. Brown-Waite. Mr. Chairman, a little bit of
housekeeping. I don't believe that it was mentioned, so I would
ask for unanimous consent that all members would have 10
legislative days to submit statements.
Mr. Mitchell. Without objection, so ordered. Thank you.
Thank you very much. I really appreciate you taking your time
to come here and give us your expertise and your testimony.
Thank you all very much.
Ms. Brown-Waite. Keep up the good work.
Mr. Mitchell. As they leave would the next panel please
position yourselves so we can keep going? It's getting late.
We've got a few more things to hear. Thank you.
Take your seats so we can get started. Thank you all for
being here and the rest of you for sticking with us. I would
like to introduce panel three. Mr. William Feeley is the Deputy
Under Secretary for Operations and Management; Dr. Edward
Huycke, the DOD-VHA Coordination Officer; Dr. Ira Katz, the
Director of Mental Health Services, are all here courtesy of
the VA. I would like to also welcome their thoughts on the
seamless transition process. In addition to these three
gentlemen we have Mrs. Kathy Pearce, who is here to tell us
exactly what she and her son have faced on the personal level
in making the transition from DOD care to the VA system. We
welcome her and thank her for appearing at such short notice to
answer questions.
I would also like to note, due to unforeseen circumstances,
Mr. Todd Bowers was unable to appear at the last minute, and we
are very sorry for the confusion.
My understanding is that Mr. Feeley, Dr. Huycke and Dr.
Katz have a statement, a 5-minute statement, and that Mrs.
Pearce also would like to be here for questions, is that
correct? Thank you.
Mr. Feeley, if you would start.
STATEMENTS OF WILLIAM F. FEELEY, MSW, FACHE, DEPUTY UNDER
SECRETARY FOR HEALTH FOR OPERATIONS AND MANAGEMENT, VETERANS
HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS;
EDWARD C. HUYCKE, MD, CHIEF DEPARTMENT OF DEFENSE COORDINATION
OFFICER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS; IRA R. KATZ, MD, PhD, DEPUTY CHIEF PATIENT
CARE SERVICES OFFICER FOR MENTAL HEALTH, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND KATHY
PEARCE, MESA, AZ (MOTHER OF TRANSITIONING VETERAN)
STATEMENT OF WILLIAM F. FEELEY
Mr. Feeley. Good afternoon, Mr. Chairman and Members of the
Committee. My statement is in the record but I would like to
read my comments. I want to thank you for the opportunity to
discuss ongoing efforts in the Veterans Health Administration
to improve the quality of care we provide to veterans returning
from Operation Iraqi Freedom and Operation Enduring Freedom.
VHA is committed to providing comprehensive, quality primary
and specialty care to all enrollees with an emphasis on
exceeding the expectations of veterans. When we don't, our
leaders want to know about it and make it right.
My comments will focus on the operational facility aspects
of the organization. Related to the access of care issue, the
quality of care VHA provides to our veterans is widely regarded
as exceptional. Offering veterans access to VA care when and
where they need it is key to this excellent clinical care.
VHA monitors how long veterans must wait for appointments,
including the time it takes for an OEF/OIF veteran to be seen.
The waiting times are reported every 2 weeks and are
distributed to network and facility leadership. Waiting times
are a key performance element in network and facility
directors' performance plans.
VHA has employed system improvement strategies in recent
years to reduce clinic wait times and help to ensure that our
clinic processes are streamlined. Some examples of these
efforts include group visits. People with diabetes or
congestive heart failure, rather than seen on an individual
appointment are seen in group teaching sessions, extended hours
in clinics, including Saturday clinics. Normal lab work, an x-
ray reporting is reported to the veteran via phone rather than
have them return for a medical visit.
And one of the issues that was discussed today is we have
clinical office space renovation providing two exam rooms for
every physician as a goal. Dr. Scott did identify space
challenges at the polytrauma center in Tampa, and we are
currently looking at a $7 million minor renovation project that
will enable him to enlarge those rooms.
I would like to talk a little bit about the polytrauma
centers. In order to meet the needs of our most severely
injured veterans, VA has created this polytrauma system of
care, which includes a phased approach to providing care for
seriously injured veterans returning from Iraq and Afghanistan.
The most intense phase, Level I, consists of four centers that
provide acute comprehensive medical and rehabilitation care for
the most complex and severe polytraumatic injuries. Each
maintains a full staff of dedicated rehabilitation
professionals and consultants from numerous specialties. The
centers serve as resources for other VA facilities and are
active in the development of educational programs to spread
national learning across our system.
These four trauma centers are located in Tampa, Richmond,
which we heard from the two physicians today, Minneapolis and
Palo Alto.
In my statements there are detailed explanations of
polytrauma that I am going to skip because I think Dr. Scott
has adequately addressed those. I would like to comment on a
point Dr. McNamee made. VHA is recognizing that severely
injured veterans may require extensive rehabilitation therapy
to successfully reintegrate back into the community, and thus
the Department is developing four transitional rehabilitation
programs collocated with the Level I polytrauma rehabilitation
centers. The activation date for these four new residential
transitional programs is July of 2007.
A transitional rehabilitation program offers additional
time to improve a veteran's physical, cognitive, communicative,
behavioral, psychological and social functioning under the
necessary scope and supervision. The goal of these programs is
to return servicemembers to the most independent status
possible, whether that is return to active duty, work, school
or independent living in the community.
Palo Alto's transitional housing is now complete. The other
three sites we are currently working on them. The Level II
sites which we have heard about exist in 17 locations, one in
each network. These sites are responsible for coordinating
lifelong rehabilitation services for patients within each
network. Level II sites provide a high level of expert care, a
full range of clinical and ancillary supports, and serve as a
resource for other facilities within the network. They provide
continued management of patients referred from the Level I
polytrauma sites and evaluate patients referred directly to the
Level II sites.
Mr. Mitchell. Could you summarize pretty quickly?
Mr. Feeley. Yes. The last comment I would make is the
extensive polytrauma network was created to adapt VHA's
existing health care system to provide care for these severely
wounded veterans. I would be happy to entertain any questions.
[The statement of Mr. Feeley appears on pg. 69.]
Mr. Mitchell. Thank you. Dr. Huycke.
STATEMENT OF EDWARD C. HUYCKE
Dr. Huycke. Thank you, Mr. Chairman, distinguished Members
of the Committee. Thank you for the opportunity to speak to you
about the progress the Department of Veterans Affair and the
Department of Defense have made in improving the delivery of
health care and benefits to our Nation's veterans. I think you
have my statement for the record, and so I will just orally
talk about some of the highlights if I can in the interest of
time.
Veterans Health Administration staff has coordinated the
transfer of care for more than 6,800 injured or ill active duty
Members and veterans from DOD to the VA, specifically those
injured or ill as part of the global war on terrorism in Iraq
and Afghanistan and in particular those transitioning directly
from the DOD treatment facilities to the VA medical centers.
In partnership with DOD, VA has implemented a number of
strategies and innovative programs to provide timely,
appropriately and seamless services to the most seriously
injured OEF/OIF active duty Members and veterans. The
centerpiece of the program supporting the seamless transition
of the seriously injured servicemembers and veterans involves
the placement of the VA social work liaison, the DOD liaisons,
VA benefit counselors and outreach coordinators at the military
treatment facilities to educate servicemembers about VA
services and benefits. These VA employees assist active duty
servicemembers during their transfer to VA medical centers and
ensure that returning servicemembers receive information about
VA benefits and services.
Currently VA social work and benefit liaisons are located
at 10 medical treatment facilities, including of Walter Reed
Army Medical Center, National Naval Medical Center, the Naval
Medical Center at Balboa, and Womack Army Medical Center.
In addition to the social work and benefits liaison a VA
certified rehabilitation registered nurse was assigned to the
Walter Reed Army Medical Center in September of 2006 to assess
and provide regular updates to the VA polytrauma centers to
which these patients may be transferred. They provide education
to the families about VA benefits and services and prepare the
active duty servicemembers for the transition to the
rehabilitative phase of their recovery.
Once the MTF team notifies VHA of its plan to transfer the
patient, the VA social work liaison and the certified
rehabilitation nurse begin to coordinate the care and
information transfer. The VHA social worker liaison begins
meeting with the patient and the family to educate them about
the patient's transition from the DOD health care system to the
VA's health care system.
The VHA social work liaison also registers the active duty
servicemember or enrolls the recently discharged veteran in the
VA health care system and begins the process of coordinating a
transfer to the VA health care facility most appropriate for
the services they need or to a location that is closest to
their home.
In the case of a polytrauma patient transfer, both the
registered nurse and the social work liaison remain an integral
part of the treatment team at the medical treatment facility
while providing input to the VHA care plan and collaborating
with the patient and the family throughout the remainder of the
health care transition process. VA case management for these
patients begins at the time of the transition from the medical
treatment facility and continues as their medical and
psychological needs dictate. Once the patient is transferred to
the receiving VA medical center or reports to his or her home
VA medical center for care, the VA social work liaison at the
medical treatment facility follows up with the receiving VAMC
to address any issues and to ensure the patient is attending
appointments.
Patients with severe injuries or those that have complex
needs will receive ongoing case management at the medical
center where they receive most of their care.
An important part of the coordination of the care between
the DOD and VA prior to transfer is the access to the clinical
information, including viewing of electronic medical
information using remote access capabilities. Video
teleconference calls are routinely conducted between the DOD
medical treatment facility team and the receiving VA
polytrauma----
Mr. Mitchell. Could you wrap it up?
Dr. Huycke. --enabling a face-to-face transfer, discussion
of the polytrauma patient's care prior to transfer.
I think I will conclude my oral statement at this point and
thank the Chairman and the Subcommittee. Meeting the
comprehensive health needs and benefits of our Nation's
veterans is our Nation's highest priority, and we are proud of
the progress we have made in the seamless transition process.
Thank you, Mr. Chairman. I would be happy to answer any
questions.
[The statement of Dr. Huycke appears on pg. 70.]
Mr. Mitchell. Thank you, Dr. Huycke. Dr. Katz.
STATEMENT OF IRA R. KATZ
Dr. Katz. Thank you. Mr. Chairman and Members of the
Subcommittee, I am pleased to be here today to discuss the
ongoing steps that the Department of Veterans Affairs is taking
to meet the mental health needs of our Nation's returning
veterans. Care for Operation Iraqi Freedom and Operation
Enduring Freedom veterans is among the highest priorities in
VA's mental health care system.
For these veterans, VA has the opportunity to apply what
we've learned through research and clinical experience about
the diagnosis and treatment of mental health conditions; to
intervene early; and to work to prevent the chronic or
persistent courses of illness that have occurred in veterans of
prior eras.
Since the start of the global war on terrorism until the
end of 2006, over 631,000 veterans have been discharged. About
a third have sought care from VHA; and, of these, 35.7 percent
have had diagnosis of a possible mental health condition. This
makes mental health second only to musculoskeletal conditions
among the classes of conditions seen in returning veterans.
Somewhat less than half of the returning veterans with a
mental health condition have a possible diagnosis of post-
traumatic stress disorder, or PTSD, making it the most common
of the mental health conditions. However, PTSD isn't the whole
story. Among the diagnosable conditions, mood disorders as a
group, when added together, are almost as common. Moreover,
many veterans experience nonspecific stress-related symptoms
that may be viewed more appropriately as normal reactions to
abnormal situations in combat, rather than any disorder.
VA, in fact, has two components of its mental health care
system: mental health services in medical centers and clinics
and vet centers. In response to the growing number of veterans
returning from combat, the vet centers have initiated an
aggressive outreach campaign to welcome home and educate
returning servicemembers at military demobilization and
National Guard and Reserve sites. Through its community
outreach and coordination efforts, vet centers provide access
to other VHA and VBA programs.
To augment this effort, the vet center program recruited
100 OEF/OIF veterans in 2004 and 2005; and just last week
Secretary Nicholson announced plans to hire an additional
hundred to conduct outreach at both medical centers and in the
community. When these outreach activities lead to
identification of mental health conditions, veterans have
choices. They may receive care in vet centers, medical
facilities or both.
VA's approach to PTSD is to promote early recognition for
those who meet formal criteria for diagnosis and those with
partial symptoms. The goal is to make evidence-based
treatments--psychological, pharmacological and rehabilitative--
available early to prevent chronicity and lasting impairment.
Throughout VHA, there is a sense of urgency about reaching
out to OIF/OEF veterans, engaging them in care, screening them
for mental health conditions and making diagnoses, when
appropriate. Screening veterans for PTSD and other stress-
related conditions is a necessary first step to helping to heal
the psychological wounds of war. In cases where there are
positive screens, patients are assessed and referred to mental
health providers for follow-up and treatment, as appropriate.
However, we recognize that even in America, even in 2007,
there can still be some degree of stigma associated with mental
health conditions and their treatment. That is why we offer a
number of options, for example, for care in mental health
specialty services, vet centers or, increasingly, for mental
health services provided in primary care settings. When
veterans with severe symptoms are reluctant to enter care,
we're prepared to educate them and their families and to work
with them to overcome resistance. When veterans with milder
symptoms are reluctant, we watch over them over time and urge
treatment if symptoms persist or worsen.
We're committed to making the best available treatments
available; and for advancing the nature of the care available,
VA has been a leader in research as well as clinical services
for PTSD. Last week, the Journal of the American Medical
Association included an article based on VA research describing
the benefits of a specific behavioral treatment for PTSD.
Before the results were even published, VHA was beginning to
establish training programs to make this intervention available
throughout our system to our patients. The translation from
research into practice won't be instantaneous, but it can be
accomplished far more readily in VA than in any other clinical
setting or system. This is how a mental health care system
should be functioning.
Thank you again, Mr. Chairman, for the opportunity to be
here; and I would be pleased to answer questions.
Mr. Mitchell. Thank you, Dr. Katz.
[The statement of Dr. Katz appears on pg. 72.]
Mr. Mitchell. Ms. Pearce, did you want to read your
statement or did you just want to answer questions?
You've got a statement here. Please do it.
STATEMENT OF KATHY PEARCE
Ms. Pearce. Thank you, Mr. Chairman and Congress, for
taking your time to listen to these veterans and these people
that work with our veterans.
I would like to say good morning--it is not morning. Good
afternoon. My name is Kathy Pearce. I am a military mom who
lives in Mesa, Arizona. I appreciate the opportunity to tell
you about my story because I believe it is similar to the
experiences of so many families of seriously wounded soldiers
across the country.
My son, Army Sergeant Brent Bretz, was seriously wounded
during his service in Iraq on December 19 of 2004. Brent was
driving a supply truck at the time in his Stryker Brigade
convoy when a remotely detonated IED blast blasted through his
vehicle. Brent lost both of his legs in the attack. His left
arm was very seriously injured, his lost his spleen, his lung
collapsed, and he suffered a head injury.
But the truth is, we are lucky Brent is alive. I know that
he would not be with us today without the exceptional medical
care he received from military doctors in the months following
his blast.
After he was stabilized in Iraq and treated at military
facilities in Germany, Brent was transferred to Bethesda Naval
Hospital, where he stayed for 5 months. He was then transferred
to Brooke Army Medical Center at Fort Sam Houston, where he was
an inpatient for 2 months before he was transferred to
outpatient status in June of 2005.
Thankfully, I was able to be with Brent from his care in
Germany to his transition to outpatient status. Despite his new
status as an outpatient, he still had unique needs, and I know
that if I had not been available to help provide care, the
transition would have been very difficult for Brent.
Unfortunately, there are many soldiers whose families
cannot help during that transition; and, as a result, their
needs are not always being met.
My experiences with Brent led me to believe that there may
be a need for many soldiers to have an option of care that is
somewhere between inpatient and outpatient status. As an
outpatient, Brent had to wheel himself with one arm severely
injured the length of three football fields from his barracks
to his appointments at the hospital and to the mess hall. On
several occasions Brent was physically unable to get himself to
appointments or to the mess hall, and he missed meals and
doctors' appointments accordingly.
In addition to the distance he had to travel to his
appointments, he has to wade through an interminable
bureaucracy that makes it difficult to get the answers he
needs. Unfortunately, as he is transitioning into a status as a
veteran, he has encountered the same bureaucracy and red tape
at the Department of Veterans Affairs.
I don't think most people know how difficult it can be for
a wounded soldier to transition into the Department of Veterans
Affairs and get the benefits and care they need. The
experiences Brent had with overloaded caseworkers at the
Department of Defense is similar at the VA, and at times it
doesn't seem like there is an adequate level of communication
between the DOD and the VA. At times, the VA counselor has been
inaccessible, unable to answer many of Brent's questions. He
frequently fills out paperwork only to be told that he needs to
secure even more documents and fill out even more paperwork to
move the transition process forward. It is time-consuming and
complicated, and it has been very difficult for Brent to get
the guidance he needs.
Brent's experience is common for many wounded soldiers.
While his initial care was world class and our family
appreciates the work of these doctors, Brent has experienced
many things no soldier should ever experience. His outpatient
care has not always met his unique needs, and he is now dealing
with significant bureaucracy gridlock at the VA.
We can do better, and our soldiers deserve better. I
appreciate the Subcommittee's interest in this issue, and I
hope that you can help military families like mine and soldiers
like Brent get the services and care they deserve.
Thank you.
Mr. Mitchell. Thank you very much.
Before we open up to questions, I would like to turn the
gavel over to Mr. Walz. I will be back in just a few seconds,
but I will have you start with the questions.
Mr. Walz [presiding]. Well, thank you all for being here. I
know it is a late hour, and I said there might be a little
discomfort, but I couldn't help even thinking before Ms. Pearce
spoke that I don't think it is a bad thing that America feel a
little discomfort when we're talking about this issue. I think
it is highly appropriate that we feel a little discomfort.
We're here today to make sure that we correct and we do
what is right for these wounded soldiers and that we're
proactive on this. As I have said, again, the VA and the
providers inside the VA are doing what they can. They're doing
a good job. But I said--when I listened to Ms. Pearce, it comes
back to what I said earlier, this is a zero sum proposition.
One that goes through this is too much in this Nation, and I
think we have every expectation in this Nation that we should
do everything possible to make sure there isn't that one.
I think it is probably good that Mr. Filner is not here at
this time because I think he would raise some questions.
But I'm going to ask the question that I think is on the
mind of a lot of my constituents; and that is, looking at this
and looking at the administration level, higher than the
gentlemen sitting in front of us, but I am going to ask your
opinion, and I am going to ask what you think when I hear this
from constituents. Are we getting a rosy picture painted by the
VA to justify this administration's--the Presidential
administration's unwillingness to put the money that was
necessary into the VA and unwillingness to plan for this war?
When we were told it was weeks and not months, when we were
told it was over and mission accomplished, was thought put into
the implications for people like Brent and his mother? Were
those types of decisions talked about at an administrative
level? Were they discussed on the level of what you could do to
change the infrastructure of the organization to prepare for
that?
When I hear experts tell me that the numbers are going to
be larger than the VA is telling me, I have to be quite honest,
from this administration, I am very skeptical that they are
planning based on reality. And I ask that question more out of
frustration for my constituents who are asking it.
Has this discussion happened at a VA level or an
administration level? Was there a preparation made? If each of
you have been there for that long, was preparation made? Was it
talked about, what the impact would be on the numbers that were
coming?
Mr. Feeley. I would indicate--I have been in the position
13 months, and I believe that this is a daily discussion going
on the entire time I have been there, and we are constantly
learning from our experiences as we go along in trying to
adjust. So that is the best answer I can give to that,
considering the length of time.
Now I also was a network director and a director in the
field, and I think we are making every effort to treat every
veteran as a family Member. I want Ms. Pearce to know that this
is my card, and you can e-mail me and call me, and I will do
whatever I can to make sure your son gets what he needs.
Ms. Pearce. Thank you.
Mr. Walz. How do I get that card to the rest of them? That
is the answer I want to hear. That is the type of reaction I
want to start seeing.
But I am feeling right now what I do feel at times. We're
with you in this. We are partners. We need to figure out how to
get this. And too many people are afraid of what the political
fallout will be by admitting that we need help, we need to
prepare, we need to make sure Brent's needs are met and do
everything in our power to do that.
I just want to know what we can do, and I feel like we're
being told it's okay.
Mr. Feeley. I think one of the key issues that was
identified here is the need for these transitional housing
options that we talked about. Because people need a longer
runway to heal, and the polytrauma center needs to have the
ability to handle the most severe injuries. But that next phase
requires additional support so that young men and women can go
to school, go to vocational tech school, get a job, test their
legs at independence.
This is a learning issue that we found out the hard way,
and only in the past 6 months has this started to gain
attention.
A conference was held in December of last year, and that is
where the decision was made to build these units. It's
essentially a halfway house with proper supervision allowing
people to integrate back in. I think that is a little bit of
what I hear Congressman Filner raise. That need may get
greater. We do have options in our system, including the
veterans domiciliary system, to assist young men and women; and
we're going to have to gear up for that.
Mr. Walz. My final question before I turn it over to the
Ranking Member, and this is to you, Ms. Pearce. You are sitting
here in front of Congress. I am sitting here as a new Member of
Congress who was a command sergeant major whose total life was
devoted to making sure those soldiers get taken care of. What
do you have to tell us? What would make life easier for you and
for Brent? What would truly honor that commitment that he made
to this Nation so that this Nation can pay it back the way it
should?
Ms. Pearce. I think that these transitional houses, they
are really needed. They're needed on the VA side as well as the
DOD side.
Brent is still going through his med board, and he has had
some dealings with the VA, but he's still with the DOD. It is a
tough--there is a tough line there, and it is like they can't
take hold of him until the DOD has let go of him. And to get
that agreement between the DOD and the VA that those medical
records, that that information, that they can have this
seamless transition that we keep talking about would really
help these guys.
Their everyday lives have changed. What they used to take
for granted--if I can take a moment here. When Brent first got
back, a reporter asked him what he missed. It was standing up
to pee. I mean, that is something so simple. But, for him, it
was something that he was looking forward to.
To give him back that dignity by giving them this
transitional housing--they go from 24/7 care to nobody there,
nobody to help him, nobody to help him with that transition. A
lot of these young men and women don't have family that can
stay with them and help them with that transition.
And he needs to know that the VA is going to be there for
the next 20, 30, or 40 years to help him. He made his
commitment to this country. He gave his all, and he just wants
to know that they're going to be there to assist him.
Mr. Walz. Thank you.
I'll recognize the Ranking Member.
Ms. Brown-Waite. Thank you very much.
Ms. Pearce, one of the things that I tell my daughter who
has teenagers is parenting doesn't end when they're 18 or 20.
And certainly you are the epitome of the world's greatest mom,
and I mean that, to be there for your son.
I'm sorry that the system wasn't there to help your son.
I'm sorry that DOD just doesn't work well with the VA. It has
been a system since--I've been here 5 years. It was long before
I ever got here that these kind of silos buildup with DOD and
the VA. That's not an excuse that anyone should fall through
the cracks, as obviously your son did. And thank you so much
for being there. I have parents in my district, too, who are
there for their son, move around the country as he transitions
from James Haley to other units.
If I may, to ask this question to you, Ms. Pearce. Did you
bring this to the attention of your Member of Congress? I don't
even know who your Member of Congress is. But did you contact
the Member of Congress' office to express these concerns and to
have somebody work on the issue? And I'll let you answer that.
Ms. Pearce. I have talked to Members of the Senate. I have
not talked to my Congressman. But these are issues that I have
recently noticed as I have spent more time travelling back and
forth, still spending time with Brent, but I had to go back to
work. But I see these young men that are in these barracks.
They're at Brooke Army Medical Center. And just over the months
of being away from Brent and back and forth, I have realized
these needs.
So it is not something that I noticed early on, but I see
that there is a need there, that they need some kind of
transitional housing, and I think it needs to be on both sides
of the fence. Because so many of our young men and women are
spending time at Bethesda and Walter Reed and Brooke and I know
Pendleton now as well as Madigan and some of the others, and
they need something to help them get to the point where they
can live independently. But I hope that it is something that--I
did stop by my Congressman's office today. He was out voting.
So I didn't get to speak with him.
Ms. Brown-Waite. But, please, as you come in contact with
any people who have served in the military, whether they're
still under DOD or whether they're in the VA, have them contact
their home Member of Congress. Because until we know that there
is a problem, we can't solve that problem.
I know in my instance of parents who are with their son
today, they're actually out in California at a private rehab
center. I know that they didn't hesitate to contact me so that
I could make sure that everything that Marine needed, he got.
So, please, I implore you, let the servicemembers and their
families that you come in contact with know; and that way we
can work on coming up with a solution that works not just for
that one person--because we are not, you know, narrow minded,
just take care of my constituent--take care of Mr. Rodriguez's
constituent, too, who may be in exactly the same situation.
But when we know about the problem, there isn't a Member on
either side that won't immediately go to work and try to solve
the problem.
Again, I commend you for your devotion to your son. You
ultimately are, you know, the mom of the year.
I would have a quick question for Mr. Feeley. That is,
Secretary Nicholson's recent letter making all sorts of
promises and initiatives, ultimately, you are probably going to
be the one implementing it. How do you plan on operationalizing
all of the health care initiatives?
And the other important question is, will you be adequately
funded to do these things?
I know I'm running out of time, so you may have to submit
the answer, but I think it is an important question.
Mr. Feeley. We're committed to the transitional housing. I
think that need is going to be greater; and, frankly, we have
excellent cooperation with Dr. Katz to help us.
Ms. Brown-Waite. I think transitional housing is one of the
issues, but there were far more than that in Secretary
Nicholson's letter. Did you see the letter?
Mr. Feeley. I have seen the letter, and there are a lot of
deployment and execution issues we're going to face, but we're
going to deal with it. The hiring of the hundred patient
advocates is something we're putting a plan together on right
now.
Ms. Brown-Waite. And you will have enough money for it?
Because, if not, you need to let us know immediately. The
Secretary needs to let us know.
Mr. Feeley. I understand.
Ms. Brown-Waite. Dr. Katz, you need to let us know.
I thank the gentleman.
Mr. Walz. I thank the gentlewoman.
Mr. Rodriguez, you are recognized for 5 minutes.
Mr. Rodriguez. Thank you very much.
Ms. Pearce, thank you very much for your testimony, and I
would want Dr. Ed Huycke, since you are responsible for--I
gather you are the one who helps coordinate between VA and the
DOD--in terms of some feedback from you as to what else can you
do or that we have to do in order to try to have a better
transition in that process.
And, number two, you know--and I was glad to hear in terms
of that specific recommendation in terms of transition--I'm
from San Antonio. We have Brooke Army facility there. It is a
beautiful facility, and I know that we just had the private
sector come in and do some--for families because we're not
providing it.
I was wondering in terms of how we can begin to look at not
only the soldier but the families. And in that I wanted to see
if Dr. Katz, I know in the area of mental health, how it
impacts the entire family, and I wanted to get your feedback in
terms of what we need to do.
Once again, I think we're working hard, and I know the
supplemental had--and I'll say it again--$3.6 billion
additional moneys that you have for the rest of this year, and
we're working hard in trying to add another $3-point-something
on the, you know, supplemental, which is probably the most you
have ever had. But the key is, now how do you use those
resources to respond to that?
And I would ask both of you to see if you might be able to
respond.
Dr. Huycke. Thank you, sir, for the question.
I think at this point in time, working together, the VA and
the DOD is at its--as good as it has been ever been. It is
not--I think you've heard that it is not perfect at this point
in time, and there is still work to do. But I think it would be
important to state up front that there has been an awful lot of
work between the DOD and VA to help transition those servicemen
and women from active duty into veteran status.
That said, I think the issue of the medical records has
been brought up. There needs to be continued work on that, and
I think the departments, both of the departments, are committed
to that. And that would be my answer.
Mr. Rodriguez. Okay. I would hope that we would come up
with something that actually makes it happen. Dr. Katz, on the
mental health side for families.
Dr. Katz. For families, that's an excellent question. We're
authorized to provide care--I'm sorry. We're authorized to
provide care to help the veteran. In our medical centers and
clinics, we can provide services to families when it is part of
the treatment plan to benefit the veteran. That is a major part
of mental health care, especially with more serious mental
illness.
Mr. Rodriguez. Can I interrupt there?
Dr. Katz. Sure.
Mr. Rodriguez. In cases of, for example, suicide or serious
situations, does that trigger the need to bring in the family?
Dr. Katz. Yes. Yes. And I want to respond in a sidetrack to
answer about suicide and then go back to talking about
families.
We've been following the Joshua Omvig bill very, very
closely in VA; and I am really very proud to say that, with
leadership of Dr. Kussman and Dr. Cruas, we're already
implementing almost all of that bill with existing legislative
authority. We're committed to doing everything possible to
prevent veteran suicides.
About families, working with families as a part of
benefiting the veteran who is in our care is only part of the
story. We've been discussing possible legislative proposals to
you, and one of them is asking for authorization to work with
the families of people who haven't come to us, families who
might notice mental illness or suffering or behavioral
difficulties, dangers. We'll be asking for authorization to
work with those families to evaluate the symptoms they report,
to educate them about resources, to talk with them about
helping to manage the veteran at home, and to collaborate with
them about a plan to help the veteran engage in care. That is a
low-cost, small-ticket item, but a kind of authorization that
could help us reach out and meet needs.
Mr. Mitchell [presiding]. Thank you.
Mr. Rodriguez. Thank you very much for the services you
provide for us.
Mr. Mitchell. Mr. Hare?
Mr. Hare. Ms. Pearce, let me just thank you for coming this
evening. I listened to your testimony. I have a son. I can't
imagine, you know, what you are going through and have gone
through. And it struck me, one of the parts of your testimony
is, you know, you were able to spend time with Brent and the
numbers of people who may not be able to spend the kind of time
and get the type of care and be around people who need them the
most when they need them the most. I just wanted to tell you
that, from my perspective and hopefully from this entire
Subcommittee and full Committee's perspective, we've got to put
an end to this.
I said this before, and I will continue to say it, as my
colleague Representative Walz has said, one soldier, one person
is one too many, and we have a responsibility. I would like you
to convey to your son and to your entire family, A, that you
have talked to a lot of congressmen here this evening and, B,
these Congress people have listened.
We may be new, as I said before, but the advantage of being
new is, you know, sometimes you get different ideas and you
can--you know, I get a little angry, as you can probably tell--
or frustrated. But I'm probably not close to what you've been
through. So please understand that we're going to work on this,
and we will get this thing solved one way or another. I don't
know how long it is going to take, but we're going to do it
because it is the right thing to do.
I want to ask Dr. Katz a question, and I'm not sure that we
do this. For people who come back from the Middle East in
whatever theater they served in, are all men and women tested
for PTSD when they exit their tour?
Dr. Katz. There are a couple levels, three levels at least,
for testing, for screening to try to observe everyone who is
suffering. There is the post-deployment health assessment just
when people are leaving from deployment. There is the post-
deployment health reassessment conducted by DOD and the vet
centers working with them, outreach to catch symptoms that may
have emerged over 3 to 6 months after deployment. When people
come to us, we screen everyone for symptoms of mental health
conditions, PTSD and others, and follow up on what we find.
Mr. Hare. And I would assume that by testing everybody or
having everybody screened, whatever term you want to use, that
would avoid someone having to feel guilty or someone, you know,
the stigma that is touched with having a problem that that they
can't necessarily--that they don't want their family to know
about.
But isn't it true that this whole--the post-traumatic
stress or the disorders people have, it affects the entire
family, as you mentioned, am I correct?
Dr. Katz. Right.
Mr. Hare. And then my other question to you--I'm sorry. I
didn't want to interrupt your answer. But then the second part
of that was, for those that don't have the symptoms or may be
developed later, how do you identify them and reach out to them
and have them come in and help them and their families?
Dr. Katz. Yeah. You know, I think because of the experience
with PTSD and returning veterans, America is learning that the
strongest, best-trained and most resilient people can still be
vulnerable to a mental illness. Unfortunately, the last people
to learn that lesson may be the soldiers, who all too often
still feel ashamed. So stigma remains a problem, in spite of
what America is learning about PTSD and other mental health
conditions.
I am really proud of the 2-year eligibility without co-
payment in VA. That gives people a chance to come in, to get to
know us and us to get to know them, to become aware of mild or
moderate symptoms or to let them grow to trust us enough to
tell us what they're suffering from.
Mr. Hare. Is that 2 years enough or should that be extended
in your opinion, Doctor? Is that 2-year window enough or should
that be down the road?
I'm not an expert. Obviously, I wouldn't know how long
symptoms are going to take before somebody has that or has a
problem. But is 2 years enough or should it be longer?
Dr. Katz. Well, symptoms can emerge at any point throughout
the lifespan, but the overwhelming number will emerge within
that--you know, the greatest good--the greatest number might
well be 2 years, although we worry about everyone we miss.
Mr. Hare. Thank you, Doctor,
Mr. Mitchell. Thank you.
I want to thank you all for being here and staying with us
for this long period of time. What you have given us is very
important. We're hoping to, as all of us are, to try to make
the lives of these veterans and these soldiers better. They
have given a great sacrifice, and I think it is our duty as a
nation to do everything we can, our utmost, to give them the
finest care that they can get, and that is the purpose of these
hearings.
If there is no other business, this meeting is adjourned.
Thank you.
[Whereupon, at 7:04 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Harry E. Mitchell
Chairman, Subcommittee on Oversight and Investigations
Good afternoon and thank you for being here today.
Two weeks ago, the American people learned that some of our most
seriously wounded warriors were recovering in dilapidated conditions at
the Walter Reed Army Medical Center, supposedly the Army's premier
medical facility.
These conditions are absolutely unacceptable--..and the American
people are rightly outraged.
Sadly, it appears the buildings are just the tip of the iceberg.
Reports have been filtering in about a labyrinth of bureaucratic red
tape our returning soldiers having to navigate to get the basic health
care benefits they need and deserve.
These problems have a direct impact on these men and women as they
transition from the military's health care system into the VA.
We have a responsibility to investigate how issues at the
Department of Defense affect soldiers as they become veterans. We have
a responsibility to make sure that the Department of Veterans' Affairs
is doing its job to make that transition as easy as possible.
I'm not convinced the Veterans' Affairs Department is doing its
part.
Last night, ABC News reported that ``a proposal to keep seriously
wounded vets from falling through the cracks of the bureaucracy was
shelved in 2005 when Jim Nicholson took over as the secretary of the
Veterans Affairs Department.''
I am deeply troubled when wounded soldiers say in news reports that
the VA has made them feel ``horrible.''
That's unacceptable and embarrassing, and the American people
deserve answers. Today we hope to get some of them.
In today's hearing, we will hear from witnesses who have seen or
experience first-hand the difficulties veterans face when they
transition from the DOD health care system to the VA network.
Their stories are compelling, and I am eager to learn how the VA is
responding to their concerns as well the health care needs of their
fellow veterans. I am pleased to note the number of new veterans who
have taken time to come and observe our hearing. In particular, I would
like to recognize Specialist Gregory Williams, Corporal Noel Santos,
Sergeant Frank Valentine, and Staff Sergeant Danny Vega. We are honored
to welcome these young heroes.
At this time, I ask unanimous consent that Mr. Filner, Mr. Buyer,
Mr. Hare, Mr. Lamborn, and Mr. Bilirakis, be invited to sit at the dais
for the Subcommittee hearing today.
Hearing no objection, so ordered.
Before I recognize the Ranking Republican Member for her remarks, I
would like to swear in all our witnesses.
I ask that all witnesses stand and raise their right hand.
Do you solemnly swear to tell the truth, the whole truth, and
nothing but the truth?
I now recognize Ms. Brown-Waite for opening remarks.
Prepared Statement of the Honorable Ginny Brown-Waite, Ranking
Republican Member, Subcommittee on Oversight and Investigations
Thank you, Mr. Chairman for yielding.
The Committee on Veterans' Affairs has been conducting oversight
reviews of the seamless transition issue for our Nation's
servicemembers for the past several Congresses. In the last Congress
alone, the Committee and its Subcommittees held 10 hearings on the
transition of our servicemembers. I believe I speak for all of us, when
I say this is a top priority issue that, despite our best efforts, has
not entirely been resolved.
Congress codified the concept of ``DOD-VA Sharing'', now known as
``Seamless Transition,'' in 1982, with passage of the Veterans
Administration and the Department of Defense Health Resources Sharing
and Emergency Operations Act (P.L. 97-174). This Act created the VA-
Care Committee to supervise and manage opportunities to share medical
resources. Now, twenty-five years later, we are still discussing this
issue.
Some progress has been made in the areas of transitioning
servicemembers back to the work force. Last Congress, P.L. 109-461 was
enacted, which included various transition assistance initiatives
ranging from health care needs to educational and employment training
provisions.
During the last Congress, Members and staff from the Committee
conducted numerous field and site visits at VA and military treatment
facilities and military bases to review efforts made on Seamless
transition, and held oversight hearings in May and September of 2005.
The transition and integration back into civilian life should be
transparent and effortless for our servicemembers. However, this does
not always appear to be the case. More often than not, the hand-offs
have been fumbles.
In a GAO report prepared for this Subcommittee on June 30, 2006, it
was found that the VA has taken many aggressive actions to provide
timely information to OEF and OIF servicemembers and their families,
especially in their critical time of need. The report also noted the
positive steps taken to increase the awareness, training and
sensitivity of staff and medical providers on the needs of OEF and OIF
servicemembers and veterans. The report also found that VA continues to
have problems accessing real time medical information from DOD
treatment facilities. These records are instrumental in continuing care
for servicemembers and veterans receiving treatment at VA facilities.
Mr. Chairman, I ask unanimous consent that a copy of this report be
inserted into the official hearing record.
Mr. Chairman, I know we have witnesses from the Walter Reed Army
Medical Center. I would like to make it clear that today's hearing is
not about the conditions at Walter Reed, but about the transition our
servicemembers are making from DOD to VA Care. How the process works?
Is there any gap in care? Is VA getting the information it needs from
DOD in a timely manner to ensure the continuity of care for these new
veterans, so that waiting periods for care do not extend for months
after separation from active duty? And, why to this day is information
on DOD personnel being cared for in the VA's polytrauma centers still
not being transmitted electronically? Is there a difference between DOD
electrons and VA electrons?
Mr. Chairman, I ask unanimous consent that any full Committee
Members attending this hearing be recognized under the 5 minute rule to
question the witnesses after the Subcommittee's Members have been
recognized.
Again, thank you Mr. Chairman, and I yield back my time.
Statement of the Hon. Cliff Stearns, a Representative in Congress from
the State of Florida
Thank you Mr. Chairman,
For several years now, we have held hearings, heard testimony, and
listened to a number of recommendations and proposals to make the
transition of service Members from active duty to the Veterans'
Administration as smooth as possible. However, here we are again today,
with many of the same issues outstanding.
Last year's GAO report on these issues quoted VA officials as
saying that the transfer of service Members to their system from the
DOD would be more efficient if the Polytrauma Rehabilitation Center
(PRC) medical personnel had real time access to the service Members'
complete DOD electronic medical records from the referral facility. As
Yogi Berra said, this is Deja-Vou all over again!
Back in 1982, Congress identified the sharing of medical records as
a critical need, and passed the ``Veterans Administration and the
Department of Defense Health Resources Sharing and Emergency Operations
Act'' that created the first interagency Committee to supervise those
opportunities to exchange information between the two departments. This
was the first in a long series of new oversight Committees, interagency
cooperative Committees, and special task forces that looked into this
same issue. Back in 2003, President Bush established the Task Force to
Improve Health Care Delivery for Our Nation's Veterans. The first
recommendation of this task force 4 years ago was that the VA and DOD
should ``develop and deploy by fiscal year 2005'' electronic medical
records that are interoperable for both systems and standards based. We
are 2 years beyond that deadline and not much closer to its completion.
Frankly, I am very concerned about the Information Security procedures
at the VA which have not even implemented basic steps like encrypting
each laptop. I would insist that those precautions are in place
immediately and done before we add any more confidential information to
the system.
Another concern of mine is the availability of mental health
services for our service Members returning from Operation Enduring
Freedom and Operation Iraqi Freedom. It is my understanding that
initial screenings by both the DOD and VA are conducted in adequate
time, but the concern is the long wait for follow up appointments. Some
veterans receiving mental health care for PTSD could be delayed in
their next appointments by up to 90 days! Currently, VA officials
report that they are managing the workload of referrals for PTSD
treatment, but are concerned about the influx of new returning veterans
from their service overseas which could strain the VA's ability to
treat them. Over 24,000 service Members have returned from these
theaters so far, and many more are anticipated over the coming year. We
need to look into ways to expand the capacity of the VA to provide
mental health services to our returning service members in a timely and
efficient manner.
Prepared Statement of Michael J. Kussman, MD, MS, MACP, Acting Under
Secretary for Health, Veterans Health Administration, U.S. Department
of Veterans Affairs
Mr. Chairman and Members of the Subcommittee, good afternoon. Thank
you for this important opportunity to comment on the Veterans Health
Administration's (VHA) efforts to ensure a seamless transition process
for our injured service men and women, and our ongoing efforts to
continuously improve this process.
VHA's work to create a seamless transition for men and women as
they leave the service and take up the honored title of ``veteran''
begins early on. Our Benefits Delivery at Discharge Program enables
active duty Members to register for VA health care and to file for
benefits prior to their separation from active service. Our outreach
network ensures returning service Members receive full information
about VA benefits and services. And each of our medical centers and
benefits offices now has a point of contact assigned to work with
veterans returning from service in Operation Enduring Freedom (OEF) and
Operation Iraqi Freedom (OIF).
VHA has coordinated the transfer of over 6,800 severely injured or
ill active duty service Members and veterans from DOD to VA. Our
highest priority is to ensure that those returning from the Global War
on Terror transition seamlessly from DOD Military Treatment Facilities
(MTFs) to VA Medical Centers (VAMCs) and continue to receive the best
possible care available anywhere. Toward that end, we continually
strive to improve the delivery of this care.
In partnership with DOD, VA has implemented a number of strategies
to provide timely, appropriate, and seamless transition services to the
most seriously injured OEF/OIF active duty service Members and
veterans.
VA social workers, benefits counselors, and outreach coordinators
advise and explain the full array of VA services and benefits. These
liaisons and coordinators assist active duty service Members as they
transfer from MTFs to VA medical facilities. In addition, our social
workers help newly wounded soldiers, sailors, airmen and Marines and
their families plan a future course of treatment for their injuries
after they return home. Currently, VA Social Work and Benefit liaisons
are located at 10 MTFs, including Walter Reed Army Medical Center, the
National Naval Medical Center Bethesda, the Naval Medical Center San
Diego, and Womack Army Medical Center at Ft. Bragg.
Since September 2006, a VA Certified Rehabilitation Registered
Nurse (CRRN) has been assigned to Walter Reed to assess and provide
regular updates to our Polytrauma Rehabilitation Centers (PRC)
regarding the medical condition of incoming patients. The CRRN advises
and assists families and prepares active duty service Members for
transition to VA and the rehabilitation phase of their recovery.
VA's Social Work Liaisons and the CRRN fully coordinate care and
information prior to a patient's transfer to our Department. Social
Worker Liaisons meet with patients and their families to advise and
``talk them through'' the transition process. They register service
Members or enroll recently discharged veterans in the VA health care
system, and coordinate their transfer to the most appropriate VA
facility for the medical services needed, or to the facility closest to
their home.
In the case of transfers of seriously injured patients, both the
CCRN and the Social Work Liaison are an integral part of the MTF
treatment team. They simultaneously provide input into the VA health
care treatment plan and collaborate with both the patient and his or
her family throughout the entire health care transition process. Video
teleconference calls are routinely conducted between DOD MTF treatment
teams and receiving VA PRC teams. If feasible, the patient and family
attend these video teleconferences to participate in discussions and to
`meet' the VA PRC team.
I should note that one important aspect of coordination between DOD
and VA prior to a patient's transfer to VA is access to clinical
information. This includes a pre-transfer review of electronic medical
information via remote access capabilities. The VA polytrauma centers
have been granted direct access into inpatient clinical information
systems from Walter Reed Army Medical Center (WRAMC) and National Naval
Medical Center (NNMC). VA and DOD are currently working together to
ensure that appropriate users are adequately trained and connectivity
is working and exists for all four polytrauma centers. For those
inpatient data that are not available in DOD's information systems, VA
social workers embedded in the military treatment facilities routinely
ensure that the paper records are manually transferred to the receiving
polytrauma centers.
Another data exchange system, the Bidirectional Health Information
Exchange (BHIE) allows VA and DOD clinicians to share text-based
outpatient clinical data between VA and the ten MTFs, including Walter
Reed and Bethesda.
VA case management for these patients begins at the time of
transition from the MTF and continues as their medical and
psychological needs dictate. Once the patient transfers to the
receiving VAMC, or reports to his or her home VAMC for care, the VA
Social Worker Liaison at the MTF continues to coordinate with VA to
address after-transfer issues of care. Seriously injured patients
receive ongoing case management at the VA facility where they receive
most of their care. Since April of 2006, points of contact or case
managers have been identified in every VA medical center. In response
to the Secretary's request this week, VA is in the process of hiring
the 100 OIF/OEF veterans to serve as case advocates to support their
severely injured fellow veterans and their families.
VA has four Polytrauma Rehabilitation Centers, located at Tampa,
FL; Richmond, VA; Minneapolis, MN; and Palo Alto, CA. The Army has
assigned fulltime active duty Liaison Officers to each one in order to
support military personnel and their families from all Service
branches. The Liaison officers address a broad array of issues, such as
travel, housing, military pay, and movement of household goods.
In addition, Marine Corps representatives from nearby local
Commands visit and provide support to each of the Polytrauma
Rehabilitation Centers. At VA Central Office in Washington, DC, an
active duty Marine Officer and an Army Wounded Warrior representatives
are assigned to the Office of Seamless Transition to serve as liaisons.
Both the Army and the Marine Liaisons play a vital role in ensuring the
provision of a wide bridge of services during the critical time of
patient recovery and rehabilitation.
VHA understands the critical importance of supporting families
during the transition from DOD to VA. We established a Polytrauma Call
Center in February 2006, to assist the families of our most seriously
injured combat veterans and service Members. The Call Center operates
24 hours-a-day, 7 days-a-week to answer clinical, administrative, and
benefit inquiries from polytrauma patients and family Members. The
Center's value is threefold. It furnishes patients and their families
with a one-stop source of information; it enhances overall coordination
of care; and, very importantly, it immediately elevates any system
problems to VA for resolution.
VA's Office of Seamless Transition includes two Outreach
Coordinators--a peer-support volunteer and a veteran of the Vietnam
War--who regularly visit seriously injured service members at Walter
Reed and Bethesda. Their visits enable them to establish a personal and
trusted connection with patients and their families.
These Outreach Coordinators help identify gaps in VA services by
submitting and tracking follow-up recommendations. They encourage
patients to consider participating in VA's National Rehabilitation
Special Events or to attend weekly dinners held in Washington, DC, for
injured OEF/OIF returnees. In short, they are key to enhancing and
advancing the successful transition of our service personnel from DOD
to VA, and, in turn, to their homes and communities.
In addition, VA has developed a vigorous outreach, education, and
awareness program for the National Guard and Reserve. To ensure
coordinated transition services and benefits, VA signed a Memorandum of
Agreement (MOA) with the National Guard in 2005. Combined with VA/
National Guard State Coalitions in 54 states and territories, VA has
significantly improved its opportunities to access returning troops and
their families. We are continuing to partner with community
organizations and other local resources to enhance the delivery of VA
services. At the national level, MOAs are under development with both
the United States Army Reserve and the United States Marine Corps.
These new partnerships will increase awareness of, and access to, VA
services and benefits during the de-mobilization process and as service
personnel return to their local communities.
VA is also reaching out to returning veterans whose wounds may be
less apparent. VA is a participant in the DOD's Post Deployment Health
Reassessment (PDHRA) program. DOD conducts a health reassessment 90-180
days after return from deployment to identify health issues that can
surface weeks or months after service Members return home.
VA actively participates in the administration of PDHRA at Reserve
and Guard locations in a number of ways. We provide information about
VA care and benefits; enroll interested Reservists and Guardsmen in the
VA health care system; and arrange appointments for referred service
Members. As of December 2006, an estimated 68,800 service Members were
screened, resulting in over 17,100 referrals to VA. Of those referrals,
32.8% were for mental health and readjustment issues; the remaining
67.2% for physical health issues.
Congress created the Readjustment Counseling Service (RCS),
commonly known to veterans as the Vet Center Program, as VHA's outreach
element. Program eligibility was originally targeted to Vietnam
veterans; today it serves all returning combat veterans. The Vet Center
Program receives high ratings in veterans' satisfaction, employee
satisfaction, and other measurable indicators of quality and effective
care.
The approximate number of OEF/OIF combat veterans served by Vet
Centers to date is 165,000 (119,600 through outreach; 45,400 seen at
centers). In February of 2004, the Secretary of Veterans Affairs
approved the hiring of 50 OEF/OIF combat veterans to support the
Program by reaching out actively to National Guard, and Reserve service
Members returning from combat. An additional 50 were hired in March of
2005. This action advanced the continuing success of our Vet Centers in
their ability to assist our newest veterans and their families. VA Vet
Centers have provided bereavement services to 900 families of fallen
warriors.
VA plans to expand its Vet Center Program. We will open 15 new Vet
Centers and eight new Vet Center outstations at locations throughout
the Nation by the end of 2008. At that time, Vet Centers will total
232. We expect to add staff to 61 existing facilities to augment the
services they provide. Seven of the 23 new centers will open this
Calendar Year 2007.
In addition, as you know this week the President created an
Interagency Task Force on Returning Global War on Terror Heroes (Heroes
Task Force), chaired by the Secretary of Veterans Affairs, to respond
to the immediate needs of returning Global War on Terror service
Members. The Heroes Task Force, which had its first meeting on Tuesday,
will work to identify and resolve any gaps in service for service
Members. As Secretary Nicholson said, no task is more important to the
VA than ensuring our heroes receive the best possible care and
services.
Finally, The VA is partnering with the State VA Directors in the
``State Benefits Seamless Transition Program'' in which severely
injured service Members can release their contact information to their
home State VA Office to be educated about their State Benefits.
VA staff assigned to major MTFs are coordinating with Heroes to
Hometown as a resource to provide to service Members returning to
civilian life.
Mr. Chairman, this concludes my presentation. At this time, I would
be pleased to answer any questions you may have.
Prepared Statement of Cynthia A. Bascetta, Director, Health Care,
U.S. Government Accountability Office
Mr. Chairman and Members of the Subcommittee:
I am pleased to be here today to discuss health care and other
services for U.S. military servicemembers wounded during Operation
Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF).\1\ On March 1,
2007, the Department of Defense (DOD) reported that over 24,000
servicemembers have been wounded in action since the onset of the two
conflicts. In 2005, DOD reported that about 65 percent of the OEF and
OIF servicemembers wounded in action were injured by blasts and
fragments from improvised explosive devices, land mines, and other
explosive devices. More recently, DOD estimated in 2006 that as many as
28 percent of those injured by blasts and fragments have some degree of
trauma to the brain. These injuries often require comprehensive
inpatient rehabilitation services to address complex cognitive and
physical impairments. In addition to their physical injuries, OEF/OIF
servicemembers who have been injured in combat may also be at risk for
developing mental health impairments, such as post-traumatic stress
disorder (PTSD), which research has shown to be strongly associated
with experiencing intense and prolonged combat.\2\
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\1\ OEF, which began in October 2001, supports combat operations in
Afghanistan and other locations, and OIF, which began in March 2003,
supports combat operations in Iraq and other locations.
\2\ Charles W. Hoge et al., ``Combat Duty in Iraq and Afghanistan,
Mental Health Problems, and Barriers to Care,'' The New England Journal
of Medicine, 351 (2004): 13-22.
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While servicemembers are on active duty, DOD decides where they
receive their care--at a military treatment facility (MTF), from a
TRICARE civilian provider,\3\ or at a Department of Veterans Affairs
(VA) medical facility. From the OEF and OIF conflict areas, seriously
injured servicemembers are usually brought to Landstuhl Regional
Medical Center in Germany for treatment. From there, they are usually
transported to MTFs located in the United States, with most of the
seriously injured admitted to Walter Reed Army Medical Center or the
National Naval Medical Center, both of which are in the Washington,
D.C., area.\4\ Once the servicemembers are medically stabilized, DOD
can elect to send those with traumatic brain injuries and other complex
trauma, such as missing limbs, to one of the four polytrauma
rehabilitation centers (PRC) \5\ operated by VA for medical and
rehabilitative care. The PRCs are located at VA medical centers in Palo
Alto, California; Tampa, Florida; Minneapolis, Minnesota; and Richmond,
Virginia. While many servicemembers who receive such rehabilitative
services return to active duty after they are treated, others who are
more seriously injured are likely to be discharged from their military
obligations and return to civilian life with disabilities.
---------------------------------------------------------------------------
\3\ DOD provides health care through TRICARE--a regionally
structured program that uses civilian contractors to maintain provider
networks to complement health care services provided at MTFs.
\4\ Other MTFs that received OEF/OIF servicemembers include Brooke
Army Medical Center (San Antonio, Texas), Dwight David Eisenhower Army
Medical Center (Augusta, Georgia), Madigan Army Medical Center (Tacoma,
Washington), Darnall Army Community Hospital (Fort Hood, Texas), Evans
Army Community Hospital (Fort Carson, Colorado), and the Naval Hospital
Camp Pendleton (Camp Pendleton, California).
\5\ The Veterans Health Programs Improvement Act of 2004, Pub. L.
No. 108-422, 302, 118 Stat. 2379, 2383-86, mandated that VA establish
centers for research, education, and clinical activities related to
complex multiple trauma associated with combat injuries. In response to
that mandate, VA established PRCs at four VA medical facilities with
expertise in traumatic amputation, spinal cord injury, traumatic brain
injury, and blind rehabilitation. A PRC addresses the rehabilitation
needs of the combat injured in one setting and in a coordinated manner.
---------------------------------------------------------------------------
Our work has shown that servicemembers injured in combat face an
array of significant medical and financial challenges as they begin
their recovery process in the DOD and VA health care systems. In light
of these challenges and recent media reports that have highlighted
unsanitary and decrepit living conditions at the Walter Reed Army
Medical Center,\6\ you asked us to discuss concerns we have identified
regarding DOD and VA efforts to provide medical care and rehabilitative
services for servicemembers who have been injured during OEF and OIF.
Specifically, my remarks today will focus on (1) the transition of care
for seriously injured OEF/OIF servicemembers--those with traumatic
brain injuries or other complex trauma, such as missing limbs--who are
transferred between DOD and VA medical facilities; (2) DOD's and VA's
efforts to provide early intervention for rehabilitation services as
soon as possible after the onset of a disability for seriously injured
servicemembers; (3) DOD's efforts to screen OEF/OIF servicemembers at
risk for PTSD and whether VA can meet the demand for PTSD services; and
(4) the impact of problems related to military pay on injured
servicemembers and their families.
---------------------------------------------------------------------------
\6\ See, for instance, Dana Priest and Anne Hull, ``Soldiers Face
Neglect, Frustration at Army's Top Medical Facility,'' The Washington
Post (Feb. 18, 2007).
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My testimony is based on issued GAO work.\7\ The information I am
reporting today reflects the conditions facing OEF/OIF servicemembers
at the time the audit work was completed and illustrates the types of
problems injured servicemembers encountered during their healing and
rehabilitation process. To complete the work for these products, we
visited DOD and VA facilities, reviewed relevant documents, analyzed
DOD data, and interviewed DOD and VA officials. Our work was performed
in accordance with generally accepted government auditing standards.
---------------------------------------------------------------------------
\7\ See Related GAO Products at the end of this statement.
---------------------------------------------------------------------------
In summary, DOD and VA have made various efforts to provide medical
care and rehabilitative services for OEF/OIF servicemembers. The
departments established joint programs to facilitate the transfer of
injured servicemembers from DOD facilities to VA medical facilities,
assess whether servicemembers will be able to remain in the military,
and assign VA social workers to selected MTFs to coordinate the
transfers. DOD has also established a program to screen servicemembers
after their deployment outside of the United States has ended to assess
whether they are at risk for PTSD. However, we found several problems
in the efforts to provide health care and rehabilitative services for
OEF/OIF servicemembers. For example, DOD and VA had problems sharing
medical records and questions arose about the timing of VA's outreach
to servicemembers whose discharge from military service was not
certain. Furthermore, we found that DOD cannot provide reasonable
assurance that OEF/OIF servicemembers who need referrals for mental
health evaluations receive them. Finally, problems related to military
pay have resulted in overpayments and debt for hundreds of sick and
injured servicemembers.
DOD and VA Have Taken Actions to Facilitate the Transfer of
Servicemembers but Experienced Problems in Exchanging Health
Care Information
In our June 2006 report, we found that DOD and VA had taken actions
to facilitate the transition of medical and rehabilitative care for
seriously injured servicemembers who were being transferred from MTFs
to PRCs.\8\ For example, in April 2004, DOD and VA signed a memorandum
of agreement that established referral procedures for transferring
injured servicemembers from DOD to VA medical facilities. DOD and VA
also established joint programs to facilitate the transfer to VA
medical facilities, including a program that assigned VA social workers
to selected MTFs to coordinate transfers.
---------------------------------------------------------------------------
\8\ GAO, VA and DOD Health Care: Efforts to Provide Seamless
Transition of Care for OEF and OIF Servicemembers and Veterans, GAO-06-
794R (Washington, D.C.: June 30, 2006).
---------------------------------------------------------------------------
Despite these coordination efforts, we found that DOD and VA were
having problems sharing the medical records VA needed to determine
whether servicemembers' medical conditions allowed participation in
VA's vigorous rehabilitation activities. DOD and VA reported that as of
December 2005 two of the four PRCs had real-time access to the
electronic medical records maintained at Walter Reed Army Medical
Center and only one of the two also had access to the records at the
National Naval Medical Center. In cases where medical records could not
be accessed electronically, the MTF faxed copies of some medical
information, such as the patient's medical history and progress notes,
to the PRC. Because this information did not always provide enough data
for the PRC provider to determine if the servicemember was medically
stable enough to be admitted to the PRC, VA developed a standardized
list of the minimum types of health care information needed about each
servicemember transferring to a PRC. Even with this information, PRC
providers frequently needed additional information and had to ask for
it specifically. For example, if the PRC provider notices that the
servicemember is on a particular antibiotic therapy, the provider may
request the results of the most recent blood and urine cultures to
determine if the servicemember is medically stable enough to
participate in strenuous rehabilitation activities. According to PRC
officials, obtaining additional medical information in this way, rather
than electronically, is very time consuming and often requires multiple
phone calls and faxes. VA officials told us that the transfer could be
more efficient if PRC medical personnel had real-time access to the
servicemembers' complete DOD electronic medical records from the
referring MTFs. However, problems existed even for the two PRCs that
had been granted electronic access. During a visit to those PRCs in
April 2006, we found that neither facility could access the records at
Walter Reed Army Medical Center because of technical difficulties.
DOD and VA Collaboration Is Important for Early Intervention for
Rehabilitation
As discussed in our January 2005 report, the importance of early
intervention for returning individuals with disabilities to the work
force is well documented in vocational rehabilitation literature.\9\ In
1996, we reported that early intervention significantly facilitates the
return to work but that challenges exist in providing services
early.\10\ For example, determining the best time to approach recently
injured servicemembers and gauge their personal receptivity to
considering employment in the civilian sector is inherently difficult.
The nature of the recovery process is highly individualized and
requires professional judgment to determine the appropriate time to
begin vocational rehabilitation. Our 2007 High-Risk Series: An Update
designates Federal disability programs as ``high risk'' because they
lack emphasis on the potential for vocational rehabilitation to return
people to work.\11\
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\9\ GAO, Vocational Rehabilitation: More VA and DOD Collaboration
Needed to Expedite Services for Seriously Injured Servicemembers, GAO-
05-167 (Washington, D.C.: Jan. 14, 2005).
\10\ We also reported on early intervention in GAO, SSA Disability:
Return-to-Work Strategies from Other Systems May Improve Federal
Programs, GAO/HEHS-96-133 (Washington, D.C.: July 11, 1996).
\11\ GAO, High-Risk Series: An Update, GAO-07-310 (Washington,
D.C.: January 2007).
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In our January 2005 report, we found that servicemembers whose
disabilities are definitely or likely to result in military separation
may not be able to benefit from early intervention because DOD and VA
could work at cross purposes. In particular, DOD was concerned about
the timing of VA's outreach to servicemembers whose discharge from
military service is not yet certain. DOD was concerned that VA's
efforts may conflict with the military's retention goals. When
servicemembers are treated as outpatients at a VA or military hospital,
DOD generally begins to assess whether the servicemember will be able
to remain in the military. This process can take months. For its part,
VA took steps to make seriously injured servicemembers a high priority
for all VA assistance. Noting the importance of early intervention, VA
instructed its regional offices in 2003 to assign a case manager to
each seriously injured servicemember who applies for disability
compensation. VA had detailed staff to MTFs to provide information on
all veterans' benefits, including vocational rehabilitation, and
reminded staff that they can initiate evaluation and counseling, and,
in some cases, authorize training before a servicemember is discharged.
While VA tries to prepare servicemembers for a transition to civilian
life, VA's outreach process may overlap with DOD's process for
evaluating servicemembers for a possible return to duty.
In our report, we concluded that instead of working at cross
purposes to DOD goals, VA's early intervention efforts could facilitate
servicemembers' return to the same or a different military occupation,
or to a civilian occupation if the servicemembers were not able to
remain in the military. In this regard, the prospect for early
intervention with vocational rehabilitation presents both a challenge
and an opportunity for DOD and VA to collaborate to provide better
outcomes for seriously injured servicemembers.
DOD Screens Servicemembers for PTSD after Deployment, but DOD and VA
Face Challenges Ensuring Further PTSD Services
In our May 2006 report, we described DOD's efforts to identify and
facilitate care for OEF/OIF servicemembers who may be at risk for
PTSD.\12\ To identify such servicemembers, DOD uses a questionnaire,
the DD 2796, to screen OEF/OIF servicemembers after their deployment
outside of the United States has ended. The DD 2796 is used to assess
servicemembers' physical and mental health and includes four questions
to identify those who may be at risk for developing PTSD. We reported
that according to a clinical practice guideline jointly developed by
DOD and VA, servicemembers who responded positively to at least three
of the four PTSD screening questions may be at risk for developing
PTSD. DOD health care providers review completed questionnaires,
conduct face-to-face interviews with servicemembers, and use their
clinical judgment in determining which servicemembers need referrals
for further mental health evaluations.\13,\ \14\ OEF/OIF servicemembers
can obtain the mental health evaluations, as well as any necessary
treatment for PTSD, while they are servicemembers--that is, on active
duty--or when they transition to veteran status if they are discharged
or released from active duty.
---------------------------------------------------------------------------
\12\ GAO, Post-Traumatic Stress Disorder: DOD Needs to Identify the
Factors Its Providers Use to Make Mental Health Evaluation Referrals
for Servicemembers, GAO-06-397 (Washington, D.C.: May 11, 2006).
\13\ Health care providers that review the DD 2796 may include
physicians, physician assistants, nurse practitioners, or independent
duty medical technicians--enlisted personnel who receive advanced
training to provide treatment and administer medications.
\14\ DOD's referrals are used to document DOD's assessment that
servicemembers are in need of further mental health evaluations.
---------------------------------------------------------------------------
Despite DOD's efforts to identify OEF/OIF servicemembers who may
need referrals for further mental health evaluations, we reported that
DOD cannot provide reasonable assurance that OEF/OIF servicemembers who
need the referrals receive them. Using data provided by DOD,\15\ we
found that 22 percent, or 2,029, of the 9,145 OEF/OIF servicemembers in
our review who may have been at risk for developing PTSD were referred
by DOD health care providers for further mental health evaluations.
Across the military service branches, DOD health care providers varied
in the frequency with which they issued referrals to OEF/OIF
servicemembers with three or more positive responses to the PTSD
screening questions--the Army referred 23 percent, the Air Force about
23 percent, the Navy 18 percent, and the Marines about 15 percent.
According to DOD officials, not all of the OEF/OIF servicemembers with
three or four positive responses on the screening questionnaire need
referrals. As directed by DOD's guidance for using the DD 2796, DOD
health care providers are to rely on their clinical judgment to decide
which of these servicemembers need further mental health evaluations.
However, at the time of our review DOD had not identified the factors
its health care providers used to determine which OEF/OIF
servicemembers needed referrals. Knowing these factors could explain
the variation in referral rates and allow DOD to provide reasonable
assurance that such judgments are being exercised appropriately.\16\ We
recommended that DOD identify the factors that DOD health care
providers used in issuing referrals for further mental health
evaluations to explain provider variation in issuing referrals. DOD
concurred with the recommendation.
---------------------------------------------------------------------------
\15\ In our review we analyzed computerized data provided by DOD to
identify 178,664 OEF/OIF servicemembers who were deployed in support of
OEF/OIF from October 1, 2001, through September 30, 2004, and who have
since been discharged or released from active duty. These
servicemembers had answered the four PTSD screening questions on the DD
2796 and had a record of their completed questionnaire available in a
DOD computerized database. We found that DOD data indicated 9,145 of
the 178,664 servicemembers in our review may have been at risk for
developing PTSD.
\16\ The John Warner National Defense Authorization Act for Fiscal
Year 2007 required DOD to develop guidelines for mental health
referrals, as well as mechanisms to ensure proper training and
oversight, by April 2007. Pub. L. No. 109-364, 738, 120 Stat. 2083,
2303 4.
---------------------------------------------------------------------------
Although OEF/OIF servicemembers may obtain mental health
evaluations or treatment for PTSD through VA when they transition to
veteran status, VA may face a challenge in meeting the demand for PTSD
services. In September 2004 we reported that VA had intensified its
efforts to inform new veterans from the Iraq and Afghanistan conflicts
about the health care services--including treatment for PTSD--VA offers
to eligible veterans.\17\ We observed that these efforts, along with
expanded availability of VA health care services for Reserve and
National Guard Members, could result in an increased percentage of
veterans from Iraq and Afghanistan seeking PTSD services through VA.
However, at the time of our review officials at six of seven VA medical
facilities we visited explained that while they were able to keep up
with the current number of veterans seeking PTSD services, they may not
be able to meet an increase in demand for these services. In addition,
some of the officials expressed concern because facilities had been
directed by VA to give veterans from the Iraq and Afghanistan conflicts
priority appointments for health care services, including PTSD
services. As a result, VA medical facility officials estimated that
follow-up appointments for veterans receiving care for PTSD could be
delayed. VA officials estimated the delays to be up to 90 days.
---------------------------------------------------------------------------
\17\ GAO, VA and Defense Health Care: More Information Needed to
Determine If VA Can Meet an Increase in Demand for Post-Traumatic
Stress Disorder Services, GAO-04-1069 (Washington, D.C.: Sept. 20,
2004).
---------------------------------------------------------------------------
Problems Related to Military Pay Have Resulted in Debt and Other
Hardships for Hundreds of Sick and Injured Servicemembers
As discussed in our April 2006 testimony, problems related to
military pay have resulted in overpayments and debt for hundreds of
sick and injured servicemembers.\18\ These pay problems resulted in
significant frustration for the servicemembers and their families. We
found that hundreds of battle-injured servicemembers were pursued for
repayment of military debts through no fault of their own, including at
least 74 servicemembers whose debts had been reported to credit bureaus
and private collections agencies. In response to our audit, DOD
officials said collection actions on these servicemembers' debts had
been suspended until a determination could be made as to whether these
servicemembers' debts were eligible for relief.
---------------------------------------------------------------------------
\18\ GAO, Military Pay: Military Debts Present Significant
Hardships to Hundreds of Sick and Injured GWOT Soldiers, GAO-06-657T
(Washington, D.C.: April 27, 2006).
---------------------------------------------------------------------------
Debt collection actions created additional hardships on
servicemembers by preventing them from getting loans to buy houses or
automobiles or pay off other debt, and sending several servicemembers
into financial crisis. Some battle-injured servicemembers forfeited
their final separation pay to cover part of their military debt, and
they left the service with no funds to cover immediate expenses while
facing collection actions on their remaining debt.
We also found that sick and injured servicemembers sometimes went
months without paychecks because debts caused by overpayments of combat
pay and other errors were offset against their military pay.\19\
Furthermore, the longer it took DOD to stop the overpayments, the
greater the amount of debt that accumulated for the servicemember and
the greater the financial impact, since more money would eventually be
withheld from the servicemember's pay or sought through debt collection
action after the servicemember had separated from the service.
---------------------------------------------------------------------------
\19\ We found that after voluntary allotments and other required
deductions, many times there was no net pay due the servicemember.
---------------------------------------------------------------------------
In our 2005 testimony about Army National Guard and Reserve
servicemembers, we found that poorly defined requirements and processes
for extending injured and ill reserve component servicemembers on
active duty have caused servicemembers to be inappropriately dropped
from active duty.\20\ For some, this has led to significant gaps in pay
and health insurance, which has created financial hardships for these
servicemembers and their families.
---------------------------------------------------------------------------
\20\ GAO, Military Pay: Gaps in Pay and Benefits Create Financial
Hardships for Injured Army National Guard and Reserve Soldiers, GAO-05-
322T (Washington, D.C.: Feb. 17, 2005).
---------------------------------------------------------------------------
Mr. Chairman, this completes my prepared remarks. I would be happy
to respond to any questions you or other Members of the Subcommittee
may have at this time.
Contacts and Acknowledgments
For further information about this testimony, please contact
Cynthia A. Bascetta at (202) 512-7101 or [email protected]. Contact
points for our Offices of Congressional Relations and Public Affairs
may be found on the last page of this statement. Michael T. Blair, Jr.,
Assistant Director; Cynthia Forbes; Krister Friday; Roseanne Price;
Cherie' Starck; and Timothy Walker made key contributions to this
statement.
Related GAO Products
High-Risk Series: An Update. GAO-07-310. Washington, D.C.: January
2007.
VA and DOD Health Care: Efforts to Provide Seamless Transition of
Care for OEF and OIF Servicemembers and Veterans. GAO-06-794R.
Washington, D.C.: June 30, 2006.
Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors
Its Providers Use to Make Mental Health Evaluation Referrals for
Servicemembers. GAO-06-397. Washington, D.C.: May 11, 2006.
Military Pay: Military Debts Present Significant Hardships to
Hundreds of Sick and Injured GWOT Soldiers. GAO-06-657T. Washington,
D.C.: April 27, 2006.
Military Disability System: Improved Oversight Needed to Ensure
Consistent and Timely Outcomes for Reserve and Active Duty Service
Members. GAO-06-362. Washington, D.C.: March 31, 2006.
Military Pay: Gaps in Pay and Benefits Create Financial Hardships
for Injured Army National Guard and Reserve Soldiers. GAO-05-322T.
Washington, D.C.: February 17, 2005.
Vocational Rehabilitation: More VA and DOD Collaboration Needed to
Expedite Services for Seriously Injured Servicemembers. GAO-05-167.
Washington, D.C.: January 14, 2005.
VA and Defense Health Care: More Information Needed to Determine If
VA Can Meet an Increase in Demand for Post-Traumatic Stress Disorder
Services. GAO-04-1069. Washington, D.C.: September 20, 2004.
SSA Disability: Return-to-Work Strategies from Other Systems May
Improve Federal Programs. GAO/HEHS-96-133. Washington, D.C.: July 11,
1996.
(290621)
__________
GAO HIGHLIGHTS
DOD AND VA HEALTH CARE
Challenges Encountered by Injured Servicemembers During Their Recovery
process
Why GAO Did This Study
As of March 1, 2007, over 24,000 servicemembers have been wounded
in action since the onset of Operation Enduring Freedom (OEF) and
Operation Iraqi Freedom (OIF), according to the Department of Defense
(DOD). GAO work has shown that servicemembers injured in combat face an
array of significant medical and financial challenges as they begin
their recovery process in the health care systems of DOD and the
Department of Veterans Affairs (VA).
GAO was asked to discuss concerns regarding DOD and VA efforts to
provide medical care and rehabilitative services for servicemembers who
have been injured during OEF and OIF. This testimony addresses (1) the
transition of care for seriously injured servicemembers who are
transferred between DOD and VA medical facilities, (2) DOD's and VA's
efforts to provide early intervention for rehabilitation for seriously
injured servicemembers, (3) DOD's efforts to screen servicemembers at
risk for post-traumatic stress disorder (PTSD) and whether VA can meet
the demand for PTSD services, and (4) the impact of problems related to
military pay on injured servicemembers and their families.
This testimony is based on GAO work issued from 2004 through 2006
on the conditions facing OEF/OIF servicemembers at the time the audit
work was completed.
What GAO Found
Despite coordinated efforts, DOD and VA have had problems sharing
medical records for servicemembers transferred from DOD to VA medical
facilities. GAO reported in 2006 that two VA facilities lacked real-
time access to electronic medical records at DOD facilities. To obtain
additional medical information, facilities exchanged information by
means of a time-consuming process resulting in multiple faxes and phone
calls.
In 2005, GAO reported that VA and DOD collaboration is important
for providing early intervention for rehabilitation. VA has taken steps
to initiate early intervention efforts, which could facilitate
servicemembers' return to duty or to a civilian occupation if the
servicemembers were unable to remain in the military. However,
according to DOD, VA's outreach process may overlap with DOD's process
for evaluating servicemembers for a possible return to duty. DOD was
also concerned that VA's efforts may conflict with the military's
retention goals. In this regard, DOD and VA face both a challenge and
an opportunity to collaborate to provide better outcomes for seriously
injured servicemembers.
DOD screens servicemembers for PTSD but, as GAO reported in 2006,
it cannot ensure that further mental health evaluations occur. DOD
health care providers review questionnaires, interview servicemembers,
and use clinical judgment in determining the need for further mental
health evaluations. However, GAO found that 22 percent of the OEF/OIF
servicemembers in GAO's review who may have been at risk for developing
PTSD were referred by DOD health care providers for further
evaluations. According to DOD officials, not all of the servicemembers
at risk will need referrals. However, at the time of GAO's review DOD
had not identified the factors its health care providers used to
determine which OEF/OIF servicemembers needed referrals. Although OEF/
OIF servicemembers may obtain mental health evaluations or treatment
for PTSD through VA, VA may face a challenge in meeting the demand for
PTSD services. VA officials estimated that follow-up appointments for
veterans receiving care for PTSD may be delayed up to
90
days.
GAO's 2006 testimony pointed out problems related to military pay
have resulted in debt and other hardships for hundreds of sick and
injured servicemembers. Some servicemembers were pursued for repayment
of military debts through no fault of their own. As a result,
servicemembers have been reported to credit bureaus and private
collections agencies, been prevented from getting loans, g1 months
without paychecks, and sent into financial crisis. In a 2005 testimony
GAO reported that poorly defined requirements and processes for
extending the active duty of injured and ill reserve component
servicemembers have caused them to be inappropriately dropped from
active duty, leading to significant gaps in pay and health insurance
for some servicemembers and their families.
Prepared Statement of Shane McNamee, MD, Director, Hunter Holmes
McGuire Richmond Veterans Affairs Medical Center, Richmond, VA, U.S.
Department of Veterans Affairs
Good afternoon, Mr. Chairman and Members of the Committee. Thank
you for the opportunity to discuss the transition of our Wounded Heroes
through the Veterans Health Administration. My name is Dr. Shane
McNamee and I will be testifying from the perspective of a clinician as
well as in my role as the Medical Director of the Richmond Polytrauma
program. To frame the issue appropriately I will describe the typical
transition process of severely Wounded Heroes and their families from
the Military Treatment Facilities (MTF), through our programs and into
communities. It is my firm belief that this highly coordinated,
effective system is unparalleled in this Nation's medical system for
those who have suffered a Traumatic Brain Injury (TBI).
The key concepts of Seamless Transition I will be discussing are as
follows:
1. The significance of medical record access across the continuum
of care;
2. The importance of Relationship Based Medicine: and
3. The recognition of the Family as part the injury complex, and
integration of family into the therapeutic plan of care.
Our four Polytrauma Rehabilitation Centers (PRC) are consulted by
the MTFs when a Wounded Hero screens positive for a TBI. The referrals
that come to Richmond are processed by our Nursing Admissions
Coordinator. Following collection and analysis of clinical and family
information, we provide the MTF a decision on the referral within
twenty 4 hours of DOD's request for referral. At the earliest possible
time the family Members of the severely wounded are contacted by
myself, the Nursing Admissions Coordinator and the Social Worker
assigned to the case. This step has proved essential for several
reasons. For the family, the transition of a Wounded Hero between
medical facilities creates anxiety due to the unknown. Importantly,
this contact provides an early opportunity to build a relationship with
key family Members. This relationship with the patient and family
Members forms the basis of successful rehabilitation. The family also
serves as an invaluable resource in the recognition of personality and
cognitive changes that are common after TBI.
Numerous systems are used to develop an individualized plan of care
prior to admission to our PRC. Medical records are obtained through our
direct access of Walter Reed Army Medical (WRAMC) and Bethesda national
Naval Medical Center. Up to date information about medications,
laboratory studies, results of imaging studies and daily progress notes
are reviewed to determine the individual case parameters. We access the
web based Joint Patient Tracking Application (JPTA) to gain further
understanding of the patient's clinical status. Specifically the field
notes from Balad, Iraq and follow up at Landstuhl, Germany are
indispensable in determining the severity of the TBI. Our Nursing
Admissions Coordinator also obtains specific documentation through the
VA/DOD liaison personnel stationed at both WRAMC and Bethesda. As
Medical Director, I contact the referring physicians and discuss the
particulars of the case. Our facilities have scheduled Video
Teleconferences (VTC) to discuss the referral and to meet the Wounded
Hero and family Members ``face to face''. These tools are essential in
developing an intensive, individualized rehabilitation medicine plan
for each Wounded Hero before admission. This also includes the
coordination of resources necessary for the family; including housing,
transportation, meals and psychosocial supports.
Upon admission to our facility, each Member of our rehabilitation
team individually evaluates the Wounded Hero within twenty 4 hours and
pays particular attention to the functional needs. Our team consists of
a Physiatrist (Rehabilitation Physician), Rehabilitation Nurses,
Physical Therapists, Occupational Therapists, Speech and Language
Pathologists, Recreation Therapists, Kinesiotherapists,
Neuropsychologists, Psychologists, Dieticians, Social Work/Case
Managers (SW/CM), Military Liaisons and Blind Rehabilitation
Therapists. Our team meets three times weekly to discuss each patient
and to continually adjust the therapeutic plan of care. Each patient
undergoes three to 6 hours of therapy each day tailored specifically to
their individual functional and cognitive needs. We actively work to
reinstitute the roles that previously defined activities of our Wounded
Heroes.
As mentioned earlier, it is not just an individual who suffers a
TBI. Rather, the entire family structure is affected and requires
attention. The literature relating to TBI is very clear on the fact
that those individuals with strong psychosocial support structures are
more successful over time. Our support is multimodal and includes
health information through site specific literature, informal education
sessions, a formalized lecture series and intensive discharge planning.
Traditionally we provide professional support, emotional support,
logistical support, involvement in the care processes and the support
of the Military Liaison Officer. To further support the families, we
have instituted a pager and cell phone that are covered 24 hours a day
by Members of our Social Work team. This allows yet another level of
support of our families. Importantly, in a very real sense, the family
Members become an integral part of our team. This programming serves to
educate the family Members, decrease their anxiety of the unknown and
prepare them to care for their loved one over time.
In recognition of this need we have developed a model of care
appropriately referred to as Relationship Based Medicine. We have found
that it is the relationships with those involved in the continuum of
care that drives the success. Initially, we intensively work with the
families and patients to gain their trust and instill the recognition
that we are on their side. Once this level of trust has been
established, we can develop an effective treatment plan and approach.
It is important to point out that this relationship does not end once
discharged from our facility. Patients are followed at regular
intervals by the SW/CM staff along with the Physiatrist.
Intensive discharge planning is the cornerstone of any successful
rehabilitation plan. Our discharge plans are initiated the moment a
patient is admitted to the facility. On a weekly basis we discuss the
discharge needs and timelines necessary for success. These are
communicated with the families and aligned with their needs. Once a
discharge disposition is provided by the family, we begin to contact
necessary resources in their community. Based upon location, a consult
is opened either with one of the Polytrauma Network Sites (PNS) or
appropriate level of private care within the patient's community.
The consultation process includes a VTC or teleconference between
our team, the consulting team, the family and patient. These
conferences allow for a smooth handoff of the plan of care and specific
questions. Because many patients are still an Active Duty Service
Member, the Military Case Managers (MCM) are responsible to obtain
authorizations from the Military regarding orders and follow up care
based upon our team's recommendations.
Each family and patient is trained prior to discharge in medical
and nursing care appropriate for the patient. At the time of discharge
each of them are encouraged to evaluate our system. Their
recommendations for improvement are always implemented if possible.
After discharge our SW/CM follows each patient at prescribed intervals.
As the Medical Director, I continue to follow their medical issues from
afar and advocate for them when appropriate.
The integrated transition plan of care from MTF to PRC and into the
community is paramount in the success of our Wounded Heroes and
families. The system set up throughout VA is world class and has no
equal for those suffering from TBI. Across the system we continually
monitor and incorporate improvements. I am proud to be a part of the
exceptional rehabilitation staff who are fully dedicated in their
mission to serve those who have sacrificed so much.
Thank you Mr. Chairman and members of the Committee for your time.
Prepared Statement of Steven G. Scott, M.D., Medical Director, Tampa
Polytrauma Rehabilitation Center, James A. Haley Veterans' Hospital,
Tampa, FL, U.S. Department of Veterans Affairs
Mr. Chairman and Members of the Committee, thank you for the
opportunity to discuss our experience as it relates to the ``Service
Members Seamless Transition into Civilian Life--our Hero's Return.'' My
name is Dr. Steven Scott and I have been a specialist in Physical
Medicine and Rehabilitation since 1980. I have been employed at the
James A. Haley Veterans Hospital in Tampa, Florida since 1990 and have
directed both the spinal cord and traumatic brain injury (TBI)
programs.
Polytrauma Rehabilitation Care
I would like to provide you with a brief history of the development
of polytrauma rehabilitation care. In the summer of 2003, we began to
receive these unique patients who had been evacuated from the
battlefield following Improvised Explosive Device (IED) blast injury.
Due to tremendous advancements in military care, we now have the
opportunity to rehabilitate young men and women who in years past would
not have survived. These patients are medically complex and have
sustained numerous injuries which are complicated by serious TBI. The
primary focus of the polytrauma system of care has been to provide
rehabilitation care to the most seriously injured. A typical patient
has TBI, vision and/or hearing loss, pain, wounds, burns and orthopedic
problems (including amputations). We deal with extended families in
crisis, including spouses, children of all ages, parents, siblings as
well as other care givers. The stress and sacrifice of the family
frequently takes its toll, sometimes resulting in conflict and serious
marital issues.
The complexity of injuries to these combat veterans was unlike
those seen previously. The unique needs of these patients required
rapid realignment of our delivery of care to routinely include a
multidisciplinary team of medical specialists. In addition to our team
of physiatrists or physicians who specialize in physical medicine and
rehabilitation, we also have specialists in surgery, neurosurgery,
internal medicine, psychiatry, infectious disease, prosthetics,
orthotics, and spinal cord injury as part of the day-to-day planning
and patient care. Physiatrists also lead an interdisciplinary
rehabilitation team consisting of physical therapists, occupational
therapists, speech therapists, rehabilitation nurses,
kinesiotherapists, vocational therapists, social workers,
neurophysiologists, psychologists, advance nurse practitioners, wound
care nurses, respiratory therapists, recreational therapists,
rehabilitation counselors, military liaisons, chaplains, blind
occupational therapy case managers, physical therapy amputee case
managers, social worker case managers, education specialist and veteran
benefit specialist. Each one of these medical specialties and health
care disciplines has specialized expertise in caring for the polytrauma
patient and family and are essential to be sure that their
comprehensive care results in excellent outcomes.
Transition Between DOD and VA Polytrauma
As we developed the program, it became essential to establish a
mechanism to exchange medical information. Initially we established
physician to physician phone conferences to National Naval Medical
Center in Bethesda, Maryland, and at the Walter Reed Army Medical
Center (WRAMC) in Washington, DC. Videoconferencing with patient and
family Members in attendance was established with Brooke Army Medical
Center in San Antonio, Texas, and the National Naval and WRAMC. A
military treatment referral form is completed by the military and sent
to the on-site case manager DOD-VA military liaison social worker. This
form initiates the referral to the Polytrauma System of Care. Medical
record exchanges occurred between the Tampa VA and the military
treatment facilities (MTFs). This was a new practice for us, and we
have progressively improved the process. We continue to work on
improvements in the transfer of radiological images and microbiology
lab results. The VA Polytrauma Rehabilitation Centers (PRCs) have been
an active participant in the video-conference Trauma Continuum of Care
with the DOD which established improved practices in the care and
transportation of trauma patients. In addition, we were able to connect
to the Patient Joint Tracking System allowing us to get more detailed
medical information.
Most polytrauma patients remain on active duty during their entire
stay at the Tampa PRC. Therefore, ongoing information sharing between
VA PRCs and DOD is necessary. The military liaison assigned to the PRC
assists the patient and family with military issues and assists with
the maintenance of non-medical attendant orders which pay for family
Members to stay at the bedside. Patients are frequently referred back
to the MTF for follow-up surgery or placement in medical hold.
Polytrauma Focus on Transition
A military greeting team and case manager meets the patient and
family on arrival in Tampa. Community volunteers arrange free housing
and transportation to families through the Haley House Fund. Our 7-day-
week program for both patients and families always has community
reentry as its primary goal. Our staff and volunteers provide family
education classes, family support groups and planned family activities
such as ``Spouses' Day Out'', trips to NASA, and so forth. Our Internet
cafe provides activities outside structured therapy time. Recreational
therapy provides community re-entry activities such as shopping and
recreational activities. The patient and family advance in their
rehabilitation to have day passes and eventually weekend overnight
passes to practice their independence in community settings.
Transition to Home
The first step for our more independent patients is the Polytrauma
Transitional Day Program. The patient and family move into private
housing in the Tampa Bay area and continue to participate in group and
individual therapies for three to 6 months or more depending on their
needs. A comprehensive work therapy program places individuals in
community jobs to help develop vocational skills. If the patient
transitions to veteran status, he or she can become a candidate for the
Chapter 31 Independent Living Benefits.
When the active duty individual is prepared to leave Tampa, our
rehabilitation team and the patient and family meet to exchange
information by video conferences with the Polytrauma Network site
closest to the patient's home. Our case managers continue to follow the
patient and family via phone and work closely with the MTF case manager
on appropriate follow-up. The Network Site case manager and team
provide progress reports to the Tampa VA on a monthly basis via video
conferencing. Most patients are transitioned to home as active duty and
may continue as such for up to one to 2 years. As active duty service
Members, additional authorization numbers are required by Tri-Care for
continued rehabilitation therapies and medical care. Patients are
encouraged to return to the Tampa Polytrauma Outpatient Program at any
time.
Conclusion
I am honored to serve these courageous young men and women and
their families. I look forward to working with DOD, Congress, our VA
leaders, advocacy groups, and private citizens to continue to provide
excellent care and to improve future care throughout the lifespan for
America's wounded heroes.
Prepared Statement of William F. Feeley, MSW, FACHE, Deputy Under
Secretary for Health for Operations and Management, Veterans Health
Administration, U.S. Department of Veterans Affairs
Good afternoon Mr. Chairman and Members of the Committee.
Thank you for this opportunity to discuss ongoing efforts in the
Veterans Health Administration (VHA) to improve the quality of care we
provide to veterans returning from Operation Iraqi Freedom and
Operation Enduring Freedom. VHA is committed to providing
comprehensive, quality primary and specialty care to all enrollees with
an emphasis on meeting the specialized needs of OEF/OIF veterans. As
Secretary Nicholson said on Wednesday, we must ensure that our heroes
receive the best possible care and services. The VHA stands ready to do
everything we can to provide top-quality health care to all returning
OEF and OIF veterans. My comments will focus on the operational or
facility based aspect of our efforts.
Access to Care
Recent publications have acknowledged that VA provides veterans
with the best health care anywhere. Ensuring veterans have timely
access to that quality VA care is equally important.
VHA monitors how long veterans must wait for appointments,
including the time it takes for an OEF/OIF veteran to be seen. The
waiting times are reported every 2 weeks and are a highly visible item
for senior officials. Waiting times are a key performance element in
Network and Facility Directors' performance plans.
VHA has employed System Improvement Strategies in recent years to
reduce clinic wait times and help us ensure that our clinic processes
are as efficient as possible.
Some examples of these innovations are as follows:
Group Health Counseling in the dietetic area for diabetic
and congestive heart failure;
Extended hours in clinics, including Saturday clinics;
and
Normal Lab and x-ray reporting via phone rather than
requiring the patient to make a return visit to the medical center.
Polytrauma Centers
In order to meet the needs of our most severely injured veterans,
VA has created a Polytrauma System of Care which involves a tiered
approach to providing care for seriously injured veterans returning
from operations in Iraq and Afghanistan.
There are four tiers of acuity in the polytrauma system of care in
VHA. Level I consists of four centers that provide acute comprehensive
medical and rehabilitation care for complex and severe polytraumatic
injuries. They maintain a full staff of dedicated rehabilitation
professionals and consultants from other specialties related to
polytrauma. The centers serve as resources for other VA facilities and
are active in the development of educational programs and best practice
models of care.
These four level one centers are located in:
Tampa, FL
Richmond, VA
Minneapolis, MN and
Palo Alto, CA
Each Level I center has social work case managers at a ratio of one
for every six patients. These case managers assess the psychosocial
needs of each patient and family, match treatment and support services
to meet identified needs, coordinate services, and oversee the
discharge planning process. The social work case managers associated
with the center ensure that the combat wounded and their families
receive intensive clinical and psychosocial case management and
coordination of the veterans lifelong care needs.
The Level I centers offer a therapeutic environment that reflects
the preferences and needs of the combat injured. Resources have been
assembled nationally and locally to meet the special needs of families
who accompany the seriously injured service Members to the center. Such
resources include lodging at Fisher Houses or hotel accommodations
where a Fisher House is not yet available, transportation, telephone
cards, and gift certificates for meals and entertainment.
Patient improvement is assessed using a standardized instrument
that measures functional improvement from admission to discharge.
VHA also recognizes the severely injured may require extensive
rehabilitative therapy to successfully integrate back into the
community. To that end, the Department will develop four Residential
Transitional Rehabilitation Programs co-located with the Level I
Polytrauma Rehabilitation Centers. The activation date for these four
new Residential Transitional Rehabilitation programs is July 2007. A
transitional rehabilitation program is time limited and goal oriented
to improve the patient's physical, cognitive, communicative,
behavioral, psychological and social functioning under the necessary
support and supervision. The goal of these programs is to return these
patients to the least restrictive environment including, return to
active duty, work and school or independent living in the community.
Level II sites provide services for veterans who do not require the
intensity of care provided in Level I centers. These sites are
responsible for coordinating lifelong rehabilitation services for
patients within their network. Level II sites provide a high level of
expert care, a full range of clinical and ancillary services, and serve
as resources for other facilities within their Network. They provide
continued management of patients referred from the Level I Polytrauma
sites and evaluate patients referred directly to the Level II sites.
Services include proactive case management as well as patient family
support and education. They also consult, whenever necessary, with the
level I sites through the use of telerehabilitation technologies.
Level III sites have teams of providers with rehabilitation
expertise to deliver follow up services in consultation with regional
and network specialists. Level III support teams treat patients with a
stable treatment plan, provide regular follow-up visits, and respond to
new problems that may emerge. They regularly consult with level I and
II sites.
Level IV sites have at least one person identified to serve as a
central referral point for consultation, assessment and referral of
polytrauma patients to a facility capable of providing the level of
services required. They work closely with level I and level II centers.
This extensive Polytrauma network was created to adapt VHA's
existing health care system to provide care for the severely wounded
and meet their complex rehabilitative needs. Each Network has a Level I
or Level II center. VHA will continue to assess its Polytrauma services
and adapt its approach to care for those brave men and women returning
from combat.
This concludes my statement. I will be happy to answer any
questions you may have.
Prepared Statement of Edward C. Huycke, MD, Chief, Department of
Defense Coordination Officer, Veterans Health Administration, U.S.
Department of Veterans Affairs
Mr. Chairman and distinguished Members of the committee, thank you
for the opportunity to speak to you about the progress the Department
of Veterans Affairs (VA) and the Department of Defense (DOD) have made
in improving the delivery of health care and benefits to our Nation's
veterans. Improving the transition from military to civilian life for
veterans and their families is a high priority at VA and I am pleased
to be here today to provide you with an overview of the programs and
initiatives that VA and DOD have implemented to improve coordination
between our two systems.
Seamless Transition of Care and Benefits
Veterans Health Administration (VHA) staff coordinated the transfer
of care for more than 6,800 injured or ill active duty members and
veterans from DOD to VA--specifically those injured or ill as part of
the Global War on Terrorism in Iraq and Afghanistan and in particular
those transitioning directly from DOD Military Treatment Facilities
(MTFs) to VA Medical Centers (VAMCs).
And in partnership with DOD, VA has implemented a number of
strategies and innovative programs to provide the timely, appropriate,
and seamless services to the most seriously injured Operation Iraqi
Freedom/Operation Enduring Freedom (OIF/OEF) active duty Members and
veterans. One such program enables active duty Members to register for
VA health care and initiate the process for benefits prior to
separation from active service.
The centerpiece program supporting the seamless transition of
seriously injured service Members and veterans involves the placement
of VA Social Work Liaisons, VA Benefit Counselors, and Outreach
Coordinators at MTFs to educate service Members about VA services and
benefits. These VA employees assist active duty service members during
their transfer to VA medical facilities and ensure that returning
service Members receive information about VA benefits and services.
Currently, VA Social Work and Benefit liaisons are located at 10 MTFs
including Walter Reed Army Medical Center (WRAMC), National Naval
Medical Center Bethesda (NNMC), Naval Medical Center San Diego and
Womack Army Medical Center at Ft. Bragg, North Carolina.
In addition to the social work and benefits liaisons, a VA
Certified Rehabilitation Registered Nurse (CCRN) was assigned to WRAMC
in September 2006 to assess and provide regular updates to the VA
Polytrauma Rehabilitation Centers (PRC) to which they may be
transferred on the medical condition of the patient, educate families
about VA benefits and services and prepare the active duty
servicemember for transition to the rehabilitation phase of recovery.
Once the MTF treatment team notifies VHA of its plan to transfer
the patient, the VA Social Work Liaisons and the CCRN begin to
coordinate the care and information prior to transfer to VA. The VHA
Social Worker Liaison begins meeting with the patient and/or family to
educate them about the patient's transition from DOD's health care
system to VA's health care system. The VHA Social Work Liaison also
registers the active duty service Member or enrolls the recently
discharged veteran into the VA health care system, and begins the
process of coordinating a transfer to the VA health care facility most
appropriate for the services they need or for a location closest to
home. In the case of a polytrauma patient transfer, both the CCRN and
the Social Work Liaison remain an integral part of the treatment team
at the MTF while providing input into the VHA care plan and
collaborating with the patient and family throughout the remainder of
the health care transition process.
VA case management for these patients begins at the time of
transition from the MTF and continues as their medical and
psychological needs dictate. Once the patient is transferred to the
receiving VAMC or reports to his/her home VAMC for care, the VHA Social
Worker Liaison at the MTF follows up with the receiving VAMC to address
any issues and to ensure the patient is attending appointments.
Patients with severe injuries or those who have complex needs will
receive ongoing case management at the VAMC where they receive most of
their care.
An important aspect of the coordination of care between DOD and VA
prior to transfer is access to clinical information including the
viewing of electronic medical information using remote access
capabilities. Video teleconference calls are routinely conducted
between the DOD MTF treatment team and the receiving VA PRC enabling a
face-to-face discussion of a polytrauma patient's care prior to
transfer. If feasible, the patient and family may attend a video
teleconference in order to meet the team at the receiving VA PRC.
Utilizing the Bidirectional Health Information Exchange (BHIE), VA and
DOD clinicians are able to share text-based clinical data from WRAMC
and NNMC, the two MTFs that refer the majority of the polytrauma
patients. In addition, VA clinicians at the four Polytrauma
Rehabilitation Centers (PRCs)have access to DOD's Joint Patient
Tracking Application (JPTA) which tracks service Members from the
battlefield through Landstuhl, Germany and to MTFs in the states. JPTA
provides demographic and clinical information vital for the continued
care and treatment of these severely injured service Members.
In addition to the transition of health care, Veterans Benefits
Administration (VBA) counselors assigned to MTFs provide VA benefits
information and assistance in applying for these benefits. These
counselors are often the first VA representatives to meet with the
service member and his or her family to provide information about the
full range of VA services including readjustment programs, and
educational and housing benefits. Service Members and their families
are assisted in completing their claims and in gathering supporting
evidence.
While service Members are hospitalized, they are routinely informed
about the status of pending claims and given the VBA counselor's name
and contact information should they have any questions or concerns.
Compensation claims taken for the seriously disabled are expedited to
the appropriate VA Regional Office (VARO) with a clear indication that
they are for an OIF/OEF seriously disabled claimant. Although benefits
are not payable prior to discharge from service, work may begin on the
claim, and service Members may be informed about the status of their
claim while they are hospitalized.
Each VAMC and VARO has designated a point of contact (POC) to
coordinate activities locally and to assure that the health care and
benefits needs of returning service Members and veterans are met. A VBA
OIF/OEF Coordinator is designated for all OIF/OEF outreach activities
and acts as the primary VBA point of contact for seriously disabled
servicemembers who first arrive in the RO's area of jurisdiction as
medical patients. For each compensation claim received for a seriously
disabled OIF/OEF servicemember, a VBA Case Manager is also assigned.
The Case Manager then becomes the primary VBA point of contact for
claims processing. The VBA Counselors at the MTF may continue to be
involved if the servicemember is still a patient at the MTF.
VA has distributed guidance to field staff to ensure that the roles
and functions of the POCs and case managers are fully understood and
that proper coordination of benefits and services takes place at the
local level.
VAMCs also host DOD representatives. In March 2005, the Army
assigned full time active duty liaison officers to the four VA PRCs
located at Tampa, FL; Richmond, VA; Minneapolis, MN; and Palo Alto, CA.
The Army Liaison Officer supports service members and their families
from all branches of the Service with a broad array of issues such as
travel, housing, military pay, and movement of household goods. In
addition, Marine Corps representatives from nearby local Marine
commands visit and provide support to each of the four PRCs. In the VA
Central Office, an active duty Marine Officer and an Army Wounded
Warrior representative are assigned to and are part of the VA Office of
Seamless Transition staff. All of the DOD liaisons have played a vital
role in ensuring the provision of a bridge to services during the
critical time of recovery and rehabilitation.
Recognizing the need to provide assistance and support to families
during the tumultuous time of transition, VA established a
PolytraumaCall Center in February 2006 to assist our most seriously
injured combat veterans and service Members. The Call Center is
operational 24 hours a day, 7 days a week to answer clinical,
administrative, and benefit inquiries from polytrauma patients and
their families. The Call Center provides patients and families with a
source of information, enhances coordination of care, and elevates
system problems to VA for resolution.
Post Deployment Health Reassessment
VA is also reaching out to returning veterans whose wounds may be
less apparent. VA is participating in the DOD's Post Deployment Health
Reassessment (PDHRA) program for returning deployed service Members. In
addition to DOD's pre- and post-deployment assessments, DOD is now
conducting an additional health reassessment 90 to 180 days after
returning home from deployment to identify health issues that may
surface weeks or months after service Members return home. VA is
actively participating in the administration of PDHRA at Reserve and
Guard locations by providing information on VA care and benefits, by
enrolling these Reservists and Guardsmen in the VA healthcare system
and by arranging appointments for referred service Members. As of
December 2006, an estimated 68,800 service Members were screened
resulting in more than 17,100 referrals to VA. Of the referrals, 32.8%
were for mental health and readjustment issues with the remaining 67.2%
for physical health issues.
Closing
Meeting the comprehensive health care and benefit needs of our
Nation's veterans is VA's highest priority. We are very proud of the
progress we have made in the area of seamless transition as recognized
by both the IG and GAO. Mr. Chairman, this concludes my statement. I
thank you and Members of this Committee for your outstanding and
continued support of our service members, veterans and their families.
Prepared Statement of Ira R. Katz, MD, PhD, Deputy Chief Patient Care
Services Officer for Mental Health, Veterans Health Administration,
U.S. Department of Veterans Affairs
Mr. Chairman and Members of the Subcommittee, I am pleased to be
here today to discuss the ongoing steps that the Department of Veterans
Affairs (VA) is taking in order to meet the mental health care needs of
our Nation's returning veterans.
Care for Operation Iraqi Freedom and Operation Enduring Freedom
(OIF/OEF) veterans is among the highest priorities in VA's mental
health care system. For these veterans, VA has the opportunity to apply
what has been learned through research and clinical experience about
the diagnosis and treatment of mental health conditions; to intervene
early; and to work to prevent the chronic or persistent courses of
illnesses that have occurred in veterans of prior eras.
Since the start of the Global War on Terror (GWOT) until the end of
FY 2006, over 631,000 veterans have been discharged. Approximately 32.5
percent have sought care from the Veterans Health Administration (VHA)
medical facilities, and, of these, 35.7 percent have had diagnosis of a
possible mental health condition or concern. This makes mental health
second only to musculoskeletal conditions among the classes of
conditions seen most frequently in these returning veterans.
Somewhat less than half of the returning veterans with a mental
health condition who are seen in our medical facilities have a possible
diagnosis of post-traumatic stress disorder (PTSD), making it the most
common of the mental health conditions. However, PTSD is not the whole
story. Among the diagnosable conditions, mood disorders as a group,
when added together, are more common. Moreover, many veterans
experience non-specific stress-related symptoms that may be viewed more
appropriately as normal reactions to abnormal situations in combat,
rather than any disorder.
In response to the growing numbers of veterans returning from
combat in OIF/OEF, the Vet Centers initiated an aggressive outreach
campaign to welcome home and educate returning service Members at
military demobilization and National Guard and Reserve sites. Through
its community outreach and coordination efforts, the Vet Center program
also provides access to other VHA and Veterans Benefits Administration
(VBA) programs. To augment this effort, the Vet Center program first
recruited and hired 50 OEF/OIF veterans in February 2004 to provide
outreach to their fellow veterans. An additional 50 were hired by March
of 2005. When outreach leads to identification of mental health
conditions, veterans have a choice. They may receive care in Vet
Centers, medical facilities, or both. Last week Secretary Nicholson
announced plans to hire an additional 100 OEF/OIF veterans to conduct
outreach at both Vet Centers and VA medical facilities.
VA's approach to PTSD is to promote early recognition of this
condition for those who meet formal criteria for diagnosis and those
with partial symptoms. The goal is to make evidence-based treatments
(i.e., psychological, pharmacological, and rehabilitative) available
early to prevent chronicity and lasting impairment.
Throughout VHA, there is a sense of urgency about reaching out to
OIF/OEF veterans, engaging them in care, screening them for mental
health conditions, and making diagnoses, when appropriate. Screening
veterans for PTSD and other stress related conditions is a necessary
first step toward helping veterans recover from the psychological
wounds of war. In cases where there is a positive screen, patients are
further assessed and referred to mental health providers for further
follow-up and treatment, as necessary.
We recognize that even in America in 2007, there can still be some
degree of stigma associated with mental health conditions and their
treatment. That is why VA offers a number of options, for example for
care in mental health specialty services, Vet centers, or, increasingly
for mental health services provided in primary care settings. When
veterans with severe symptoms are reluctant to enter care, we are
prepared to educate them and their families, and to work with them to
overcome resistances. When veterans with milder symptoms are reluctant,
we watch them over time, and urge treatment if symptoms persist or
worsen.
VA has been a leader in research as well as clinical services for
PTSD. Last week, the Journal of the American Medical Association (JAMA)
included an article describing the benefits of a specific behavioral
treatment for PTSD. Before the results were even published, VHA was
establishing training programs to make this intervention available to
our patients. The translation from research into clinical practice will
not be instantaneous, but it can be accomplished more rapidly in VA
than in any other clinical setting.
Thank you, again, Mr. Chairman, for the opportunity to be here.
U.S. Department of Veterans Affairs
Washington, DC, 20420
March 7, 2007
The Hon. Ginny L. Brown-Waite
U.S. House of Representatives
Washington, DC 20515
Dear Congresswoman Brown-Waite:
In the past few weeks, questions have been raised about the ability
of the Department of Defense (DOD) and the Department of Veterans
Affairs (VA) to provide the world-class health care our service members
and veterans earned through their service and sacrifices. Many of these
questions are focused on conditions at Walter Reed Army Medical Center,
a DOD facility. Concerns have also been raised about VA's ability to
care for our returning Operation Iraqi Freedom and Operation Enduring
Freedom (OIF/OEF) veterans. So, I am writing to tell you what VA did,
is doing, and will do in the future to care for these heroes, who share
the honored title of ``American veteran.''
VA provides exceptional health care for veterans at more than 1,400
locations throughout our Nation. This year, we estimate more than 5.8
million patients will be cared for at our 154 hospitals, 135 nursing
homes, 45 domiciliaries, and 881 outpatient clinics. Approximately
209,000 of those veterans will have served in Iraq or Afghanistan. The
VA health care system is rated by many as the best health care system
in the country and a failure to provide our absolute best to even one
veteran is inexcusable.
I will not tolerate conditions within the facilities of the
Department of Veterans Affairs that do not meet our high standards. I
directed that all facilities for which I am responsible be inspected by
management to assure that they are up to par. Moreover, I directed that
VA focus all possible resources on providing priority service to our
returning OIF/OEF veterans and streamlining their access to that
service.
I am concerned some service Members may not have experienced a
seamless transition as they move from active military service to care
administered by VA. Often that transition takes a severely injured
service member from a military treatment facility (MTF) to a VA
polytrauma center, which is equipped to deal with the multiple injuries
we see in those patients, to include traumatic brain injury (TBI) and
amputations. The transition also includes the service Member's move
from the polytrauma center to his or her home, which may be distant
from our facilities. If even one of these young men or women does not
receive needed care, that is one too many, and we will do all within
our power to ensure such a situation is rectified.
Toward that end, I would like to tell you about a number of changes
I directed to further improve the way VA provides health care to these
heroes:
We expanded our network of polytrauma centers from the
original 4 to 1 in each of our 21 Veterans Integrated Service Networks.
Enclosed is an information paper describing our Polytrauma System of
Care.
All VA health care professionals are being trained to
recognize and care for patients with TBI.
We will be screening all patients who served in the
combat theater of operations for TBI and post-traumatic-stress disorder
(PTSD).
Every VA medical center now has specialty PTSD treatment
capability.
We are adding 23 new Vet Centers to our existing 209,
each with the professional capacity to intervene on PTSD and other
mental health issues.
We will engage a panel of outside clinical experts to
review and evaluate our Polytrauma System of Care.
We will establish a VA Advisory Committee on OIF/OEF
Veterans and Their Families. Membership will include severely wounded
combat veterans who have experienced VA care, family Members and care
givers of wounded veterans, and survivors. They are to help us identify
where we can, and must, do better.
Earlier this week, 1 directed that each of our polytrauma patients
be provided an advocate who will Work with that patient and his or her
family to ensure everything possible is done to minimize the strains on
the family and to assist them in navigating the VA system of care and
benefits. To expedite this, I directed the hiring of 100 additional
people, most of whom will be veterans of the Global War on Terror, to
be the personal advocates for these severely injured young men and
women and their families. These advocates will be available to the
veterans and their families around the clock, whether the patients are
at polytrauma centers, other VA medical facilities or their homes.
As service Members leave active duty, many will receive VA
disability compensation for injuries received. Since the onset of
combat operations in Iraq and Afghanistan, VA has expedited the claims
of seriously injured OIF/OEF veterans and their families. I have now
directed the Veterans Benefits Administration (VBA) to move the claims
of all combat veterans who have served in Iraq or Afghanistan to the
head of the line so processing their claims is a top priority. To
support expedited processing of all OIF/OEF claims and reduce the
claims backlog, I directed VBA to immediately begin an aggressive
hiring program to increase our on-board staffing level in the regional
offices by over 400 benefits employees between now and the end of June.
The President announced the creation of a bipartisan Commission on
Care for America's Returning Wounded Warriors to review the care of
wounded service men and women from the time they leave the battlefield
through their return to civilian life as veterans. The President has
asked me to chair his new interagency Task Force on Returning Global
War on Terror Heroes. We are charged to respond to the President in 45
days with a report and recommendations to address the immediate needs
of those making the transition from active military to veteran status.
I invite you to visit our VA facilities in your district or
elsewhere as soon as your schedule permits. When you do, I am confident
that you will be impressed with the care and commitment of those
serving our veterans. I would like to hear your reactions following
such visits. Certainly, if you find there are any situations you
consider unacceptable, I ask you to contact me. I can assure you I will
take immediate corrective action.
I have enclosed a separate fact sheet concerning the many VA
initiatives under way to assist OIF/OEF veterans. Further, to ensure
your concerns can be conveyed to me expeditiously, I have asked Tom
Harvey, Acting Assistant Secretary for Congressional Affairs, to
establish a separate phone number (202) 368-8895 for Members to call at
any time. That line will be monitored by him or by one of his senior
staff to assure your concerns about our Nation's veterans receive the
prompt attention they deserve. Thank you for your support of our
veterans.
Sincerely yours,
R. James Nicholson
Secretary
Enclosures
__________
Department of Veterans Affairs (VA) Fact Sheet
Poly trauma System of Care
VA established a Poly trauma System of Care for veterans
and active duty personnel with lasting disabilities due to poly trauma
and traumatic brain injury (TBI).
The mission of the Poly trauma System of Care is to
provide the highest quality medical, rehabilitation, and support
services to veterans and active duty service Members injured in service
to our country.
Development of the Poly trauma System of Care followed
three fundamental principles:
Geographic distribution of specialty rehabilitation
programs to facilitate transitioning veterans into their home
communities.
Use an interdisciplinary model of care delivery where
specialists from several medical and rehabilitation disciplines
work together to develop an integrated treatment plan for each
veteran.
Provide lifelong services for veterans with severe
impairments and functional disabilities resulting from poly
trauma and TBI.
The Poly trauma System of Care is currently comprised of
21 network sites, including 4 regional centers. Local polytrauma/TBI
support teams are under development at all other VA facilities.
VA is improving coordination of care for veterans with
poly trauma and TBI by assigning a social work case manager to every
patient treated at the poly trauma centers. The assigned case manager
handles the continuum of care and care coordination, acts as the point-
of-contact for emerging medical, psychosocial, or rehabilitation
problems, and provides psychosocial support and education.
A Poly trauma Telehealth Network (PTN) links facilities
in the Poly trauma System of Care and supports care coordination and
case management. The PTN provides state-of-the-art multipoint
videoconferencing capabilities. It ensures poly trauma and TBI
expertise are available throughout the system of care and that care is
provided at a location and time most accessible to the patient.
From the experience of the Poly trauma Rehabilitation
Centers, we have learned that inpatient rehabilitation is only the
beginning of a long road toward recovery for many poly trauma patients.
Efforts are under way to develop a full spectrum of rehabilitation
services to include transitional rehabilitation and programs for
patients who are slow to recover or have long-term care needs.
Polytrauma System of Care Sites
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Polytrauma Rehabilitation Centers VISN Polytrauma Network Sites
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McGuire VAMC 1 VA Boston HCS--West Roxbury Campus
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Richmond, VA
2 Syracuse VA Medical Center
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3 Bronx VA Medical Center
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4 Philadelphia VA Medical Center
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5 Washington DC VA Medical Center
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6 Richmond VA Medical Center
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James A. Haley VAMC 7 Augusta VA Medical Center
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Tampa, FL
8 Tampa VA Medical Center
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9 Lexington VA Medical Center
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16 Houston VA Medical Center
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VA North Texas Health Care System--
17 Dallas VA Medical Center
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Minneapolis VAMC 10 Cleveland VA Medical Center
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Minneapolis, MN
11 Indianapolis VA Medical Center
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12 Hines VA Medical Center
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15 St. Louis VA Medical Center
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23 Minneapolis VA Medical Center
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Palo Also VAMC VA Southern Arizona Health Care
Palo Alto, CA 18 System--Tucson VA Medical Center
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VA Eastern Colorado Health Care
19 System--Denver VA Medical Center
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VA Puget Sound Health Care
20 System--Seattle VA Medical Center
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VA Palo Alto Health Care
21 System--Palo Alto VA Medical Center
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VA Greater Los Angeles Health Care
22 System--West LA VA Medical Center
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__________
Department of Veterans Affairs (VA) Fact Sheet
Initiatives to Enhance Care and Service to Operation Iraqi Freedom and
Operation Enduring Freedom (OIF/OEF) Veterans
Summary
VA is committed to its veterans. These courageous men and
women serving in Iraq, Afghanistan and elsewhere in the Global War on
Terror are Priority One.
In a system that is rated by many as the ``best health
care system in the country,'' not providing our absolute best to even
one veteran is unacceptable.
VA wants veterans, and all Americans, to know that it can
and will do better.
President Bush has made the administration's priority
very clear: There should be no excuses, only action.
On March 5, 2007, Secretary Nicholson directed the
immediate hiring of 100 patient advocates. These new hires will serve
as ``ombudsmen'' for seriously injured returning service Members and
their families, helping them cut through red tape and navigate the
system--24/7.
Secretary Nicholson will also be working closely with
President Bush's new Presidential Commission tasked to review the care
provided to our wounded servicemen and women--from the time they leave
the battlefield through their return to civilian life as veterans.
Secretary Nicholson will head an interagency Task Force
on Returning Global War on Terror Heroes, charged to respond to the
President in 45 days, to address the immediate needs of those making
the transition from active military to veteran status.
Secretary Nicholson is establishing an advisory committee
to focus on the concerns and needs of our returning OIF/OEF veterans
and their families. Veterans and their families will be represented on
the panel, and they will help us identify where we can do better.
Funding
Earlier this month, VA announced the Administration is
requesting a landmark budget of nearly $87 billion for VA in FY 08.
This budget proposal represents a 77-percent increase in
the overall budget since the President took office in FY 01, and more
than 83 percent more for health care spending.
With the continued support of Congress, the
administration's FY 08 budget will provide VA with the resources it
needs to continue its important mission.
Health Care
Combat veterans have access to free health and dental
care from VA for 2 years--bypassing the normal rules that require
determinations of service-connected injuries or income levels.
VA operates the largest integrated health care system in
the country. VA treats patients at over 1,400 sites of care, including
154 hospitals, more than 800 outpatient clinics and 135 nursing homes.
To care for severely injured veterans, VA established 4
regional Polytrauma Rehabilitation Centers (Palo Alto, CA; Minneapolis,
MN; Richmond, VA; and Tampa, FL), staffed with the full range of
specialists needed to treat these veterans. VA has expanded the
polytrauma system of care to include 21 Polytrauma Network Sites (the 4
regional Polytrauma Rehabilitation Centers serve as the Polytrauma
Network Site for their respective Networks) and Polytrauma Support
Clinic Teams across the country to care for these veterans as they
return to their homes and communities.
VA has mandated traumatic brain injury (TBI) training for
all VA health care professionals.
VA is implementing a program to screen all patients who
served in the combat theaters of Iraq or Afghanistan for TBI.
VA is also establishing a panel of outside experts to
review its complete Polytrauma System of Care, including TBI programs.
More than half of the physicians practicing in the United States
received some of their professional education at VA medical centers.
VA health care facilities help train students from 107
medical schools, 55 dental schools and more than 1,200 schools of
allied health.
Mental Health
VA is the largest provider of mental health services in
the country. VA employs more than 9,000 frontline mental health
workers-- psychologists, psychiatrists and social workers-- up more
than 15 percent since 2003.
Last year, VA provided mental health care to about 1
million patients.
VA's FY 08 budget request calls for nearly $3 billion in
mental health services, plus another $100 million for the operation of
its Vet Centers.
VA's health care system currently features more than 200
specialized hospital-based Post-Traumatic Stress Disorder (PTSD)
programs. Every VA medical center now has specialty PTSD capability.
On February 7, 2007, Secretary Nicholson announced plans
to open 23 new community-based ``Vet Centers,'' which are an important
part of VA's mental health program, especially the treatment of PTSD.
These will augment the more than 200 Vet Centers already operating.
VA is the recognized leader in the study and treatment of
PTSD. The National Center for PTSD operated by VA is an internationally
recognized resource for research and clinical improvement in treatment
of PTSD and other combat-related mental health problems.
Seamless Transition
VA is reaching out to ensure our newest generation of
combat veterans is aware of benefits available to them. Over the past 4
years, VA has provided 29,000 briefings about VA benefits to over 1
million active duty and reserve personnel.
VA has hired 100 veterans to serve as ``outreach
specialists'' in the Vet Center program to provide outreach and
educational services to their fellow veterans returning from OIF/OEF.
VA has been working aggressively to make contact with our newest
generation of veterans at military demobilization and National Guard
and Reserve sites.
To date, VA has seen nearly 350 veterans at its
polytrauma centers and has coordinated the transfer of 6,869 seriously
injured and ill service Members directly from Department of Defense
Military Treatment Facilities (MTFs) to VA hospitals throughout the
Nation.
On February 12,2007, Secretary Nicholson announced a
collaborative effort between VA and the states. It will use VA staff to
put the most severely injured veterans still in MTFs in contact with
the veterans affairs departments in their home-states.
Secretary Nicholson is establishing the position of
Special Assistant to the Under Secretary for Health for OIF/OEF Health
Issues to begin the process of offering polytrauma patients and their
families ``second opinions'' from private rehabilitation facilities on
their treatment plans and to continue the Secretary's policy of meeting
regularly with small groups of GWOT veterans and their families to
listen to concerns and resolve these issues quickly.
U.S. General Accounting Office
Washington, DC, 20548
June 30, 2006
The Hon. Michael Bilirakis
Chairman
Subcommittee on Oversight and Investigations
Committee on Veterans' Affairs
House of Representatives
Subject: VA and DOD Health Care: Efforts to Provide Seamless
Transition of Care for OEF and OIF Servicemembers and Veterans
Dear Mr. Chairman:
As of the end of March 2006, over 1.3 million \1\ U.S. military
servicemembers had served or were serving in Operation Enduring Freedom
(OEF) or Operation Iraqi Freedom (OIF).\2\ These servicemembers,
including Members of the reserves and National Guard, may be eligible
to receive health care from the Department of Veterans Affairs (VA)
while serving on active duty or upon separating from active duty.
Although the Department of Defense (DOD) provides health care services
to servicemembers under TRICARE,\3\ legislation passed by the Congress
in May 1982 authorized VA to provide health care services to
servicemembers in time of war or national emergency, when DOD may have
insufficient resources to care for casualties.\4\ Through December 16,
2005, DOD had arranged for 193 active duty servicemembers with serious
injuries--traumatic brain injuries and other complex trauma, such as
missing limbs--to receive medical and rehabilitative \5\ care at VA
polytrauma rehabilitation centers (PRC).\6\ In addition, about 30
percent (over 144,000) of the servicemembers who had separated from
active duty following service in OEF or OIF have sought VA health care,
including over 4,000 who received inpatient care at VA medical
facilities.
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\1\ DOD's Contingency Tracking System Deployment File for
Operations Enduring Freedom and Iraqi Freedom reported that as of March
31, 2006, the total number of servicemembers ever deployed was
1,312,221.
\2\ OEF, which began in October 2001, supports combat operations in
Afghanistan and other locations, and OIF, which began in March 2003,
supports combat operations in Iraq and other locations.
\3\ DOD provides health care through TRICARE--a regionally
structured program that uses civilian contractors to maintain provider
networks to complement health care services provided at military
treatment facilities.
\4\ The Veterans' Administration and Department of Defense Health
Resources Sharing and Emergency Operations Act, Pub. L. No. 97-174,
4(a), 96 Stat. 70, 74-75.
\5\ Most servicemembers receive medical care from DOD providers.
However, DOD does not typically provide long-term rehabilitative
services and looks to VA to be a provider of these services.
\6\ The Veterans Health Programs Improvement Act of 2004, Pub. L.
No. 108-422, 302, 118 Stat. 2379, 2383-86, mandated that VA establish
centers for research, education, and clinical activities related to
complex multiple trauma associated with combat injuries. In response to
that mandate, VA established PRCs at four VA medical facilities with
expertise in traumatic amputation, spinal cord injury, traumatic brain
injury, and blind rehabilitation. The PRCs address the rehabilitation
needs of the combat injured in one setting and in a coordinated manner.
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In September 2005, we testified on VA's collaboration with DOD to
provide seamless transition of care for servicemembers between DOD and
VA health care systems--that is, no interruption of care as the person
moves from being a DOD patient to being a VA patient.\7\ We reported
that VA has developed policies and procedures that direct its medical
facilities to provide OEF and OIF servicemembers with timely access to
care but that the sharing of health information between DOD and VA was
limited. You asked us to update the information we provided in our
testimony by reviewing the efforts VA is making to inform
servicemembers and veterans about VA health care services and to help
ensure that there is a seamless transition of care for servicemembers
from DOD's to VA's health care system. We addressed the following
questions:
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\7\ GAO, VA and DOD Health Care: VA Has Policies and Outreach
Efforts to Smooth Transition from DOD Health Care, but Sharing of
Health Information Remains Limited, GAO-05-1052T (Washington, D.C.:
Sept. 28, 2005). Also see Related GAO Products at the end of this
report.
1. What outreach efforts has VA made to inform OEF and OIF
servicemembers and veterans about the VA health care services that may
be available to them?
2. What actions has VA taken to facilitate the seamless transition
of medical and rehabilitation care for seriously injured OEF and OIF
servicemembers who are transferred between DOD medical treatment
facilities (MTF) and PRCs?
3. What special educational activities or clinical tools is VA
using to help ensure its medical providers are aware of and recognize
the needs of eligible OEF and OIF servicemembers and veterans?
To determine outreach efforts VA has made to inform OEF and OIF
servicemembers and veterans about the VA health care services that may
be available to them, we interviewed, and collected supporting
documentation from, VA officials on their efforts and programs that
have been established to inform servicemembers and veterans about VA
health care services. We also observed briefings given by VA
representatives at two military installations \8\ to active duty and
reserve servicemembers about VA health care services for which they may
be eligible.
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\8\ VA provides briefings at hundreds of MTFs. We attended
briefings at two judgmentally selected installations--the Naval Station
Norfolk, Norfolk, Virginia, and Fort Benning Army Base, Columbus,
Georgia.
---------------------------------------------------------------------------
To identify actions VA has taken to facilitate the seamless
transition of care between MTFs and PRCs for servicemembers seriously
injured in OEF and OIF, we reviewed VA directives, policies, and
handbooks governing access to VA health care by OEF and OIF
servicemembers and veterans. We also visited the two MTFs that treat
most of the seriously injured OEF and OIF servicemembers--Walter Reed
Army Medical Center and the National Naval Medical Center, both located
in the Washington, D.C., area--and the four PRCs that treat them. The
PRCs are located at VA Medical Centers in Palo Alto, California; Tampa,
Florida; Minneapolis, Minnesota; and Richmond, Virginia. During those
visits, we interviewed medical providers and reviewed the VA electronic
medical records of the 193 seriously injured servicemembers who were
admitted to the PRCs from January 7, 2002,\9\ through December 16,
2005. In addition, we attended a discharge planning conference for an
OIF servicemember being discharged from a PRC to document the
information provided to the servicemember about his follow-up health
care from VA and DOD. We made subsequent visits to the Richmond and
Tampa PRCs to observe the capability of PRC providers to access DOD
electronic medical records.
---------------------------------------------------------------------------
\9\ Although OEF began in October 2001, the earliest recorded date
that a servicemember injured in OEF was admitted to a PRC for treatment
was January 7, 2002.
---------------------------------------------------------------------------
To identify the special educational activities or clinical tools
that VA is using to help ensure its medical providers are aware of and
recognize the needs of eligible OEF and OIF servicemembers and
veterans, we interviewed, and collected supporting documentation from,
VA officials. While we were at the Naval Station Norfolk conducting
audit work, we also visited the VA Medical Center in Hampton, Virginia,
to obtain information on the educational activities and clinical tools
VA uses when treating OEF and OIF servicemembers and veterans. We also
obtained this information from the four PRCs. Further, we determined
the number of VA medical providers and other staff who completed online
educational courses developed by VA.
Our review was conducted from May 2005 through June 2006 in
accordance with generally accepted government auditing standards.
Results in Brief
VA has made a variety of outreach efforts to provide OEF and OIF
servicemembers and veterans and their families with information on VA
health care services. VA reported that from October 1, 2000, through
May 31, 2006, it provided about 36,000 briefings to almost 1.4 million
active duty, reserve, and National Guard servicemembers about VA health
care services that may be available to them. In some cases, family
Members also attended these briefings, which were provided at over 200
sites, including 70 sites outside the United States. VA also maintains
a Web site containing health information focused on OEF and OIF
servicemembers and veterans, distributes brochures and pamphlets to
provide information about topics of interest to OEF and OIF
servicemembers and veterans and their families, and sends letters and
newsletters to veterans about VA health care services and health issues
specific to veterans.
VA has taken several actions to facilitate the transition of
medical and rehabilitative care for seriously injured servicemembers
who are being transferred from MTFs to PRCs. In April 2003, the
Secretary of VA authorized VA medical facilities to give priority to
OEF and OIF servicemembers over veterans, except those with service-
connected disabilities. In April 2004, VA signed a memorandum of
agreement (MOA) with DOD that established the referral procedures for
transferring injured servicemembers from DOD to VA medical facilities.
VA and DOD also established joint programs to ease the transfer of
injured servicemembers to VA medical facilities, including a program
that assigned VA social workers to selected MTFs to coordinate patient
transfers to VA medical facilities. Nevertheless, problems remain in
the process for electronically sharing the medical records VA needs to
determine whether servicemembers are medically stable enough to
participate in vigorous rehabilitation activities. According to VA
officials, the transfer could be more efficient if PRC medical
personnel had real-time access to the servicemembers' complete DOD
electronic medical records from the referring MTFs. VA and DOD reported
that as of December 2005 only two of the PRCs had requested and been
granted real-time access to the electronic medical records maintained
at Walter Reed Army Medical Center. One of these PRCs had also been
granted access to the electronic medical records at the National Naval
Medical Center. However, problems continue to exist with the PRCs'
ability to access DOD electronic medical records. During a visit to the
two PRCs in April 2006, we found that neither facility could access the
DOD electronic medical records at Walter Reed Army Medical Center
because of technical difficulties. Furthermore, while VA's electronic
medical record system captures a wide range of patient information, we
found that at the time we conducted our audit work it did not always
contain a complete record of information related to the patient's
discharge from the PRC, such as dates and times of follow-up medical
appointments--information that could be useful for maintaining
continuity of care or responding to a patient inquiry about future
appointments. In response to our concerns about this problem, VA has
taken corrective action. The department has developed a template that
identifies the information given to servicemembers at discharge from
PRCs. The template has been included in VA's electronic medical record
for use systemwide.
VA has developed a number of educational activities and online
clinical tools to help ensure that VA medical providers and other staff
are aware of and recognize the health care needs of OEF and OIF
servicemembers and veterans. Examples of VA's educational efforts
include developing online courses on infectious diseases of Southwest
Asia; holding conferences on brain injuries; conducting conference
calls, each of which provided more than 100 VA staff with information
on transferring servicemembers from DOD to VA health care services; and
developing publications on the long-term effects of using an
antimalarial drug. VA has also provided educational activities at two
East Coast centers targeting medical professionals (such as physicians,
nurses, and social workers), including conferences on topics such as
physical and mental health issues, infectious disease issues, and
health care services provided by VA. Furthermore, VA has developed
clinical tools to help its staff be aware of and responsive to the
needs of OEF and OIF servicemembers and veterans. For example, it has
added reminder screens to its electronic medical records that pop up
when staff are accessing patients' records and prompt them to ask
questions about OEF- and OIF-related medical and psychological
conditions, such as infectious diseases and depression. VA and DOD have
also developed guidelines to assist clinicians in providing medical
care to OEF and OIF veterans.
We provided a draft of this report to VA and DOD for comment. VA
concurred with the information presented in our draft report. DOD
commented that the report portrays the numerous efforts that have been
made to improve the efficacy of programs designed to ensure a smooth
transition and continuity of care as servicemembers transition back and
forth between DOD and VA health care systems. DOD also stated that the
report contained several inaccuracies; however, we maintain that the
information contained in the report accurately presents the results of
our audit work.
Background
DOD has reported that as of June 26, 2006, over 19,000
servicemembers have been wounded in action since the onset of OEF and
OIF. Some of these servicemembers are surviving injuries that would
have been fatal in past conflicts. In World War II, about 30 percent of
American servicemembers wounded in combat died. Because of medical
advances, this proportion has dropped to 3 percent for OEF and OIF
servicemembers, but many of them are returning home with severe
disabilities, including traumatic brain injuries and missing limbs. In
2005, DOD reported that about 65 percent of the OEF and OIF
servicemembers wounded in action were injured by blasts and fragments
from improvised explosive devices, land mines, and other explosive
devices. More recently, DOD estimated in 2006 that the percentage of
those injured by blasts and fragments who have some degree of trauma to
the brain ranged from less than 20 percent to 28 percent. These
injuries may require comprehensive inpatient rehabilitation services to
address complex cognitive, physical, and mental health impairments.\10\
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\10\ Traumatic brain injuries may cause problems with cognition
(concentration, memory, judgment, and mood), movement (strength,
coordination, and balance), sensation (tactile sensation and vision),
and emotion (instability and impulsivity).
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While servicemembers are on active duty, DOD manages where they
receive their care--at an MTF, a TRICARE civilian provider, or a VA
medical facility. Once discharged from the military or demobilized from
the reserves or National Guard, veterans may be eligible to receive
care from VA's health care system.
From the OEF and OIF conflict areas, seriously injured
servicemembers are usually brought to Landstuhl Regional Medical Center
in Germany for treatment. From there, they are usually transported to
MTFs located in the United States, with most of the seriously injured
admitted to Walter Reed Army Medical Center or the National Naval
Medical Center. Once seriously injured servicemembers are medically
stabilized, DOD can elect to send those with traumatic brain injuries
and other complex trauma, such as missing limbs, to one of the four
PRCs for rehabilitative services.
The transfer of injured servicemembers from MTFs to VA medical
facilities for medical care requires the exchange of health information
between DOD and VA. In August 1998, the President issued a directive
requiring VA and DOD to develop a computer-based patient record system
that would accurately and efficiently exchange information between the
departments. The directive stated that VA and DOD should define,
acquire, and implement a fully integrated computer-based patient record
available across the entire spectrum of health care delivery over the
lifetime of the patient.\11\
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\11\ National Science and Technology Council, A National
Obligation: Planning for Health Preparedness for and Readjustment of
the Military, Veterans, and Their Families After Future Deployments,
Presidential Review Directive 5 (Washington, D.C.: Executive Office of
the President, Office of Science and Technology Policy, August 1998).
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Since receiving the President's directive, VA and DOD have been
working to exchange patient health information electronically and
ultimately to have interoperable electronic medical records. VA and DOD
have begun to implement applications that exchange limited electronic
medical information between the departments' existing health
information systems. One of these applications--the Bidirectional
Health Information Exchange--is a project to achieve the two-way
exchange of health information on patients who receive care from both
VA and DOD. The application has been implemented at all VA sites and at
14 DOD sites to exchange information such as pharmacy and allergy data,
but as we testified in September 2005, the goal of systemwide two-way
electronic exchange of patient records remains far from being
realized.\12\ As a separate effort, VA and DOD have undertaken an
initiative to allow the four PRCs to electronically access medical
records at Walter Reed Army Medical Center and the National Naval
Medical Center to obtain information on seriously injured OEF and OIF
servicemembers. The capability for electronic access was requested by
the Richmond and Tampa PRCs in 2005 and by the Palo Alto and
Minneapolis PRCs in 2006. This capability will be limited to a small
number of providers at each of the PRCs.
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\12\ GAO, Computer-Based Patient Records: VA and DOD Made Progress,
but Much Work Remains to Fully Share Medical Information, GAO-05-1051T
(Washington, D.C.: Sept. 28, 2005).
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Apart from joint efforts to share medical information, VA and DOD
separately have developed electronic systems for recording and
accessing patient health information. VA's electronic medical records
are maintained in a system that captures a wide range of patient
information, including doctors' progress notes, vital signs, laboratory
results, medications dispensed, drug allergies, radiological images,
and clinical reminders. VA's system also allows the patient's complete
medical record to be accessed from any VA medical facility. While DOD's
electronic medical record system also captures information such as
doctors' progress notes, vital signs, medications dispensed, and
laboratory results, it does not include radiological images, vision and
hearing tests, or anesthesia notes. In addition, DOD does not have a
systemwide approach to electronic medical record management since the
information is maintained and stored at individual MTFs or, in some
locations, in networks that service multiple MTFs within a small
geographic area. Under DOD's approach, all medical information cannot
be electronically accessed by providers throughout DOD's health care
system. For example, providers at Walter Reed Army Medical Center and
the National Naval Medical Center can access each other's electronic
medical records but cannot access medical records from Landstuhl
Regional Medical Center in Germany.
VA's Outreach Includes Briefings, Web Sites, and Newsletters
VA has taken a number of actions to provide OEF and OIF
servicemembers and their families with information about VA health care
services, such as the cost of the services, how to register for VA
health care, and where to obtain VA health care. VA reported that from
October 1, 2000, through May 31, 2006, it held about 36,000 briefings
for almost 1.4 million active duty, reserve, and National Guard
servicemembers. These briefings were held at over 200 sites, including
70 sites located outside the United States. VA reported that over 8,000
family Members attended some of these briefings from October 1, 2005,
through May 31, 2006. In addition, under a May 2005 MOA between VA and
the National Guard, VA has trained staff hired by the National Guard to
provide VA health and benefit information to National Guard units in
each state.
For both servicemembers and veterans, VA has also created a Web
site \13\ that provides information for those who served in OEF and
OIF, such as information on VA health and medical services, dependents'
benefits and services, and transition assistance from military to
civilian life. The Web site contains information about VA benefits
available to active duty military personnel, including a page that
briefly describes these benefits. VA has also developed a variety of
informational materials, including a wallet-sized card with relevant
toll-free telephone numbers and Web site addresses, fact sheets and
pamphlets summarizing VA benefits, and a monthly video magazine called
The American Veteran. VA reported that almost 1.4 million of the
wallet-sized cards have been distributed during briefings. Fact sheets
and pamphlets are sent to VA medical facilities for distribution to
veterans and are also available on VA's Web site. The video magazine
reports information about VA services on a VA Web site \14\ and on the
Pentagon Channel, which is available online\15\ and on cable
television.
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\13\ See http://www.seamlesstransition.va.gov.
\14\ See http://www1.va.gov/opa/feature/amervet/index.htm.
\15\ See http://www.pentagonchannel.mil.
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VA also has outreach efforts designed specifically for active duty,
reserve, and National Guard OEF and OIF veterans. The Secretary of VA
sends new veterans a letter thanking them for their service to the
country and informing them about VA health care services and assistance
in their transition to civilian life. As of May 15, 2006, the Secretary
had sent letters to over 530,000 OEF and OIF servicemembers who had
left active duty. These letters include information about the VA health
care services available to veterans and a toll-free number for
obtaining additional health care information. In addition, from
December 2003 through March 2006 VA sent four newsletters to OEF and
OIF veterans with information on health issues of interest to these
veterans.
VA Activities Facilitate the Transition of Care for Seriously Injured
OEF and OIF Servicemembers Transferred to PRCs
VA has taken a number of actions to facilitate the transition of
medical and rehabilitation care for servicemembers who have been
seriously injured in OEF and OIF and are being transferred between DOD
and VA medical facilities. These actions focus on establishing and
expanding internal initiatives for providing care to this population as
well as VA's efforts to electronically share medical records with DOD.
In April 2003, when the President declared a national emergency
with respect to the Iraq conflict, the Secretary of VA issued a
memorandum authorizing VA medical facilities to give priority to
servicemembers who sustained injuries in OEF and OIF over veterans and
others eligible for VA health care, except those with service-connected
disabilities. In October 2003, VA issued a directive requiring its
medical facilities to designate a point of contact to receive and
expedite transfers of servicemembers from DOD to VA medical facilities.
In April 2004, VA signed an MOA with DOD to provide health care and
rehabilitation services to servicemembers who sustain spinal cord
injury, traumatic brain injury, or visual impairment. The MOA
established the referral procedures for transferring active duty
inpatient servicemembers from DOD to VA medical facilities.\16\ In June
2005, VA issued a directive expanding the scope of care it would
provide to include psychological treatment for family Members and
intensive clinical and social work case management services \17\ at its
four regional traumatic brain injury rehabilitation centers and renamed
these facilities PRCs.
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\16\ In addition to outlining DOD's and VA's responsibilities in
the transfer process, the MOA also established the reimbursement rate
between the two departments for inpatient care that VA would provide.
\17\ Case management includes assessment of the individual's health
care needs, care planning and implementation, referral coordination,
monitoring, and periodic reassessment of the individual's health care
needs.
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VA has also established joint programs with DOD to ease the
transfer of injured servicemembers to VA medical facilities. In August
2003, VA and DOD established a program that assigned VA social workers
to selected MTFs \18\ to coordinate patient transfers between DOD and
VA medical facilities. The social workers make appointments for care,
ensure continuity of therapy and medications, and follow up with
patients after discharge. By late February 2006, VA reported that the
social workers had received requests for transfer of care for over
6,000 patients, and over three-fourths of them had been transferred to
VA facilities; the rest of the requests were pending.\19\ Under another
program, a uniformed servicemember was stationed at each PRC beginning
in March 2005 to assist servicemembers being admitted to the PRC. The
uniformed servicemembers serve as liaisons among injured servicemembers
and their families, the MTFs, the PRCs, and the servicemembers' units.
For example, they assist with reimbursement for travel and lodging
costs for immediate family Members.
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\18\ Five MTFs were originally selected because they received most
of the OEF and OIF casualties. These facilities were Walter Reed Army
Medical Center (Washington, D.C.), Brooke Army Medical Center (San
Antonio, Texas), Dwight David Eisenhower Army Medical Center (Augusta,
Georgia), Madigan Army Medical Center ( Tacoma, Washington), and the
National Naval Medical Center (Bethesda, Maryland). In 2004 and 2005,
three additional MTFs--Darnall Army Community Hospital (Fort Hood,
Texas), Evans Army Community Hospital (Fort Carson, Colorado), and the
Naval Hospital Camp Pendleton (Camp Pendleton, California)--were added
to care for returning OEF and OIF servicemembers.
\19\ According to VA, patients remain in pending status until DOD
determines that the patient is ready for transfer to a VA facility and
VA determines the patient's medical condition is stable.
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In January 2005, VA established the Seamless Transition Office to
enhance servicemembers' transition back to civilian life by improving
coordination within the Veterans Benefits Administration and the
Veterans Health Administration,\20\ as well as between DOD and VA. The
goals of the Seamless Transition Office related to health care include
improving communication, coordination, and collaboration within VA and
with DOD concerning health care, educating VA staff about OEF and OIF
veterans' health care, and other needs. The office has been active in
areas such as coordinating efforts of the VA social workers assigned to
MTFs to help servicemembers transfer their health care from MTFs to VA
health care facilities and issuing a handbook on the policy and
procedures for PRCs, including recommended staffing levels for the
different types of medical providers caring for patients.
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\20\ The Veterans Benefits Administration provides benefits and
services, such as disability compensation, to veterans. The Veterans
Health Administration's primary responsibility is the delivery of
health care to veterans.
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There are also a number of routinely scheduled teleconferences and
videoconferences within VA and between VA and the military medical
facilities to coordinate medical care for injured servicemembers and to
discuss and resolve medical issues. Topics include issues that are
general in nature and would apply to a number of servicemembers or that
are specific to individual servicemembers. For example, monthly, and as
needed, VA's Seamless Transition Office and PRC staff hold
teleconferences to discuss such issues as obtaining DOD medical records
and how to provide follow-up medical care once the servicemember is
discharged from the PRC. Further, on a bimonthly basis, PRCs hold
teleconferences or videoconferences with Walter Reed Army Medical
Center and the National Naval Medical Center to discuss issues arising
during the transfer of injured servicemembers from their facilities to
the PRCs, such as obtaining military medical records. Servicemembers
and their families sometimes participate in the videoconference to meet
PRC staff prior to transfer. Also on a monthly basis, VA and DOD hold
videoconferences to discuss medical and logistical issues that arise
with injured servicemembers. These videoconferences include DOD medical
providers from Landstuhl Regional Medical Center in Germany and combat
medical units located in Iraq. For example, during one videoconference,
VA and DOD staff discussed the blood filters \21\ that were being
surgically implanted in injured servicemembers in Iraq.\22\ Medical
providers in Baghdad asked if there was a different type of blood
filter that they could use that would make removal easier at the
stateside MTF or PRC.
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\21\ Blood filters are filters that screen blood to remove clots
that could result in death.
\22\ VA officials in attendance included staff from the PRCs and
the Seamless Transition Office. DOD officials in attendance included
staff from Walter Reed Army Medical Center; the National Naval Medical
Center; Brooke Army Medical Center; Wilford Hall Medical Center; Army
Institute for Surgical Research; Landstuhl Regional Medical Center in
Germany; and combat medical units located in Balad and Baghdad, Iraq.
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Despite coordination, we found that the departments are having
problems exchanging health care information electronically between the
four PRCs and the two MTFs--Walter Reed Army Medical Center and the
National Naval Medical Center. While our current review focused on the
electronic transfer of information among these six facilities, over 5
years ago we recommended that VA and DOD create comprehensive and
coordinated plans to ensure that the departments can share
comprehensive, meaningful, accurate, and secure patient health
data.\23\ Both VA and DOD concurred with this recommendation and are in
the process of implementing it. From a systemwide perspective, we
testified over 2 years ago and again last September on the need for VA
and DOD to intensify their efforts to implement the capability to share
health care information electronically. In those testimonies, we
recognized the actions VA and DOD had taken to electronically exchange
health information but also acknowledged that much work remains to
attain this goal.\24\
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\23\ GAO, Computer-Based Patient Records: Better Planning and
Oversight by VA, DOD, and IHS Would Enhance Health Data Sharing, GAO-
01-459 (Washington, D.C.: Apr. 30, 2001).
\24\ GAO, Computer-Based Patient Records: Sound Planning and
Project Management Are Needed to Achieve a Two-Way Exchange of VA and
DOD Health Data, GAO-04-402T (Washington, D.C.: Mar. 17, 2004);
Computer-Based Patient Records: Short-Term Progress Made, but Much Work
Remains to Achieve a Two-Way Data Exchange Between VA and DOD Health
Systems, GAO-04-271T (Washington, D.C.: Nov. 19, 2003); and GAO-05-
1051T.
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During our visits to the PRCs from October through December 2005,
we observed that none of the PRCs had real-time access to the injured
servicemembers' DOD electronic medical records from the transferring
MTFs. Instead, the MTF faxed copies of some of the medical information,
such as the servicemember's medical history and physical and doctor's
progress notes from these records, to the PRC. Because this information
did not always provide enough data for the PRC provider to determine if
the servicemember was medically stable enough to be admitted to the PRC
and to engage in vigorous rehabilitation activities and because the PRC
did not have access to the complete medical records (paper or
electronic), VA developed a standardized list of the minimum types of
health care information needed about each servicemember transferring
from an MTF. However, after they reviewed this basic medical
information PRC providers stated that they frequently needed additional
information and had to ask the PRC social worker to obtain it from the
VA social worker at the MTF. For example, if the PRC provider noticed
that the servicemember was on a particular antibiotic therapy, the
provider might request the results of the most recent blood and urine
cultures to determine if the servicemember was medically stable enough
to participate in strenuous rehabilitation activities.
According to PRC officials, obtaining additional medical
information in this way rather than electronically was very time
consuming and often required multiple phone calls and faxes between the
facilities.
According to VA officials, the main barrier to PRC medical
providers' getting real-time access to medical records was DOD's
interpretation of the Health Insurance Portability and Accountability
Act 1996 (HIPAA) \25\ and the HIPAA Privacy Rule.\26\ The HIPAA Privacy
Rule permits VA and DOD to share servicemembers' health information
under certain circumstances, such as for purposes of treatment or if
the individual signs a proper authorization. However, DOD officials
told us they initially were reluctant to provide this access to VA
because they were concerned that VA would have access to health
information of all servicemembers, not only the information of those
being transferred to the PRC for treatment.
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\25\ Pub. L. No. 104-191, 110 Stat. 1936 (1996).
\26\ The Privacy Rule, which became effective on April 14, 2001,
specifies how individually identifiable health information may be used
and disclosed by covered entities, which include health plans, health
care clearinghouses, and certain health care providers. See 45 C.F.R.
164.500(a), 164.502 (2005). Both TRICARE and the VA health care
system are health plans. See 45 C.F.R. 160.103 (2005).
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Since we initiated our review, the four PRCs and Walter Reed Army
Medical Center and the National Naval Medical Center have reached
separate agreements on the records VA would be able to access and have
begun to take action to share medical records.\27\ During our initial
visits, two PRCs--Richmond and Tampa--were in the process of separately
negotiating with Walter Reed Army Medical Center to obtain real-time
access to injured servicemembers' electronic medical records. VA
reported that as of December 27, 2005, PRC providers in Richmond and
Tampa have real-time access to these records. The Tampa PRC also gained
access to the National Naval Medical Center's electronic medical
records on February 21, 2006. VA and DOD officials have not established
a date when all PRCs would have real-time access to electronic records
at Walter Reed Army Medical Center and the National Naval Medical
Center.
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\27\ This initiative is a unique undertaking by the four PRCs,
Walter Reed Army Medical Center, and the National Naval Medical Center.
It is distinct from VA's and DOD's Bidirectional Health Information
Exchange.
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In April 2006, we revisited the Tampa and Richmond PRCs and found
that problems continued with access to DOD electronic medical records.
Providers at both PRCs that had been granted electronic access by DOD
to obtain medical information stated that they could not always access
the DOD electronic records. For example, during our visits neither
facility could access the DOD electronic medical records at Walter Reed
Army Medical Center because of a technical problem. Furthermore, while
a nurse practitioner at the Tampa PRC was able to access the electronic
medical records at the National Naval Medical Center, the admitting PRC
provider for rehabilitative services could not.
While VA's electronic medical records offer ready access to VA
medical information for its medical providers, we found that during our
site visits some information related to servicemembers' and veterans'
discharge from PRCs was not always entered into the records. When
servicemembers and veterans are discharged from PRCs, many still
require follow-up medical care at VA, DOD, or private-sector
facilities. The social worker at the PRC is responsible for arranging
follow-up appointments prior to the patient's discharge from the PRC.
Information on follow-up appointments and points of contact is provided
to the servicemember or veteran during the discharge planning
conference, along with a large amount of other medical information and
discharge instructions. Our review 193 servicemembers' VA electronic
medical records showed that 126 patients required follow-up medical
appointments after discharge from the PRC.\28\ An examination of the
126 records indicated that appointments were made for 122 of the
patients, with the remaining 4 patients instructed to call their local
VA medical centers for appointments. However, while the date and time
for the appointment was in the electronic medical record, it was not
clearly summarized in 96 of 122 of these records, nor was there
evidence that it was given to the patient. In addition, 75 of the 122
records did not clearly indicate the points of contact, nor was there
evidence that this information was given to the patient. If this
information were clearly documented in patients' electronic medical
records, it would be available to VA providers who may need it to
manage future care.
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\28\ The remaining 67 patients did not need follow-up outpatient
appointments because they were still patients in the PRC; had been
transferred to another inpatient facility, such as an MTF or VA long-
term care facility; or did not need follow-up medical care.
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In February 2006, in response to questions we raised during our
review, VA developed a template for PRC social workers to complete when
a patient is discharged. The social worker includes on the template
information on follow-up medical appointments, contact names and
telephone numbers for the medical facilities where the servicemember is
going to obtain follow-up medical care, military contacts, and PRC
contacts. This template is entered into the electronic medical record.
During our visit to the Tampa and Richmond PRCs in April 2006, we found
that the social workers had been using the templates for patients
discharged since mid-March 2006.
VA Is Using Courses, Conferences, and Online Clinical Tools to Help
Ensure Medical Providers Are Aware of and Recognize Needs of
Eligible OEF and OIF Servicemembers and Veterans
VA has developed activities to educate its medical providers and
other staff on the health care needs of those who are or have been
deployed in OEF and OIF. As part of its Veterans Health Initiatives, VA
produced 14 educational courses that address OEF- and OIF-related
topics, such as traumatic brain injuries and infectious diseases of
Southwest Asia. These courses are available on VA's intranet, over the
Internet, and on compact discs. As of December 31, 2005, VA reported
that nearly 2,000 courses had been completed by VA staff, including
nearly 1,200 courses that were completed by physicians. Also over
12,000 courses were completed by non-VA staff, such as veterans, family
Members, and staff from veterans service organizations.
VA medical centers have also used conferences and in-house
presentations to train staff on the needs of OEF and OIF servicemembers
and veterans. For example, the Tampa PRC sponsored blast injury
conferences in 2004 and 2005 that were attended by physicians, nurses,
psychologists, and social workers. In addition, from April 2005 through
April 2006, VA held five 1-hour conference calls for VA social workers
that focused on the transfer of care for servicemembers from DOD to VA
medical facilities, including information such as ways to be proactive
in working with military families as they transition from active duty
to veteran status and recognizing the signs and symptoms of stress and
post-traumatic stress disorder in returning OEF and OIF veterans. VA
reported that attendance for the conference calls ranged from 105 to
360 social workers.
VA's educational efforts have also included publications. VA's
Under Secretary for Health has issued five informational letters to
VA's medical providers offering guidance on OEF- and OIF-related
topics. The topics of these letters include the long-term effects of
heat-related illnesses and the long-term effects of using an
antimalarial drug. In addition, VA's War-Related Illness and Injury
Study Centers have produced publications providing information for
combat veterans and providers on topics such as management of chronic
pain and the effects of exposure to depleted uranium.\29\
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\29\ In May 2001, VA established the two War-Related Illness and
Injury Study Centers, one in Washington, D.C., and one in East Orange,
New Jersey. The mission of these centers includes providing health-
related educational services to veterans and health care professionals.
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VA's War-Related Illness and Injury Study Centers have also
provided educational activities and clinical tools to help medical
professionals treat OEF and OIF servicemembers and veterans. In 2004
and 2005 the centers reported that they held three conferences, with a
total attendance of more that 450 health care providers, including
physicians, nurses, and social workers, that addressed such topics as
physical and mental health issues, infectious disease issues, and
health care services provided by VA. They also held six workshops from
2003 through 2005 on topics such as patient-provider communication and
the recognition and treatment of undiagnosed illnesses, and established
Web sites that provide links to their publications and to other sources
of education for medical providers.
VA has also developed various clinical tools to enhance the ability
of its providers and other staff to be aware of and responsive to the
needs of OEF and OIF servicemembers and veterans. For example, VA has
added reminder screens to its electronic medical records that pop up
when a patient's record is opened if the veteran served in the military
after September 11, 2001. These screens prompt providers to ask
questions about medical and psychological issues related to OEF and OIF
veterans, such as infectious diseases and depression. The screens
continue to pop up each time the patient's medical record is opened
until the information requested is entered into that record. The pop-up
reminder screens were the subject of one of the informational letters
issued to VA staff. Further, VA and DOD developed 25 guidelines for
clinical practice,\30\ which can be viewed on a VA Web site.\31\ VA
officials stated that any of the guidelines may be used for OEF and OIF
servicemembers and veterans depending on their needs. Finally, VA's
National Center for Post-Traumatic Stress Disorder and DOD developed
the Iraq War Clinician Guide. It addresses the needs of veterans of the
Iraq war and is available on a VA Web site.\32\
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\30\ Clinical practice guidelines are recommendations for treating
specific diseases or conditions.
\31\ See http://www.oqp.med.va.gov/cpg/cpg.htm.
\32\ See http://www.ncptsd.va.gov/war/guide/index.html.
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Agency Comments and Our Evaluation
VA and DOD reviewed a draft of this report and provided written
comments, which appear in enclosures I and II respectively. VA
concurred with the information presented in our draft report. It also
stated that PRCs' access to DOD's electronic medical records has been a
significant challenge for VA in accomplishing its mission. VA further
commented that it is justifiably proud of the accomplishments of its
dedicated staff in successfully responding to the often overwhelming
transitional needs of these young servicemembers and their families.
DOD commented that the report portrays the numerous efforts that have
been made to improve the efficacy of programs designed to ensure a
smooth transition and continuity of care as servicemembers transition
back and forth between DOD and VA health care systems.
DOD commented that the statements in the draft report concerning
its lack of a systemwide approach to electronic medical record
management and the inability of providers throughout DOD's health care
system to access medical records is completely inaccurate. Our
statements are not inaccurate. While our draft report recognizes DOD's
longstanding ongoing efforts to achieve the capability to
electronically share the complete medical record, we did not find that
this capability exists yet at DOD. For example, in March 2006 the Chief
Information Officer at the National Naval Medical Center explained to
us that MTFs did not have access to electronic medical records at other
MTFs across the United States. He told us that while information could
be shared among providers linked by a local area network, those
providers could not electronically access medical records from other
local area networks. Specifically, he noted that providers at Walter
Reed Army Medical Center and the National Naval Medical Center can
access each other's medical records electronically, but they cannot
access medical records from Landstuhl Regional Medical Center in
Germany or from MTFs in San Antonio, Texas. He acknowledged that DOD's
Armed Forces Health Longitudinal Technology Application (AHLTA)--a
comprehensive electronic health record--will allow providers to access
medical information. In its comments, DOD also cited the access that
AHLTA will provide. However, DOD documentation that describes the
system states that it is for outpatient care--only one part of the
complete medical record. VA providers treating OEF and OIF
servicemembers are in need of information concerning the inpatient
care--not just the outpatient care--that servicemembers received at
DOD. Furthermore, AHLTA cannot be accessed by all of DOD's providers.
In its comments on our draft report DOD stated that AHLTA is not
operational at 19 percent of DOD's MTFs and that full deployment is not
expected until December 2006. In comparison, VA's system allows the
patient's complete medical record to be accessed from any VA medical
facility.
In its comments, DOD also mentioned that a section of our draft
report that described the actions VA has taken to facilitate the
transition of care from DOD to VA is misleading. However, the section
is an accurate presentation of VA initiatives as presented to us by VA
and as observed during our audit work. Furthermore, DOD stated that it
transmits certain medical information to VA on a monthly basis,
although VA providers told us they need ready electronic access to
current medical record information for the seriously injured OEF and
OIF servicemembers. We believe that in order to plan and begin
appropriate treatment immediately upon a servicemember's arrival at a
PRC, medical record information is best provided through direct
electronic access, not through monthly transmissions. Our draft report
recognized the technical advances that VA has made in that it has the
capability to electronically share the complete medical record of each
of its beneficiaries among all its providers at all its medical
facilities. This means that all medical services provided by VA to its
beneficiaries--including information such as outpatient or inpatient
procedures, pharmacy, or radiology notes--are included in VA's
electronic record.
VA and DOD provided technical comments that we incorporated where
appropriate.
______
As agreed with your office, unless you publicly announced its
contents earlier, we plan no further distribution of this report until
30 days after its report date. We will then send copies of this report
to the Secretaries of Veterans Affairs and Defense and appropriate
congressional committees. We will also make copies available to others
on request. In addition, the report will be available at no charge on
GAO's Web site at http://www.gao.gov.
If you or your staff have any questions, please contact me at (202)
512-7101 or [email protected]. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last
page of this report. GAO staff who made major contributions to this
report are Michael T. Blair, Jr., Assistant Director; Cynthia Forbes;
Roseanne Price; Shannon Slawter; and Cherie Starck.
Sincerely yours,
Cynthia A. Bascetta
Director, Health Care
Enclosures--2
Comments from the Department of Veterans Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Comments from the Department of Defense
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Related GAO Products
Information Technology: VA and DOD Face Challenges in Completing
Key Efforts. GAO-06-905T. Washington, D.C.: June 22, 2006.
VA and DOD Health Care: VA Has Policies and Outreach Efforts to
Smooth Transition from DOD Health Care, but Sharing of Health
Information Remains Limited. GAO-05-1052T. Washington, D.C.: September
28, 2005.
Computer-Based Patient Records: VA and DOD Made Progress, but Much
Work Remains to Fully Share Medical Information. GAO-05-1051T.
Washington, D.C.: September 28, 2005.
1Military and Veterans' Benefits: Improvements Needed in Transition
Assistance Services for Reserves and National Guard. GAO-05-844T.
Washington, D.C.: June 29, 2005.
Military and Veterans' Benefits: Enhanced Services Could Improve
Transition Assistance for Reserves and National Guard. GAO-05-544.
Washington, D.C.: May 20, 2005.
DOD and VA: Systematic Data Sharing Would Help Expedite
Servicemembers' Transition to VA Services. GAO-05-722T. Washington,
D.C.: May 19, 2005.
Vocational Rehabilitation: VA Has Opportunities to Improve
Services, but Faces Significant Challenges. GAO-05-572T. Washington,
D.C.: April 20, 2005.
VA Disability Benefits and Health Care: Providing Certain Services
to the Seriously Injured Poses Challenges. GAO-05-444T. Washington,
D.C.: March 17, 2005.
Vocational Rehabilitation: More VA and DOD Collaboration Needed to
Expedite Services for Seriously Injured Servicemembers. GAO-05-167.
Washington, D.C.: January 14, 2005.
Computer-Based Patient Records: Sound Planning and Project
Management Are Needed to Achieve a Two-Way Exchange of VA and DOD
Health Data. GAO-04-402T. Washington, D.C.: March 17, 2004.
Computer-Based Patient Records: Short-Term Progress Made, but Much
Work Remains to Achieve a Two-Way Data Exchange Between VA and DOD
Health Systems. GAO-04-271T. Washington, D.C.: November 19, 2003.
Computer-Based Patient Records: Better Planning and Oversight by
VA, DOD, and IHS Would Enhance Health Data Sharing. GAO-01-459.
Washington, D.C.: April 30, 2001.
__________
UNITED STATES GOVERNMENT ACCOUNTABILITY OFFICE
Report to the Ranking Democratic Member, Committee on Veterans'
Affairs, House of Representatives
VOCATIONAL REHABILITATION--More VA and DOD Collaboration Needed to
Expedite Services for Seriously Injured Servicemembers
______
Contents
Letter
Results in Brief
Background
VA Has Taken Steps to Expedite Vocational Rehabilitation and Employment
Services for Seriously Injured Servicemembers
VA Faces Significant Challenges in Expediting Services to Seriously
Injured Servicemembers
Conclusions
Recommendations
Agency Comments
Appendix I--Comments from the Department of Veterans Affairs
Appendix II--Comments from the Department of Defense
Related GAO Products
Figures
Figure 1: Seriously Injured Army Servicemembers Receive Treatment at
Five Major Army Medical Facilities and Relocate to One of 57 VA Regions
after Medical Stabilization
Figure 2:VA's Early Intervention Could Work at Cross Purposes to DOD's
Retention Evaluation Process
Abbreviations
DOD Department of Defense
MTF Military Treatment Facility
VR&E Vocational Rehabilitation and Employment
VA Department of Veterans Affairs
U.S. General Accounting Office
Washington, DC, 20548
January 14, 2005
Hon. Lane Evans
Ranking Democratic Member
Committee on Veterans' Affairs
House of Representatives
Dear Mr. Evans:
Since the onset of U.S. operations in Afghanistan in October 2001
and Iraq in March 2003, the Department of Defense (DOD) has reported
that more than 10,000 service men and women have been injured in
combat. While many return to active duty after they are treated, others
who are more seriously injured are likely to be discharged from their
military obligations and return to civilian life with disabilities. In
addition to cash compensation, the Department of Veterans Affairs (VA)
offers vocational rehabilitation and employment (VR&E) services to help
veterans with disabilities restore their lives and participate in the
civilian work force. We have reported that intervening early after a
disabling injury increases the likelihood that an individual will
successfully return to work.\1\ Moreover, there is growing awareness
that people with disabilities can and want to work and that changes in
the nature of work and advances in assistive technologies help them to
do so. Further, as the U.S. work force is projected to shrink, the U.S.
economy will need all who are able to participate in the paid labor
force. Because federal disability programs, including VA's, lack
emphasis on the potential for vocational rehabilitation to return
people to work and also rely on outmoded assumptions about the
relationship between impairment and work, we have designated these as
``high-risk'' programs.\2\
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\1\ GAO, SSA Disability: Return-to-Work Strategies From Other
Systems May Improve Federal Programs, GAO-96-133 (Washington, D.C.:
July 11, 1996).
\2\ GAO, High-Risk Series: An Update, GAO-03-119 (Washington, D.C.:
Jan. 2003).
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In view of the importance of early intervention in returning people
who have been disabled to work, you asked that we review how quickly VA
is able to provide VR&E services to seriously injured servicemembers
from Afghanistan and Iraq who are likely to become veterans with
disabilities. We assessed (1) how VA expedites VR&E services to these
seriously injured servicemembers and (2) the challenges VA faces in its
efforts to do so.
To address these objectives, we reviewed VA's formal and informal
procedures for expediting VR&E services to seriously injured
servicemembers returning from Afghanistan and Iraq. We reviewed
applicable laws and regulations. We interviewed officials at VA's
central office and at 12 of VA's 57 regional offices. Five of these
offices are located near the five major Army medical treatment
facilities treating the majority of the seriously injured Army
servicemembers: Brooke Army Medical Center at Fort Sam Houston, Texas;
Darnall Army Community Hospital at Fort Hood, Texas; Eisenhower Army
Medical Center at Fort Gordon, Georgia; Madigan Army Medical Center at
Fort Lewis, Washington; and Walter Reed Army Medical Center in
Washington, D.C. The corresponding VA regional offices are Houston and
Waco, Texas; Atlanta, Georgia; Seattle, Washington; and Washington,
D.C. We selected the other seven regional offices based on Army data
indicating that servicemembers injured in Afghanistan and Iraq are
being treated at military treatment facilities in their regions. They
are Buffalo, New York; Denver, Colorado; Muskogee, Oklahoma; Nashville,
Tennessee; New Orleans, Louisiana; Wichita, Kansas; and Winston-Salem,
North Carolina. Our findings for these regional offices cannot be
generalized to all of VA's regional offices. We focused on Army
servicemembers, including activated National Guard and Reserve, because
they constituted the majority of servicemembers wounded in Afghanistan
and Iraq. In addition, we visited Walter Reed Army Medical Center in
Washington, D.C., where most seriously injured Army servicemembers are
initially treated. We also interviewed DOD officials about their
efforts to work with VA on the transition of injured servicemembers
being discharged from active duty. We conducted our work between April
2004 and November 2004 in accordance with generally accepted government
auditing standards.
Results in Brief
We found that VA has taken steps to expedite VR&E services for
seriously injured servicemembers returning from Iraq and Afghanistan.
VA has instructed its regional offices to make seriously injured
servicemembers a high priority for all VA assistance and asked DOD to
share data that would help VA identify and monitor them. Because most
seriously injured servicemembers are initially treated at major
military treatment facilities, VA deployed staff to these sites to
provide information on VA benefits programs, including VR&E services,
to servicemembers injured in the conflicts in Afghanistan and Iraq. To
ensure the identification and monitoring of all seriously injured
servicemembers, VA initiated a memorandum of agreement proposing that
DOD systematically provide information on them, including their names,
location, and medical condition. Pending an agreement with DOD, VA
instructed its regional offices to establish local liaison with
military medical treatment facilities in their areas to learn who the
seriously injured are, where they are located, and the severity of
their injuries. Reliance on local relationships, however, has resulted
in varying completeness and reliability of information developed by the
12 regional offices in our review. We also found that VA has no policy
for VR&E staff to maintain contact with seriously injured
servicemembers who do not apply for VR&E services. Nevertheless, some
offices reported efforts to maintain contact with these servicemembers,
noting that some who are not initially ready to consider employment
when contacted about VR&E services may be receptive at a future time.
We found significant challenges to VA's efforts to expedite VR&E
services. An inherent challenge is that individual differences and
uncertainties in the recovery process make it difficult to determine
when a seriously injured service Member will be ready to consider VR&E
services. Additionally, given that VA is conducting outreach to
servicemembers whose discharge from military service is not yet
certain, VA is challenged by DOD's concerns that VA's outreach about
benefits, including early intervention with VR&E services, could work
at cross purposes to the military's retention goals. Finally, VA is
currently challenged by a lack of access to DOD data that would, at a
minimum, allow the agency to readily identify and locate all seriously
injured servicemembers. VA officials we interviewed both in the
regional offices and at the central office reported that this
information would provide them with a more reliable way to identify and
monitor the progress of those servicemembers with serious injuries.
However, DOD officials reported that they have privacy concerns about
the type of information that VA had requested and the time that VA
wants it to be provided.
To improve VA's efforts to expedite VR&E services, we recommend
that VA and DOD collaborate to reach agreement about information that
VA needs to promote the recovery and return to work of seriously
injured servicemembers and that VA develop a policy and procedures for
maintaining contact with those who do not initially apply for VR&E
services. VA and DOD provided written comments on a draft of this
report. Both VA and DOD generally concurred with our findings and
recommendations.
Background
VA's VR&E program is designed to ensure that veterans with
disabilities find meaningful work and achieve maximum independence in
daily living. In 2004, VA estimates that it spent more than $670
million on its VR&E program to serve about 73,000 participants. This
represents about 2 percent of VA's $37 billion budget for nonmedical
benefits, most of which involves cash compensation for veterans with
disabilities.
VR&E services include vocational counseling, evaluation, and
training that can include payment for tuition and other expenses for
education, as well as job placement assistance. Interested veterans
generally apply for VR&E services after they have applied and qualified
for disability compensation based on a rating of their service-
connected disability. This disability rating--ranging from 0 to 100
percent in 10 percent increments--entitles veterans to monthly cash
payments based on their average loss in earning capacity resulting from
a service-connected injury or combination of injuries. To be entitled
to VR&E services, veterans with disabilities generally must have at
least a 20 percent disability rating and an employment handicap as
determined by a vocational rehabilitation counselor. Although cash
compensation is not available to servicemembers until after they
separate from the military, they can receive VR&E services prior to
separation under certain circumstances.\3\ To make these services
available prior to discharge, VA expedites the determination of
eligibility for VR&E by granting a preliminary rating, known as a
memorandum rating.
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\3\ Hospitalized military personnel pending discharge may receive
all vocational rehabilitation and employment benefits--such as
counseling, evaluation, and training--except for the monthly
subsistence allowance. 38 U.S.C. 3102, 3104, and 3113.
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VA's outreach to servicemembers who plan to apply for veterans'
disability compensation has been part of its transition assistance
program, which was established in 1990.\4\ Either in group sessions or
in one-on-one encounters, VA provides servicemembers with information
about disability benefits and services, which includes the VR&E
program, and offers assistance in applying for them. In addition, VA
administers a pre-discharge program that expedites the disability
compensation claims processing for servicemembers who are pending
discharge. This program also helps VR&E staff identify those who could
benefit from vocational rehabilitation and employment services. VA has
recently included activated National Guard and Reserve Members in its
outreach efforts.
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\4\ GAO, Military and Veterans' Benefits: Observations on the
Transition Assistance Program, GAO-02-914T (Washington, D.C.: July 18,
2002).
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Servicemembers injured in Iraq and Afghanistan are surviving
injuries that would have been fatal in past conflicts, due, in part, to
advanced protective equipment and medical treatment. However, the
severity of their injuries can result in a lengthy transition from
injured servicemember to veteran. Initially, most seriously injured
servicemembers, including activated National Guard and Reserve Members,
are brought to Landstuhl Regional Medical Center in Germany for
treatment. From there, they are transported to the appropriate U.S.
medical facilities, which are usually major military treatment
facilities (MTFs) but may also be VA medical centers. According to DOD
officials, once stabilized and discharged from the hospital,
servicemembers usually relocate to be closer to their homes or military
bases and are treated as outpatients by the closest VA or military
hospital. (See fig. 1.) At this point, the military generally begins to
assess whether the servicemember will be able to remain in the
military, a process that could take months to complete. The process can
take even longer if the servicemember appeals the military's initial
disability decision.
Figure 1: Seriously Injured Army Servicemembers Receive Treatment at
Five Major Army Medical Facilities and Relocate to One of 57 VA
Regions after Medical Stabilization
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
In response to recommendations made by the VA Vocational
Rehabilitation and Employment Task Force, VA is beginning to change its
approach to VR&E to better reflect contemporary views of disability.
The Secretary of Veterans Affairs established this external task force
in 2003 to conduct a comprehensive review of VA's VR&E program.\5\ In
addition, faced with the immediate need to provide benefits and
services to a new generation of veterans with disabilities, VA in
August 2003 formed an internal task force to develop and implement
policies to improve the transition of injured servicemembers back to
civilian life. Known as the Seamless Transition Task Force, it included
ad hoc participation from DOD.\6\ Although this task force's initial
priority was to ensure the continuity of medical care for injured
servicemembers as they transition from military to VA health care, it
has also coordinated efforts to ensure access to all other VA benefits,
including VR&E services.
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\5\ VA Vocational Rehabilitation and Employment Task Force. Report
to the Secretary of Veterans Affairs: The Vocational Rehabilitation and
Employment Program for the 21st century Veteran (Washington, D.C.:
March 2004).
\6\ DOD has supported transition assistance in various ways. For
example, the VA/DOD Joint Executive Committee was established in
February 2002 to further promote collaboration between the two
agencies, including resolving obstacles to information sharing. The
Committee is chaired by the Deputy Secretary of Veterans Affairs and
the Under Secretary of Defense for Personnel and Readiness. In
addition, the Army--in cooperation with VA--established the Disabled
Soldier Support System (DS3) in April 2004 as an advocacy group and
information clearinghouse to clarify the services available to disabled
soldiers as they transition to civilian life.
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We have previously reported on the importance of early intervention
to maximize the work potential of individuals with disabilities. We
have also reported, however, that current Federal disability programs
offer little opportunity for early intervention with individuals who
apply for compensation. These programs require lengthy assessments in
which applicants must focus on demonstrating their work limitations
rather than their abilities and potential to work.\7\ Consequently,
vocational rehabilitation is typically introduced late in the process.
Furthermore, we have designated Federal disability programs, including
VA's, as high-risk programs because they lack emphasis on the potential
for vocational rehabilitation to return people to work and also rely on
outmoded assumptions about the relationship between impairment and
work.
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\7\ GAO, SSA Disability: Program Redesign Necessary to Encourage
Return to Work, GAO/HEHS-96-62 (Washington, D.C.: Apr. 24, 1996).
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VA Has Taken Steps to Expedite Vocational Rehabilitation and Employment
Services for Seriously Injured Servicemembers
VA has instructed its regional offices to make seriously injured
servicemembers a high priority for all VA assistance and asked DOD to
provide data that would ensure VA's ability to identify and monitor
this population. Because many seriously injured servicemembers are
initially treated at major military treatment facilities, VA has
deployed staff to these sites to provide information on all veterans'
benefits, including VR&E services. To ensure the identification and
monitoring of all seriously injured servicemembers, VA initiated a
memorandum of agreement proposing that DOD share a range of
information, including the names of those with serious injuries, their
medical condition, and their military status. As of December 2004, a
formal agreement with DOD had not been reached. In the meantime, VA has
instructed its regional offices to develop local liaison with DOD in
order to identify and assist seriously injured servicemembers. The 12
regional offices we reviewed have developed information of varying
completeness and reliability. However, once regional offices have
identified and contacted seriously injured servicemembers, VA has no
policy for VR&E staff to maintain contact with those individuals who do
not apply for VR&E services while in the hospital or after they return
home. Nevertheless, some regional offices reported maintaining contact
with these servicemembers while others did not.
VA Has Instructed Its Regional Offices to Make Seriously Injured
Servicemembers a High Priority and Asked DOD for Data to Help
Identify Them
In a September 2003 letter, VA instructed its regional offices to
provide priority consideration and assistance to seriously injured
servicemembers returning from Afghanistan and Iraq. VA specifically
instructed regional offices to focus on servicemembers whose
disabilities are definitely or likely to result in military separation.
Minimally, this includes servicemembers with injuries DOD has
classified as ``very serious,'' ``serious,'' or in a ``special
category.'' \8\ In this letter, VA instructed its regional offices to
assign a case manager to each seriously injured servicemember who
applies for disability compensation. In addition, VA noted the
particular importance of early intervention for those who are seriously
injured and emphasized that seriously injured servicemembers applying
for VR&E should receive the fastest possible service. Moreover, VA
reminded VR&E staff that they can initiate evaluation and counseling
and, in some cases, authorize training before a servicemember is
discharged.
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\8\ Army regulations classify illness and injuries as ``very
serious'' when life is imminently endangered; as ``serious'' when there
is a cause for immediate concern but there is no imminent danger to
life; and as ``special category'' when the patient has a particular
condition, such as loss of limb or sight, a psychiatric condition,
paralysis, or a permanent disfigurement.
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Since most seriously injured servicemembers are initially treated
at major MTFs, VA has detailed staff to these facilities.\9\ These
staff have included VA social workers and disability compensation
benefits counselors. In addition to these staff, at Walter Reed, where
the largest number of seriously injured servicemembers has been
treated, VA's Washington D.C. regional office has since 2001 provided a
vocational rehabilitation counselor to work with hospitalized patients.
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\9\ These six facilities are Brooke Army Medical Center in Texas;
Walter Reed Army Medical Center in Washington, D.C.; Madigan Army
Medical Center in Washington; Darnall Army Community Hospital in Texas;
Eisenhower Army Medical Center in Georgia; and the Bethesda Naval
Medical Center in Maryland. We focused on the five Army medical
treatment facilities.
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To identify and monitor those whose injuries may result in a need
for VA services, including vocational rehabilitation, VA has asked DOD
to share data about injured servicemembers. VA has been working to
develop a formal agreement with DOD on what specific information to
share. In the spring of 2004, VA submitted a draft memorandum of
agreement to DOD's Office of the Assistant Secretary of Defense for
Health Affairs proposing that DOD provide lists of all injured
servicemembers admitted to MTFs. In addition, VA requested personal
identifying information, medical information, and DOD's injury
classification for each listed servicemember. VA also requested monthly
lists of servicemembers being evaluated for medical separation from
military service. Several VA officials and regional office staff we
interviewed said that systematic information from DOD would provide
them with a way to more reliably identify and monitor seriously injured
servicemembers. As of December 2004, a formal agreement with DOD was
still pending.
VA Regional Offices Have Relied on Local Liaisons with MTFs In Order to
Identify Seriously Injured Servicemembers Who May Need
Assistance
In the absence of a formal arrangement to ensure that DOD provides
data on seriously injured servicemembers, VA has relied on its regional
offices to obtain information about them. In its September 2003 letter,
the agency asked the regional offices to coordinate with staff at MTFs
and VA medical centers in their areas to ascertain the identities,
medical conditions, and military status of the seriously injured. While
VA officials reported to us that they had provided veterans' benefits
information to injured servicemembers, they did not have complete and
reliable data as to how many of these were seriously injured.
In response to guidance by VA's central office, every regional
office has designated a coordinator to serve as a point of contact with
MTFs and VA medical centers, as well as other VA regional offices, in
order to monitor injured servicemembers as they relocate across the
country. When servicemembers are discharged from an MTF, VA officials
told us that the affiliated VA regional office coordinator notifies the
coordinator in the region to which the person relocates. The new
coordinator contacts the seriously injured servicemember to discuss any
claims that have been filed and to provide those who have not already
done so an opportunity to apply for other benefits, including VR&E
services. Regional officials we interviewed reported that they have
followed VA's instructions to keep updated logs of all contacts they
have with seriously injured servicemembers. Regional offices are
required to send these logs to VA's central office, which uses them to
monitor outreach.
In our review of 12 regional offices, we found that they have
developed different information sources resulting in varying levels of
information on seriously injured servicemembers. The nature of the
local relationships between VA staff and military staff at MTFs was a
key factor in the completeness and reliability of the information that
the military provided. For example, the military MTF staff at one
regional office provided VA staff with only the names of new patients
with no indication of the severity of their condition or the theater
from which they were returning. Another regional office reported
receiving lists of servicemembers for whom the Army has initiated a
medical separation in addition to lists of patients with information on
the severity of their injuries. Some regional offices were able to
capitalize on longstanding informal relationships. For example, the VA
coordinator responsible for identifying and monitoring the seriously
injured at one regional office had served as an Army nurse at the local
MTF and was provided all pertinent information. In contrast, staff at
another regional office reported that local military staff did not
until recently provide them with information on seriously injured
servicemembers admitted to the MTF.
Once they have identified the seriously injured servicemembers,
regional office staff reported that they are largely following
outreach, coordination, and case management procedures outlined in VA's
September 2003 guidance. Under these procedures, disability
compensation benefit counselors usually conduct VA's initial outreach
by contacting hospitalized servicemembers to provide information on all
veterans' benefits, including VR&E. Traditionally responsible for
taking applications and processing disability compensation claims,
these staff Members are neither vocational rehabilitation experts nor
are they generally trained to work with persons who have serious
injuries. Accordingly, VA reported that it has begun requiring all
staff Members who provide in-person or telephone outreach to receive
training on how to interact with seriously injured servicemembers. VR&E
staff reported that they generally rely on the benefits counselors to
notify them of injured servicemembers at MTFs who are interested in or
who apply for VR&E. Only then would a vocational rehabilitation
counselor or counseling psychologist usually contact the hospitalized
servicemember to begin counseling and evaluation. In one regional
office, VR&E staff said that they do not contact injured servicemembers
until they apply for services and obtain a memorandum rating
establishing their eligibility.
The Washington, D.C., regional office has assigned a vocational
rehabilitation counselor to be available on site at Walter Reed Army
Medical Center, where a large number of seriously injured
servicemembers are treated. Although VA also deployed benefits
counselors to Walter Reed who are responsible for outreach activities
and the provision of information on all VA benefits, the VR&E counselor
works with hospitalized patients specifically to offer and provide
vocational counseling and evaluation. She reported attempting to
contact all patients within 48 hours of their arrival and visiting them
routinely thereafter to establish rapport. Her primary mission is to
work with servicemembers who will need to prepare for civilian
employment, although she told us that her early intervention efforts
could also help servicemembers who are able to remain in the military.
According to VA staff, many seriously injured servicemembers are
not ready or able to consider VR&E services when they are first
contacted. Yet, we found that VA has no policy for maintaining contact
with those servicemembers who do not apply for VR&E services when they
were in the hospital or when they returned to a home base or to their
residence. Several regional offices reported that they do not stay in
contact with these individuals while others attempt to do so in various
ways. One office said it is considering contacting them after 1 year.
Another regional VR&E officer reported that staff ask the
servicemembers to specify when they would like to be contacted for
further information or to BEGIN Program participation. Staff at this
regional office noted that they are strong advocates of early
intervention. They said that they try to contact servicemembers as soon
as possible to establish rapport and provide VR&E program information
even before the servicemembers are physically ready to begin developing
a vocational rehabilitation plan. At the same time, they noted that
readiness to participate in VR&E varies by individual and that
professional judgment is required to balance effective outreach with an
approach that could be viewed as intrusive.
VR&E program officials noted the potential value of maintaining
contact with seriously injured servicemembers who may not initially be
ready to participate when initially contacted by VA, but they also
recognized the need to focus resources on those who do participate.
Nevertheless, officials from a veterans service organization told us
that it is critical to maintain contact with seriously injured veterans
who do not initially apply for VR&E because they may need months or
even years before they are ready. In our prior work, we have also noted
that maintaining contact with individuals who have disabilities may
help encourage their return to work.\10\
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\10\ GAO, SSA Disability: Return-to-Work Strategies From Other
Systems May Improve Federal Programs, GAO/HEHS-96-133 (Washington, D.C:
July 11, 1996).
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VA Faces Significant Challenges in Expediting Services to Seriously
Injured Servicemembers
While experts and advocates for individuals with disabilities
attest to the value of early intervention for returning people to work,
VA is challenged to reach injured servicemembers early for several
reasons. First, determining the best time to approach recently injured
servicemembers and gauge their personal receptivity to consider
employment in the civilian sector is inherently difficult. The nature
of the recovery process is highly individualized and requires
professional judgment to determine the appropriate time to begin
vocational rehabilitation. Further, because VA is trying to prepare
servicemembers who are still on active duty for a transition to
civilian life, DOD is concerned that VA's efforts may be working at
cross purposes to the military's retention goals. Finally, because VA
lacks systematic information from DOD on seriously injured
servicemembers, VA cannot ensure that all servicemembers and veterans
who could benefit from the VR&E program have the opportunity to receive
services at the appropriate time.
Individual Differences in the Recovery Process Complicate the Timing of
Early Intervention
Individual differences and uncertainties in the recovery process
make it inherently difficult to determine when a seriously injured
servicemember will be ready to consider vocational rehabilitation.
Since the appropriate time to intervene depends to a large extent on
the individual's medical condition and personal readiness, the time to
broach the subject of a return to work, whether in the military or the
civilian labor force, will vary. Regional office staff reported that
many servicemembers are eager to return to military duty and do not
intend to consider a career outside military service. They also
reported that many injured servicemembers need time to recover and
adjust to the likelihood that they may have to leave the military and
prepare for civilian employment.
Because of the individual differences in receptivity to VR&E, VA
staff reported needing to monitor the condition of seriously injured
servicemembers and to engage them more than once during their recovery
to be able to gauge their readiness for VR&E. One regional VR&E
official told us that VA could benefit from more collaboration with DOD
medical staff in order to make decisions on the appropriate timing of
VR&E intervention. The vocational rehabilitation counselor at Walter
Reed reported visiting servicemembers routinely, including evenings and
weekends, so that she would be available when they were ready to
discuss their need for vocational rehabilitation. For one patient, she
reported visiting him 12 times before he expressed interest in VR&E. In
some locations, VA staff reported participating in pre-discharge
planning meetings with military and medical staff, which they said
helped them stay informed about the servicemember's condition and
likely discharge and provided an opportunity to include VR&E in their
discharge planning.
VA Is Challenged by DOD's Concern that Early Intervention Could Work at
Cross Purposes to Military Retention
VA is also challenged by DOD's concern that outreach about VA
benefits, including disability compensation and VR&E services, could
work at cross purposes to military retention goals. In particular, DOD
expressed concern about the timing of VA's outreach to servicemembers
whose discharge from military service is not yet certain. To expedite
VR&E services, VA's outreach process may overlap with the military's
process for evaluating servicemembers for a possible return to duty.
According to DOD officials, it may be premature for VA to begin working
with injured servicemembers who may eventually return to active duty.
(See fig. 2.) With advances in medicine and prosthetic devices, many
serious injuries no longer result in work-related impairments. Army
officials who track injured servicemembers told us that many seriously
injured servicemembers overcome their injuries and return to active
duty. Recognizing this potential, both Congress \11\ and the President
have recently expressed interest in seeing the military provide the
retraining needed to support the return of injured servicemembers to
their military occupations or other occupations within the military if
possible. In an attempt to enable more amputees to return to active
duty, Walter Reed Army Medical Center plans to open a new
rehabilitation center in 2005.
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\11\ Congress expressed its sense that the Secretary of Defense
should develop protocols that include options for injured
servicemembers who are highly motivated to return to active duty
service and for them to be retrained to perform military missions fo
which they are fully capable. Ronald W. Reagan National Defense
Authorization Act for Fiscal Year 2005, Pub. L. No. 108-375, 588,
Oct. 28, 2004, the ``Sense of Congress Regarding Return of Members to
Active Duty Service upon Rehabilitation from Service-Related
Injuries.''
---------------------------------------------------------------------------
Both VA and DOD officials suggested that the earliest appropriate
time for VA to intervene for regular active duty servicemembers would
be when it is clear that the servicemember will not be retained by the
military. Currently, VA can only provide VR&E services to active duty
servicemembers who are pending discharge due to a disability. VR&E
services could begin earlier for injured Members of the National Guard
and Reserve since these individuals usually expect to return to their
previous civilian employment. They may need VR&E services to return to
their prior employment or to prepare for a different occupation in the
civilian economy.
Figure 2: VA's Early Intervention Could Work at Cross Purposes to DOD's
Retention Evaluation Process
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
VA Is Also Challenged by the Lack of Access to Systematic Data
Regarding Seriously Injured Servicemembers
In the absence of a formal information sharing agreement with DOD,
VA does not have systematic access to DOD data about the population who
may need its services. Specifically, VA cannot reliably identify all
seriously injured servicemembers or know with certainty when they are
medically stabilized, when they are undergoing evaluation for a medical
discharge, or when they are actually medically discharged from the
military. VA has instead had to rely on ad hoc regional office
arrangements at the local level to identify and obtain specific data
about seriously injured servicemembers. While regional office staff
generally expressed confidence that the information sources they
developed enabled them to identify most seriously injured
servicemembers, they have no official data source from DOD with which
to confirm the completeness and reliability of their data nor can they
provide reasonable assurance that some seriously injured servicemembers
have not been overlooked. In addition, informal data sharing
relationships could break down with changes in personnel at either the
MTF or the regional office.
DOD officials expressed their concerns about the type of
information to be shared and when the information would be shared. DOD
noted that it needed to comply with legal privacy rules on sharing
individual patient information.\12\ DOD officials told us that
information could be made available to VA ``upon separation'' from
military service, that is, when a servicemember enters the separation
process. At this time, servicemembers would undergo assessment by a
physical evaluation board, which DOD officials said typically takes
between 30 to 90 days and usually results in a medical discharge from
the military. However, prior to separation, information can only be
provided under certain circumstances, such as when a patient's
authorization is obtained.\13\
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\12\ Health Insurance Portability and Accountability Act (HIPAA)
Privacy Rule, 45 C.F.R. Parts 160 and 164.
\13\ 45 C.F.R. 164.508(a).
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Conclusions
VA has taken steps to help the nation's newest generation of
veterans move forward with their lives, particularly those who return
from combat with disabling injuries. VA has made seriously injured
servicemembers a priority and, among other measures, deployed staff to
major MTFs to conduct outreach to them prior to separation. However, VA
benefits counselors are usually the first VA representatives to contact
injured servicemembers. While they may provide an overview of all VA
benefits, they may not emphasize vocational rehabilitation and
employment services.
The importance of early intervention for returning individuals with
disabilities to the work force is well documented in the vocational
rehabilitation literature. However, the lack of an agreement with DOD
for systematic data sharing impedes VA's attempt to identify all
seriously injured servicemembers who might benefit from such
intervention. It also poses the risk that some who are discharged with
disabilities may be overlooked and not afforded the opportunity for
VR&E. As VA recognizes, the current ad hoc approach of their regional
offices for obtaining information is not the most efficient way to
proceed. Furthermore, because individuals with disabilities vary in
their readiness and need for VR&E services, maintaining contact with
them would better ensure that VR&E staff know when the person is ready
to participate. Because VA has no policy for maintaining contact with
those who do not apply for VR&E, opportunities to rehabilitate veterans
who have sustained serious injuries in Afghanistan and Iraq may be
lost.
At a time when the U.S. labor force is projected to shrink, it is
imperative that those who can work, whether in military or civilian
jobs, are well supported in their efforts to do so. VA's early VR&E
efforts, rather than working at cross purposes to DOD goals, could
facilitate servicemembers' return to the same or different military
occupation, or to a civilian occupation, if they were not able to
remain in the military. In this regard, the prospect for early
intervention with VR&E services presents both a challenge and an
opportunity for VA and DOD to collaborate to provide better outcomes
for this new generation of seriously injured servicemembers.
Recommendations
To improve VA's efforts to expedite VR&E services to seriously
injured servicemembers, we recommend that VA and DOD collaborate to
reach an agreement for VA to have access to information that both
agencies agree is needed to promote servicemembers' recovery and return
to work.
We also recommend that the Secretary of Veterans Affairs direct the
Under Secretary for Benefits to develop a policy and procedures for
regional offices to maintain contact with seriously injured
servicemembers who do not initially apply for VR&E services, in order
to ensure that they have the opportunity to participate in the program
when they are ready.
Agency Comments
In commenting on a draft of this report, VA concurred with our
findings and recommendations. VA emphasized that access to DOD
information is crucial to promoting servicemembers' recovery and return
to work and, to that end, is currently negotiating an agreement to
allow VA to obtain protected medical information on servicemembers
prior to their discharge for VA benefits purposes. In addition, VA
noted that its follow-up policies and procedures include sending
veterans information on VR&E benefits upon notification of a disability
compensation award and 60 days later. However, we believe a more
individualized approach, such as maintaining personal contact, could
better ensure the opportunity for veterans to participate in the
program when they are ready. VA noted that it is currently reviewing
its outreach and follow-up procedures for injured servicemembers and
will make any appropriate revisions. VA's written comments are
reprinted in appendix I.
DOD also concurred with our findings and recommendations. DOD
stated its commitment to retaining seriously injured servicemembers who
are able and willing to return to duty. DOD also noted that a draft
memorandum of agreement for information sharing between VA and DOD is
under consideration by the two departments and the military services.
DOD's written comments are reprinted in appendix II.
As agreed with your office, unless you publicly announce the
contents of this report earlier, we plan no further distribution of
this report until 30 days after the date of this letter. We will then
send copies of this report to the Secretary of Veterans Affairs, the
Secretary of Defense, appropriate congressional Committees, and other
interested parties. The report will also be available on GAO's Web site
at http://www.gao.gov.
If you or your staff have any questions regarding this report,
please call me at (202) 512-7215 or Irene Chu, Assistant Director, at
(202) 512-7102.
Susan Bernstein, Connie Peebles Barrow, Margaret Boeckmann, William
R. Chatlos, Clarette Kim, Joseph J. Natalicchio, and Roger Thomas also
made key contributions to this report.
Sincerely yours,
Cynthia A. Bascetta
Director, Education, Work force,
and Income Security Issues
__________
Appendix I: Comments from the Department of Veterans Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Appendix II: Comments from the Department of Defense
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Related GAO Products
VA and Defense Health Care: More Information Needed to Determine if
VA Can Meet an Increase in Demand for Post-Traumatic Stress Disorder
Services. GAO-04-1069. Washington, D.C.: September 20, 2004.
VA Vocational Rehabilitation and Employment Program: GAO Comments
on Key Task Force Findings and Recommendations. GAO-04-853. Washington,
D.C.: June 15, 2004.
VA Benefits: Fundamental Changes to VA's Disability Criteria Need
Careful Consideration. GAO-03-1172T. Washington, D.C.: September 23,
2003.
High-Risk Series: An Update. GAO-03-119. Washington, D.C.: January
2003.
Major Management Challenges and Program Risks: Department of
Veterans Affairs. GAO-03-110. Washington, D.C.: January 2003.
SSA and VA Disability Programs: Re-Examination of Disability
Criteria Needed to Help Ensure Program Integrity. GAO-02-597.
Washington, D.C.: August 9, 2002.
Military and Veterans' Benefits: Observations on the Transition
Assistance Program. GAO-02-914T. Washington, D.C.: July 18, 2002.
SSA Disability: Other Programs May Provide Lessons from Improving
Return-to-Work Efforts. GAO-01-153. Washington, D.C.: January 12, 2001.
Vocational Rehabilitation: Opportunities to Improve Program
Effectiveness. GAO/T-HEHS-98-87. Washington, D.C.: February 4, 1998.
Veterans Benefits Administration: Focusing on Results in Vocational
Rehabilitation and Education Programs. GAO/T-HEHS-97-148. Washington,
D.C.: June 5, 1997.
Vocational Rehabilitation: VA Continues to Place Few Disabled
Veterans in Jobs. GAO/HEHS-96-155. Washington, D.C.: September 3, 1996.
SSA Disability: Return-to-Work Strategies From Other Systems May
Improve Federal Programs. GAO/HEHS-96-133. Washington, D.C: July 11,
1996.
SSA Disability: Program Redesign Necessary to Encourage Return to
Work. GAO/HEHS-96-62. Washington, D.C.: April 24, 1996.
Cedar Park, TX
March 27, 2007
Hon. Harry E. Mitchell
Hon. Virginia Brown-Waite
Subcommittee on Oversight and Investigations
Committee on Veterans' Affairs
U.S. House of Representatives
Dear Chairman Mitchell and Ranking Member Brown-Waite:
Please find my enclosed answers to your follow-up questions from
your March 8, 2007, hearing regarding seamless transition of new Iraq
and Afghanistan war veterans from the military to the Department of
Veterans Affairs (VA).
From July 2000 through March 2006, I worked as a lead program
analyst (GS-14) in the Office of Performance Analysis and Integrity
(OPA&I), which reported directly to the office of the Under Secretary
for Benefits. The team I led as a project manager was identifying,
monitoring, and providing analysis on the VA disability claims activity
of veterans who had been deployed to the Iraq and Afghanistan wars,
often referred to as the Global War on Terror (GWOT), and Operation
Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF).
In addition to regular briefings to OPA&I's Assistant Director and
Director, on several occasions I briefed the Deputy Under Secretary for
Benefits and the Chief of Staff at the Veterans Benefits
Administration. During 2004, I regularly attended then-VA Secretary
Anthony Principi's Task Force on Seamless Transition and prepared the
year end report in 2004, which is also attached.
Question One: In your testimony, you referenced data sent to your
supervisors relating to possible surges in disability compensation
claims among the Iraq and Afghanistan war veterans. Please submit this
material to the Committee.
In early 2005, the Department of Defense (DOD) began providing VA
with consistent and nearly complete data on service Members deployed to
the war zones who had separated from active duty. Shortly thereafter,
VA began matching the DOD data with VA systems in order to count the
number of veterans filing VA disability claims and monitor trends. Here
are three e-mails containing statistics and/or analysis.
July 8, 2005, e-mail from Susan Perez, Assistant
Director, Office of Performance Analysis and Integrity to Jack McCoy,
Associate Deputy Under Secretary for Benefits, citing ``concerns''
about GWOT claims. There were 13 attachments with this e-mail.
August 26, 2005, e-mail from Paul Sullivan to Susan
Perez, with a ``strong warning'' about claims activity among GWOT
veterans. There were six attachments with this e-mail.
October 5, 2005, e-mail from Paul Sullivan to Doris
Morgan containing a power point briefing describing increasing claims
among GWOT veterans for the Performance Analysis (PA) staff within
OPA&I. The PA staff also briefs senior VA management each month. There
is one attachment for this e-mail.
Question Two: Please also provide the Committee with a copy of the
report by Harvard professor, Linda Bilmes, estimating the number of
patients and the cost of the war.
Attached for your review is Professor Bilmes' report about the
impact of the Iraq and Afghanistan wars on veterans and VA along with
two columns she wrote about her report.
``Battle of Iraq's Wounded,'' Los Angeles Times, January
5, 2007
``Soldiers Returning from Iraq and Afghanistan: The Long-
term Costs of Providing Veterans Medical Care and Disability
Benefits,'' Harvard University, January 8, 2007
``Soldiers Trapped in Limbo,'' Boston Globe, March 21,
2007
I thank you for the opportunity to testify on March 8. If the
Subcommittee has any additional question, please contact me.
Sincerely,
Paul Sullivan
[The Attachments reference above letter are being retained in
Committee files.]