[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
TRANSITIONING HEROES:
NEW ERA, SAME PROBLEMS?
=======================================================================
HEARING
before the
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
JANUARY 21, 2010
__________
Serial No. 111-55
__________
Printed for the use of the Committee on Veterans' Affairs
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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 JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas VERN BUCHANAN, Florida
JOE DONNELLY, Indiana DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
HARRY E. MITCHELL, Arizona, Chairman
ZACHARY T. SPACE, Ohio DAVID P. ROE, Tennessee, Ranking
TIMOTHY J. WALZ, Minnesota CLIFF STEARNS, Florida
JOHN H. ADLER, New Jersey BRIAN P. BILBRAY, California
JOHN J. HALL, New York
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
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C O N T E N T S
__________
January 21, 2010
Page
Transitioning Heroes: New Era, Same Problems?.................... 1
OPENING STATEMENTS
Chairman Harry E. Mitchell....................................... 1
Prepared statement of Chairman Mitchell...................... 39
Hon. David P. Roe, Ranking Republican Member..................... 2
Prepared statement of Congressman Roe........................ 39
Hon. Timothy J. Walz............................................. 3
Hon. John J. Hall, prepared statement of......................... 40
WITNESSES
U.S. Department of Defense, Hon. Noel Koch, Deputy Under
Secretary of Defense, Wounded Warrior Care and Transition
Policy......................................................... 27
Prepared statement of Hon. Koch.............................. 51
U.S. Department of Veterans Affairs, Madhulika Agarwal, M.D.,
MPH, Chief Officer, Office of Patient Care Services, Veterans
Health Administration.......................................... 29
Prepared statement of Dr. Agarwal............................ 53
______
American Legion, Joseph L. Wilson, Deputy Director, Health Care,
Veterans Affairs and Rehabilitation Commission................. 7
Prepared statement of Mr. Wilson............................. 44
Iraq and Afghanistan Veterans of America, Tom Tarantino,
Legislative Associate.......................................... 9
Prepared statement of Mr. Tarantino.......................... 47
Johnson, Staff Sergeant Sean D., USA, Aberdeen, SD............... 4
Prepared statement of Sergeant Johnson....................... 41
Wounded Warrior Project, Captain Jonathan Pruden, USA (Ret.),
Area Outreach Coordinator...................................... 11
Prepared statement of Captain Pruden......................... 48
TRANSITIONING HEROES:
NEW ERA, SAME PROBLEMS?
----------
THURSDAY, JANUARY 21, 2010
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Oversight and Investigations,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:05 a.m., in
Room 334, Cannon House Office Building, Hon. Harry E. Mitchell
[Chairman of the Subcommittee] presiding.
Present: Representatives Mitchell, Walz, Adler, Hall, Roe,
and Stearns.
OPENING STATEMENT OF CHAIRMAN MITCHELL
Mr. Mitchell. Good morning, and welcome to the Subcommittee
on Oversight Investigations hearing on ``Transitioning Heroes:
New Era, Same Problems?'' This meeting will come to order.
I ask unanimous consent that all Members have 5 legislative
days to revise and extend their remarks and submit statements
for the record. Hearing no objection so ordered.
I would like to thank everyone for attending today's
Oversight and Investigations Subcommittee hearing entitled,
``Transitioning Heroes: New Era, Same Problems?'' Thank you
especially to our witnesses for testifying today.
We are here today to address what both the U.S. Department
of Defense (DoD) and the U.S. Department of Veterans Affairs
(VA) are doing to assist the men and women of our armed forces
to seamlessly transition back to civilian life. Time and again
we have heard from our returning servicemembers expecting a
smooth transition back to the lives they once lived only to
find themselves lost in a complex and frustrating bureaucracy.
Today we will hear from a severely injured veteran, Staff
Sergeant Sean Johnson who was hit by a mortar round in Iraq and
is now completely blind. Although he has received excellent
treatment at the Blind Rehabilitation Center in Chicago, he was
never assigned a Federal Care Coordinator after contacting the
VA almost a year ago.
In addition, Staff Sergeant Johnson and his family are
experiencing the hardships of navigating through both the DoD
system and VA system at the same time.
This is just one example of many. Staff Sergeant Johnson
joins those veterans and their families who share the same
concerns that our veterans service organizations (VSOs) will
voice here today.
Additionally, as I have said before, outreach to our
Nation's veterans is an equally important task. Both the VA and
DoD must ensure that veterans and their families are properly
informed about the benefits and services they have earned when
they return to civilian life.
We need to proactively bring the VA to our veterans, as
opposed to waiting for veterans to find the VA. This is a
critical part of delivering the care they have earned in
exchange for their brave service.
The VA should be a place where veterans can easily, and
with confidence, go for the help they seek, but the VA must
also be willing to reach out to those veterans. Effective
outreach will not only ensure better delivery of services for
our veterans, but will also increase morale.
I am hopeful that today both the VA and DoD will shed light
on what they are doing to make certain our veterans are
receiving the best possible care available; they are being
provided with the services and resources they have earned; and
most importantly, that the two Departments are working together
to ensure that these benefits earned are seamlessly delivered.
I believe that all my colleagues join me in being steadfast
in our hopes that Secretary Shinseki, as he transforms the VA
into a 21st century organization, will help eliminate the
stigma that so many of our Nation's veterans have placed upon
the VA. We must ensure that both the VA and DoD are working
together and providing veterans the services that they
rightfully deserve.
Again, thanks to all our witnesses for testifying today,
and we look forward to hearing your testimony.
Before I recognize the Ranking Member for his remarks I
would like to swear in our witnesses. I ask that all witnesses
please stand and raise their right hand.
[Witnesses sworn.]
Thank you. I would like to now recognize Dr. Roe for
opening remarks.
[The prepared statement of Chairman Mitchell appears on p.
39.]
OPENING STATEMENT OF HON. DAVID P. ROE
Mr. Roe. Thank you for yielding, Mr. Chairman.
I would first like to thank the Members of the first panel
for their service to this country. Not only their military
service, but their continued service by appearing here today to
share their testimony and help us work toward a better
transition for our Nation's veterans.
Prior to this hearing, my staff provided me with a list of
the hearings held by the Committee on Veterans' Affairs over
the past 10 years, totaling around 33 hearings. The topics have
ranged from employment transition through the use of polytrauma
centers, pre- and post-deployment heath assessments, sharing of
electronic health records of our wounded servicemembers,
transition assistance programs (TAPs) for Guard and Reserve
forces, and the list goes on.
As you can tell, helping our servicemembers move from the
military to civilian life is of great importance to this
Committee.
Concern in Congress about helping our servicemembers
transition to civilian life didn't start 10 years ago. During
the 97th Congress, Congress codified this 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. This act
created the VA Care Committee to supervise and manage
opportunities to share medical resources.
Today's hearing will enable the Committee to review the
various programs that have been instituted to assist our
Nation's veterans and wounded warriors in their transition to
civilian life. We will be looking forward not only at the
medical record exchange between VA and DoD, but also at the
various other transition services, the use of polytrauma
centers across the country, and programs available to assist
our veterans.
This is not the first hearing to look at these items, and I
am certain it will not be our last. We here in Congress must do
everything we can to make certain that the transition our
military personnel undergo is smooth, easy, and the programs
available are truly helping our Nation's veterans.
In the past it appears that any transition many
servicemembers have encountered have not been exactly seamless,
and certainly not easy or smooth.
Mr. Chairman, I appreciate you holding this hearing today,
and I believe we have much to learn from the witnesses today.
Again, thank you, Mr. Chairman, and I yield back.
[The prepared statement of Congressman Roe appears on p.
39.]
Mr. Mitchell. Thank you. Mr. Walz.
OPENING STATEMENT OF HON. TIMOTHY J. WALZ
Mr. Walz. Well thank you, Mr. Chairman and Ranking Member,
and I will submit a statement to the record, but I want to
thank both of you for holding this hearing and for our
witnesses for being here. There is nothing more important that
we do than to care for our veterans, and many of you in this
room, and I know my colleagues up here, have heard me talk
about seamless transition until I am blue in the face. There
might be a reason for this. I just heard Dr. Roe talking about
when we first started talking about this here, that is before I
started basic training and did a 25-year career, and took some
time off, and came to Congress, and here we sit today still
talking about it.
It is unacceptable, it is not getting the care for our
veterans, it is costing this country money, and it is
undermining the faith in what we do for them. We have the
capability, we have the technology. I am absolutely convinced
that this is the fundamental systemic issue on claims backlogs,
on many other issues, and so I want to congratulate the
Chairman and the Ranking Member once again for tackling this
issue.
It is complex and all of you who will testify today know
that, but when we hear from Staff Sergeant Johnson, and I think
you are going to hear some of the issues he faced is, no one in
this country thinks that is acceptable. No one thinks it is
acceptable. And the problem with it is, is that I think Tom
Zampieri is out there somewhere from the Blinded Veterans of
America, they can predict this every time what is going to
happen, and they tell us exactly what the pitfalls are, exactly
where the veteran is going to fall through the cracks, and then
they give us suggestions on how to fix that.
And I hope now that this is the time. It feels like the
momentum is there, and so I look forward to hearing from our
witnesses on ways we can correct this. I yield back.
[No statement was submitted.]
Mr. Mitchell. Thank you. At this time I would like to
welcome Panel 1 to the witness table. Joining us on our first
panel is Staff Sergeant Sean Johnson, an Operation Iraqi
Freedom (OIF) veteran from South Dakota. Joseph Wilson, Deputy
Director of Health Care, Veterans Affairs and Rehabilitation
Commission, American Legion; Thomas Tarantino, Legislative
Associate for Iraq and Afghanistan Veterans of America (IAVA);
and Captain Jonathan Pruden, Area Outreach Coordinator for the
Wounded Warrior Project (WWP). Each will have 5 minutes to make
their presentation, but I also want them to know their complete
statement will be entered into the record, but please keep it
to 5 minutes. And I will ask in this order the speakers: Staff
Sergeant Johnson, Mr. Wilson, Mr. Tarantino, and Captain
Pruden.
Thank you again for being here, and first Staff Sergeant
Johnson, would you please begin.
STATEMENTS OF STAFF SERGEANT SEAN D. JOHNSON, USA, ABERDEEN, SD
(OIF VETERAN); JOSEPH L. WILSON, DEPUTY DIRECTOR, HEALTH CARE,
VETERANS AFFAIRS AND REHABILITATION COMMISSION, AMERICAN
LEGION; TOM TARANTINO, LEGISLATIVE ASSOCIATE, IRAQ AND
AFGHANISTAN VETERANS OF AMERICA; AND CAPTAIN JONATHAN PRUDEN,
USA (RET.), AREA OUTREACH COORDINATOR, WOUNDED WARRIOR PROJECT
STATEMENT OF STAFF SERGEANT SEAN D. JOHNSON, USA
Sergeant Johnson. Chairman Mitchell, Ranking Member Roe,
and the rest of the Committee. I thank you for giving me the
invitation and the chance to give my testimony today. And I
have to put in a disclaimer. I am not here in a military
capacity, I am here as a veteran and a private citizen.
My name is Sean Johnson and I am 38 years old. I am a
three-time deployed vet, Persian Gulf, Bosnia, and Iraq. And I
was deployed to Iraq on October 19th, 2005. And between October
19th, 2005, and March 25th, 2006, I was exposed to four mortar
blasts within 30 feet and a rocket blast, also within 30 feet.
On March 25th, 2006, I was exposed to a mortar blast 10 feet
away. I remember a bright light and a loud boom and that is it.
It blew me 3 feet in the air and 7 feet back and I landed on my
shoulders and my neck. I have received damage to my C-spine
from C1 to C7. Before I got up, I was kind of paralyzed, I
didn't know what was going on. As I looked through my feet
another mortar hit 25 feet away. The other blast I was able to
shake it off, this blast I couldn't. I didn't hear for almost a
day. I was dizzy, confused, I couldn't see in the distance, I
couldn't see at night, I had headaches and abdominal pain.
And then I went into the hospital in May of 2006, and I was
there for 7 days. A trauma surgeon was in charge of my case,
and they concentrated on the abdominal pain. Sent me back and
forth to Germany twice, and they couldn't figure it out. And
they said it has got to be a gastrointestinal problem.
Well, in between these trips to Germany they gave me
antibiotics and stopped antibiotics, so I ended up with a
serious infection. And I was sent back to the States to Fort
Riley, Kansas. I was placed in the med hold there.
There were all kinds of problems there. I had to launch
seven Congressional complaints, and I was told at one time that
if I stopped talking to my Congressmen, they would actually
treat me.
Fort Riley, the doctors there want to take care of their
patients. They don't want to make referrals, they don't want
Walter Reed or Brooke Army Medical Center (BAMC) to evaluate
their patients, they want to treat them themselves. It is a
type of an ego problem I believe.
After the Congressional complaints, I did receive treatment
at Walter Reed for pain, and at that time I got back to Fort
Riley and they said we can't help you anymore. And at that time
they sent me home, because the program, the Community Based
Health Care Organization (CBHCO) that you guys created, they
said my case was too complex and they couldn't help me anymore.
And the Reserves, had hands tied.
I have had an Medical Evaluation Board (MEB) waiting for 2
years, and I just started it now. And they told me would take
another 2 years to get through it. They are making me drill,
and basically I go to drill and they pay me to sit in a small
room to do nothing.
I did not receive the transition of care. I wasn't
contacted by a Federal Recovery Coordinator, I wasn't contacted
by anybody. I had to copy my medical records on paper, take
them to the VA, and at that point they entered them into their
system, then they started all over again. Checking the
abdominal pain. And then somebody referred me to the polytrauma
doctors because of the blast injury. And they said, well you
have a head injury, you have severe post-traumatic stress
disorder (PTSD), and at that point I was treated, and then my
vision loss came about a year later.
I was seen by one optometrist and a couple of
ophthalmologists. They said my eyes are fine. The VA spent
thousands of dollars to send me to a neuro-ophthalmologist and
she said my eyes are--my optic nerves are dead. When we came
back the Compensation and Pension (C&P) panel said, no, that
doesn't count. My question is, why did they spend thousands of
dollars to get an expert opinion and they don't use it?
So you are going through comp and pension exams
unnecessarily over and over again before you get your benefits,
and that just adds to the backlog. Not only that, but if they
keep going back to a lower level of care, they won't be able to
correct the problem.
It really bothers me that it took 21 months to figure out a
Traumatic Brain Injury (TBI). Twenty-one months. I went through
all the Army treatment, I went through part of the VA
treatment, and it took them 21 months to discern that it was a
traumatic brain injury, and that is really scary. Because you
can't get the treatment that you need timely enough to benefit
you.
The Federal Recovery Coordinators, we didn't even know
about them. Nothing was ever said to us. And 4 years later I
got a call from one the night before last. Two to 4 years
later. There is no transition between case managers in the DoD
side, and case managers in the VA side. None. There was no
transition. If I wouldn't have brought my paperwork they
wouldn't know what was going on. And there are a lot of younger
soldiers that don't know that, don't know to copy their
paperwork, or aren't given the opportunity to stay and get
their disability. They are given a severance check and sent
off. I know it has happened several times. I have talked to
people in the med holds about it, and it is just shameful. You
know, they put the burden on the VA instead of taking care of
the soldier and then transferring him. There is no seamless
transition, it is just not there.
And one of the suggestions that I have, the Vision Center
of Excellence needs to be staffed and needs to be--the building
needs to be created at Bethesda and they need to get that done.
They were given $6 million in the last round of money that was
handed out and nothing has been done. They need to get that
building up, they need to get the staff, because they are the
ones who are going to do the trauma research and the eye
research, which is what the injuries are coming out of Iraq and
Afghanistan. The number of eye injuries is staggering, and it
is happening 2 years after the injury. So it is not something
that happens right away.
And the scary part is, the benefits, Traumatic
Servicemembers Group Life Insurance (TSGLI). If you are past
730 days they don't pay out the money, and that is a
legislative thing, the DoD put that disclaimer in there. Well
if you have eye injuries and you go blind 2\1/2\ years later
there is no help for you, and that is the money that is
supposed to help you get started on getting your house done,
getting your bills paid.
The other thing that I would like to see, and I think it
would help, is the Caregiver Bill, and I believe that was
brought up and it is in the Senate and the House. My wife has
given me tremendous care and looked out for me, and it is
really a strain. A strain on my children, a strain on her work,
and she may end up losing her job because she has to be gone
all the time to take care of me. I can't go to doctor's
appointments without her because I don't remember what goes on.
And I suggest that that may be a fix.
And there needs to be red flag system. There needs to be.
For TBI and seriously injured soldiers. They need to be in
polytrauma care, and they need to be taken care of. And not a
year down the road. The Federal Recovery Coordinators, they
need to be there right away to make sure that the patients are
getting the care they need. Because up until now there are
hundreds, maybe a thousand soldiers like me who get left
behind. It is unacceptable.
You have people that aren't getting the care they need, and
they are getting left behind or slipped through the cracks, and
you sit there for 4 years to get a med board that probably
takes 3 days. Four years later. I was injured on the
battlefield. Four years later. They still haven't given me a
Purple Heart. You know, things like that, where soldiers are
waiting, and there is no need for that. The care is there, it
just needs to get the soldiers to the care. And the doctors are
strained. The doctors are strained, the nurses are strained
because of the overloaded system. And I understand they added
four or five Federal Recovery Coordinators just recently this
past week and they are overloaded. You have 100,000 people that
are potentially patients and you have 20 Federal Recovery
Coordinators. How effective is that?
I guess the biggest thing I want you to know is that people
are falling through the cracks and this needs to be addressed.
And the Federal Recovery Coordinators, they need to have access
to get this taken care of. The severely injured soldiers can't
wait.
You know, if you are blind in the VA, if you are not
permanent and total they won't give you the benefits of a
vehicle payment, or a house grant. They give a certain amount
of money for your house to be structured. They won't give it to
you unless you are permanent and total. Well blind soldiers
need to have that money so that they can make their houses safe
and their lives better, not to wait endlessly through exams and
exams and exams to finally get permanent and total. That needs
to be done right away.
You know, there are five neuro-ophthalmologists in the
country. If they say you are blind, you are not going to get
better, then they need to accept that.
And I hope that by my testifying today that some of the
problems are out there, and you can come up with ways to help.
And I hope that my testimony has helped bring things to light.
And I speak not for myself today, but for all the soldiers
that can't be here to speak, that are falling through the
cracks and not getting the care they need, and not getting the
care they need in a timely manner.
And I want to thank you for the opportunity to be here
today, and I will answer any questions that I can. And I
appreciate you giving me a little extra time to give my
testimony, as it is a little difficult to summarize when you
have a vision problem. So that is all I have and I will answer
any questions that I can. Thank you.
[The prepared statement of Sergeant Johnson appears on p.
41.]
Mr. Mitchell. Thank you very much. Mr. Wilson?
STATEMENT OF JOSEPH L. WILSON
Mr. Wilson. Chairman Mitchell and Members of the
Subcommittee, thank you for the opportunity to present the
American Legion's views on seamless transition issues.
Currently, there are approximately 23.4 million veterans in the
United States; of that total, 7.8 million are enrolled in the
VA health care system. VA treats 5.8 million veterans at more
than 150 hospitals and 800 plus clinics.
As we examine the transition process, the American Legion,
in its efforts to ensure transitioning servicemembers receive
continuous/seamless care, has determined that veterans are
facing various challenges, which may irrevocably deter any
chance of a successful and smooth transition back into their
local communities.
An example of challenges include incomplete Post Deployment
Health Reassessment questionnaires or PDHRA, inability to fully
share medical records among the Department of Defense and VA
health care facilities, lack of space at VA medical facilities,
and shortage of staff, to include nurses and physicians.
VA and DoD both play important roles in the transition
process. As women and men return from Iraq and Afghanistan
facing uncertainty with injuries and illnesses, the American
Legion contends that closer oversight must be placed on various
programs, such as the PDHRA and Federal Recovery Coordination
Program, or FRCP, that have been implemented to ensure no one
falls through the cracks. We ask Congress to assess these roles
to ascertain the appropriateness of functional tools required
to accommodate the Nation's veterans, their families, and the
complex issues they are met with.
DoD and VA have created and implemented various programs to
support each servicemember and veterans as they transition from
active duty to civilian life to include the PDHRA.
The PDHRA program was established to identify and address
servicemembers health concerns that emerge over time following
deployments. To be in compliance with DoD's policy, each
military service must electronically submit PDHRA
questionnaires to DoD's central depository. However, a recent
audit disclosed that the central depository did not contain
questionnaires for approximately 23 percent of the 319,000 OEF/
OIF, Operation Enduring Freedom or Operation Iraqi Freedom,
servicemembers who returned from theater. This means
approximately 72,000 servicemembers were without questionnaires
in the repository. The response to the absence of the
questionnaires concluded that DoD does not have reasonable
assurance that servicemembers, to whom the PDHRA requirement
applies, were given the opportunity to fill out the
questionnaire and identify as well as address health concerns
that could emerge over time following deployment.
The American Legion believes the administration of the
PDHRA is essential to the success of the servicemembers
transition, because the results would disclose telltale signs
of debilitating illnesses, such as the disorders that plague
many veterans who have gone undiagnosed at separation from
active duty.
Next the Federal Recovery Coordination program. The
American Legion would also like to ensure that the FRCP is
successfully assisting all recovering servicemembers and
veterans suffering from severe wounds, illnesses, and injuries,
as well as their families in accessing the care, services, and
benefits provided through specifically, DoD and VA.
There are more challenges transitioning servicemembers and
veterans face. There have been various reports of critical
challenges involving veterans who have recently departed from
active-duty service. These challenges, as reported by RAND,
includes barriers to mental health care access in community
settings. More to specify it was discovered that military
servicemembers and veterans are often reluctant to seek mental
health care. The mental health workforce has insufficient
capacity.
The American Legion recently passed Resolution No. 29,
Improvements to Implement a Seamless Transition, which
recognized gaps in services, and has consistently advocated
improvements be made to the process of servicemembers in their
transition from active duty to civilian life. The American
Legion continues to express that servicemembers and their
families are easily overwhelmed when dealing with the
bureaucracy of multiple departments. However, a more
expeditious process that explicitly focuses on moving
servicemembers from point A to point B, i.e., DoD to VA,
respectively, would ensure timely and accessible care.
The American Legion believes it is extremely vital that
this Nation's servicemembers, before their departure, should be
placed in a comparable or full duplex capable, fully
compatible, DoD/VA database with appointment reminders to
ensure their transition isn't stifled by the unknown; after
all, active-duty servicemembers have been conditioned to be
directed to all military appointments and events.
Upon separation from service these newly transitioned
veterans may continue to have the expectation that everything
will be set up for them. Both DoD and VA are working to ensure
servicemembers and veterans successfully receive information
and treatment respectively.
It is the American Legion's contention that the interaction
between DoD and VA be heightened, most importantly, by complete
shared access of medical records of servicemembers and
veterans, as well as assessments of this relationship.
Let us remember that there is no pause button for veterans.
Every moment is critical and must be treated as such. Although
the World War II veterans' population is diminishing at
approximately 1,000 daily; other veterans, to include those
from the Vietnam era to current OEF/OIF are presenting to VA
with old and new issues. Complacency and communication between
DoD and VA and implementation of programs can never be
relative.
The American Legion hereby reiterates its position and urge
careful oversight of effective communication between DoD and VA
to include verbal and written, as well as full implementation
of programs to ensure no one is left behind during the
transition process.
Mr. Chairman and Members of the Subcommittee, the American
Legion sincerely appreciates this opportunity to submit
testimony, and looks forward to working with you and your
colleagues to ensure all servicemembers are met with the best
of health care upon transitioning into the community. Thank
you.
[The prepared statement of Mr. Wilson appears on p. 44.]
Mr. Mitchell. Thank you. Mr. Tarantino.
STATEMENT OF TOM TARANTINO
Mr. Tarantino. Mr. Chairman, Ranking Member, and Members of
the Subcommittee, on behalf of Iraq and Afghanistan Veterans of
America's 180,000 members and supporters, I would like to thank
you for the opportunity to speak before you today.
As an OIF veteran with 10 years of service in the Army, I
have seen firsthand the difficulties that many veterans face
when transitioning from servicemember to veteran for both the
wounded warrior who is torn from service due to their
extraordinary sacrifice or the young veteran who spent most of
their formative years in uniform, the transition can be
difficult.
At a time when most of our civilian peers have begun to hit
their professional stride, many of us now must start over, and
this transition is felt by all, but none more acutely than the
brave men and women who have sacrificed blood and limb for the
country and who now must enter a world that does not fully
understand their needs.
Veterans of Iraq and Afghanistan may regularly receive
excellent care in the ever-expanding polytrauma system. And
while these centers can provide excellent care for
servicemembers and veterans, there is a noticeable drop in the
quality of care when transitioning to community-based
institutions near the veterans home of record.
Additionally, the quality of services for disabled veterans
near their home generally does not match the standards of care
that a veteran receives at a polytrauma center, and no where is
this more true for veterans who are in the National Guard and
Reserve component.
Additionally, IAVA is concerned with the structure of some
adaptive services benefits that many veterans use after leaving
polytrauma care. Veterans are being forced into debt because of
shortcomings in the benefits and the services that the VA
provides.
Currently, benefits for adaptive housing and automobiles
are stuck at 1970's funding levels, and most are just one-time
deals. With about 80 percent of OIF and OEF veterans under the
age of 30, a veteran living with permanent disabilities will
more than likely require more than one automobile in his or her
life. The current rate may have bought a van equipped with
adaptive modifications back in 1972. Today, that same amount
might get you a mid size Kia with no adaptive technology.
These veterans are left to pay the difference, and we
cannot tolerate a benefits system that requires a veteran to
incur debt just to perform everyday functions.
Also, many veterans wounded in Iraq and Afghanistan are not
homeowners and must return to their family homes to recover.
They are then faced with the choice during their critical time
in their recovery to choose between adapting the home that they
are recovering in, or save that benefit for the home that they
will eventually settle.
The need for these services is obvious and the figures that
require upgrading are absolutely known, so there is no excuse
for leaving a veteran with substandard benefits.
VA social workers play an indispensible role in the
treatment of veterans recovering from multiple traumatic
injuries, and the VA must rapidly expand their numbers. As more
and more OIF and OEF veterans enter the VA health system, their
overall needs will continue to inundate the overworked and
understaffed cadre of social work professionals within the VA
system. Private sector social workers, on an average, work on a
caseworker to client ratio of 1 to 10 to 1 to 15. In
comparison, in-house VA social workers operate at a ratio near
1 to 35. The VA must address this issue before the ratios
expand further, and these caseworkers cannot properly address
the needs of our veterans and their families under these
currently crushing workloads.
For spouses and dependents of veterans who gave the last
full measure of devotion to this country, the VA provides
educational benefits under Chapter 35, the Survivors' and
Dependents' Education Assistance Act or DEA. In 2008, the VA
reported that over 80,000 family members took advantage of this
program, more than the number of reservists using Chapter 1606,
and unlike the generous Post-9/11 GI Bill or the recently
increased Montgomery GI Bill, DEA provides a paltry sum of just
over $900 a month, which will cover less than 60 percent of the
cost of an education.
IAVA believes that DEA benefit rates should be aligned with
those of the new GI Bill, and if we don't what will end up
happening is a two-tiered benefits system. One tier our family
members were able to attend college because they qualified for
the Gunnery Sergeant Fry Scholarship under the Post-9/11 GI
Bill. The second tier are those forced to use DEA who take out
student loans just to pay for a community college.
Now since 2008, we have seen a noticeable shift in how the
VA educates veterans about the benefits and services that we
are talking about today. I have personally met with
representatives from the Veterans Health Administration (VHA),
the Veterans Benefits Administration (VBA), and the VA Business
Office to discuss how they can better reach out to veterans of
Iraq and Afghanistan. There has been a visible improvement with
online and television advertisement, but there is a clear lack
of coordination between VA departments. Within the VA, I firmly
believe that there is talent, will, and desire to change the
passive nature of VA communication; however, there are still
substantial cultural and structural hurtles that must be
overcome.
IAVA believes that in order for the VA to conduct effective
outreach to let these veterans know what is available to them
it must centralize its efforts and speak as one Department of
Veterans Affairs.
See, the average veteran doesn't understand the difference
between VHA and VBA. The average American certainly doesn't
understand. When I wait an entire semester for my GI Bill check
to come, I am not upset with the VBA, I am upset at the VA.
When I wait 2 months to get a medical appointment, I am not
upset at the VHA, I am upset at the VA. If the VA ever wants to
effectively improve its communications, it must speak to the
veteran population and the American people clearly and avoiding
government jargon.
Thank you once again for the chance to communicate our
opinions on several of the issues facing veterans of Iraq and
Afghanistan, and we look forward to continuing to work with the
Committee, and I appreciate your time and attention. Thank you.
[The prepared statement of Mr. Tarantino appears on p. 47.]
Mr. Mitchell. Thank you. Mr. Pruden.
STATEMENT OF CAPTAIN JONATHAN PRUDEN
Captain Pruden. Mr. Chairman and Members of the
Subcommittee, thank you for inviting Wounded Warrior Project to
share its perspective on issues of seamless transition between
the Departments of Defense and the VA.
I was an Army captain who in 2003, became one of the first
improvised explosive device casualties of Operation Iraqi
Freedom. I have made that transition myself. Now after 20
operations at seven different hospitals, including amputation
of my right leg, I work as an Area Outreach Coordinator for the
Wounded Warrior Project. I work with hundreds of warriors
around the southeast covering Florida, Georgia, Alabama, and
South Carolina.
Over the past 6 years, I have witnessed DoD and VA making
significant strides in care coordination and information
sharing. This Subcommittee's steady focus on these issues has
helped to achieve greater seamlessness for wounded warriors.
But even the most well coordinated, seamless handoff from DoD
to VA will not change the fact that for many wounded warriors
this transition feels like they have been thrown off a cliff.
While the two departments can take pride in certain areas
of real progress, wounded warriors leaving the service continue
to face programmatic, cultural, and structural barriers at the
VA. It is critical, in our view, that those barriers be toppled
and that key VA programs and service-delivery mechanisms be re-
engineered with the goal of having wounded warriors thrive
physically, psychologically, and economically.
Currently the VA does not provide wounded warriors 21st
century help that they need. As you know, many are not only
combating co-occurring PTSD and substance-use issues, but co-
occurring traumatic brain injuries, burns, amputations. Often,
they are dealing with the constellation of issues which is
pain, anger, depression, unemployment, lack of employment
opportunity, and lack of permanent housing. In some cases these
issues and behavioral health problems have resulted in run-ins
with the law.
VA has an array of programs targeted at specific problems,
but little in the way of a holistic coordinated approach to
turn these lives around. It must move in the direction of
providing wraparound services that integrate the work of VA's
Health and Benefits Administrations. Much work also needs to be
done within those administrations to make existing programs
more veteran centric.
Let me cite a few examples. Too many veterans under VA care
for PTSD or other mental health conditions are still simply
being given pills to manage their symptoms despite a policy
that emphasizes a goal of recovery and rehabilitation rather
than just symptom management. This needs to change.
OEF/OIF veterans who are struggling with PTSD need good
clinical care, but they also need support and mentoring from
peers who have made strides in battling the same demons. We
urge the VA employ OEF/OIF veterans at every medical center to
provide such peer support, as well as to do outreach to the
many who have been reluctant to seek treatment.
To offer another example, our own work with wounded
warriors has highlighted the difficulties facing those who have
PTSD and need in-patient treatment. VA's in-patient programs
don't have uniform admission criteria. Each facility seems to
set its own criteria. Too often warrior's circumstances don't
fit those inflexible criteria for specialized PTSD care and
they are denied admission to these programs they so vitally
need.
In short, rather than veteran-centered care this seems to
be more like barrier-centered care. A veteran centric systems
would not, as some facilities do, impose rigid requirements
that a veteran must have had success in out-patient therapy for
3 to 6 months to qualify for admission, must have had no
suicidal attempts or suicidal ideation even for the past 6
months, must first complete out-patient anger management before
they can receive treatment, must first be substance abuse free
for a certain amount of time, and must first be interviewed,
and if accepted, may be admitted at a later date.
Tragically many OEF/OIF veterans who are suffering with
severe PTSD are hanging on by a fingernail, and they don't have
months to wait to receive the in-patient care.
Wounded Warrior Project field staff has considerable
experience in helping OEF/OIF veterans get needed mental health
care from VA facilities, but we have encountered great
difficulty with placements when veteran's conditions pose a
relatively urgent need for specialized in-patient treatment.
The most pronounced of these cases have involved veterans who
have been jailed because of behaviors linked to PTSD and
substance abuse, and whose cases have come before a judge who
is willing to having the veteran undergo treatment rather than
incarceration.
In several cases, however, VA medical center personnel who
have attempted to facilitate such placements have been stymied
by long waiting lists at specialized in-patient facilities
inside their VISN. On numerous occasions, our field staff have
inquired on behalf of our warriors about in-patient PTSD
placement options beyond the confines of a particular VISN,
only to learn that VA staff have no central repository of
information or clearinghouse to turn to, to find out about
programs that exist outside of their Veterans Integrated
Services Network (VISN) or their immediate area.
I am aware of one case where in Tuscaloosa, Alabama, there
were 125 individual veterans on a waiting list for a dual
diagnosis substance abuse PTSD program. One hundred eighty
miles away in Jackson, Mississippi, was an analogous program
with empty beds the next week. The two programs didn't know the
other one exist because there was a VISN line between them, and
this is unacceptable.
We have urged the Department of Veterans Affairs to
establish a clearinghouse on these programs to provide
relatively real-time patient and placement information. To
date; however, this recommendation has elicited no response.
To cite another area, employment is certainly key to
successful reintegration. Yet in programs targeted at helping
veterans gain Federal employment, wounded warriors encounter
troubling obstacles even at the VA, the one agency you would
expect to go the extra mile in employing veterans.
As you know, Mr. Chairman, service-connected disabled
veterans are entitled to a ten-point preference in Federal
hiring, but those extra points seem to give our warriors little
or no practical help. Instead, the complex hurdles of the KSAOs
(Knowledge, Skills, Abilities and Other characteristics) in
demonstrating ones qualifications for a particular Federal job
often knock qualified warriors out of contention, even in the
VA. Surely the Department could establish some mechanisms to
help overcome these hurdles.
Mr. Mitchell. Captain, could you wrap this up?
Captain Pruden. Yes, sir.
Mr. Mitchell. Thank you.
Captain Pruden. In short, Mr. Chairman, to achieve its
ultimate goals of seamless transition it will not only require
work to bring VA and DoD closer to fill the gaps, but a
substantive transformation within the VA to insure that this is
the most successful and well-adjusted generation of veterans
ever.
Thank you. That concludes my testimony.
[The prepared statement of Captain Pruden appears on p.
48.]
Mr. Mitchell. Thank you very much. There are a couple
questions I want to ask, and first to Staff Sergeant Johnson.
Did I understand you correctly that you are still going to
Reserve meetings?
Sergeant Johnson. Yes. I was put in a transients, trainees,
holdees and students (TTHS) holding cell, and they told me that
until my MEB is over and they give me a disability rating that
I have to go to monthly drills. And like I said, I go into a
room, I sit there, that is it.
Mr. Mitchell. How long after you returned home did you
become blind?
Sergeant Johnson. About a year.
Mr. Mitchell. About a year?
Sergeant Johnson. Year and a half.
Mr. Mitchell. Could this have been prevented?
Sergeant Johnson. No. From the blast injury my optic nerves
already started to die, and the TBI had affected--my brain so
it can't comprehend what my eyes are seeing, so according to
what they told me it couldn't have been prevented, but the eye
services would have helped tremendously.
Mr. Mitchell. In that time period there could have been
some transition to knowing what was going to happen, instead
nothing happened until after you actually became blind?
Sergeant Johnson. Yes.
Mr. Mitchell. And did I hear you say that you have not even
received your Purple Heart yet?
Sergeant Johnson. Correct.
Mr. Mitchell. And how many years has that been?
Sergeant Johnson. Four years.
Mr. Mitchell. Four years? Thank you.
Let me ask Mr. Wilson something. What are the top two
concerns for veterans that you hear from in your organization
transitioning from DoD?
Mr. Wilson. I actually heard those issues yesterday, during
a site visit at one of the four Level 1 polytrauma centers in
Tampa, transitioning, and screening.
Mr. Mitchell. They what?
Mr. Wilson. Servicemembers/veterans have no knowledge of
the program. We have heard that some weren't screened
extensively. So screening and pretty much ignorance of VA
programs or even the transition from DoD to VA itself.
Mr. Mitchell. So even if the VA comes--and they will
testify I am sure--that they have all these programs, the
problem is the veterans don't know about them.
Mr. Wilson. The American Legion conducts site visits at
VAMC's from January to June; we write that publication and we
disseminate it to all 535 Congressional Members. If one
evaluates the VA they are going to find very good programs.
DoD, very good programs.
Again, the problem is the transition from DoD to VA and/or
the communication between the two, which begins also with
medical records. Yesterday there was a doctor speaking on
really good new patient programs, I asked him about challenges.
He stated, ``The challenge is getting records from DoD.'' I
asked, ``Well how do you do it? Do you do it the conventional
way?'' He says, ``Exactly, the conventional way, and that takes
lots of time.''
Being an old computer guy I know there is such technology
as duplex capability. There has to be more oversight on this. I
mean it is frustrating now even to computer users who don't use
computers that often, they know that there is a program that
will allow both DoD and VA to communicate with one another.
Mr. Mitchell. Thank you. Mr. Tarantino. What complaints do
you hear most from veterans who are in the process of
transitioning?
Mr. Tarantino. Well, I think what we are hearing is
definitely that there is a lack of communication, and this is
not just for servicemembers leaving active duty, this is
particularly for servicemembers in the National Guard and the
Reserve. I know myself, I would have never gone to see the VA
if an old sergeant major who was going through the Army Alumni
Program with me hadn't grabbed me and said, ``You know, sir,
right now you are young, you are macho, and you are stupid.
When you get to be my age you are going to be old, you are
going to be less macho, and you will probably still be stupid,
but you are going to be in pain and you are going to need to
know what is available to you.'' And the VA does not make
itself known to active duty or to the Reserve component.
And what we are seeing especially in the National Guard and
the Reserve component, is that soldiers get these invisible
injuries, they get discharged 48 to 72 hours after they leave
Baghdad, and now they are home, they are drilling, and they
need care, and they have to go to the VA. But there is no
mechanism to bring them back into the fold of the DoD and say,
okay, you are injured, you need a medical retirement, or we
need to take care of you.
In many cases we are seeing members, Iraq and Afghanistan
veterans that are 70 to 80 percent VA disabled that are getting
called up out of the IRR back onto active duty because the DoD
has absolutely no idea that these guys were injured. And that
is the big nightmare scenario that we are seeing with our
membership.
Mr. Mitchell. Thank you. And one last question to Captain
Pruden. Do you think that the Office of Wounded Warrior Care
and Transition Policy is on the right track? What improvements
could be made?
Captain Pruden. From what I know I think they are on the
right track. I think they have made some very substantial
improvements over the past several years here, and the addition
of five more Federal Recovery Care Coordinators is certainly a
step in the right direction.
I would like to see again a more seamless handoff to the
VA. I would like to see case managers who are--as Secretary
Shinseki created the Seamless Transition Patient Advocate (TPA)
Program doing the handoffs from the VA to DoD, unfortunately a
lot of those slots were filled by social workers with no DoD
experience, but a lot of experience in finding employment in
the VA. And so I would like to see, again, TPAs be able to do
their job and reach across and work directly with DoD to pull
them into the new system.
Mr. Mitchell. Thank you. Dr. Roe.
Mr. Roe. Thank you, Mr. Chairman. Just a comment to Mr.
Tarantino. In your testimony you had concerns raised over the
seventies, and rightly so, funding level of the adaptive
housing grants, and I want to make certain that you are aware
that Congressman John Boozman who is on the Committee and
Ranking Member of the Subcommittee on Economic Opportunity,
introduced legislation that would increase funding, H.R. 1169,
from the small housing grants of $12,000 to $36,000 and the
larger housing grants from $60,000 to $180,000. The bill would
also increase automobile grants up to $33,000.
So I understand that there are some PAYGO issues with this
obviously that have to be worked through, but I think all the
Members on this Committee will look favorably toward that. So I
just wanted to pass that along.
You know, and the Chairman has been here one term, but you
know you haven't been here a lot of terms when your group goes
to Great Lakes, Illinois, in January, which is what we did.
When other people are going to Hawaii, we went to Great Lakes.
And what I keep hearing. I have been in the infantry, I
have been to Afghanistan and spent a week there, been to Walter
Reed and now to Great Lakes, and we have a VA in my hometown,
so I have a pretty good idea, but I am still having a problem
getting my arms around this. And after 33 hearings we are still
hearing the same thing. And I think it is time to sit down. And
I agree with you all, I see a VA at home that is trying to do
the right thing. I go to a Walter Reed and I see them doing
great work with the veterans there and the rehab with the
wounded warriors. No doubt about it, as a physician I am amazed
at the recovery that a lot of these wounded warriors are
achieving now. But it is not coordinated where the left hand
and the right hand knows what is going on. It is not because
people are not trying. I absolutely believe that.
But I am going to ask any one of you if you will take this
pass and just tell us, is it beginning when the warrior--and I
believe that what we need is, is when a soldier signs up that
that soldier needs to have--be in the VA system that day, and I
think they need to have one record. And I think, Mr. Wilson,
you are absolutely right, you've got information here and
information here and nobody can share the information. So I am
beginning to get my arms around on what we need to do, but just
to comment on my statement. Mr. Wilson you can start if you
would like, or Mr. Tarantino.
Mr. Wilson. Okay. You know, I had mentioned and it was in
the testimony that the role of DoD and VA must be that of
``safety net catalyst.'' Titled terminology epitomizes a
respective program. For example, we notice that the term
``seamless transition'' they pretty much shied away from; it's
now called ``continuum of care.'' Seamless transition, I think
the terminology holds us to a standard, and I will give you an
analogy. VA's nursing home care facilities are now called
community living centers. The American Legion has visited many,
over 50 in this Nation, and they are holding to that standard,
I think it's even better, because they are trying to pretty
much help that veteran who is transitioning identify with their
respective community by transforming the nursing home facility
into a main street type community facility. So with VA,
everything may be in a name. So seamless transition makes us
aware of this process. Before it was called seamless transition
as I said the name was changed to continuum of care, and I
think we shied away from that level boost.
Mr. Roe. Let me interrupt for just a second because I don't
have much time left. But I know when I got out of the Army
basically I gave myself my own physical to get out, because I
wanted out, like most of us do. And I think that is what
happens when you said we are young and stupid. I think you are
right about that.
Would it help when a veteran ETS's (Expiration of Term of
Service) from the military if the VA were there at the time of
separation and to prepare that veteran to move on? And I know I
was given a physical, but is everybody given a physical on the
way out the door? Do you have a record when you leave the
military, are you examined by a physician or a physician
assistant or whatever and get a complete physical exam before
you leave so that you have that information when you leave?
Because, see I think if you are injured, the best time to find
out how bad your injury is, and it may change. As you pointed
out, as you get older things change. But you at least at that
point in time you would know exactly what was wrong with that
soldier. And Captain Pruden or Mr. Tarantino. Either one.
Captain?
Captain Pruden. I think that having a pre-release physical
is vital as part of this. But I will tell you that
servicemembers who are coming off active duty currently because
of enhanced oversight and programs that have been implemented
in the last 6 years, do have a whole array of briefings about
benefits that are available to them as they leave the service.
Oftentimes there is a bit of information overload. They don't
remember most of what is told them. They have 100 forms they
have to sign. And so they leave the service having heard one
time this thing that goes in one ear, out the other. They don't
recognize that they will need that in the future.
So I think again, it is critical the VA be there doing
outreach as these guys are coming into the VA system. And you
know, when the OEF/OIF folks are coming into the VA and
enrolling in the VA, that they have the best primary care
physicians around. As you guys know, the primary care managers
at the VA are sort of the gatekeepers to all of their specialty
care and will be the primary folks interacting with our wounded
warriors and our veterans. And if nurse case managers--OEF/OIF
nurse case managers could have override capabilities to put
wounded warriors and veterans with appropriate primary care
managers instead of sort of leftovers after--older veterans
talk, and they know who the best doctors at the VA are.
Mr. Roe. Not only veterans talk.
Captain Pruden. Yeah. But they know who the best doctors
are at the VA, and so there is a waiting list to get on with
that primary care manager. The newest nurse case managers and
the least experienced and perhaps maybe not the best physicians
in the VA are the ones who have open slots typically, and
oftentimes these warriors are assigned to folks who don't know
about head or trophic ossification, a lot of the conditions
that these guys are coming back from Iraq and Afghanistan with.
You need a primary care manager who is familiar with these
things, who is competent to serve as the gatekeeper to push
them out to the appropriate services.
Mr. Roe. Okay. Thank you, Mr. Chairman.
Mr. Mitchell. Thank you. Mr. Hall.
Mr. Hall. Thank you, Mr. Chairman and Ranking Member and
other Members of the Committee for allowing me to go out of
order. I have a meeting like most of us that I'm double booked
on. But proud to say we have a member of the Wounded Warrior
Project who has joined our staff in the 19th District in New
York, and the meeting I am going to is for another veteran who
we hope will join our staff here working on veterans' issues.
It is disappointing to know that as we enter 2010, more
than 9 years after we first entered Afghanistan, transitioning
our troops is still such a challenge, and that we have to do
better for all of our men and women in uniform, and our heroes
like Staff Sergeant Johnson deserve better.
I have visited the wounded warrior transition (WWT) unit at
West Point, which is in my district, and commend the men and
women who are working there. But even this success illustrates
the shortcoming we have with only 35 WTUs in the whole country.
We have servicemen and women from as far away as Vermont coming
down to southern New York to Hudson Valley to come to the WTU
in West Point to receive treatment.
There is also a limited VA presence at West Point, and
these are among the reasons that I plan to introduce
legislation to improve this seamless transition by mandating
that the VA have a permanent presence on all active-duty
military facilities and require one-on-one consultations with
active troops as they begin the transition process. There
should be no improperly filled out enrollment forms, you know,
it should cut down on processing time, and reduce the ever
growing backlog, which is going to grow even more, as a result
of the addition of three new Agent Orange connected diseases.
Leukemia, Ischemic Heart Disease, and Parkinson's Disease, but
I am sure you can fill me in.
I wanted to ask you, Staff Sergeant Johnson, in your
written testimony you said that you were told if you stopped
contacting your Senators you would be given medical treatment.
Can you tell us who told you that?
Sergeant Johnson. The Reserve case manager at Fort Riley,
Kansas. Shortly after that I was transferred to another case
manager, because I stood up to her and said that this is not
right, it is ridiculous, and I am not going to stand for it.
And then I was transferred to another care manager.
But like it was said before, the case managers are
stretched thin. So instead of one-on-one or one-on-five it is
one-on-ten or fifteen. So you get left behind.
Mr. Hall. Well good for you for standing up like that, and
I am not surprised, but many veterans get their problems solved
or at least help getting their problems solved in part by
coming to Members of Congress or Senators, and it is just
shameful that somebody should tell you to stop contacting your
elected representatives as if you gave up your rights as a
citizen by being a soldier. That is very unfortunate.
But I wanted to ask Captain Pruden, you mentioned the
difficulty of some OEF/OIF veterans to get PTSD treatment. Do
you believe that presumptive service connection for a PTSD will
help this problem, such as the rule change that we are
expecting from VA?
Captain Pruden. Could you clarify the question as far as
what a presumptive PTSD diagnosis would look like in your mind?
Mr. Hall. Well there was a rule change proposed by the
Department, the Secretary has testified before the full VA
Committee about it, and the public comment period closed before
Christmas, I think it was in November, and they are evaluating
thousands of pages of testimony now before making the final
announcement of what the rule change will be, but it would
presume any PTSD to be service connected if that man or woman
in question had served in a combat zone or an area of
hostilities with the enemy so as to remove the need for a
particular incident being proven.
Captain Pruden. I think that is appropriate. I think that
PTSD obviously is not necessarily caused by a certain focal
instance where your own life is threatened, but it can be
caused by the generalized fear of mortar attack or seeing dead
bodies all around, seeing civilian casualties. So no, I think
that is an appropriate step and would help facilitate more
appropriate care for these guys as they are coming back. And
unfortunately it is oftentimes when you have the burden of
proof heaped on these guys, these warriors as they are
returning it is a real challenge with the psychological issues
they are dealing with to try to come up with the evidence they
need. So I think a presumptive rating makes a lot of sense.
Mr. Hall. Thank you very much. Thank you, Mr. Chairman. I
will submit my statement in writing.
[The prepared statement of Congressman Hall appears on p.
40.]
Mr. Mitchell. Thank you. Mr. Stearns.
Mr. Stearns. Thank you, Mr. Chairman, and thank you very
much for holding this hearing. Perhaps going along with what
Mr. Hall said and the opening statement of Mr. Roe when he
mentioned we had 33 hearings--I think Mr. Roe mentioned we had
about 33 hearings on this topic the last 10 years. I asked
staff to give me, going back to 2000 to the 106th Congress, the
Subcommittee on Health had a VA hearing on health care sharing
between DoD and the Veterans Administration. In 2002, there was
a hearing in the Subcommittee on Benefits on the Transition
Assistance Program and Disabled Transition Assistance Program.
You can even go through this list and you can just see that in
2005 we had an oversight hearing on the Transition Assistance
and Disabled Transition Assistance Program. So this issue has
not been without hearings.
I think now, Mr. Chairman, what we need to do is, as a
result of this hearing, come up with a bill, one perhaps that
Mr. Hall mentioned and one that I think both Mr. Roe and I can
work on to amend. I have several ideas, and Captain Pruden is
in my Congressional district from Gainesville, Florida, and is
working with the Wounded Warrior Project.
So I think, Mr. Chairman, you have a unique opportunity,
based upon what we heard today, and what the record shows, that
we should try and solve this problem. And I know the second
panel is going to mention veterans or the Veterans
Administration, some of their personnel are here, but it
appears to me there are two problems.
One is when the veteran leaves, when he leaves the military
active service, the coordination with the Veterans
Administration has not been successful. Perhaps we should have
some VA employees at the point of demobilization that are there
when a veteran leaves the military, whether that is at the
military base or at the country where he is just so that he
gets it.
The second thing is, I think we have to have enforced by
the Veterans Administration the medical checks. Staff Sergeant
Johnson, when you left the military did you actually have a
medical screening, including an eye exam? I wasn't clear on
that.
Sergeant Johnson. Yes, when I was demobilized because the
hospital could no longer do anything for me I was given an exit
physical.
Mr. Stearns. Including an eye exam?
Sergeant Johnson. Yes.
Mr. Stearns. Okay.
Sergeant Johnson. Before I went back home to my unit.
Mr. Stearns. Yes.
Sergeant Johnson. The problem is the reservists have been
deployed for a year. They come back and instead of debriefing
them and keeping them for a little bit to see if they have the
PTSD issues, they are in and out in 3 days.
Mr. Stearns. I understand.
Sergeant Johnson. Nobody wants to stay at the site, they
want to go home and see their families.
Mr. Stearns. Yes, I understand.
Sergeant Johnson. So they are going to say whatever they
want to hear----
Mr. Stearns. To get out of there.
Sergeant Johnson [continuing]. Or whatever they need to say
so they can go home.
Mr. Stearns. Did you have a mental health screening?
Sergeant Johnson. Yes.
Mr. Stearns. And you had a dental examination?
Sergeant Johnson. Yes.
Mr. Stearns. Captain Pruden, I think with all your injuries
and everything, you obviously had a medical screening. Did you
also have a mental health screening? Do you recollect when you
left?
Captain Pruden. There was a screening form that I filled
out and a PTSD screening criteria form that I filled out, but
did not have psychological evaluation.
Mr. Stearns. Yes. So you were asked to sign something, but
were you briefed on what you were signing and the meaning of it
and so forth?
Captain Pruden. I believe that I was. And again, I think
the issue really is you are doing so much so fast, going
through the NEBPB process----
Mr. Stearns. You don't understand the significance of what
you are doing.
Captain Pruden. Exactly.
Mr. Stearns. Yes. Based upon the conversations you and I
have had in my office and based upon your testimony, what kind
of changes, if you could wave a wand today, based upon your
experience, would you like to see? Communication between the VA
central office and the caseworkers working in the different
VISNs? What would you do today at the Veterans Administration
to help those that are suffering from traumatic brain injuries,
PTSD, or other serious mental health issues and what we as
members could follow up and do based upon your recommendation?
Captain Pruden. You know, as I mentioned in the testimony,
sir, I would recommend that there be a central clearinghouse of
information that pulls in information about specialized PTSD,
substance abuse, TBI programs across VISNs, and that that also
would be pushed back out to the caseworkers who could use the
information. Most caseworkers are overloaded, as the other
witnesses have testified to, and they have a window of about
this big, and when they get a warrior in front of them, a
veteran in front of them that needs help they are going to send
them to the place down the street, because it is the place down
the street, it is the place they know. Not because it has
available beds, not because it is necessarily the best facility
for them, they send them to that facility because they don't
know any better, and there is no information coming in, and the
VISNs have become small feed centers. And so having a central
clearinghouse for information would I think be a tangible way
to make a difference with the case managers of these warriors.
Mr. Stearns. Mr. Chairman, I think based upon his
testimony, what we should do is write a letter to the Secretary
of Veterans Affairs asking them if they have a central point of
communication. I think they will say they do. What we would ask
is for them to put in writing if it is systemwide. They might
have it in different geographical locations, but what I think
the captain is saying, is we need something that is systemwide
so that everybody can go to that one person, not to separate
geographic locations.
Captain Pruden. Yes, sir. I talked to over two dozen OEF/
OIF caseworkers across the Nation about these programs, not a
single one of them could tell me about programs outside of
their VISN except occasional anecdotal things. So if the
information exists it is not getting to the folks who need it.
Mr. Stearns. So I think that would be appropriate. And then
as a result of what he says we can follow up if necessary with
legislation.
The other big problem that I have heard over the years
serving on the Veterans Affairs Committee is the effectiveness
of peer-to-peer support and peer-to-peer mentoring amongst
veterans. Captain Pruden, is that, in your opinion, being
effectively done by the Veterans Administration?
Captain Pruden. It is not at this point. I mean, that is
something that the Wounded Warrior Project and other VSOs are
working on laterally, but I think that the best shot the VA has
taken was creating the transition patient advocate physicians,
were supposed to be filled by OEF/OIF personnel, and
unfortunately when that has been the case, I know of six
personally who have filled those positions, OEF/OIF personnel,
four of them are no longer working for the VA because they were
so frustrated and a variety of issues that arose with that job.
They thought they would have carte blanche to go out and do
good and make sure the guys were taken care of as they came
from DoD to the VA, and unfortunately that wasn't the way it
worked out oftentimes.
Mr. Stearns. Well let me just conclude, Mr. Chairman, by
saying I think we have some very constructive ideas that have
come from this panel. I think in addition to what Mr. Hall
mentioned about having the VA representative there at the day
they are discharged, that somehow we should have this
mentoring, this peer-to-peer support and peer-to-peer
mentoring, available for them in a consistent way so veterans
before they sign up on these sheets can see these peer-to-peer
mentor who can tell them what they are signing off and what it
means. So if a fellow Marine, a fellow Army, a Navy, an Air
Force personnel said to me, ``Cliff, before you sign off let me
tell you what the situation is. I have had post-traumatic
stress disorder and I signed off and I shouldn't have. This is
serious.'' So this idea of being young, macho, and stupid would
be balanced by having fellow soldiers who have been through it,
who have lost their eyesight, lost their limbs--sitting here
with shrapnel in their body--could say listen, let us not be
stupid here. I want to tell you what my life story is, and then
they would get their attention rather than just saying I want
to get to Dayton, Ohio, I want to get back to West Virginia.
This is really serious, and you are looking in the eyes of guys
that are veterans who are wounded and have suffered and they
can tell them about the experience that their spouses have also
suffered. So that would make them more informed.
So I appreciate all of your testimony and thank you for
your time.
Mr. Mitchell. Mr. Walz.
Mr. Walz. Well thank you, Mr. Chairman, and thank each of
you for your service. And Mr. Tarantino, I am that old sergeant
major you talked to and I have sat through far too many of
these. I think I am at a breaking point on this, along with
many of you.
Mr. Johnson and especially Mrs. Johnson, who I will be
talking to most of the time, because that is a key here that we
have missed and it hurts this Nation and it is the wrong thing
to do. But to you, Mr. Johnson, on behalf of the people of
southern Minnesota, and I think it is fair to say the people of
this country apologize to you for what you have been through,
but I also realize that and a yellow ribbon magnet don't even
get you a cup of coffee. And I have had it with that type of
rhetoric, I have had it with that type of support, if you would
call it.
And you want to hear a real sad story? In that very chair
you are sitting in last year a young man named Travis Fugate
sat in that same chair and went through the same thing. And we
were warned about it, we were told about it, we lamented about
it, we rang our hands, we gave--and you are going to hear Mr.
Koch is going to come up, we will rail at DoD for not talking
to VA, when those people are absolutely committed to our
veterans and we are simply still not finding a fix.
I find it absolutely appalling a caregiver bill--and Mrs.
Johnson you will attest this when we hear what you have gone
through and how your life has changed--passed this House,
passed the Senate and sits there now. It took a week to pass
the TARP bill, money sure moved quick to Wall Street. It took 3
days to pass the money to re-build the bridge in Minneapolis
after it fell. Well your bridge is falling every day. And the
euphemism of that or the vision, I am just appalled that we
can't see this.
And I have to tell you, I have talked to Secretary Gates, I
have talked to Secretary Shinseki, talked to Admiral Mullins,
they are all committed. But you know if I was you, if I was
asking today is, ask Members up here if they know their
counterparts on the House Armed Services Committee. Why aren't
they in here? Why can't we as a Congress talk together to
figure it out? We keep talking about that. Oh no, we got our
silo we got to protect. Go over and talk with who is on
Representative Davis' Committee. If we can't name them shame on
us. And you got them, and it is we that are handling that. We
got it. It is our silo. It is our area of expertise. You know,
I am the chairman there and all this.
So I have to tell you, the time for the rest of the talk is
done. We can scream and yell at DoD and at VA and all that. We
are not setting the model here. We are not pushing the thing
forward.
And I want to just watch a few things. I think it is great.
And Mr. Tarantino, a year or so ago we had VA in here and asked
them about their outreach. We had to direct them, letter and
spirit of the law to tell them that they could advertise. For
every ad trying to get you in to be one of the few and the
proud there ought to be one that say when you come home you are
still few, you are still proud, and this country cares about
you. But we had to tell them to do that. So then all of a
sudden I saw a sign on the side of a bus. And then I go to the
Web site and I can't even read it. My 9-year-old's club penguin
site is more functional. And those are the things that how can
we miss that? How can we get it wrong?
So I ask Mrs. Johnson, as all of us talk about this if all
those things happen or whatever and we debate the little things
on this, could you just tell us on the Committee how has your
life changed since your husband and our staff sergeant was
wounded? How have things changed for you?
Mrs. Johnson. Well we have three teenage children. We have
been married for 15 years. And he came back to Fort Riley, and
from the very beginning I knew things weren't right, but I
didn't have the ability to be there with him. I had to be at
work, I had a family to take care of, he was 12 hours away.
Most of our conversations were by phone where, you know, my
proud soldier would deceive me the best he could with oh, I am
fine, it is great, I am feeling good today, I took my pills, it
is all good. And so I had to do a lot of calling and
complaining. And I used a lot of my time at work, asking a lot
of favors from different people to, you know, can you cover my
class for just a little bit while I go make this call? While I
go call Senator Johnson's office back. I mean he would call and
say, well maybe you shouldn't do that anymore because today
they brought me in and said I need to quit making these phone
calls, or I need to quit asking for this. And I knew he wasn't
right.
It took 9 months to get him home. He came home, was not
able to be on the CBHCO Seal program. Was told that he was too
severely injured, it is not a long-term program, we don't have
the availability in your area, you need to just go home and go
back to your regular job as a firefighter, as a lieutenant, in
a position where he--first of all his physical stamina wasn't
good, his confusion, he has memory loss, he can't make
decisions. And to be able to say that he was going to come back
and fill that capacity, I mean that was not good.
It took about 6 months. They had him on a mostly paper
shuffling job at the fire department. They worked very well
with him. But within a year he had to take a medical
retirement. He could not meet the demands of that job and the
quick thinking and decision-making things that he needed to do.
So we started with the VA when he got home. We did all of
the legwork for that. He copied every one of his medical
records from the military. At times we had to beg to get
records of things. We had to search for things that didn't
happen or didn't exist. We had to do all of the legwork on the
VA end. And then throughout that process, while we have been
very fortunate to have a great doctor in our polytrauma unit,
prior to that there were no questions about blast injuries,
about falls, about head injuries. They were focusing on the
wrong problem. And I would say, ``Look, you know what, he
doesn't remember conversations we had yesterday.'' And the kids
and myself were saying dad's not right, this is wrong, there is
something missing here.
And so he returned home in May of 2007, and in December of
2007 someone finally asked, ``Were you ever near a blast
injury? Were you ever near an explosive device?'' That is what
finally tipped them off that well maybe we better examine him
for a brain injury.
When we finally got that information--again, I really liked
the doctor that we work with at the Sioux Falls VA, I think he
does a great job--but the VA doesn't have any information on
PTSD or TBI that they are handing out. They would sit us down,
we would have our hour or half an hour appointment and then
drive the 3 hours home and go home and Google everything.
Everything that we know about every disability and injury and
infection he has had is because we looked it up ourselves. And
that is time consuming, it is difficult, it is hard to focus on
your own position, focus on your children. We have to be at
this or whatever appointment or activity, and fit in his
appointments.
I am very fortunate with my principal at my school that he
does let me be gone as often as I need to be. I can go in and
say, this is what is going to happen and I need a sub. But I
know that there are so many more that aren't that fortunate to
be able to go in and say hey, I have to be gone for 3 days and
just have that be okay, have that be provided, and to be able
to have that support system.
I mean not a lot of your younger family members, especially
if you are busy, you have young children, you don't know who to
ask, you don't know where to go. And I think a lot of those
younger soldiers don't know that it is okay to yell and scream
and call and complain and keep looking for things. And I think
the sad part is a lot of them believe what they are told. If
you are told well if you do this, this will happen, or if you
do this, you know, there is nothing more we can do, then that
is what they accept.
And that was part of our goal from the very beginning, was
let us see what we can do to make it a little easier for
someone else so that when you come home after serving your
country, you don't have to fight and you don't have to search
on your own and try and find your own answers.
Mr. Walz. Well thank you, and I think we all need to be
very, very clear, this chain of events for this family was put
in place because someone raised their hands and choose to
defend this Nation and do what they were asked. That is the
only thing that put them in this position. And these people are
not victims. And the idea that this mother, this wife, this
American has to come back and spend that time fighting is just
appalling.
But I will tell you, everyone of us here better soul search
a little bit. That seat will be occupied by another Travis
Fugate, another Mr. Johnson, another down the road unless we
determine at some point to stop it.
So I appreciate all the advice that is getting here. You
are all exactly right on. But I am convinced it is far more
than just logistical fixes on this, it is systemic cultural
change on how we view this. And if it doesn't happen that is
the result.
Mr. Stearns. Will the gentleman yield before you close?
Mr. Walz. Yes.
Mr. Stearns. I think it was very important that you asked
Mrs. Johnson that I appreciate you taking the time, Mr.
Chairman, I ask unanimous consent if there is anything she
wanted to add.
The question I have for her is, do you think that wives of
veterans that are wounded like your husband should have an
opportunity for counseling or some kind of support group for
yourself?
Mrs. Johnson. Yes.
Mr. Stearns. Because in effect you are becoming not only
his regular wife and the mother to the children and working,
but the stress on you must be unbelievable too, and there must
be a breaking point where you can't go on unless you have some
kind of support.
Mrs. Johnson. Yeah, I think that would be very beneficial.
I mean, in our area we had the great family support with our
unit when they were deployed, but everyone else's spouse came
back, they went back to their normal lives with all their own
little problems, but they didn't have injuries in our area. We
don't have a lot of support for that. They don't have the
family programs or the family counseling available.
Most recently Sean came back from a PTSD program through
the VA in St. Cloud and during that time I was not contacted by
any member of that staff from that VA to ask about any input
from the family or the home regarding his PTSD, regarding his
behaviors at home. I was not contacted while he was there. I
wasn't contacted when he came home. They sent home his medical
record, which is over 300 pages, and said if your wife has any
questions she can call us.
Mr. Walz. Unbelievable.
Mrs. Johnson. They did tell him that there are groups that
are available for the wives and families if you live in that
area. It is 4\1/2\ hours for us. The likelihood of me being
able to take time off to go and go to these groups and get this
support is not there.
And at one point the VA had a V-tel capability where Sean
could get some OEF/OIF group peer support. That is no longer
available. So now if he is going to have that peer-on-peer
support it will be if he can make the appointments 3 hours
away.
So yeah, I think there is a huge need to provide those
things.
Mr. Walz. The gentleman from Florida, that is a great point
on that. And again, this is one of the issues, that portion is
in the House version of the Caregivers Bill, but where is it
at? It is setting. And he is exactly right.
So I appreciate the comments and for us to keep focus on
this. It is our responsibility to get it done. So I yield back.
Mr. Mitchell. Thank you very much. And I want to before you
all leave and I hope you stay around for the next panel, want
to express my gratitude, and I think everyone's up here for the
service and the sacrifices that you have all made. You know, we
sit through a lot of these hearings, and I just wish other
people could get the same feeling out of this that we do. And I
just want to say thank you so much for everything you have
done.
Sergeant Johnson. I appreciate that. It was an honor.
Mr. Mitchell. Thank you. And this panel is excused.
I want to welcome panel number 2 to the witness table. And
for our second panel we will hear from the Honorable Noel Koch,
Deputy Under Secretary of Defense for the Office of Wounded
Warrior Care and Transition Policy, U.S. Department of Defense,
Dr. Madhulika Agarwal, Chief Officer of Patient Care Services,
Veterans Health Administration. Dr. Agarwal is accompanied by
Dr. Karen Guice, Executive Director of the Federal Recovery
Coordination Program, and Paul Hutter, Chief Officer of
Legislative, Regulatory, and Intergovernmental Affairs,
Veterans Health Administration.
And I would like to ask all of those who are making a
presentation, Mr. Koch and Dr. Agarwal, if you would please
keep your comments to 5 minutes, and your complete testimony
will be put in the record. Mr. Koch.
STATEMENTS OF HON. NOEL KOCH, DEPUTY UNDER SECRETARY OF
DEFENSE, WOUNDED WARRIOR CARE AND TRANSITION POLICY, U.S.
DEPARTMENT OF DEFENSE; AND MADHULIKA AGARWAL, M.D., MPH, CHIEF
OFFICER, OFFICE OF PATIENT CARE SERVICES, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY KAREN GUICE, M.D., MPP, EXECUTIVE DIRECTOR,
FEDERAL RECOVERY COORDINATION PROGRAM, U.S. DEPARTMENT OF
VETERANS AFFAIRS; AND PAUL HUTTER, CHIEF OFFICER OF
LEGISLATIVE, REGULATORY, AND INTERGOVERNMENTAL AFFAIRS,
VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
AFFAIRS
STATEMENT OF HON. NOEL KOCH
Mr. Koch. Thank you, Mr. Chairman, and thank all of the
distinguished Members of this panel for the opportunity and the
privilege to come before you this morning. You have already
agreed that our written testimony would be submitted for the
record, and so let me just make a few oral observations.
The Members, the speakers in the last panel obviously leave
all of us somewhat shaken. This panel didn't call us up here to
listen to a litany of excuses for where we are and why we are
where we are.
But let me say before I proceed too far into this, that
what we are attempting to do is novel. We have never done it
before in our history. And if we go back 15 years we were
reducing the size of our armed forces, that we were cutting all
the talent, anybody that wanted to leave got to leave, and
suddenly we find ourselves in a war--in two wars in which we
are being presented with the kind of problems that we are being
presented with today. Some of these problems are as old as
history. Post-traumatic stress goes back to the Greeks. We
still haven't figured it out, and it is the biggest problem
that we have. When people look at our wounded veterans they
look at traumatic amputations and their heart goes out to that,
and all of ours do, but these people deal with these things
very easily. The people who have difficulties are those who
suffer from post-traumatic stress, and so that is one of the
things we are wrestling with.
Now it has been noted that we have a lot of effort behind
this and we have a lot of programs, and that our biggest
problem is a lack of ability to put this before the people who
need it. We don't communicate well.
I spend most of the time out of my office. I spend time at
places like Fort Riley and Fort Drum and Fort Benning and Fort
Bragg and Balboa and BAMC and the polytrauma centers and all
these places that you are familiar with, and I spend hundreds
of hours with these wounded warriors and ill and injured
warriors, so I have a pretty good sense of what it is that we
are trying to do for them, what they feel that we need.
One of the things I want to say to you is that we are, you
are, we all are dealing with something of a moving train here,
and so while we take into account and take on board both
emotionally and intellectually what we have heard here, a lot
of these problems are legacy issues, and we are moving ahead,
and I think we are doing a better job at addressing the kinds
of problems that were brought up here today.
Now having said that to the question of outreach, my
office, The Wounded Warrior Care and Transition Policy Office
has a number of programs to try to deal with this. One that I
think most of the members are familiar with is the Transition
Assistance Program. This was started back during the Gulf War,
it is 20 years old, has never been updated, never been
addressed, never been reformed. And in that period from the
time that was back when we fought a war with most of our active
components, now we are fighting two wars and chewing up our
Reserve components, none of those changes in the realities that
we were confronting were not addressed in the Transition
Assistance Program. So in November we spend a week tearing this
thing a part, putting it back together, and in the process of
correcting that.
And one of the things that Congressman Roe said resonates
here, and that is that we need to start at the beginning. We
need to start not when a youngster becomes a veteran, but when
they become a soldier or a Marine or an airman or a sailor to
deal with this. So we need to start the counseling process at
reveille, and it ought to run all the way through to TAPs. It
ought to begin from the time we recruit them until the time we
intern them. And so we are looking at that. We are looking at
that.
And there are some very prosaic issues that come into this
thing when you look at it. It is not the things that attract us
emotionally such as a wounded soldier and his family. It is
simpler things. It is like financial management. And when you
are young, you know, you think the money just continues to
flow. If you don't understand how to handle it by the time you
get to be my age and you haven't learned to handle it you are
going to be in an awful lot of trouble.
And so we have these youngsters coming back from down
range, they have no place for them to spend money down there,
they've got their base pay, they got trigger time, hazardous
duty pay, all these things. They come home with $100,000,
$150,000, $200,000. And what do they do with it? Well they are
home, they are happy, they want to buy mom something.
One of my favorite stories is the young Marine that came
home and bought himself a Porsche, which might have been
reasonable enough, except that this young man is blind and the
car is sitting in his living room.
So we need to teach them how to handle their money. It is
just one of the things that we need to deal with. But I agree
with Congressman Roe, we need to start at the beginning, and
that is part of the TAP program. And part of that program since
the VA has brought to task for not doing their share of this
thing, part of this involves pre-separation counseling, which
is mandatory for all these people, but the VA provides an
extensive briefing, at least 4 hours on what is going to be
when they get out.
Now the point is, at what point does that occur? And is it
useful? And you have heard previous witnesses talk about what
happens when people come home. They don't want to come home and
listen to a lot of lectures. They want to come home and go
home.
And it becomes even more difficult with our Reserve
components when these people are not coming back to a base
where we sort of have our hands on them. Because they are going
to disperse to all the places that we have brought them in
from. The Reserves and the National Guards tend to be not
centered around our major bases where our active components
are. So these are some of the problems that we confront.
And another one that was raised by one of the witnesses was
a question of the effect of PTSD and people getting in trouble
with the law. We are looking at veterans courts. We would like
to nationalize this effort. We would like to have your help
doing it. It is obvious these courts are not Federal courts
that deal with these problems, but if there was a message that
came out from this Congress, from this Committee saying that we
need to treat people, or we at least need to take into account
the fact that when they come back with difficulties, these
difficulties may manifest themselves in going down the 405 at
127 miles an hour on a motorcycle. And when they lose a leg
people say, well that is not a combat wound. Oh yes, it is. It
probably it is. And so we need to look at how these effects
occur and we need to look at how the courts handle these
issues.
I think I am approaching the end of my 5 minutes, so I will
defer the rest of my comments for questions and answers. But
again, I want to thank you all for giving me the privilege of
coming before you.
[The prepared statement of Hon. Koch appears on p. 51.]
Mr. Mitchell. Thank you. Dr. Agarwal.
STATEMENT OF MADHULIKA AGARWAL, M.D.
Dr. Agarwal. Good morning, Mr. Chairman and Members of the
Subcommittee. Thank you for giving me the opportunity to be
here today and to update you on various ways in which VA is
improving the transition for returning servicemembers and
veterans.
I would like to begin by thanking Staff Sergeant Johnson
and his family for their service to our country and apologize
for the difficulties he has had to face.
Together VA and DoD, as we just heard, are building a
state-of-the-art post-combat care service for our returning
servicemembers and veterans. We are continuing to refine these
services, identify additional areas of need, and conduct wider
research to improve outcomes.
VA has made significant advances in several ways in very
important areas, and I will list a few. First VA has increased
its outreach efforts for the returning servicemembers,
including Guard and Reserve component and veterans. We are
collaborating with DoD in expanding the TAP and the Disabled
Transition Assistance Program (DTAP) briefings, the yellow
ribbon reintegration program events, PDHRA, and the Combat Call
Center Initiative.
VA is also aggressively pursuing the social media like
Twitter, Facebook, YouTube, blogs. Also VA, DoD, and the
Department of Labor support the National Resource Directory
which has undergone significant revisions and is going to be
relaunched in mid-February.
Second, we have expanded the Federal Recovery Coordination
Program. This is a joint VA/DoD program which helps coordinate
and access Federal, State and local programs benefits and
services for the seriously wounded ill and injured
servicemembers and veterans through recovery rehabilitation and
reintegration into the community.
Third, our care management system begins at the military
treatment facility where VA liaisons work in concert with the
DoD case managers to facilitate a smooth transition of care
from DoD to VA. Our OEF/OIF care management system is veteran
and family centered. The case managers are actively involved in
assisting our ill or injured veterans with reintegration into
their home communities.
Fourth, our polytrauma system of care provides coordinated
in-patient transitional and out-patient rehab services. Each of
our four polytrauma centers and the 21 network sites offer
unique and highly specialized rehab services which help
servicemembers and veterans achieve optimal function and
independence in their communities.
Fifth, VA has greatly enhanced its mental health services.
We have hired more than 4,000 new mental health professionals
in the last 3 years.
Sixth, we continue to emphasize interdisciplinary care,
which is veterans centered and requires the treating
disciplines to coordinate and integrate care. And we are
achieving this through new education initiatives and TBI, PTSD
sleep disorders, and in pain management.
Now a recent example is the joint VA/DoD clinical practice
guideline on mild TBI that addresses the core conditions such a
PTSD pain and sleep disorders.
Another example of integrated care is the post-deployment
integrated care clinic. These are primary case based clinics
where specialists are integrated into interdisciplinary teams
who address the special needs of combat veterans.
We are also supporting more research for new treatments,
and increasing the use of telehealth to reach those who live at
great distances from our facilities and in rural areas.
Finally VA does recognize and deeply appreciates the
critical role of caregivers and families in supporting
veterans. VA offers a variety of respite and home services to
supplement the care that is provided by family members to
improve the quality of life of veterans and their caregivers;
however, much needs to be done in this arena, and we are
grateful to Congress for its support.
Secretary Shinseki is committed to transforming VA into a
21st century organization. A 21st century VA will focus on
results and make sure our services are timely, consistent, and
of the highest quality, and adapt to the changing needs of
veterans. We will leverage technology and educate our workforce
to achieve results. It is our privilege to care for those who
have borne the battle in Iraq and Afghanistan and our previous
Nation's conflicts, and it is our solemn responsibility to do
all we can to restore them to their highest and best level of
functioning and support them in their journey home every step
of the way.
I thank the Subcommittee and you, Mr. Chairman. My
colleagues and I are ready to answer your questions.
[The prepared statement of Dr. Agarwal appears on p. 53.]
Mr. Mitchell. Thank you. Let me just say that--and I know,
Mr. Koch you have a specialty in the Wounded Warrior Care and
Transition Policy of the Defense Department, but you are in the
Defense Department. Can't you do something about getting the
sergeant his Purple Heart? Four years. I think that is
unacceptable. And I was just asking around here--he is required
to go to Reserve meetings. If he didn't go to a Reserve meeting
would he be classified as AWOL? I just don't understand.
You know, Dr. Roe mentioned 33 hearings. We can have a
hearing every week on this same issue, and we would hear the
same things. And I know Dr. Agarwal and Dr. Guice and Mr.
Hutter have all been here before, you hear these things. I
don't leave these meetings very uplifted. It is a downer for a
long time, and we have these continually. Because I know the
people who spoke on the first panel, they are just the tip of
the iceberg. They represent a lot of other people. And I just
feel horrible that we have to have all this, and we hear the
same thing over and over, different kinds of cases.
But I think particularly since Staff Sergeant Johnson is
still on the roles or in the Reserve, I don't know who takes
care of him. I can see the problem here. He tries to get some
VA benefits; he tries to get some DoD benefits. You know, we
could have one, we probably could have a hearing like this
every day, and we would hear the same response from DoD, the
same response from VA.
The point I think we are all trying to make is why can't we
get it done?
When I heard Mr. Tarantino talk about the reimbursement
rates for automobiles, or to refit or retrofit a home because
of disabilities, and we are using 1970 figures. And then I
heard Dr. Roe say that Mr. Boozman has a bill in. I don't know
if Mr. Wilson found this out on his own, but I would think that
DoD or the VA would come and say, hey guys, we need to change
this. I can't imagine why it would take somebody to introduce a
piece of legislation unless that is what is required. And I
would think that this piece of legislation should put in an
inflation factor.
Now and I also heard Dr. Roe said we are talking about
PAYGO and so on. Let me tell you, we ought to pay for this the
same way we paid for the war, the same way we got these people
over there ought to be the same way we pay for it.
And I am really kind of appalled also that no one has come
forward to say to any of these Committees, we need to upgrade
the amount of money we are giving to people to retrofit cars,
houses, or any other kind--caregivers, the family givers.
I used to teach government in high school, and I know that
we used to teach them how important the legislative branch was
and that the most important job is to legislate. But the longer
I have been here I think the most important job we have is
oversight. It is too bad that we have to continually hear over
and over the same thing and we get the same responses back. You
guys ought to feel bad. And somewhere you are in a better
position than we are. If we need legislation, we will do it,
just tell us what needs to be done.
And I don't have any other questions, because I get the
same answers over and over anyway. So, Dr. Roe.
Mr. Roe. Thank you, Mr. Chairman and the rest of the
Committee Members. I think we all share frustration. And I know
that I have spent a career, when I see a problem, I fix it and
work on fixing it, and if it takes more people than one, we try
to get it together and fix it.
And this is a huge problem when you are dealing with
hundreds of thousands and millions of veterans as Mr. Wilson
pointed out.
Here is a bit of frustration. When we send a soldier to
Afghanistan to war, it takes $1 million a year of support to
keep that one soldier in theater. So this 30,000 troops that we
are going to send to Afghanistan in the next several months is
going to cost $30 billion. And yet we have a system here that
when we bring soldiers back, that we nickel and dime on what we
are doing to take care of them. And I think I share that
frustration with everybody here. We spend $1 million per year
to keep you in combat, to keep you in harms way, we get you
home, we don't have that same commitment to you. And I believe
being a Vietnam era veteran that we owe you a lifetimes worth
of service. And I know Mr. Koch is a Vietnam veteran.
And you know, we had a group of veterans that were left off
the charts for about 20 years. We dropped the ball big time.
And I think and I agree with Chairman Mitchell, I talked to him
before the meeting and I am meeting with General Shinseki this
afternoon, and I am going to share what we have said in this
particular hearing today.
And I think we just need to sit down now with a group at
the table, not in a formal setting, and get this problem fixed.
I mean, we will have 33 more hearings. I mean a year ago
exactly, when Travis was here--and sergeant major you are
absolutely right, I mean exactly sitting right over there where
Sergeant Johnson was.
We are having a meeting in Johnson City, Tennessee, for
rural health. There is a sizeable sum of money, $250 million in
rural health, and that is where I live, in a rural area, that
is where Sergeant Johnson lives, in a rural area. And I am
going to talk to the Secretary this afternoon, and hopefully he
will visit Mountain Home VA in Johnson City, Tennessee, and I
hopefully he will be there for this meeting, but it is a way
how we provide support for these veterans who are a long way
away.
And I think developing these out-patient clinics is vital.
And right now what happens in an out-patient clinic, a
particular VA like ours at home gets a certain amount of money,
but it comes out of their budget to put an out-patient center
near where the veteran is. I think that is essential. And the
more I think about this the more essential I believe it is--is
to get the care that the veteran needs out to the veteran,
instead of having to travel not 3 hours, 6 hours. You have to
go and get back home once you start.
And I also agree with Mrs. Johnson. I really appreciated
your comments, I think to support the veterans. I remember very
well that my scout master was killed in 1965 in Vietnam. He was
a first sergeant in 101st airborne division. His family of four
had a $10,000 insurance policy, and that was it. That is what
we left him with, nothing.
We not only can do better, we are going to do better. And
if I seem a bit frustrated I am. I don't have any questions
either, Mr. Chairman, I just want to now not sit here next year
with our same group here. And I can assure you that one of the
things that I have been most impressed with in this Committee
is that this Committee is not Republican or Democrat, it is
about veterans and about doing the right thing.
Thank you, Mr. Chairman.
Mr. Mitchell. Thank you. Mr. Walz.
Mr. Walz. Thank you, Mr. Chairman, and thank each of you
for your service. Your commitment to our veterans is never in
question. We understand that. And Mr. Koch, your service to
this Nation and as a veteran and CO I very much appreciate
that.
I just had a question for each of you to just take up as,
how does a situation like Staff Sergeant Johnson's happen
still? How does that happen with a chain of command? There is a
first sergeant there somewhere, there is a sergeant major, and
I am just at wits end to figure out how this still happens. I
mean our hope is that it is the anomaly, but as I said, I see
too many of these.
Does anybody have like an insight into how we are losing? I
understand this when you transition back home. When I came back
from a deployment, it was 48 hours. If you said you had an
injury, you had to stay over till the next Monday, and there
was no way in heck with a 3-year-old at home I was going to do
that, so they showed me the horse whisperer and told me to be
nice to my wife and sent us home, and that was it. And I
understand we are all learning, but how does this still happen
today? How did the Johnsons end up in this situation, if you
could? I know I am asking you a generality here, but I am
trying to grasp it.
Mr. Koch. Let me try to take a shot at this, sir. I have to
say in the first place we have the benefit of coming here and
listening to the frustrations of other panels, and we have the
benefit of listening to your frustrations, but there is a
separation of powers and there are certain political issues
that make it difficult for us to share our frustrations with
you, but I can assure you they will probably balance out, and I
understand how great yours are. And I won't go on too much in
that vain, but you can hear it from General Chiavelli and
others who I am sure you can talk to behind closed doors.
I would say I think first of all that Sergeant Johnson's
situation is an anomaly. It is a tragic anomaly, but I think
nevertheless that it is an anomaly. You don't generally bring
folks up here to throw roses at you and bring Valentine's with
you, I mean you are looking for the problems and not for all
the things that are done right so that you can correct the
problems and make sure that more things are done right. I don't
know why he doesn't have his Purple Heart. I know a number of
other people who have suffered wounds many years ago who don't
have Purple Hearts, and they are usually administrative reasons
or other reasons that the paper shufflers come up with. I will
take this back and see what I can find out and see if I can get
an answer to that and get back to you with it and see if we can
expedite his receiving what he is entitled to receive.
In the area of sharing what little frustration I can, I
mean, I can give you an example, things take time, and
sometimes you don't discover problems unless you actually go
out and look for them. So I happened to be at one military
treatment facility and it was a naval facility, but I was
talking to all these people, and I was talking to them in a
group, and a number of them were soldiers. And I said, ``How is
the DES pilot going for you?'' And they said, ``We are not in
it.'' And I said, ``Why not?'' ``Well, we can't. They want us
to go up to Fort Irwin.''
So we came back, we wrote new policy to universalize the
MEB process, and that was probably 2 or 3 months ago, and it is
slowly--we tried to do it procedurally because it has such a,
you know, seemed to be congruent with common sense that maybe
we can get this done and we tried to push it up, but no it got
pushed back down, and so we have had to write a policy and we
are walking that through the system, and ultimately we will
have more people going through the desk pilot and they won't be
disadvantaged because they are in a different service than the
MTF.
Mr. Walz. My question, I guess what I would ask, Mr. Koch,
is in 2007, I was in Iraq and I witnessed as they had seven
databases open on medical records, not even including VistA and
the transition to that, and I made a comment in a hearing here
now going on 3 years ago that wouldn't it make sense to record
serial concussive blasts, because we were starting to see data
at that point that those were going to add to long-term issues.
Because mark my word on this, just like Agent Orange or
whatever it will be, in 10 years we will have people here
trying to come to us and say I was exposed to a blast, there
was no record, I asked why we didn't have blast meters that are
cheap and carried. You know, we put them on packages of milk so
if it is shaken and the thing breaks, we know. How difficult
would it be to attach it to a soldier and we would know that
they have been in these, record them, and have that data. One,
for the care. Two to make sure they don't come back and fight.
That was 3 years ago.
This virtual lifetime record we are talking about all of us
agree with, is it going to happen? Is this an IT issue? I don't
know how many platforms we operate. I heard somebody say people
are frustrated with Windows 7, but you guys are using Windows 1
or whatever. How do we get beyond that?
Mr. Koch. Can I respond to that, sir?
Mr. Walz. Sure.
Mr. Koch. First of all with regard to registering blast
effects that may produce traumatic brain injury, there is an
awful lot of work going on, and we are working with the
National Football League (NFL), I think probably some of you
had talked to the NFL, because they have the same problems, and
however well we are pushing toward that the Marines, you know,
God love them, they had to keep it simple because they don't
have as much to work with. And so while the rest of us are
looking at helmets with sensors in them and things like this,
which sound wonderful, but you are always looking for a
technological solution, and the Marines, that is not the Marine
way. So what they do is if you are in a blast situation and
they bring you back and they ask you some simple questions. You
get your bell rung? Yes. Okay. How long, you know, what do you
think 30 seconds, 40 seconds? Okay. So you go through that
three times, three strikes you are out of theater and there is
a record of it. And that is simple, and it works, and it is
smart.
With regard to what comes under the broader umbrella of
information technology, if I go too far down that road I am
going to embarrass myself, but I know that the President
himself is behind the virtual lifetime electronic record. When
we started out with it, it was to look at medical records, and
people who don't understand, including myself, who don't
understand much about information technology, it is a kind of
magical thing. So if we are going to do the medical records, as
long as we are going to do that why don't we throw in personnel
records and why don't we throw in the benefits records? And so
we have done that. And the idea is that increases the
complication arithmetically. Well it doesn't increase it
arithmetically.
Mr. Mitchell. Excuse me, Mr. Koch, we are about to be
called for votes.
Mr. Walz. Yes, I will yield back, but I thank you, and we
will look into this more.
Mr. Mitchell. And I would like Mr. Stearns to say something
before we get called.
Mr. Stearns. Thank you, Mr. Chairman. Dr. Agarwal, let me
ask you a question. How long have you been an employee of
Veterans Affairs?
Dr. Agarwal. Sir, over----
Mr. Stearns. How many years?
Dr. Agarwal. Twenty plus years.
Mr. Stearns. Twenty plus years?
Dr. Agarwal. Yes, sir.
Mr. Stearns. And how long have you been in your present
position?
Dr. Agarwal. Five years.
Mr. Stearns. Five years. How many times have you had to
testify before this Committee? Either the Subcommittee, full
Committee, or any one of the Subcommittees?
Dr. Agarwal. Sir, I would say at least three times.
Mr. Stearns. My staff thinks it is between five and ten.
Dr. Agarwal. Your staff is likely correct.
Mr. Stearns. Also it appears to us that you have had to
apologize in this area multiple times. Do you recollect that?
Dr. Agarwal. Yes, sir.
Mr. Stearns. Does it occur to you that your apology over
these number of years--you have been in this position for 5
years--is at the point where there should be action rather than
apologies?
Dr. Agarwal. Sir, if I may respond to that.
Mr. Stearns. Oh, sure. Sure.
Dr. Agarwal. Indeed. You know, we continually strive to
improve our system, but when we make mistakes we do apologize
for it. And in this instance, sir, and in the past also.
Mr. Stearns. So you are saying in the future you will have
to apologize again? I mean, do you have any confidence you can
come up here and testify and not have to apologize?
Dr. Agarwal. Sir, I would love to be here and never have to
apologize.
Mr. Stearns. And you are saying the reason you have to
apologize is because you don't have the resources or you don't
have the manpower or you don't have the--the job is too much
for you? I mean, at what point can we get the assurance that
you will come up here and you won't have to apologize? What do
we have to do to help you?
Dr. Agarwal. Sir, as I said previously, you know, we are a
system that continually looks to improve the quality of care
that we deliver across the board. We are a large system. And by
and large we do very well. We have created a great network in
this instance of how to take care of servicemembers who are
returning to us.
Mr. Stearns. Okay.
Dr. Agarwal. And the instance when we do not step up and do
what we think we should be achieving I feel that it is my
responsibility to make sure that we take it back and then we of
course correct.
Mr. Stearns. Well if I were in your position, I would come
to this Committee in a proactive way and say I don't want to
come up here and apologize anymore. Here is what I want to do
to solve the problem. You are on the clinical side, right?
Dr. Agarwal. Yes, sir.
Mr. Stearns. So I mean, I would just outline it in a letter
to the Chairman here, Mr. Filner and Mr. Buyer, and say this is
what I need to get the job done so I don't have to apologize
anymore.
Mr. Koch, let me ask you a question. The American Legion
has testified that the Department--DoD has implemented a
seamless transition to servicemembers, which includes medical
screening, eye exam, dental examination, mental health
screening. But we are under the understanding that these
examinations for the Army and the Air Force are not being
implemented. Is that true?
Mr. Koch. I am not sure that that is true.
Mr. Stearns. Well we have a fact here that the Army and the
Air Force are not implementing separation physicals. It is done
on a volunteer basis by them. And if they are doing it on a
voluntary basis isn't that in violation of the law?
Mr. Koch. The individual does have to agree to the
examination. The individual as I understand it that is
voluntary. Now let me refer to my notes here, because this is
an area of some complication. There is a requirement that we do
the things that are anticipated. Evaluate the health of the
member at the time of separation and so on. If that person has
been examined in the last 12 months then that may be waived.
And that is one of the things that may be occurring here that
gives the American Legion concern. And that is done with the
consent of the member.
Mr. Stearns. But let us say the person is injured and he
doesn't want to do it? I think you have to have some kind of--
--
Mr. Koch. I think, sir----
Mr. Stearns. Or let us say he is injured and the injury
doesn't appear until later. It seems to me that it should be
sort of--I mean the law is saying that everyone should have a
separation physical, but our understanding is the Army and the
Air Force are not doing it, and that is in violation of the
law. Does that sound right? Am I all wrong or not?
Mr. Koch. If I take your example if he is injured, and I
mean, you have offered two cases here.
Mr. Stearns. Okay, sure. Okay.
Mr. Koch. If he is injured then the probability is he is
going to be in care and this issue is not going to arise
because it is going to be a constant----
Mr. Stearns. Well, it is an injury they don't detect
though. Maybe it is an injury they don't detect.
Mr. Koch. Well that is the second case you present.
Mr. Stearns. Yeah, okay.
Mr. Koch. And if he has been examined previously within the
last 12 months, if that injury--if he is in an incident which
is likely to produce an injury then he is going to be examined
for it. So I don't know that we can give you a categorical case
or you can give us a categorical case that right across the
board these examination are not being performed.
Mr. Stearns. Okay. Mr. Chairman, I just want to conclude by
saying you had mentioned this, the purpose is oversight. I had
a bill in Congress in which no more legislation would be
proposed for 2 years, and all we did was implement oversight of
the legislation that we have passed in previous years. Now this
bill didn't go anywhere. But at some point you are exactly
right, this Committee, any Committee, Energy and Commerce, Ways
and Means, they pass--we vote 1,000 times a year, and there is
no oversight on any of these bills, and we sit here and wonder
why some of them don't work. Well you need oversight and you
need support. So I think you are right about oversight being a
big, big important part of our job.
Mr. Mitchell. I just want to before we conclude thank all
of you for your service and what you are doing and recognize
that Mr. Adler is here, and any other question that he has we
will submit them and it will be a part of the record.
One last thing. I know, Mr. Koch, you said it takes time,
and I understand that. But in the meantime people have house
payments, they have bills. And it may be in the long run, but
you have heard that phrase before, in the long run we are all
dead. It is today that we live.
There is one other thing that we may end up having another
hearing on, which I think may be under your control or
somebody, and that is the Vision Center of Excellence. Where is
it? What is the status of it? You know, that is something I
just don't understand. We have already had hearings on that,
and as I understand right now it is really in disarray again.
Mr. Koch. My understanding is that it is in limbo, Mr.
Chairman. I can't give you a----
Mr. Mitchell. I don't want an answer. I just want you to
know that we will probably have to have another one.
Mr. Koch. Right.
Mr. Mitchell. And you will all come back and say, you know,
we are trying, we are trying to hire people, you know, all
those other things. If I understand there is about the only
employee right now in that is part-time employee. That is not
going to help. That is not going to do anything.
We have to go. And I just would say that this hearing is
adjourned, and if anybody has any questions please submit them
for the record.
[Whereupon, at 12:04 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
I would like to thank everyone for attending today's Oversight and
Investigations Subcommittee hearing entitled, Transitioning Heroes: New
Era, Same Problems? Thank you especially to our witnesses for
testifying today.
We are here today to address what both the Department of Defense
and the Department of Veterans Affairs are doing to assist the men and
women of our armed forces to seamlessly transition back to civilian
life. Time and again, we have heard from our returning servicemembers,
expecting a smooth transition back to the lives they once lived, only
to find themselves lost in a complex and frustrating bureaucracy.
Today, we will hear from a severely injured veteran, Sergeant Sean
Johnson, who was hit by a mortar round in Iraq and is now completely
blind. Although he has received excellent treatment at the Blind
Rehabilitation Center in Chicago, he was never assigned a Federal Care
Coordinator, after contacting the VA almost a year ago. In addition,
Sergeant Johnson has also found himself experiencing the hardships of
navigating through both the DoD system and VA system at the same time.
This is just one example of many. Sergeant Johnson joins those
veterans and their families who share the same concerns that our
Veterans Service Organizations will voice here today.
Additionally, as I have said before, outreach to our Nation's
veterans is an equally important task. Both the VA and DoD must ensure
that veterans and their families are properly informed about the
benefits and services they have earned when they return to civilian
life.
Proactively bringing the VA to our veterans, as opposed to waiting
for veterans to find the VA, is a critical part of delivering the care
they have earned in exchange for their brave service.
The VA should be a place where veterans can easily, and with
confidence, go for the help they seek, but the VA must also be willing
to reach out to these veterans. Effective outreach will not only ensure
better delivery of services for our veterans, but will also increase
morale.
I am hopeful that today, both the VA and DoD will shed light on
what they are doing to make certain our veterans are receiving the best
possible care available; they are being provided with the services and
resources they have earned; and most importantly, that the two
Departments are working together to ensure that these earned benefits
are seamlessly delivered.
I believe that all my colleagues join me in being steadfast in our
hopes that Secretary Shinseki, as he transforms the VA into a 21st
century organization, will help eliminate the stigma that so many of
our Nation's veterans have placed upon the VA. We must ensure that both
the VA and DoD are working together and providing veterans the services
that they rightfully deserve.
Again, thank you to all our witnesses for testifying today, and we
look forward to hearing your testimony.
Prepared Statement of Hon. David P. Roe, Ranking Republican Member,
Subcommittee on Oversight and Investigations
Thank you for yielding, Mr. Chairman.
I would first like to thank the members of the first panel for
their service to this country, not only for their military service, but
their continued service by appearing here today to share their
testimony and help us work toward a better transition for our Nation's
veterans.
Prior to this hearing, my staff provided me with a list of the
hearings held by the Committee on Veterans' Affairs over the past 10
years. Totaling around 33 hearings, the topics have ranged from
employment transition, through the use of the polytrauma centers, pre-
and post-deployment health assessments, sharing of the electronic
health record of our wounded servicemembers, transition assistance
programs for guard and reserve forces, and the list goes on. As you can
tell, helping our servicemembers move from military to civilian life is
of great importance to this Committee.
Concern in Congress about helping our servicemembers transition to
civilian life didn't start 10 years ago. During the 97th Congress,
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.
Today's hearing will enable the Committee to review the various
programs that have been instituted to assist our Nation's veterans, and
wounded warriors in their transition to civilian life. We will be
looking not only at the medical record exchange between VA and DoD, but
also at the various other transition services, the use of the
polytrauma centers across the country, and programs available to assist
our veterans. This is not the first hearing to look at these issues,
and I am certain that it will not be our last.
We here in Congress must do everything we can to make certain that
the transition our military personnel undergo is smooth, easy and the
programs available are truly helping our Nation's veterans. In the
past, it appears that the transition many servicemembers have
encountered have not been exactly seamless and certainly not easy or
smooth.
Mr. Chairman I appreciate you holding this hearing today. I believe
we have much to learn from the witnesses here today.
Again, thank you Mr. Chairman, and I yield back.
Prepared Statement of Hon. John J. Hall
Thank you Mr. Chairman, and thank you to all the panelists here
today to discuss the issue of a seamless transition for our disabled
veterans.
It is disappointing to know that as we enter 2010, more than 9
years since we first entered Afghanistan, transitioning our troops to
veteran life still remains a challenge.
In particular, we must do better to care for those men and women
injured in the line of duty. Heroes like Staff Sergeant Johnson deserve
better.
Both the Department of Defense and the VA have improved how they
handle transitioning disabled veterans.
The Wounded Warrior Program, and its Warrior Transition Units, has
been a great success. The ability to care for our wounded soldiers
while keeping them in an active-duty mindset has helped thousands of
soldiers since 2007 who have experienced traumatic and life-altering
events.
I have visited the Warrior Transition Unit at West Point, and
commend the men and women working there for their service.
However, even this example of a success has its shortcomings. There
are only 35 WTUs in the country. Servicemen and women from as far away
as Vermont have to travel to the WTU in my district to receive
treatment.
Also, the VA has a limited presence at the West Point WTU,
traveling from VA facilities in the area to give classes on TAP and
other benefits programs.
This is why I plan to introduce legislation that I believe will
improve the seamless transition this hearing is addressing today.
This legislation will mandate that the VA have a permanent presence
on active-duty military facilities, and require one-on-one
consultations with active troops as they begin the transition process.
There should be no improperly filled out enrollment forms. This
will cut down on processing times, and reduce the ever-growing backlog.
Men and women separating from the service deserve to be fully informed
of the benefits they have earned. An increased VA presence on these
facilities is an important first-step toward a seamless transition for
our wounded warriors.
Thank you again, Mr. Chairman, and to the men and women testifying
today. I yield back the balance of my time.
Prepared Statement of Staff Sergeant Sean D. Johnson,
USA, Aberdeen, SD (OIF Veteran)
Chairman Mitchell, Ranking Member Congressman Roe, and Subcommittee
Members, I appreciate the invitation to testify today from my
perspective as a severely injured soldier returning from Iraq. I want
to speak for those veterans who cannot be here today.
I am a Staff Sergeant with the 452nd Ordnance Co. of the United
States Army Reserves. I am currently awaiting a medical review board so
I can be medically retired from the military. Following a 15-year
career as a Paramedic/Firefighter in my civilian life, I had to take a
medical retirement in June 2008 due to my TBI, PTSD, and chronic health
issues.
I entered the military on June 22, 1988, and completed basic
training at Ft. Leonardwood, MO. I attended the lab technician program
in San Antonio, TX, in 1989. I was deployed to UAE during the Persian
Gulf War from December 1990-March 1991 with the 311th EVAC Hospital
from Minot, ND. I transferred to the 452nd ORD CO in Aberdeen, SD in
1995. From March-November 1997 my unit was deployed to Taszar, Hungary
in support of Operation Joint Guard during the Bosnian War. I was
called to serve under Operation Iraqi Freedom from June 2005-August
2006 in Balad, Iraq.
Between October 2005 and March 2006, I was in close proximity to
one rocket and five mortar attacks where I was within 30 feet of the
impact. On March 25th, 2006, around 6:40 AM four mortars were marched
in from the outer perimeter into our location with the third landing in
the middle of our group and approximately 10 feet from me. The blast
knocked me through the air and about 7 feet back. I landed on my neck
and shoulders and was unconscious for 3 to 4 minutes. When I awoke I
could not hear and was in shock. I looked up through my feet and
another mortar hit about 25 feet away. My hearing wasn't right for
several hours and I had a severe headache, dizziness, difficulty seeing
distance, and light sensitivity throughout the next several days. I was
seen in sick call on April 12, 2006, for abdominal pain, dizziness, and
headache.
I was hospitalized in 332 EDMGTH on May 11, 2006, for 7 days with
extreme abdominal pain, nausea, vomiting, diarrhea, headache, neck
pain, and dizziness. There was an initial diagnosis of salmonella
poisoning and I was given high doses of antibiotics. During the next
month the symptoms persisted and I lost almost 40 pounds. From June 21-
July 10, 2006, I was evaluated at Landstuhl Hospital in Germany. The
doctors were unable to find the cause of the abdominal problems and I
was returned to Iraq for regular duty. I was transported to Germany
again on August 7, 2006 and this time was diagnosed with clostridium
dificile (c-diff) infection. On August 25, 2006, I was sent back to the
states with orders from my doctor that I be sent to Walter Reed Army
Medical Center for further evaluation and treatment. Instead, the Army
sent me to Ft. Riley, KS, where I was placed in the medical holdover
barracks and was told by the physician that I would be treated for
irritable bowel syndrome (IBS) as my records did not indicate c-diff
infection or other health concerns.
In October 2006, after much insistence on my part, I was seen by a
GI doctor in Topeka, KS. After extensive testing he determined the c-
diff infection had cleared and that my persistent abdominal pain,
nausea, diarrhea, dizziness, and headaches were not caused by anything
related to my digestive system.
I remained at Ft. Riley from August 2006 to May 2007 on medical
holdover. During this time I had to file several Congressional
complaints in order to be evaluated at WRAMC. My symptoms were not
improving and the doctors were offering no explanations. I was told,
``Just take your pain meds and you'll be fine.'' On several occasions I
was told that if I stopped contacting my state Senators, I would be
given medical treatment. The doctors admitted they didn't know exactly
what was wrong with me, but were not willing to make the referral to
WRAMC or BAMC where specialists might evaluate my case.
In December 2006, I was sent to WRAMC for an evaluation at
Deployment Health Clinical Center (DHCC). During this time I was
diagnosed with Medically Unexplained Physical Symptoms (MUPS) and was
scheduled for the 3-week Specialized Care Program for pain management
in February 2007.
In March 2007, with no definitive diagnosis or treatment plan, I
began to push for a means to leave med hold and return home to my
family. I applied for Community Based Health Care Organization (CBHCO)
so I could go home and work at my local reserve center until my health
improved or stabilized. My request was denied due to the severity of my
symptoms. I was told that my condition was likely to be long-term or
not improve and CBHCO is a short-term program for soldiers with less
severe health problems. Ft. Riley decided to send me home as they had
done all they could for me. I asked to be reconsidered for CBHCO as I
would not be able to meet the physical demands of my civilian job at
this time, and was told that my civilian job was not the concern of the
Army. I was released from med hold and came home to return to my
position as a Lieutenant at the Aberdeen Fire Department. I was placed
on light duty within a month of my return home due to my weakened
physical state and inability to make decisions and think quickly. I had
to accept a medical retirement in June of 2008 after being diagnosed
with a TBI.
When I returned home, I contacted my local VA CBOC and began
medical treatment in Aberdeen, SD. There was no contact between Ft.
Riley and the VA regarding my case. I had to initiate all care and
provide the VA with a complete ``paper copy'' of my military medical
files. My wife and I spent many appointments going over my symptoms and
the growing problems I was having with memory, concentration, decision-
making, confusion, dizziness, and episodes of staring/non-
responsiveness and now ask ``why were these not picked up'' as warning
signs of a probable TBI? Also, I was still having daily headaches,
persistent nausea, intermittent diarrhea with abdominal pain, and
wonder if those were all related to the initial blast forces sustained
from the injury in Iraq. The VA continued to search for a GI answer to
the problems, despite the previous determination that it was not a
digestive track problem. Finally, in December 2007, I was asked a
series of questions at the VA concerning falls and blasts that I had
encountered in Iraq. My profile was flagged for head injury, and I was
referred to Dr. Hof at the Polytrauma Unit at the Sioux Falls, SD VA
Hospital. This was the first time since my injury in March 2006 that I
had been asked ANY questions about blast injuries. Dr. Hof and Dr.
Muntz did a battery of tests and determined I had a mild TBI due to
multiple blast exposures in Iraq.
In June of 2008, my eye exam noted double vision in multiple fields
and loss of peripheral vision at 60 degrees. I also had nystagmus and
recurrent eye pain. By December of 2008 my double vision was in all
visual fields and I had pain behind my eyes daily. On December 17,
2008, I suffered stabbing eye pain and my vision was reduced to colors
and shapes. I was treated for optic neuritis with IV steroids which
brought some pain relief, but no change in vision loss. My vision was
noted at 20/800. I was referred to the Visual Impairment Service Team
(VIST) who provided me with some tools to help me magnify reading
materials and protect my eyes from bright light. My VIST also made
arrangements for me to be a patient at the Central Blind Rehabilitation
Center at the Hines VA in Chicago, IL. I was at Hines from February 27,
2009, to May 16, 2009. I learned to do things independently despite my
vision loss, and how to use the vision I have left to the fullest. The
Hines Blind Center did an excellent job of keeping my wife informed of
my progress, and we both appreciated the family program at the end of
my stay where my wife was able to experience my program, my blind
training was reviewed, and skills learned were demonstrated.
Most recently, I was an inpatient in the PTSD program at the St.
Cloud, MN VA as my nightmares of my combat have grown worse. It saddens
me that I had to wait 3 years for some of this treatment after hearing
the doctor tell me I have an extreme case of PTSD. Think of all the
time that I have wasted with my family and not being my best due to the
combination of PTSD and TBI, and difficulties encountered in sorting
this out since the time of my injury. I feel the program was very
beneficial for my well-being; however, there was absolutely no contact
between my family and staff members. I was told that if my wife wanted
to read through my records (375 pages) she could do so and call with
any questions. They did not ask for any input from my family regarding
my behaviors at home, nor did they provide any feedback on my progress
or treatment plan. At this time, there is a suggested treatment plan,
but no programs available in my rural area, even if I am willing to
travel 3 hours to the nearest VA Hospital. I am receiving 1:1
counseling once per month.
The impact on my family has been overwhelming. We have three
teenage children receiving private counseling and all on anti-
depressant and/or anxiety medication. They struggle with the ``weird''
things dad does, the changes in my personality, the difficulty of
helping take care of a blind dad when I should be taking care of them,
driving me to and from appointments, helping me shop, explaining how to
do things I used to know how to do, and the physical changes. My
appointments take my wife and myself away from home, sometimes for days
at a time. I have been at Hines and St. Cloud for a total of 5 months
this year, which adds to the separation and reintegration problems
similar to my deployment. My wife uses most of her sick leave to take
me to appointments and like many wounded warriors' families is worried
about loss of her job and meeting our financial needs. Although there
is a DAV van available in our area that helps me with travel, my memory
problems make it difficult to see the doctor on my own effectively. She
is a full-time mother, caregiver to me, and works full-time as a
teacher. My wife has spent countless hours researching my conditions,
treatments, searching for strategies to help me or to help cope, and
looking for information for our children and families.
The most frustrating feeling is having a meeting with a doctor,
caregiver, or social worker and being left with confusion and questions
not receiving any information from the VA regarding my total care plan,
both physical and the PTSD emotional injuries. Verbal descriptions are
given, some theories, possible treatment plans, but I feel, probably
like many others, that care managers are needed for more complex cases.
When a servicemember is diagnosed with TBI or PTSD, the VA should
immediately provide something tangible for the family to read and
review. It is not right that we are names and case numbers; when we
leave the office, the doctor goes on to the next case, but we live with
this all day, every day. A wait-and-see approach does not feel very
reassuring on the 3-hour drive home. We need tools we can use now for
daily care. We need someone to check in and see how things are going.
We need to know we are not in this alone.
Again, in conclusion, I am concerned with the lack of continuity or
``seamless transition'' between active duty, the return home, the VA
health care system, and the family. It is unreasonable that an injured
soldier who is not able to be rehabilitated for deployment must wait
more than 2 years for his medical review board to be completed. As I
look back, I find it shocking that it took 21 months for any medical
personnel, be it military or VA, to diagnose my exposure to blasts with
a TBI head injury while in Iraq then discern the PTSD. I am
disheartened that soldiers are brushed aside in medical holding units
or at home waiting for repeated exams and claims decisions. After years
of work on electronic exchange of medical computer records, it doesn't
seem to be any closer than before.
Veterans should be introduced to one Primary Case Manager, then
they should consult with one Primary Federal Recovery Coordinator
(FRC), so difficult cases are jointly managed at the local level, and
for special care programs like the VIST and Blind Rehabilitative
Outpatient Specialists (BROS). While every injured servicemember might
not need an FRC Coordinator immediately to enable them to make
connections with those in charge of their case, there should be a red
flag system for polytrauma cases. These people in turn must work with
individuals, not numbers or files. Veterans need to be treated with
dignity and respect. Many veterans do not know what to ask, what is
available, and who can help them.
The VA benefits system should use the experts' written records to
make rating decisions permanent, instead of making veterans go through
numerous evaluations and exams, as if to make the veteran prove his or
her disability again. Providing veterans with certification of all
benefits, like adaptive housing and other vehicle grants, would prevent
repeated claims from being filed for the same case. These soldiers have
paid the price in battle to serve their country selflessly, and they
don't deserve the runaround when trying to get the benefits to which
they are entitled. As of today, I still do not have my Purple Heart,
and can only wonder how many others are ``pending reviews'' for theirs?
Defense and VA Vision Center of Excellence need adequate funding,
staffing today, and operational registry systems. The comprehensive
system must include those with hearing, vision, and orthopedic problems
along with the new TBI and Mental Health Defense Center of Excellence
to ensure the care of the severely injured. More funding is necessary
for adequate TBI and vision trauma research. The number of soldiers
returning from battle with these combined injuries is staggering, and
our country should not rest until we have provided for the needs of
every one of them.
The Veterans' Caregiver Bill, S. 1963, would be greatly
advantageous to those families who are primarily responsible for the
veterans' care, many finding it difficult to work while providing daily
care for the veteran. Many have families to raise in addition to
providing care, transporting to appointments (increasingly difficult in
rural areas with fewer services), and trying to find their way around
the VA system.
I speak today not for myself, but for the thousands of veterans who
do not have a voice, who are struggling in a faulty system where their
concerns go unnoticed, where their specialized medical needs are
sometimes delayed, where they are left waiting often months or years
for a VA claims review. Timely and accurate diagnosis and treatment of
conditions help the claims system. The burden of proof is put back on
the veteran and should not be, it should be on the VA. I speak for
families struggling with the changes and uncertainty of a future they
never imagined when they proudly stood beside their soldier and
professed their pride in America. I am but one example of thousands. I
hope my story helps as you work on this Committee to find solutions and
make the necessary changes. This concludes my testimony and I will try
to answer any questions that you have for me.
``To care for him who shall have borne the battle.''
Abraham Lincoln
Prepared Statement of Joseph L. Wilson, Deputy Director, Health Care,
Veterans Affairs and Rehabilitation Commission, American Legion
Mr. Chairman and Members of the Subcommittee:
Thank you for this opportunity to present the American Legion's
views on seamless transition issues. Since 2001, the Department of
Veterans Affairs (VA) Health Care system has undergone a major
transformation in an attempt to accommodate the Nation's veterans; to
include increasing outpatient and preventive care in its growing
network of outpatient clinics. Currently, there are approximately 23.4
million veterans in the United States; of that total, 7.8 million are
enrolled in the VA Health Care system. VA treats 5.8 million veterans
at more than 150 hospitals and 800 plus clinics.
As we examine the transition process, the American Legion, in its
efforts to ensure transitioning servicemembers receive continuous/
seamless care, has determined that veterans are facing various
challenges, which may irrevocably deter any chance of a successful and
smooth transition back into their local communities. An example of
challenges include, incomplete Post Deployment Health Reassessment
(PDHRA) questionnaires, inability to fully share medical records among
the Department of Defense (DoD) and VA Health care facilities, lack of
space at VA Medical Facilities, and shortage of staff, to include
nurses and physicians.
VA and DoD both play important roles in the transition process. As
women and men return from Iraq and Afghanistan facing uncertainty with
injuries and illnesses, the American Legion contends that closer
oversight must be placed on various programs, such as the PDHRA and
Federal Recovery Coordination (FRCP) programs that have been
implemented to ensure no one falls through the cracks. We ask Congress
to assess these roles to ascertain the appropriateness of functional
tools required to accommodate the Nation's veterans, their families,
and the complex issues they are met with.
The transition period is very important because many conditions
servicemembers are suffering from may go undiagnosed due to being in
the emergent stage. The role of DoD and VA must be that of ``safety net
catalysts'' that carefully guide servicemembers and veterans as they
transition from active duty military treatment facilities to VA Medical
Centers; thereby ensuring every servicemember or veteran is the
recipient of adequate and continuous care.
The following are some of the obligations DoD and VA have taken on
to support each servicemember and veteran as they transition from
active duty to civilian life:
Department of Defense and Seamless Transition:
To ensure that each servicemember's transition is successful, DoD
has implemented the following:
When transitioning from active duty service to civilian
life, servicemembers must undergo final physical examinations before
separation which includes: Medical screening (including eye exam);
dental examination; and
mental health screening.
They are offered a Medical Board Review for any unfitting
conditions. This review is scheduled and performed at the request of
the servicemember.
Post-Deployment Health Reassessment Program
The PDHRA program was established to identify and address
servicemembers' health concerns that emerge over time following
deployments. To be in compliance with DoD's policy, each military
service must electronically submit PDHRA questionnaires to DoD's
central depository.
However, a recent audit disclosed that the central depository did
not contain questionnaires for approximately 23 percent of the 319,000
(OEF/OIF) servicemembers who returned from theater. This means
approximately 72,000 servicemembers were without questionnaires in the
repository. The response to the absence of the questionnaires concluded
that DoD does not have reasonable assurance that servicemembers, to
whom the PDHRA requirement applies, were given the opportunity to fill
out the questionnaire and identify as well as address health concerns
that could emerge over time following deployment.
The American Legion believes the administration of the PDHRA is
essential to the success of the servicemember's transition, because the
results would disclose telltale signs of debilitating illnesses, such
as the disorders that plague many veterans who have gone undiagnosed at
separation from active duty. These illnesses and injuries include
Depression, Post-Traumatic Stress Disorder (PTSD), Mood Disorders and
Traumatic Brain Injuries (TBI), Spinal Cord Injuries (SCI), Blind Eye
Injuries, respectively.
Department of Veterans Affairs and Seamless Transition:
Upon separation from active duty service, VA informs the veteran of
the following:
Eligibility to enroll for health care at any VA
Medical Center or clinic within 5 years following military
separation date. Upon enrollment, VA will administer health
care benefits to the veteran immediately.
VA provides dental examinations and benefits to
veterans with service-related dental conditions. The veteran
may be eligible for one-time dental care; however, each veteran
must apply for a dental exam within the first 180 days
following the separation date.
Every VA Medical Center (VAMC) has a team ready to
welcome Operation Enduring Freedom and Operation Iraqi Freedom
(OEF/OIF) servicemembers and help coordinate their care.
Federal Recovery Coordination Program:
The American Legion would also like to ensure that the FRCP is
successfully assisting all recovering servicemembers and veterans
suffered from severe wounds, illnesses and injuries, as well as their
families in accessing the care, services, and benefits provided through
specifically, DoD and VA.
According to recent VA reports, the greatest challenge for Federal
Recovery Coordinators (FRCs) is the integration of Information
Technology (IT) access within VA and the Military Training Facility
(MTF). Although DoD and VA state that these challenges will be overcome
with the implementation of more IT integration between VA and DoD, the
American Legion would like to know the status of DoD and VA full IT
integration and medical records sharing. Further, the American Legion
recommends a strong emphasis by this Subcommittee for expediting the
effort be made.
VA Polytrauma of Care, VA Social Worker and Seamless Transition:
VA's Seamless Transition Social Worker, who is assigned to the MTF
responsible for caring for the patient, makes contact with staff at the
receiving Polytrauma System of Care facility. Vital clinical
information is then transmitted to the Admission Case Manager at the
Polytrauma Rehabilitation Center for review.
The Admission Case Manager remains in contact with the Seamless
Transition Social Worker and the clinical team at the Military
Treatment Facility until the patient is transferred to the receiving VA
Polytrauma facility. During the servicemember's stay, the VA Case
Manager remains in contact with the patient's military branch to keep
them informed of progress and/or changes in the patient's condition.
VA and DoD, both ensure open communication and effective
coordination through the following resources: phone calls, secure
record transfers, and meetings. In addition, physicians in the VA
Polytrauma System of Care and at Military Treatment Facilities contact
each other directly through teleconferencing, videoconferencing, and
through VA social workers assigned to each facility. Although the
aforementioned duties are outlined and in place, VA continues to face
challenges, such as screening and evaluating veterans for TBI.
More Challenges Transitioning Servicemembers and Veterans Face:
There have been various reports of critical challenges involving
veterans who had recently departed from active duty service. These
challenges, as reported by RAND, includes barriers to mental health
care access in community settings.
More specifically, it was discovered that:
Military servicemembers and veterans are often reluctant
to seek mental health care. The following reasons being:
Concern that admitting a mental health problem is a
sign of weakness
Fear that use of mental health services will have
negative career repercussions (especially among active-duty
personnel, who are required to disclose treatment)
Skepticism about the effectiveness of treatment and
concerns about the negative side effects of medication.
The mental health workforce has insufficient capacity.
The following reasons being:
Mental health specialty care for conditions such as
Post-Traumatic Stress Disorder (PTSD) and Depression are not
readily available in many parts of the country.
Studies also show that most mental health specialists
are concentrated in urban areas.
Even where specialty care is available, limited
health plan coverage may reduce access for veterans seeking
care outside of the Veterans Health Administration (VHA).
The American Legion ``A System Worth Saving'' Site Visits:
During the American Legion's 2009 Site Visits, it was discovered
that challenges were systemwide when it comes to meeting the needs of
OEF/OIF servicemembers turned veterans. Lack of sufficient and
appropriate staff to meet increasing workloads, a lack of support for
families caring for returning severely injured veterans, and difficulty
reaching new veterans who recently separated from active duty military,
especially significant number that may be possibly suffering from
psychological disorders are among the critical issues. According to VA,
during outreach, it was reported that the battlefield mindset may be
preventing veterans from seeking health care from the VA by admitting
that there is a problem.
When women veterans' experiences include defragmentation of care,
this cannot be deemed a successful transition. For example,
approximately 49 percent of women veterans continue to split care
between VA and the private sector. There continues to be a lack of
space for a women veterans' clinic in some VA facilities. A common
deterrent for women veterans include, the provision of day care for
their children, and women veterans being uninformed of full service
provided by VA which, at times, causes available clinics to be
underutilized. Currently, an unknown number of veterans, men and women,
are missing VA appointments due to childcare challenges.
The American Legion recently passed Resolution No. 29,
``Improvements to Implement a Seamless Transition,'' which recognized
gaps in services, and has consistently advocated improvements be made
to the process of servicemembers in their transition from active duty
to civilian life. The American Legion continues to express that
servicemembers and their families are easily overwhelmed when dealing
with the bureaucracy of multiple departments. However, a more
expeditious process that explicitly focuses on moving servicemembers
from point A to point B, i.e., DoD to VA, respectively, would ensure
timely and accessible care.
The American Legion believes it is extremely vital that this
Nation's servicemembers, before their departure, should be placed in a
comparable or full duplex capable, fully compatible, DoD/VA database
with appointment reminders to ensure their transition isn't stifled by
the unknown; after all, active duty servicemembers have been
conditioned to be directed to all military appointments and events.
Upon separation from service, these newly transitioned veterans may
continue to have the expectation that everything will be set up for
them. Both DoD and VA are working to ensure servicemembers and veterans
successfully receive information and treatment respectively. It is the
American Legion's contention that the interaction between DoD and VA be
heightened, most importantly, by complete shared access of the medical
records of servicemembers and veterans, as well as assessments of this
relationship.
Let us remember that there is no pause button for veterans. Every
moment is critical and must be treated as such. Although the World War
II veterans' population is diminishing at approximately 1000 daily;
other veterans, to include those from the Vietnam era to current OEF/
OIF are presenting to VA with old and new issues. Complacency in
communication between DoD and VA and implementation of programs can
never be relative.
The American Legion hereby reiterates its position and urge careful
oversight of effective communication between DoD and VA, to include,
verbal and written, as well as full implementation of programs to
ensure no one is left behind during the transition process.
Mr. Chairman and Members of the Subcommittee, the American Legion
sincerely appreciates this opportunity to submit testimony and looks
forward to working with you and your colleagues to ensure all
servicemembers are met with the best of health care upon transitioning
into the community. Thank you.
Prepared Statement of Tom Tarantino, Legislative Associate,
Iraq and Afghanistan Veterans of America
Mister Chairman, Ranking Member, and Members of the Subcommittee,
on behalf of Iraq and Afghanistan Veterans of America (IAVA), I thank
you for the opportunity to share our views and concerns on some very
important issues facing veterans of Iraq and Afghanistan and their
families.
Polytrauma and Adaptive Benefits
Veterans of Iraq and Afghanistan regularly receive excellent care
in the ever-expanding polytrauma system. However, the DoD and the VA
must continue to innovate, develop, and improve methods of care that
address the changing nature of injuries from Iraq and Afghanistan.
While these centers provide excellent care for servicemembers and
veterans, there is a noticeable drop in the quality of care when
transferring to community based care near the veteran's home of record.
Additionally, the quality of services for the disabled veteran near
their home does not match the standards of care that a veteran receives
while in a polytrauma center.
Additionally, IAVA is concerned with the structure of the adaptive
services benefits that many veterans will use after leaving polytrauma
care. Veterans are being forced into debt because of shortcomings in
their benefits and the services that the VA provides. Currently,
benefits for adaptive housing and automobiles are stuck at 1970's
funding levels; most are one-time deals. With about 80 percent of OIF
and OEF veterans under the age of 30, a veteran living with permanent
disabilities will require more than one automobile in his or her life.
The current rate of $12,000 may have bought a van, equipped with
adaptive modifications, back in 1972. Today, that might get you a mid
size Kia with no adaptive technology. The veterans are left to pay the
difference. We cannot tolerate a benefits system that requires a
veteran to incur debt to perform everyday functions.
Finally, many veterans, wounded in Iraq and Afghanistan, are not
homeowners and must return to their family homes to recover. They are
then faced with a choice during a critical time in their recovery. The
must choose between adapting the home where they are recovering, or
save that benefit for the home where they will eventually settle. The
need for these services is obvious, and the figures that require
upgrading are known. There is no excuse for leaving a veteran with
substandard benefits.
Social Work Case Management
VA Social Workers play an indispensible role in the treatment of
veterans recovering from multiple traumatic injuries. The VA must
rapidly expand their numbers. As more and more OIF and OEF veterans
enter the VA health system their overall needs will continue to
inundate the overworked and understaffed cadre of social work
professionals within the VA system. Private sector social workers, on
average, work on a caseworker to client ratio of 1:10 to 1:15. In
comparison, in-house VA social workers operate near a ratio of 1:35.
The VA must address this issue before the ratios expand further. These
caseworkers cannot properly address the needs of our veterans and their
families under these currently crushing workloads.
Dependent & Survivor Education Services
To the spouses and dependents of veterans who gave their last full
measure of devotion to this country the VA provides educational
benefits under Chapter 35, the Survivors' and Dependents' Education
Assistance Act (DEA). This benefit is limited to family members of
veterans who died or became permanently and totally disabled due to a
service-connected disability. In 2008, the VA reported that 80,191
family members took advantage of this program. This is more than the
number of reservists using Chapter 1606.
Unlike the generous Post-9/11 GI Bill or the recently increased
Montgomery GI Bill, DEA provides a paltry sum of $925/month, which will
cover less than 60 percent of a public school education. The Post-9/11
GI Bill has become a game changer for many spouses and dependents that
can now utilize their veteran's unused education benefits to attend any
public school in the country. IAVA believes that DEA benefits rates
should be aligned with the generous benefits of the new GI Bill, to
include tuition/fees, a living allowance and a book stipend. These
changes will help prevent the creation of a two-tiered benefits system.
The first tier being family members that can afford to go to school
using the new GI Bill, because they meet the criteria under the Marine
Gunnery Sergeant Fry Scholarship. The second tier being family members
who are left to use DEA and will have to take out student loans just to
attend a community college.
Last, we believe that the definition of a ``child'' used under
Chapter 35 and new Post-9/11 GI Bill, which requires dependents who
have started college before the age of 23, unfairly excludes a number
of dependents who simply got a late start attending college and should
not be punished for doing so.
VA Outreach Efforts
Since early 2008, we have seen a noticeable shift in how the VA
educates veterans about the care and services that they offer.
Beginning with the suicide prevention ads in the DC region, the VA has
continued to rethink how it communicates with the veteran population at
large. I have personally met with representatives from the VHA, VBA and
the VA Business Office to discuss how the VA can better reach out to
veterans of Iraq and Afghanistan. While there has been visible
improvements with online and television advertisement, there is a clear
lack of coordination between VA departments. Within the VA there is
talent, will and desire to change the passive nature of VA
communication, however there are still substantial cultural and
structural hurtles that must be overcome.
IAVA believes that in order for the VA to conduct effective
outreach, it must centralize its efforts between VHA, VBA, and NCA and
speak as one Department of Veterans Affairs. The average veteran (and
the average American for that matter) does not understand the
difference between the VHA and the VBA. When I wait an entire semester
for my GI Bill check to come, I'm upset with the VA, not the VBA. When
I wait 2 months for a medical appointment, I'm upset with the VA, not
the VHA. If the VA wants to effectively improve communications, it must
speak to the veteran population clearly, avoiding government jargon.
Thank you once again for the chance to communicate our opinions on
several of the issues facing veterans of Iraq and Afghanistan. We look
forward to continuing to work with the Committee and I appreciate your
time and attention.
Prepared Statement of Captain Jonathan Pruden, USA (Ret.),
Area Outreach Coordinator, Wounded Warrior Project
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting Wounded Warrior Project to share its
perspective on issues of ``Seamless Transition'' between the
Departments of Defense and Veterans Affairs.
I was an Army captain who in 2003 became one of the first IED
casualties of Operation Iraqi Freedom, and have made that transition
myself. Now, after 20 operations at 7 different hospitals including
amputation of my right leg, I am an Area Outreach Coordinator with WWP,
working with hundreds of wounded warriors and covering Florida,
Georgia, South Carolina and Alabama.
Over the past 6 years DoD and VA have made significant progress in
care coordination and information sharing. I have seen firsthand real
dedication to wounded warriors and their families. Certainly this
Subcommittee's steady focus on these issues has helped achieve greater
``seamlessness'' for wounded warriors in making a transition from the
military to VA care and to receipt of VA benefits.
The Goal: That Warrior's Thrive
Even the most well coordinated, ``seamless'' handoff to a welcoming
VA will not change the fact, however, that for many wounded warriors
this transition feels like having been thrown off a cliff. In short,
more work needs to be done by the departments and by the Congress to
achieve not only ``seamlessness'' but to ensure that our new veterans
have a successful transition and reintegration into the community.
Certainly much progress has been made in coordinating the clinical
care of the severely injured servicemember. The DoD-VA Disability
Evaluation System pilot program has also had success in expediting VA
disability ratings. But while the departments can take pride in certain
areas of real progress, wounded warriors leaving the service continue
to face programmatic, cultural, and structural barriers at VA. It is
critical, in our view, that those barriers be toppled and that key VA
programs and service-delivery mechanisms be re-engineered, as
necessary, to help wounded warriors not simply to recover from their
injuries but to thrive physically, psychologically and economically.
Meeting Warrior's ``Co-occurring'' Needs
More specifically, critical VA programs, benefits, and service-
delivery models fall short in many instances of providing the array of
21st century services wounded warriors need. We work with men and women
who are not only combating co-occurring PTSD and substance-use
problems, but ``co-occurring'' traumatic brain injury, burns and
amputations. Often, they're also dealing with pain, anger, depression,
unemployment and lack of employment opportunity, lack of permanent
housing, and more. In some cases, behavioral health problems have
resulted in difficulties with the law.
VA has an array of programs targeted at specific problems, but
little in the way of a holistic coordinated approach to turn these
lives around. The goal of ``One VA'' a department that provides
``wraparound'' services that seamlessly and effectively integrate
Veterans Health Administration (VHA) services and Veterans Benefits
Administration (VBA) benefits seems sadly remote. Yet, as a panel of
the National Academy of Public Administration has observed, care and
benefits to veterans could be improved if VA management, organization,
coordination, and business practices were transformed with the aim of
improving outcomes for veterans, rather than simply aiming to improve
operational processes.\1\ Most importantly, that National Academy panel
has provided VA detailed recommendations constituting a comprehensive
blueprint for that needed transformation.\2\ At its core is its
emphasis on the importance of leadership commitment to creating and
maintaining veteran-centered systems, including a ``no wrong door''
policy to ensure receipt of appropriate guidance regardless of point of
contact. The Academy has provided VA a vision, strategy and detailed
recommendations for organizing and delivering veteran-centered
services. We urge the Committee to press VA to implement these
important recommendations.
---------------------------------------------------------------------------
\1\ National Academy of Public Administration, ``After Yellow
Ribbons: Providing Veteran-Centered Services,'' October 2008, p. ix.
\2\ Ibid.
---------------------------------------------------------------------------
Bridging Programmatic Gaps
The Academy report aptly cites the need to strengthen VA's system
of care, including its care-management tools.\3\ The need for better
coordination between VHA programs serving wounded warriors is aptly
illustrated by reference to the separate development and separate
administration of its specialized PTSD programs and its polytrauma
system of care. As VA researchers observed in a recently published
paper,\4\ the Department has not developed a systemwide program or set
of guidelines for treating the many OEF/OIF veterans who may have both
combat-related stress disorders and mild explosive-induced concussive
injury. Researchers pursuing this important subject initiated
interviews with VA clinicians who provide specialized PTSD or TBI
services with the aim of helping to identify systemwide approaches to
improve services offered to OEF/OIF veterans with mild TBI and PTSD.
Highlighting just some of the findings, the interview data reportedly
suggested considerable variation in the degree and type of
collaboration between PTSD and polytrauma teams, and indicated that
coordinating assessment and treatment depend on individual clinician
initiative and can take considerable time, as well as entail potential
problems in managing medications across teams and care-settings.\5\ Of
particular note, many providers emphasized that TBI/PTSD can co-occur
with other clinical problems, and expressed particular concern about
the lack of adequate treatment availability for pain and sleep-related
problems.\6\ To their credit, providers also cited a need for
vocational services for these veterans, noting that employment
difficulties are a significant problem for them.\7\
---------------------------------------------------------------------------
\3\ Ibid, p. 51 et seq.
\4\ Nina Sayer, Nancy Rettmann, Kathleen Carlson, Nancy Bernardy,
Barbara Sigford, Jessica Hamblen, Matthew Friedman, ``Veterans with
History of mild traumatic brain injury and posttraumatic stress
disorder: Challenges from provider perspective,'' Journal of
Rehabilitation Research & Development 46 (Nov. 6, 2009).
\5\ Ibid., 710.
\6\ Ibid., 711.
\7\ Ibid.
---------------------------------------------------------------------------
While it is encouraging that VA researchers are searching for best
practices for treating these two, often co-occurring ``signature
wounds'' of this war, what does this knowledge-gap say about care-
coordination for wounded warriors with even more complex co-occurring
problems?
In that regard, we applaud the Department for having initiated the
Federal Recovery Coordination (FRC) program, which plays an important
coordinating role for those it serves. But with only about 15 Federal
Recovery Coordinators already carrying full workloads, many severely
injured warriors, who are still struggling years after their injuries,
are unable to benefit from such efforts. We see a real need to augment
the number of FRC's assigned to help wounded warriors, but more
profound system changes are also needed. To illustrate, the most able
FRC or other case-manager cannot solve such problems as a systemwide
lack of treatment capacity, whether in the area of treatment of pain or
sleep-disorder, or of co-occurring PTSD and substance-use disorder.
Individual case-management assistance afforded by an FRC is surely no
substitute for the kind of delivery-system changes needed to most
effectively help individuals who, for example, may be struggling with
``co-occurring'' polytraumatic injury, behavioral health problems, and
unemployment.
The importance of VA's developing more holistic, integrated
systems' approaches to help wounded warriors thrive should not,
however, detract from improving targeted programs.
Mental Health: An Example of Need for Programmatic Change
Much more must be done, for example, to make VA mental health care
more ``veteran-centric,'' a yet-to-be realized VA policy goal. VA
mental health policy (articulated in a recent VHA publication
establishing uniform mental health services requirements for VA
facilities) is clear: ``Mental health services must be recovery-
oriented.'' \8\ The policy explains that ``recovery-oriented care'' is
individualized, person-centered care; care that empowers the individual
and builds on his or her strengths; and is aimed at enabling the person
to live a meaningful life in the community.\9\ But too many veterans
under VA care for PTSD or other mental health problems are still simply
being given pills to manage their symptoms. That has to change.
---------------------------------------------------------------------------
\8\ Department of Veterans Affairs, Veterans Health Administration,
Uniform Mental Health Services in VA Medical Centers and Clinics, VHA
Handbook 1160.01, September 11, 2008, 5.
\9\ Ibid.
---------------------------------------------------------------------------
One concrete step VA can take toward realizing a recovery-
orientation for returning veterans who need mental health care is to
employ a cohort of OEF/OIF veterans to provide peer-outreach and peer-
support. VA policy recognizes that peer-support is one of the
fundamental components of recovery,\10\ but only requires that that
service be provided to veterans with ``serious mental illness.'' \11\
Peer-support and peer-mentoring, however, are as beneficial to veterans
struggling with PTSD as to veterans with so-called ``serious mental
illnesses,'' and should be a widely available, integral component of VA
mental health care afforded OEF/OIF veterans.
---------------------------------------------------------------------------
\10\ Ibid.
\11\ Ibid., 30.
---------------------------------------------------------------------------
To offer another example of a need for change, our own work with
wounded warriors has highlighted the difficulties facing those who have
severe PTSD (and often co-occurring substance use problems) and need
residential treatment. Too often, those veterans' circumstances do not
``fit'' VA placement criteria for specialized PTSD care. In essence,
OEF/OIF veterans in the greatest need of mental health care too often
confront barriers that effectively deny them access to the very care
they need. In short, they seem to be experiencing ``barrier-centric
care'' rather than ``veteran-centered care.'' Let me illustrate my
point. VA inpatient PTSD programs lack systemwide uniformity in
admissions policy; they appear instead to be governed by an array of
differing rules that have barred warriors from needed specialized
inpatient care based on such diverse requirements as that the veteran?
have had success in outpatient group therapy for 3 to 6
months to qualify for admission;
must have no suicidal attempts or ideations in the past 6
months;
not be on benzodiazepines (a drug some physicians use for
treating the anxiety that accompanies PTSD);
must first complete outpatient anger management
treatment;
must be substance-free for a certain amount of time; and
must first be interviewed and, if accepted, will be
admitted at a later date.
Tragically, many OEF/OIF veterans have suffered with severe PTSD
for some time before VA encounters them. In such instances, an
individual may be barely hanging on, and cannot wait for a residential
PTSD program admission date which is anywhere from a few weeks to
several months away. In such instances, the individual is generally too
acutely ill to benefit from outpatient treatment, and due to
unavailability of services are generally seen once every 2 to 6 weeks
for ongoing therapy. During that time they often relapse, and may be
readmitted to the psychiatric unit, become involved with the justice
system or experience severe deterioration of their condition.
Wounded Warrior Project field staff has considerable experience in
helping OEF/OIF veterans get needed mental health care from VA
facilities, but we have encountered great difficulty in attempting to
facilitate needed placements under circumstances where a veteran's
condition poses a relatively urgent need for specialized inpatient
treatment for PTSD (or co-occurring PTSD and substance-use problems).
The most pronounced of these cases have involved veterans who have
been jailed because of behaviors linked to PTSD and substance use, and
whose cases have come before a judge who is open to having the veteran
undergo treatment rather than incarceration. In several such cases,
however, VA medical center personnel who have attempted to help
facilitate such placements have been stymied by long waiting lists at
specialized inpatient facilities in their network (VISN). On numerous
occasions, our field staff have inquired on behalf of our warriors
about placement options for specialized inpatient PTSD care beyond the
confines of the particular VISN, only to learn that VA staff have no
national data base or centralized information source to which to turn
to identify other potential VA placement sources. Yet I'm aware of an
instance in which a VA facility's inpatient PTSD/substance-use
treatment program had 125 veterans on its waiting list while a similar
program 180 miles away in a neighboring VISN had open beds.
In light of this troubling information-gap, we have urged the
Department to establish a regularly updated ``clearinghouse'' on all
specialized VA PTSD programs to provide relatively real-time placement
information, to include nature of the program (such as whether the
program provides treatment for dual-diagnosis patients; program
requirements; length-of-stay limits; etc.); capacity; bed availability;
length of any waiting list; OEF/OIF veteran census; and contact-
personnel. Such a resource should be available and accessible to VA
personnel as well as to veterans' advocates. To date, however, our
recommendation has elicited no response.
Employment: Programmatic Gaps
We have highlighted some of the programmatic gaps relating to VA
mental health, not because these programs are uniquely flawed, but
because mental health is so important to overall health and to whether
wounded warriors are thriving. To cite another area that cries out for
programmatic improvement, employment is certainly key to successful
reintegration. Yet even in programs targeted at helping disabled
veterans gain Federal employment, wounded warriors encounter obstacles
in gaining employment. It is particularly painful to find that warriors
encounter problems in seeking employment with VA, the one Federal
department one would expect to go the extra mile. VA certainly appears
to have the needed legislative authority to be a leader in employing
wounded warriors. As you know, Mr. Chairman, service-connected disabled
veterans (and those retired from service on disability) are entitled to
a ten-point preference in Federal hiring (in a system using 100 as the
top score), and are entitled to hiring preference over other applicants
with the same or lower scores. But those extra points seem to give
veterans little or no practical help. Instead, the complex hurdles
associated with demonstrating one's qualifications for a particular
Federal job (in particular, demonstrating that one has the requisite
``KSAO's,'' namely the Knowledge, Skills, Abilities, and Other
Characteristics) often knock otherwise qualified wounded warrior
applicants out of contention, even in VA. Surely the Department could
establish mechanisms to help overcome such hurdles. But wounded
warriors encounter frustration with VA even when they get jobs through
a Veterans Recruitment Appointment (VRA), a special authority by which
a Federal department or agency can employ a disabled veteran without
competition. While the VRA authority has occasionally provided warriors
jobs, such VA appointments seldom tap the leadership and other skills
wounded warriors developed in service.
In short, Mr. Chairman, to achieve its ultimate goals, ``seamless
transition'' will not only require more work to close the remaining
gaps between DoD and VA, but substantial transformation within VA in
the area of mental health programming, vocational rehabilitation and
employment, and many other areas to make warriors' transition an easier
journey to successful community reintegration.
That concludes my testimony; I would be happy to answer any
questions you may have.
Prepared Statement of Hon. Noel Koch, Deputy Under Secretary of
Defense, Wounded Warrior Care and Transition Policy,
U.S. Department of Defense
Mr. Chairman, thank you for inviting me to join you today to
discuss how the Department of Defense (DoD) transitions our Wounded,
Ill and Injured Servicemembers to the care of the Department of
Veterans Affairs (VA). The Departments continue to work together to
address these issues through the auspices of the DoD/VA Senior
Oversight Committee and the Joint Executive Council.
The Office of Wounded Warrior Care and Transition Policy's (WWCTP)
mission is to ensure Wounded, Ill, Injured & transitioning Warriors
receive the highest quality care and seamless transition support. Some
of our Wounded, Ill or Injured Servicemembers may be able to return to
active duty following their recovery, and may choose to do so, while
others may leave military service. But while in the care of DoD, it is
my office's job to develop policy and provide oversight of several
parts of a Servicemember's care, recovery and transition.
As you are aware, one of the most important efforts we have made
was in response to the recommendations sent forth by the President's
Commission on Care for America's Returning Wounded Warriors and
required by the National Defense Authorization Act for Fiscal Year 2008
(NDAA 2008) to provide a single point of contact for recovering
Servicemembers and their families. In response to the NDAA requirement,
we launched the Department of Defense Recovery Coordination Program
(RCP).
The RCP places Recovery Care Coordinators (RCCs) in each Military
Department's Wounded Warrior Program. The RCCs support eligible
Wounded, Ill and Injured Servicemembers, including members of the
Reserve Component, and their families, by ensuring their non-medical
needs are met along the road to recovery.
With the Servicemember's Recovery Team, including the Commander,
Non-medical Care Manager and Medical Care Case Manager, the Recovery
Care Coordinator oversees the development and completion of a Recovery
Plan. The patient-centered Recovery Plan identifies the Servicemember's
and family's goals and action steps and points of contact to achieve
them. Effectively, the plan is a roadmap guiding the recovering
Servicemember and family along the process of recovery, rehabilitation,
and reintegration. It may include information to assist the family
member serving as the primary caregiver in receiving compensation,
financial assistance, job placement services, support with child care,
counseling, respite services, and other benefits and services available
from Federal, state, and local governments, as well as our non-profit
partners.
The Recovery Coordination Program is guided by a new DoD
Instruction (1300.24) on the Recovery Coordination Program, which was
drafted by my office with input from a Policy Working Group composed of
representatives from across the Military Departments, the Office of the
Secretary of Defense and the Department of Veterans Affairs. The policy
provides uniform guidelines and procedures for our Military Service
Wounded Warrior Programs and assigns responsibilities for
implementation of the Recovery Coordination Program. It establishes
parameters for determining the type of care a Servicemember needs,
provides the support of a Recovery Care Coordinator and lays out the
process for developing a Recovery Plan. It also requires that the same
support be provided to qualified Reserve Component Servicemembers. In
addition to the Recovery Plan, the Recovery Care Coordinators bring to
bear several other resources for our recovering Servicemembers and
their families through a variety of Web sites and publications. Our
Recovery Coordinators, Recovery Teams and providers, Servicemembers and
their families all make use of these resources, including:
The National Resource Directory (NRD): A successful tri-
agency initiative including DoD, VA, and the Department of Labor, the
National Resource Directory is an online resource linking
Servicemembers, care providers and family caregivers to information on
more than 12,000 Federal, state and local support services. The NRD
provides information on state-by-state resources and benefits.
The Compensation and Benefits Handbook: This book
includes a section dedicated exclusively to caregivers. It provides
community options such as transportation services, respite care,
financial assistance, and counseling resources.
Surveys of our Recovery Care Coordinators and providers indicate
over 90 percent utilize these resources as they develop and execute
recovery plans.
The Disability Evaluation System (DES) Pilot is another program
that my office coordinates with VA. As of the first week of January,
138 Servicemembers entered the DES Pilot from 21 Military Treatment
Facilities (MTFs) during the reporting week for a cumulative enrollment
of 6,408 Servicemembers since November 26, 2007, when the DES Pilot
began. Of those, 1,164 Servicemembers completed the DES Pilot and
returned to duty, separated from service, or retired, and 212
Servicemembers were removed from the DES Pilot for reasons such as
additional medical treatment or case terminated pending administrative
discharge processing. 5,032 Servicemembers are currently enrolled in
the DES Pilot.
Active Component Servicemembers who completed the DES Pilot
averaged 275 days from Pilot entry to a VA benefits decision, excluding
pre-separation leave. Including pre-separation leave, Active Component
Servicemembers completed the DES Pilot in an average of 291 days. This
is 1 percent faster than the goal established for Active Component
Servicemembers and is 46 percent faster than the current DES and VA
claim process. Reserve Component Servicemembers who completed the DES
Pilot averaged 279 days from Pilot entry to issuance of a VA Benefits
Letter, which is 9 percent faster than the projected 305 day timeline.
Survey results show that across all Servicemembers, Pilot
participants were significantly more satisfied with DES Pilot Medical
Evaluation Board (MEB), Physical Evaluation Board (PEB), and Transition
processes than non-Pilot participants. Soldiers in the Pilot were
significantly more satisfied with MEB, PEB, and Transition processes
than Soldiers in the non-Pilot. Sailors and Marines were significantly
more satisfied with the Pilot than non-Pilot MEB and PEB processes.
Pilot participants reported DES Pilot MEB and PEB processes to be
significantly fairer than did non-Pilot participants.
In September 2009, six additional sites were approved for expansion
of the DES Pilot between January and March 2010. The Departments of the
Army and Navy completed initial site assessments and are currently
conducting site visits to each of these locations. Upon expansion of
the DES Pilot to these locations, approximately 46 percent of all new
DES enrollees will be covered under the Pilot. We are conducting a
joint DoD/VA evaluation of the Pilot that will help us determine the
best way to expand the DES ``Pilot Model'' worldwide, the results of
which will provide the basis for the final report on the Pilot due to
Congress in May.
But these programs notwithstanding, much remains to be done. Both
DoD and VA are aware that we can improve how we care for our
Servicemembers and Veterans, be it through further research, continuing
to ease access to benefits for those who earned them, and better
support for our Caregivers.
Mr. Chairman, we are reminded daily of our obligation to our
Servicemembers and their families, and particularly to the Wounded, Ill
and Injured, and those who bear the greatest burden of caring for them.
We are committed to providing the support they need to help ensure a
successful transition through recovery and rehabilitation and back to
active duty or reintegration into their communities.
We appreciate the opportunity to come before you today to discuss a
subject which the Secretary of Defense has said repeatedly is a
Departmental priority second only to the wars in which we are engaged.
I will be happy to answer your questions.
Thank you.
Prepared Statement of Madhulika Agarwal, M.D., MPH, Chief Officer,
Office of Patient Care Services, Veterans Health Administration,
U.S. Department of Veterans Affairs
Good morning, Mr. Chairman and Members of the Subcommittee. Thank
you for the opportunity to discuss the Department of Veterans Affairs'
(VA) efforts to help returning servicemembers transition back to
civilian life. I am accompanied today by Dr. Karen Guice, Executive
Director of the Federal Recovery Coordination Program, and Mr. Paul
Hutter, Chief Officer, Office of Legislative, Regulatory and
Intergovernmental Affairs.
VA's primary mission is to care for those who have borne the
battle. As science and technology have advanced, more and more of our
brave heroes survive what would have been fatal wounds in previous
conflicts. However, survival is only the immediate goal--our job is to
restore Veterans to the greatest level of health, independence and
quality of life that is medically possible. To facilitate a smooth
transition from the Department of Defense (DoD), VA has stationed 33
health care liaisons at 18 Military Treatment Facilities to facilitate
the transfer of care to VA facilities. This program grew considerably
during 2009 with six additional liaisons at five new sites. Altogether
these liaisons have assisted more than 20,000 servicemembers in
transitioning from DoD to VA since 2004. We continue to work with DoD
to identify additional sites that have increasing numbers of wounded
warriors who may benefit from these services.
My testimony today will describe the advances made in VA's
Polytrauma System of Care, which provides coordinated inpatient,
transitional, and outpatient rehabilitation services; our care
management system, which coordinates complex components of care for ill
and injured servicemembers, Veterans and their families, as well as the
education services VA provides to dependents and family members of
injured Veterans; the Federal Recovery Coordination Program; and VA's
outreach efforts to returning servicemembers and Veterans.
Polytrauma System of Care and Specialty Care
Polytrauma refers to complex, multiple injuries occurring as a
result of the same event. Some examples of polytrauma injuries include
Traumatic Brain Injury (TBI), amputations, severe musculoskeletal
injuries, burns, hearing loss or tinnitus, memory loss, visual
impairment, cognitive impairment, pain, fatigue, or mental health
conditions such as post-traumatic stress disorder (PTSD). Individuals
with polytrauma require extraordinary levels of integrated and
coordinated medical, rehabilitation and support services. To respond to
these unique patient needs, VA developed a comprehensive model of care
that includes interdisciplinary teams of health care providers that
coordinate care as the patient moves from a Military Treatment Facility
to a VA Polytrauma Rehabilitation Center, a local VA hospital, and
reintegration into the Veteran's or servicemember's home community.
Since the designation of VA's TBI Centers as Polytrauma
Rehabilitation Centers in 2005, VA has continued to expand its
Polytrauma System of Care by adding new specialized rehabilitation
programs and teams of rehabilitation specialists at sites across the
country. The VA Polytrauma System of Care has four levels of
facilities: Polytrauma Rehabilitation Centers, Polytrauma Network
Sites, Polytrauma Support Clinic Teams, and Polytrauma Points of
Contact.
The four Rehabilitation Centers (located in Minneapolis, MN; Tampa,
FL; Richmond, VA; and Palo Alto, CA) provide comprehensive medical and
rehabilitation services on both an inpatient and outpatient basis for
Veterans and servicemembers with the most complex and severe injuries.
These facilities typically have between 12 and 18 inpatient beds
staffed by specialty rehabilitation teams that provide acute
interdisciplinary evaluation, medical management and rehabilitation
services. A fifth Rehabilitation Center is currently under construction
in San Antonio, Texas and is expected to be completed in 2011.
Occupancy rates at these centers fluctuate over time and location.
The average length of stay is 30 days, but for the most severely
injured the average is 67 days. Upon discharge from a VA Polytrauma
Rehabilitation Center, patients may be transferred to another facility,
although more than 70 percent are discharged to their home. From March
2003 through fiscal year (FY) 2009, the Centers have treated
approximately 1,500 inpatients with severe injuries; approximately 56
percent of these patients have been active duty servicemembers.
Slightly more than half of the patients treated in the Polytrauma
Rehabilitation Centers were injured in non-combat, non-deployed
incidents.
Recent new specialized rehabilitation initiatives at the Polytrauma
Rehabilitation Centers include:
In July 2007, 10 bed residential Transitional
Rehabilitation Programs were established at the four Centers to provide
rehabilitation in a home-like environment to facilitate community
reintegration for Veterans and their families.
Beginning in 2007, VA implemented a specialized Emerging
Consciousness care path at each of the four Polytrauma Rehabilitation
Centers to serve those with severe TBI who are slow to recover
consciousness. These patients require complex and intensive medical
services and resources to improve their level of responsiveness and
reduce medical complications. VA collaboratively developed this care
path with subject matter experts from the Defense and Veterans Brain
Injury Center (DVBIC) and the private sector. VA and DVBIC continue to
collaborate on research in this area, and our models of care continue
to be updated in response to scientific advances.
In October 2008, all inpatients with TBI at VA Polytrauma
Rehabilitation Centers began receiving special ocular health and visual
function examinations. To date, 649 inpatients have received these
examinations.
In April 2009, VA began an advanced technology initiative
to establish assistive technology laboratories at the four Polytrauma
Rehabilitation Centers. These facilities will serve as a resource for
VA health care and provide the most advanced technologies to Veterans
and servicemembers with ongoing needs related to cognitive impairment,
sensory impairment, computer access, communication deficits, wheeled
mobility, self care, and home telehealth.
VA continues to optimize its Polytrauma Telehealth
Network to facilitate provider-to-provider and provider-to-family
coordination, as well as consultation from Polytrauma Rehabilitation
Centers and Network Sites to other providers and facilities. Currently,
about 30 to 40 videoconference calls are made monthly across the
Network Sites to VA and DoD facilities. New Polytrauma Telehealth
Network initiatives in development include home buddy systems to
maintain contact with patients with mild TBI or amputation, and remote
delivery of speech therapy services to Veterans in rural areas.
The Polytrauma Rehabilitation Centers have been renovated
to optimize healing in an environment respectful of military service.
Military liaisons located at the Centers support active duty patients
and coordinate interdepartmental issues for patients and their
families. Working with the Fisher House Foundation, we are also able to
provide housing and other logistical support for family members staying
with a Veteran or servicemember during his or her recovery at one of
our facilities.
The remaining components of the VA Polytrauma System of Care
include 22 Polytrauma Network Sites, 82 Polytrauma Support Clinic
Teams, and 48 Polytrauma Points of Contact. The Polytrauma Network
Sites are available in each Veterans Integrated Service Network (VISN),
as well as San Juan, Puerto Rico. These sites develop and support a
patient's rehabilitation plan through comprehensive, interdisciplinary,
specialized teams; provide both inpatient and outpatient care; and
coordinate services for Veterans with TBI and polytrauma throughout the
VISN.
In 2008, the Polytrauma Support Clinic Teams expanded to 82 VA
facilities. These interdisciplinary teams of rehabilitation specialists
provide dedicated outpatient services closer to home and manage the
long-term or changing rehabilitation needs of Veterans. These teams
coordinate clinical and support services for patients and their
families. They also conduct comprehensive evaluations of patients with
positive TBI screens, and develop and implement rehabilitation and
community reintegration plans.
VA Polytrauma Points of Contact are available at 48 VA medical
centers without specialized rehabilitation teams. These Points of
Contact, established in 2007, are knowledgeable about the VA Polytrauma
System of Care and coordinate case management and referrals throughout
the system.
In addition to enhancements to its Polytrauma System of Care, VA
has implemented several other recent initiatives to improve care for
Veterans and servicemembers with TBI:
In 2009, VA developed clinical practice guidelines for
mild TBI in collaboration with DoD and deployed them to VA health care
providers. VA also developed recommendations in the areas of cognitive
rehabilitation, drivers' training, and managing the co-occurrence of
TBI, PTSD and pain.
In 2009, VA began collaborating with the National
Institute on Disability and Rehabilitation Research TBI Model Systems
to collect rehabilitation outcomes data and establish a TBI Veterans
Health Registry.
Since April 2009, VA has developed an individualized
rehabilitation and community reintegration plan for every outpatient
Veteran with TBI who requires ongoing rehabilitation care. This
national template is integrated into the electronic medical record and
includes the results of a comprehensive assessment, measurable goals,
and recommendations for specific rehabilitative treatments. The patient
and family participate in crafting the treatment plan and receive a
copy of the plan.
VA regularly collaborates with private sector facilities
to successfully meet the individualized needs of Veterans and
complement VA care in cases when VA is not readily able to provide the
needed services or the required care in geographically inaccessible
areas. VA medical facilities have identified private sector resources
within their catchment area that have expertise in neurobehavioral
rehabilitation and recovery programs for TBI. In FY 2009, 3,708
Veterans with TBI received inpatient and outpatient hospital care and
medical services from public and private entities, with a total
disbursement of over $21 million.
Several educational materials for patients and families
are in the final stages of being developed and distributed nationally
including: TBI Family Education Manual, TBI Information Brochure, TBI
Screening Brochure, and the Family Care Map. VA and DVBIC also
collaborated to develop a training curriculum for family members in
providing care and assistance to Servicemembers and Veterans with TBI.
VA has also established an Amputation System of Care and the Blind
Rehabilitation System of Care to provide specialty care for Veterans
and servicemembers. The Amputation System of Care is composed of 7
Regional Amputation Centers, 15 Polytrauma Amputation Network Sites,
100 Amputation Clinic Teams, and 30 Amputation Points of Contact. These
resources have been dedicated to reduce variance and improve access
across VA to amputation rehabilitation care. More than 43,000 Veterans
have major limb amputations, of which about 950 are Operation Enduring
Freedom or Operation Iraqi Freedom (OEF/OIF) Veterans.
Blind Rehabilitation Outpatient Specialists are assigned to
Polytrauma Rehabilitation Centers and Network Sites, and patients with
severe visual impairments receive further comprehensive services at any
of our 10 inpatient Blind Rehabilitation Centers. In addition to these
Centers, VA has 77 Blind Rehabilitation Outpatient Specialists and 137
Visual Impairment Services Coordinators. VA has also assigned Blind
Rehabilitation Outpatient Specialists to Walter Reed Army and Bethesda
Naval Medical Centers to serve visually impaired servicemembers.
VA works closely with DoD to support high quality integrated care
for severely injured servicemembers and Veterans. The two Departments
recently developed revisions to clinical codes to improve
identification and tracking of TBI. In 2009, a 5 year pilot project to
provide assisted living services for Veterans with severe TBI was
initiated in collaboration with the DVBIC. We have placed three
Veterans in Virginia, Florida and Wisconsin, and enrollment is pending
for two Veterans in Texas and Kentucky.
VA Care Management and Education Services
Care management refers to a patient- and family-centered approach
to care by an interdisciplinary team of professionals with specialized
knowledge in the management of patients with complex care needs. VA has
developed a robust care management system for OEF/OIF Veterans. Each VA
medical center has an OEF/OIF Program Manager, OEF/OIF Case Managers,
and Transition Patient Advocates. The Program Manager coordinates
clinical care and oversees the transition and care for this population.
The Program Manager also serves as the primary point of contact for all
referrals from the VA Liaisons for Health Care. OEF/OIF Case Managers
coordinate patient care activities and ensure that all clinicians
providing care to the patient are doing so in a cohesive and integrated
manner. Transition Patient Advocates help Veterans navigate the VA
system and Veterans Benefits Administration (VBA) team members assist
Veterans with the benefit application process and education about VA
benefits.
All severely ill and injured OEF/OIF servicemembers and Veterans
receiving care at VA facilities are provided a case manager. All others
are screened for case management needs and, based upon the results of
the assessment; a case manager may be assigned as indicated. In
addition, OEF/OIF servicemembers and Veterans with special needs,
including polytrauma, spinal cord injury, and blindness, are served by
a specialty case manager. The patient and family serve as integral
partners in the assessment and treatment care plan. Since many of the
returning OEF/OIF Veterans connect to more than one specialty case
manager, VA introduced a new concept of a ``lead'' case manager. The
lead case manager serves as a central communication point for the
patient and his or her family. Our case managers maintain regular
contact with Veterans and their families to provide support and
assistance to address any health care and psychosocial needs that may
arise. As of December 31, 2009, 2,484 OEF/OIF severely ill and injured
servicemembers and Veterans were receiving on-going case management
services, an increase of 49 percent in 2009. Case managers collaborate
with VA, DoD and community resources to address the needs of OEF/OIF
Veterans.
VA is training its staff and developing new models to support
better care for severely injured and ill servicemembers and Veterans.
We have implemented Web-based training to disseminate best practices
and guidelines, and a mentoring program for OEF/OIF Program Managers to
share expertise. VA updated policies for transitioning and care
managing OEF/OIF Veterans and servicemembers with new handbooks
published in October and November 2009. We will continue to integrate
these services with our Post-Deployment Integrated Care Clinics and
other specialty care such as mental health and polytrauma.
VA has adopted the Care Management Tracking and Reporting
Application (CMTRA), a Web-based tracking system that includes a care
management schedule for each Veteran, identifies a lead case manager,
produces management reports and creates data to assist VA in measuring
performance. While CMTRA initially focused on the severely ill and
injured, CMTRA has now been extended to track case management of non-
severely ill or injured OEF/OIF servicemembers and Veterans.
VA works with family members and Veterans prior to discharge to
train and educate them on specific health care needs and issues. For
example, prior to discharge from a Polytrauma Rehabilitation Center,
family members may be scheduled to stay with the Veteran in a family
training apartment or the Veteran may participate in the Transitional
Rehabilitation Program. This allows the family member to experience
what the return home will be like for their loved one while still
having rehabilitation staff and nursing staff available to answer
questions, address unexpected problems, and provide the emotional
support a family may need as they prepare for the next phase of
rehabilitation.
VA case managers are actively involved in assisting ill and injured
Veteran's with re-integration into their home communities. VA provides
skilled home care, homemaker/home health aide services, and a variety
of respite care options to support Veterans and their families who
require additional assistance at home. In FY 2009, VA Home-Based
Primary Care interdisciplinary teams provided comprehensive primary
care in the homes of 431 OEF/OIF Veterans. VA provides home
modification grants and special adaptive equipment as needed to ensure
a safe home environment. For OEF/OIF ill and injured Veterans who are
unable to remain in their own homes, VA has developed an in-home
alternative to nursing home care, the Medical Foster Home. VA is
rapidly expanding its Medical Foster Home initiative, also known as
``Support at Home: Where Heroes Meet Angels,'' across the Nation. There
are several OEF/OIF Veterans who would otherwise have required nursing
home placement that have been served in the Medical Foster Home program
this year.
VA recognizes the significant sacrifices made by family caregivers
of severely ill and injured OEF/OIF Veterans. With support from
Congress, VA was able to conduct eight caregiver support pilot programs
at 39 VA medical centers across the country. The lessons learned from
these pilot programs have provided us with the foundation to develop a
comprehensive caregiver support program that will enhance caregiver
education and training while providing a flexible menu of respite care
options to reduce caregiver burden and improve the quality of life of
Veterans and their caregivers.
Federal Recovery Coordination Program
The Federal Recovery Coordination Program (FRCP), a joint VA/DoD
program, helps coordinate and access Federal, state and local programs,
benefits and services for seriously wounded, ill and injured
servicemembers, Veterans, and their families through recovery,
rehabilitation, and reintegration into the community. As of January 11,
2010, 15 Federal Recovery Coordinators (FRCs) were coordinating care
for 425 severely wounded, ill or injured servicemembers and Veterans;
another 38 individuals were being evaluated for program enrollment.
Five (5) new FRCs completed their orientation in early January,
bringing the total number of FRCs to 20. FRCs are located at Walter
Reed Army Medical Center, National Naval Medical Center, Naval Medical
Center San Diego, Camp Pendleton Naval Hospital, San Antonio Military
Medical Center, Eisenhower Army Medical Center, Houston VA Medical
Center, and Providence VA Medical Center.
Recovering servicemembers and Veterans are referred to the FRCP
from a variety of sources, including from the servicemember's command,
members of the multidisciplinary treatment team, case managers,
families already in the program, Veterans Service Organizations and
non-governmental organizations. Generally, those individuals whose
recovery is likely to require a complex array of specialists, transfers
to multiple facilities, and long periods of rehabilitation are referred
to FRCP. After referral, an FRC conducts an evaluation that serves as
the basis for problem identification and determination of needed
services. After enrollment in FRCP, clients develop a Federal
Individual Recovery Plan (FIRP) with their FRC.
FRCs have the delegated authority for oversight and coordination of
the clinical and non-clinical care identified in each client's FIRP.
Working with a variety of case managers, FRCs assist their clients in
reaching their goals as identified and tracked in the FIRP. The FRC and
the relevant case manager determine responsibility and timeline for
implementing the steps necessary to reach a goal. The FRC then monitors
progress with the case manager and the client, providing support and
additional resources to both, until the goal is reached. FRCs
frequently organize meetings with providers, case managers and clients
to make sure objectives and expectations are clear. The plan and goals
change as a client progresses through the stages of recovery,
rehabilitation and reintegration. The FRC provides a single, consistent
point of coordination through this progression.
Outreach
VA is continuously looking for ways to improve and achieve a smooth
and seamless transition for servicemembers and their families. VA
conducts numerous outreach activities to support this seamless
transition. In FY 2009, VA conducted over 8,500 Transition Assistance
Program and Disabled Transition Assistance Program briefings attended
by over 356,800 servicemembers and their families. VA launched a pre-
discharge program home page (http://www.vba.va.gov/predischarge/) on
June 9, 2009 to complement its Benefits Delivery at Discharge and Quick
Start programs. In addition, VA launched the eBenefits portal on
October 22, 2009 to streamline information to servicemembers, Veterans
and families (www.ebenefits.va.gov/ebenefits-portal/).
VA also conducts outreach to returning Reserve Component
servicemembers through different approaches and settings, including: 61
demobilization sites; the Yellow Ribbon Reintegration Program events at
30, 60, and 90 days post-demobilization; Post-Deployment Health
Reassessments, including those conducted at VA facilities; partnerships
with the National Guard; Individual Ready Reserve musters, through the
Combat Veteran Call Center Initiative; and for all servicemembers, the
VA OEF/OIF Web site (http://www.oefoif.va.gov/).
Additionally, VA establishes contact and provides assistance
through annual focus groups held at VA medical centers, annual Welcome
Home events held by each medical center, and community partnerships
with providers, colleges and universities, job fairs, and other
activities.
Our outreach efforts have provided Veterans with knowledge and
access to VA services and benefits. Of the 1,100,000 Veterans who have
separated since 2002, 48 percent have used VA health care services.
Between 2005 and September 2009, more than 86,000 referrals to VA were
made through DoD's Post-Deployment Health Reassessment, and since 2008,
more than 70,000 Veterans have enrolled in VA health care prior to
leaving a demobilization site. We also are reaching and conversing with
Veterans through social media, including Facebook, Twitter, YouTube,
Flickr, and blogs. Currently, VA has the fastest growing Facebook page
among cabinet-level agencies with over 11,000 fans, most of whom have
been gained since Veterans Day (over 1,000 fans per week). VA
participation on Facebook is expanding. Each Administration has its own
page for topic-specific conversations, as do a dozen VA medical
centers. VA has plans to launch a Facebook page for every VA medical
center.
VA now has four separate official Twitter feeds for the Department
and each of the administrations. In the past 2 months, VA's primary
Twitter feed has added followers at a higher growth rate than any other
cabinet-level agency: nearly 2,000 have joined in that time. Half a
dozen VA medical centers have active Twitter feeds. As with Facebook,
VA plans to expand Twitter feeds to all medical centers beginning in
2010. VA just launched the first official Twitter feed for a VA
principal in January, with Assistant Secretary Tammy Duckworth now
engaging regularly with the public via her own VA Twitter account.
VA also has embraced video- and photo-sharing media with the use of
YouTube (videos) and Flickr (photos). VA began posting each segment
from its news magazine program The American Veteran on YouTube, while
showcasing a selection of them on the VA homepage. At the same time, VA
has a separate health care-related YouTube channel (administered by
VHA) which has posted more than 90 videos, has 1,300 subscribers and
more than 58,000 views.
In terms of blogging, VA has thus far been spreading its message
via other sites--with pieces published at the White House Blog, and
others with messages posed by Secretary Shinseki and Assistant
Secretary Duckworth at outlets like Military.com.
VA's main Web site has also been rebuilt to make it more user-
friendly for Veterans. Up-to-date information about benefits and
services is added daily. Reaching returning Veterans through their
expected and familiar modes of communication is a priority. The OEF/OIF
generation expects a communication style that allows conversation and
engagement, and these resources help VA enhance information sharing
with this group of Veterans, as well as other stakeholders.
Conclusion
VA is focusing its resources and attention to meet the needs of
Veterans and their families and to ensure that as servicemembers return
home, they receive the care and support they have earned.
Thank you again for the opportunity to speak about VA's efforts to
support transitioning servicemembers and Veterans. My colleagues and I
are prepared to answer your questions at this time.