[Senate Hearing 111-217]
[From the U.S. Government Publishing Office]
S. Hrg. 111-217
HEARING TO EXAMINE THE IMPLEMENTATION OF WOUNDED WARRIOR POLICIES AND
PROGRAMS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON PERSONNEL
of the
COMMITTEE ON ARMED SERVICES
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
APRIL 29, 2009
__________
Printed for the use of the Committee on Armed Services
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COMMITTEE ON ARMED SERVICES
CARL LEVIN, Michigan, Chairman
EDWARD M. KENNEDY, Massachusetts JOHN McCAIN, Arizona
ROBERT C. BYRD, West Virginia JAMES M. INHOFE, Oklahoma
JOSEPH I. LIEBERMAN, Connecticut JEFF SESSIONS, Alabama
JACK REED, Rhode Island SAXBY CHAMBLISS, Georgia
DANIEL K. AKAKA, Hawaii LINDSEY GRAHAM, South Carolina
BILL NELSON, Florida JOHN THUNE, South Dakota
E. BENJAMIN NELSON, Nebraska MEL MARTINEZ, Florida
EVAN BAYH, Indiana ROGER F. WICKER, Mississippi
JIM WEBB, Virginia RICHARD BURR, North Carolina
CLAIRE McCASKILL, Missouri DAVID VITTER, Louisiana
MARK UDALL, Colorado SUSAN M. COLLINS, Maine
KAY R. HAGAN, North Carolina
MARK BEGICH, Alaska
ROLAND W. BURRIS, Illinois
Richard D. DeBobes, Staff Director
Joseph W. Bowab, Republican Staff Director
______
Subcommittee on Personnel
E. BENJAMIN NELSON, Nebraska, Chairman
EDWARD M. KENNEDY, Massachusetts LINDSEY GRAHAM, South Carolina
JOSEPH I. LIEBERMAN, Connecticut SAXBY CHAMBLISS, Georgia
DANIEL K. AKAKA, Hawaii JOHN THUNE, South Dakota
JIM WEBB, Virginia MEL MARTINEZ, Florida
CLAIRE McCASKILL, Missouri ROGER F. WICKER, Mississippi
KAY R. HAGAN, North Carolina DAVID VITTER, Louisiana
MARK BEGICH, Alaska SUSAN M. COLLINS, Maine
ROLAND W. BURRIS, Illinois
(ii)
C O N T E N T S
__________
CHRONOLOGICAL LIST OF WITNESSES
Hearing to Examine the Implementation of Wounded Warrior Policies and
Programs
april 29, 2009
Page
Gadson, LTC Gregory D., USA...................................... 5
Noss, Kimberly R., Ph.D.......................................... 6
Kinard, 1st Lt. Andrew K., USMC (Ret.)........................... 7
Williamson, Randall B., Director, Health Care, Government
Accountability Office; Accompanied by Daniel Bertoni, Director,
Education, Workforce, and Income Security Issues; and Valerie
C. Melvin, Director, Human Capital and Management Information
Systems Issues................................................. 26
McGinn, Gail H., Deputy Under Secretary of Defense for Plans,
Department of Defense.......................................... 54
Embrey, Ellen P., Acting Principal Deputy Assistant Secretary of
Defense for Health Affairs..................................... 60
Dimsdale, Roger, Executive Director, Department of Veterans
Affairs/Department of Defense Collaboration, Office of Policy
and Planning, Department of Veterans Affairs................... 65
Meurlin, Maj. Gen. Keith W., USAF, Director, Office of Transition
Policy and Care Coordination, Department of Defense............ 70
Timberlake, RADM Gregory A., USN, Director, Interagency Program
Office, Department Of Defense/Department Of Veterans Affairs... 75
Guice, Karen S., M.D., M.P.P., Executive Director for the Federal
Recovery Coordination Program, Department of Veterans Affairs.. 80
(iii)
HEARING TO EXAMINE THE IMPLEMENTATION OF WOUNDED WARRIOR POLICIES AND
PROGRAMS
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WEDNESDAY, APRIL 29, 2009
U.S. Senate,
Subcommittee on Personnel,
Committee on Armed Services,
Washington, DC.
The subcommittee met, pursuant to notice, at 2:33 p.m. in
room SH-216, Hart Senate Office Building, Senator E. Benjamin
Nelson (chairman of the subcommittee) presiding.
Committee members present: Senators E. Benjamin Nelson,
Hagan, Begich, Graham, Chambliss, Thune, and Wicker.
Committee staff member present: Leah C. Brewer, nominations
and hearings clerk.
Majority staff members present: Jonathan D. Clark, counsel;
Gabriella Eisen, counsel; and Gerald J. Leeling, counsel.
Minority staff members present: Paul C. Hutton IV,
professional staff member; Daniel A. Lerner, professional staff
member; Lucian L. Niemeyer, professional staff member; Diana G.
Tabler, professional staff member; and Richard F. Walsh,
minority counsel.
Staff assistants present: Mary C. Holloway, Jessica L.
Kingston, Brian F. Sebold, and Breon N. Wells.
Committee members' assistants present: Ann Premer,
assistant to Senator Ben Nelson; Gordon I. Peterson, assistant
to Senator Webb; Roger Pena, assistant to Senator Hagan; Clyde
A. Taylor IV, assistant to Senator Chambliss; Adam G. Brake,
assistant to Senator Graham; Erskine W. Wells III, assistant to
Senator Wicker; and Rob Epplin, assistant to Senator Collins.
OPENING STATEMENT OF SENATOR E. BENJAMIN NELSON, CHAIRMAN
Senator Ben Nelson. Good afternoon. The subcommittee meets
today to discuss the implementation of wounded warrior
programs, policies, and plans by the Department of Defense
(DOD) and the Department of Veterans Affairs (VA).
This hearing was originally scheduled for April 1, 2009,
but unfortunately, had to be postponed due to a series of
stacked votes. I want to thank the members of our second and
third panels, who were all present and accounted for, ready to
testify, when the hearing was called off at the last minute. We
thank you for your patience and understanding.
The delay produced a very positive result. On that same
day, April 1, Senator Graham and I were fortunate enough to
meet with a group of wounded warriors and some of their family
members who candidly shared with us the positive and negative
experiences they'd gone through, and are still going through,
on their journeys through treatment, the disability evaluation
process, and transition to the next chapters of their lives.
During that meeting, Senator Graham and I mentioned the
possibility of the group testifying at a hearing on a future
date, to which they all graciously agreed. Now, little did they
know the day would come so soon. Because of the hearing's
postponement, we were able to create a new first panel and we
have invited them all to speak about their experiences as
seriously wounded servicemembers, veterans, and as spouses of
wounded warriors.
We all remember February 18, 2007, the day the first in a
series of articles appeared describing problems faced by our
wounded warriors receiving care in an outpatient status. Many
of these servicemembers, who were wounded or injured in service
to our Nation, were living in substandard facilities, were
unaccounted for, and were fighting their way through a bungled,
adversarial administrative process to rate their disabilities.
After they left DOD care, they had to start all over with the
VA, and many fell through the cracks in the transition. As a
result of these articles and various reports on wounded warrior
transition policies and programs, Congress passed the Wounded
Warrior Act, which was incorporated into the National Defense
Authorization Act (NDAA) for Fiscal Year 2008.
The Wounded Warrior Act, among many other things, required
DOD and VA to work jointly to develop and implement a
comprehensive set of policies to improve the care, management,
and transition of recovering wounded, ill, and injured
servicemembers. The Act also required the Comptroller General
to assess and report on the progress made by the two
departments in this endeavor. This report is near completion,
so on our second panel we have personnel from the Government
Accountability Office (GAO) to share their findings.
On our third panel, we'll have several representatives from
DOD and VA. They will discuss DOD and VA efforts to organize
and resource wounded warrior program and policy improvements,
as well as the accomplishments to date of the DOD/VA Wounded,
Ill, and Injured Senior Oversight Committee (SOC) which has
been in place for nearly 2 years and is comprised of several
high-level DOD and VA officials. In fact, in a hearing earlier
this year, Secretary Gates himself pledged to chair this
oversight committee's meetings during this period of
administration transition, along with Secretary Shinseki of the
VA. This is evidence of the priority placed on helping wounded
warriors and their families within the highest echelons of
these departments. I'll introduce our DOD and VA witnesses when
the third panel convenes.
I'm very pleased to welcome our first panel. These men and
women, who represent wounded, Active Duty servicemembers,
veterans, and their families, are the reason we're all here
today. We have with us Lieutenant Colonel Gregory D. Gadson,
United States Army; Lieutenant Colonel Raymond T. Rivas, United
States Army; his wife, Mrs. Colleen O. Rivas; Ms. Kimberly R.
Noss, Ph.D., the spouse of a seriously wounded servicemember;
and First Lieutenant Andrew K. Kinard, United States Marine
Corps.
The wounded warrior legislation passed by Congress required
DOD and VA to collaborate on many levels. The departments have
been tasked with great challenges, such as jointly developing a
fully interoperable electronic health record, improving the
disability evaluation system (DES), establishing centers of
excellence for psychological health, traumatic brain injury
(TBI), and eye and auditory trauma coordinating care, and much
more. Collaboration on such a large scale was new ground for
these two huge government agencies. The fact that DOD and VA
have been able to work so closely on so many different levels
is a sign of great commitment on their part to ensuring that
our wounded, ill, and injured servicemembers and their families
are given the best care management and support possible while
navigating through these bureaucratic processes. With any
undertaking of this magnitude, there are bound to be
outstanding issues and problems to work out along the way.
I visited with many of our wounded warriors, including
soldiers from Nebraska, at Walter Reed Army Medical Center
(WRAMC). The servicemembers that I've spoken with lauded the
treatment they were receiving at WRAMC, and so, I commend the
efforts of those who have worked to improve the outpatient care
and treatment of our wounded warriors. I also learned, however,
of many issues that indicate there's still work to be done.
We've heard of the shortage of healthcare professionals. We
owe it to our troops and our country to adequately assess the
medical condition of our servicemembers prior to their
deployment. I recently learned of incomplete medical
assessments, due to a shortage of time or manpower, which, in
one case, resulted in the unnecessary exacerbation of a
servicemember's medical condition. In another case, the
incomplete medical assessment resulted in the deployment of a
medically unfit servicemember whose condition quickly
deteriorated in Afghanistan, causing him to collapse in the
field. This servicemember consequently had to be medically
evacuated from the forward deployment for a known medical
condition.
When our servicemembers return home with war wounds, it's
imperative that we have the medical personnel and resources
available to care for them. It's also essential that we make
efforts to treat our servicemembers as close to home as
possible. The ability to receive care near their home base
provides a better network of support for the servicemember, and
will likely speed recovery time.
Ensuring we have the means and resources in place for
medical assessments and adequate treatment facilities is why
oversight hearings such as this are so very important. As we
reflect on the work done to date in improving these policies
and programs for our servicemembers and their families, we must
also identify any existing gaps or problems in the care,
coordination, and transition process. Only after we identify
problems can we work to find answers and provide the highest
quality of care for our wounded, ill, and injured
servicemembers and their families.
This is far more than just a procedural issue. The purpose
of these massive policy and program reforms is to care for our
wounded warriors.
Now it's my pleasure to welcome Senator Graham. We're
delighted to have you here with us today to discuss these
critical issues, and I ask if you would like to make an opening
statement.
Senator Graham, would you like to make an opening
statement?
Senator Graham. Very briefly, Mr. Chairman.
STATEMENT OF SENATOR LINDSEY GRAHAM
Senator Graham. I want to thank you for conducting this
hearing. You've been a terrific supporter of the Wounded
Warrior Program, and men and women in the military, in general.
We met with this group. We were going to have a hearing a
couple of weeks ago, and we had a bunch of votes scheduled, but
the Chairman was kind enough to come to my office, and I think
we got a lot out of that meeting with our wounded warriors who
are here today, and Andrew Kinard who worked in my office
(gesturing), and we learned a lot. One thing I learned is that
I don't want these hearings to be taken by anybody as there's a
lack of caring--there's not a lack. People care a lot. There's
a lot of bureaucracy out there that cares a lot. We've just got
to get it focused on doing the best job it can.
Secretary Gates has put $300 million in the budget, which
will help us. It's a budgetary item now for the Wounded Warrior
Program, and the purpose of these hearings is to learn how to
do it better, and not to question anybody's motives. If the
services are not being delivered well, it's not because people
don't care, it's because it's just not working right.
For these Warrior Transition Units (WTUs), we hear some
disturbing reports that people feel like the odd guy out.
Family members feel like the command climate wasn't as
responsive as it could be. That disturbs me. I'd just say this,
if you're in charge of a WTU, we're going to judge you by how
you take care of those who have paid a real heavy price. I hope
that problem can be fixed and is not as bad as some people have
said it was.
We're here today to learn, and the best way to learn is
from people who live it. That's panel one, and the next panel
are the people in charge of making sure it works. We're going
to be a team. Every American wants us to get this right. This
has nothing to do with party politics. This is the one thing
that will bring this country together above all else, taking
care of the men and women who have been hurt.
Thank you, Mr. Chairman, for having the right tone and
attitude about how to do this.
Senator Ben Nelson. Thank you, Senator Graham. You have
been steadfast in your support for this program, whether the
roles were reversed and you were chairman and I was ranking
member, or the current situation, we will continue to make it
bipartisan, nonpartisan, because there's nothing partisan about
the need for care for our men and women and their families who
serve our country in so many different ways.
Now to our first panel. We welcome four frank assessments
of the strengths and weaknesses of the systems supporting
wounded warriors and their families, as well as any
recommendations that they may have for improvements in the
future.
We'll begin by hearing opening statements, followed by some
questions. First, Lieutenant Colonel Gadson, if you would
please start us off, and then we'll work our way down the
table.
STATEMENT OF LTC GREGORY D. GADSON, USA
Colonel Gadson. Chairman Nelson and Senator Graham,
distinguished members of this subcommittee, thank you for this
opportunity to testify today to share my experiences as a
wounded warrior in the Army medical system.
First and foremost, I cannot overstate how impressed I am
with the treatment and care I have received since I was
wounded, nearly 2 years ago. WRAMC and other Service medical
centers have treated unprecedented injuries and trauma, and not
only successfully treated those injuries, but enabled those who
have been injured to rejoin society and live productive lives.
For that, I am truly grateful and humbled by those in the
medical community who have dedicated their lives to making us
well.
Dealing with severe injury and trauma is not easy. When you
consider the myriad of injuries, as well as the unfamiliarity a
typical family has in dealing with an injured servicemember,
it's easy to understand how difficult a task it is to recover.
I can say, from my vantage point, that our medical system is up
to the task.
Over the past 23 months, I have seen tremendous
improvements in the quality of care for injured servicemen and
their families. However, that does not mean that there isn't
room for improvement or gaps don't exist in the system.
One such gap that I personally experienced involves support
from a nonmedical attendant. Current policy allows nonmedical
attendants to be reimbursed for meals and lodging. Nonmedical
attendants' roles are to provide assistance to injured
servicemembers in activities they cannot do for themselves--
i.e., bathing and driving, et cetera. In my case, my wife was
reimbursed as a nonmedical attendant while our household was at
Fort Riley, KS. However, when we decided to relocate to the
local area in proximity to WRAMC, her nonmedical attendant
reimbursement was discontinued.
What I want to illustrate to you is that we don't want to
put families in a hardship situation when deciding how and who
will assist the servicemember who needs assistance. The fact
that per diem and lodging are paid to nonmedical attendants
shows an inconsistency in rate, essentially paying nonmedical
attendants based on location. I believe there should be a set
rate for nonmedical attendants, as well as the per diem and
lodging. The situation that family members often find
themselves in is how to deal with the loss of income while the
servicemember recovers. I have personally seen families remain
apart while the serviceman recovers, because they cannot afford
to remain together. This is a choice families should not be
forced to make.
I would like to emphasize the Army's dedication to our
wounded warriors. Our purpose here is to see continued
improvement.
Thank you for holding this hearing, and thank you for your
continued support for warriors. I look forward to your
questions.
Senator Ben Nelson. Dr. Noss?
STATEMENT OF KIMBERLY R. NOSS, PH.D.
Dr. Noss. First of all, I'd like to thank the committee for
allowing me to speak today on behalf of my husband, Sergeant
First Class Scot Noss, U.S. Army.
Scot was severely injured in Afghanistan in 2007. He
suffered a severe brain injury, with damage to his frontal
lobes and brain stem. He had two broken ribs, a pelvic
fracture, three fractured vertebras, and broken feet. So, he
sustained a very polytraumatic injury. However, the brain
injury was the worst, where, 2 years later, he is currently
minimally conscious and is 100 percent dependent for daily
living activities.
The past 2 years have been very challenging, considering
that we, as a country, were not prepared to take care of these
severely injured soldiers. Men and women of the Armed Forces
are surviving injuries that would not have survived other wars
because of the medical technology available in theater and
because of our excellent training from the medic, corpsmen, and
from the para-rescuemen. However, there is a huge gap between
that technology and training available in theater and what is
available stateside for continued long-term healthcare and
services for our severely wounded warriors.
I come here today representing the minority of injured, the
minimally conscious realm of injury, but represent the ones who
need the majority of the long-term healthcare for the rest of
their life. One issue that needs to be addressed is TRICARE's
lack of coverage of cognitive rehabilitative therapies. Those
on Active Duty are able to access this care, but are
prohibited, once retired, which is why many families fight to
stay in Active Duty service. Unfortunately, just recently at
the DOD Cognitive Rehabilitation Consensus Conference, DOD
commissioned a formal Emergency Care Research Institute,
Institute of Technology Assessment on the benefits of cognitive
rehabilitation for combat-injured veterans. This report stated
that the assessment, in question, found that the available
evidence was of insufficient quantity nor quality to reach
meaningful evidenced-based conclusion on the efficacy of
cognitive rehabilitation for TBI. However, the Defense Center
of Excellence (DCoE) of Psychological Health and Traumatic
Brain Injury, a center created by this committee, recently
issued a white paper supporting cognitive rehabilitation as a
well-accepted and usual-customary component of comprehensive
rehabilitation for persons with moderate to severe TBI.
Unfortunately, for no other reasons, the conclusion of the
report stated that, even though cognitive rehabilitation
research shows promising results, they are now, at this time,
not covering for veteran-status injured soldiers.
If DOD will cover cognitive rehabilitation for Active Duty
soldiers, why will they not cover it once he is a veteran? Why
is it sound therapy for an Active Duty servicemember, but not a
retiree?
While I understand that this committee does not have
jurisdiction over disability compensation, it is still
important that you understand that compensation for men and
women with mild to moderate functional TBI needs to be
addressed. These men and women will not have the opportunity to
have a career or retirement because of their limitations from
their combat injuries. What will their future entail? These
individuals fall short for benefit coverages that will ensure a
healthy lifestyle, but they are not employable, because of
their injuries.
What about the caregivers of the severely injured soldiers?
The mean age of injured soldiers is 22 years old. If this
individual requires 24-hours/7-days-a-week care or constant
supervision for safety, how can their family, which most likely
are in the prime of their career, afford to quit their jobs and
forego retirement benefits to take care of their loved one?
What about the 18-year-old wife who did not have the
opportunity for education and chose to take care of her
severely injured husband instead of putting him in a nursing
home? This wife will not have means to income, and should be
compensated for her caregiving capabilities and services.
Nursing homes are not an option for these young men and women
coming back from overseas injured.
The collaborative efforts of DOD and VA have been evident;
however, there is still much work to be done. For example, it
would be very helpful if a Veteran Benefit Administration (VBA)
employee was housed in all of the wounded warrior advocacy
offices. For example, the United States Special Operations
Command (SOCOM) Care Coalition has been my main source of
information and advocacy. Due to the classified nature of SOCOM
warriors, if the VBA employee was located in their office, the
transfer of veteran status would be smoother because of the
initial and continual presence from the transition to veteran
status.
Finally, I'd like to say that we should not reinvent the
wheel. If TBI rehabilitation and care is better in the private
sector, that's where our men and women should go. This country
alone has 1.5 million brain injuries a year, where the Armed
Forces have only sustained 8,000 since 2001. The VA should have
an open mind and a higher fee-based budget to provide the
necessary care for these individuals, as well as TRICARE
stepping up to the plate to provide such services as cognitive
rehabilitation. These men and women of the Armed Forces have
earned options and deserve the best in continued healthcare
services for their entire life.
I would like to say that, even though these have been the
negative aspects of our journey, I do thank DOD and the SOCOM
Care Coalition. Scot was a proud Army Ranger, and he fought
gallantly for his country. I'd also like to thank the VA. They
kept my husband alive and have done superb. Thank you.
Senator Ben Nelson. Lieutenant Kinard?
STATEMENT OF 1ST LT. ANDREW K. KINARD, USMC (RET.)
Lieutenant Kinard. Yes, sir. Good afternoon, Chairman
Nelson, Senator Graham, and members of the subcommittee.
I'm pleased to appear before you today to discuss my
experiences as a warrior in transition. I hope that, by sharing
some of these challenges that I've faced, and some of the
successes that I've had, that you can gain a collective
understanding of the path forward from here. What I'd like to
focus on are some common themes that unite a lot of the wounded
warriors that are returning home.
I've faced many challenges in the 2\1/2\ years of my
recovery since being injured in Iraq, first of all let me say
that I would not be here today were it not for the dedication
and professionalism of our medical service personnel. Every
breath that I take is a testimony to their service. I mean
that.
I was injured, like I said, 2\1/2\ years ago, and my
subsequent medical evaluation and recovery consisted of over 60
surgeries and countless hours of physical therapy, occupational
therapy--you name it, I went to just about every service except
for gynecology. [Laughter.]
I was an inpatient at WRAMC when the Washington Post broke
the stories, and remained there through all the changes that
ensued during the fallout. Some of them have been pretty
effective, and some of them we have some way to go forward.
If I might just make a quick comment on the GAO study that
you will hear about in the next panel, I've had a chance to
read that study, and their overall assessment shows that 60 out
of 76 of the criteria have been met. My comment to that is,
although mathematically that sounds like a pretty good progress
report, even the GAO itself admits that they did not actually
study the effectiveness of each of those policies that had been
met. All they did was check the box that there is a policy that
was created; they didn't actually look at ``is this working or
not?''
What I'd like to talk to you about today is how we can look
at some of these policies that have been out there and say:
``are they working or are they not? How can we reduce
redundancies within the system? How can we streamline things so
that the net effect is a decrease in the amount of confusion
amongst the wounded veterans and their families?''
The biggest item is case management and care coordination.
The need for competent case management at all phases of
transition cannot be overstated, but it's especially critical
during the rehabilitation and reintegration phases of a
person's transition. If you can get the proper care identified,
I think you're going to have a very successful chance of a good
recovery. When my doctors knew what was going on and when we
identified which specialty service I needed to go see, there's
no question, I thought the care that I received at WRAMC in
Bethesda was excellent. However, the problem arises in an
outpatient status, keeping track of the number of case managers
alone can be overwhelming. I can count eight different case
managers that I had to keep track of at any one time. The
burden of responsibility fell on me to make sure that I knew
which of my case managers to go to for which problem. In
effect, I was left with a handful of business cards. They all
said, ``Hey, call me if you have any problems.'' I said, ``I
don't really know what to ask or not to ask.''
I think one of the things that has been a great success has
been the creation of the overall care coordination program
within DOD and VA. The DOD has a coordination program called
the Recovery Care Coordination Program. The VA, on the other
hand, has the Federal Recovery Coordination Program (FRCP).
What they simply do is bring together all the resources that we
have available within the DOD and the VA, and, at a 30,000-
level view, say, ``How can we coordinate some of these
things?'' It's a one-stop shop.
My concern is that, while the Recovery Care Coordinators
(RCCs) and the Federal Recovery Care Coordinators (FRCCs) are
really doing the same thing, and the only difference is what
category of wounded person they're treating, FRCCs typically
manage the care of the more seriously injured and more
critically injured servicemembers, while RCCs treat the less
severely injured. The two systems are administered by two
different departments. One's by VA, one's by DOD, and yet,
they're supposed to be doing the same thing and bringing the
same resources to bear.
At what level are we going to be coordinating these two
programs to make sure that we're getting the most effective
treatment delivered to the servicemember and that we're
reducing redundant programs so we can also make sure we're
spending dollars on beans and bullets where we need to, as well
as maximizing our dollars spent on wounded warriors?
I'd also like to comment briefly on the DOD DES Pilot
Program that was created directly as a response to some of the
criticisms raised in the WRAMC coverage by the Washington Post.
In an effort to simplify and streamline the process, before
the DES pilot was created, a recovering servicemember would
have to be rated, their whole body rated by the DOD, found
unfit to continue service, then transferred into the VA, rated
again, and then receive disability compensation. The VA would
take quite a while, and there would be a many-month gap between
receiving that critical compensation. What DOD and VA did was,
they streamlined that process by eliminating one of those two
medical examinations. At the same time, I think we still need
to make sure and follow up that DOD and VA are doing the
handoff correctly and effectively. For myself--and I don't want
to get into specifics of my case; but, as an example, it took
me roughly 9 months for DOD and VA to figure out that my legs
were not growing back. There's some efficiencies that I think
we can still continue to enjoy and benefit from if we take hard
looks and ask the second and third panel of witnesses how we
can really make it work for us up here on the first panel.
Thank you, gentlemen and ma'am, for your time, and I
appreciate the opportunity to answer your questions.
[The prepared statement of Lieutenant Kinard follows:]
Prepared Statement by 1st Lt. Andrew K. Kinard, USMC (Ret.)
Good afternoon, Chairman Nelson, Senator Graham, and members of the
committee. I am pleased to appear before you today to discuss my
experiences as a warrior in transition. I hope that by sharing with you
some of the challenges that I have faced and the successful experiences
that I've had, this committee will gain a better understanding of the
issues that are common to all recovering servicemembers.
Although I have faced many challenges since I was wounded in Iraq
2\1/2\ years ago, let me first say that I wouldn't be here today were
it not for the dedication and professionalism of the medical personnel
who treated me from the battlefield through surgical centers in Al
Asad, Balad, Landstuhl, Bethesda, and Walter Reed. Every breath that I
take is a testimony to their service.
I was injured in the Al Anbar Province, Iraq on October 29, 2006.
My subsequent medical evacuation and recovery consisted of over 60
surgeries and countless hours of occupational and physical therapy. I
was an inpatient at Walter Reed when the Washington Post stories broke
and remained there through all of the changes that followed. Some of
the changes to the transition system have been very effective and
others remain ineffective due to lack of oversight or interagency
coordination.
As you have heard from the other witnesses, recovering
servicemembers are facing a myriad number of issues at each phase of
transition--recovery, rehabilitation, and reintegration. These three
phases were formalized by the Department of Defense (DOD) in the
Directive-Type Memorandum of January 19, 2009 which establishes policy
for the Recovery Coordination Program. One caveat is that the three
phases cannot be viewed exclusively as a linear progression; it is not
uncommon for reintegration to begin prior to the completion of
rehabilitation or for a recovering servicemember to require services
typically associated with the recovery or rehabilitation phases after
reintegration is considered complete. For example, this is the case for
many servicemembers who have a Traumatic Brain Injury (TBI). Oftentimes
they will have returned to their home communities but require ongoing
cognitive therapy. I have tried to capture thematic issues faced by
recovering servicemembers at the second two phases of transition:
rehabilitation and reintegration.
rehabilitation
The need for competent care management at all phases of transition
cannot be overstated, but it is especially critical during the
rehabilitation phase as the recovering servicemember navigates the
various outpatient services available. Two programs are now available
to assist recovering servicemembers in coordinating their care: the
Recovery Care Coordination (RCC) Program and the Federal Recovery
Coordinator (FRC) Program. While each of these two programs essentially
provide the same service--with very seriously injured servicemembers
managed by a FRC and less severely servicemembers managed by a RCC--the
RCC program is managed by the DOD and the FRC program is managed by the
Department of Veterans Affairs (VA). It is essential that Congress not
view these two programs as completely unrelated, but rather Congress
should ensure interagency coordination as DOD and VA implement these
relatively new programs.
Prior to the FRC and RCC programs becoming available, the onus was
on the recovering servicemember to keep up with all of the different
case managers and their individual responsibilities. When I was at
Walter Reed Army Medical Center, I had a medical case manager, a non-
medical case manager, a social worker, a medical board case manager, a
Physical Evaluation Board Liaison Officer, a Navy-Marine Corps Liaison
Officer, a Wounded Warrior Regiment case manager, and a Marine Corps
patient administration team. This list of medical support personnel is
roughly the same for all recovering servicemembers in its composition
and in the confusion it creates among wounded warriors. What became
especially problematic before the advent of recovery coordinators was
the transfer of a recovering servicemember to a different medical
facility. At each transfer, recovering servicemembers commonly started
fresh with case managers who had no previous knowledge of medical
history for that patient.
The long list of case managers and other support staff that I
previously mentioned all fall within the DOD health care system. As
servicemembers transition from active to veteran status, most, if not
all, of those case managers will be exchanged for new ones in the VA
system. Rather than veterans navigate a new health system with no
institutional memory of their medical history, a FRC or RCC can ensure
a continuity of medical care.
Additionally, the net result of the number of support staff is that
there is a broad diffusion of responsibility among case workers, and
the recovering servicemember loses confidence in the government's
ability to maintain accountability of his care. Each case worker has a
specific role in that servicemember's recovery, and the burden of
responsibility falls on the servicemember to keep track of which case
manager provides each service. The assignment of a FRC or RCC provides
the recovering servicemember with a single point of contact for
decisions regarding his or her care. The effectiveness of these two
programs, however, should not be measured exclusively by the mere
presence of a policy statement outlining the program, but rather by
continuous assessments by stakeholders in the process and by recovering
servicemembers themselves.
reintegration
Disability Evaluation System Pilot Program
In an effort to simplify and streamline the process by which
servicemembers are medically evaluated, retired, and enrolled into the
VA, the National Defense Authorization Act for Fiscal Year 2008
authorized the Secretary of Defense to develop a Disability Evaluation
System pilot program. For those who are evaluated through the pilot,
the advantages are that there is only one medical evaluation instead of
two and that the veteran is immediately enrolled in the VA upon
retirement. Those who are not a part of the pilot program must be
medically evaluated by their Service--with each Service having
different medical standards--then retire. Upon retirement, the veteran
must then be medically evaluated by the VA and oftentimes wait many
months before receiving disability compensation.
Despite the efficiencies gained by a single medical evaluation
using a common standard, the process is often delayed because the
disability claim jumps back and forth between the DOD and VA. Health
records may be shared electronically, but disability claims are still
printed out and physically sent through each office responsible for the
paperwork.
Additionally, there has been no change in streamlining the case
managers responsible for each claim. Each servicemember must keep track
of up to five different case managers who each have some part in the
claim process. DOD and VA have both retained a case manager for each
segment of the pre-pilot process; the pilot should make an effort to
reduce the number of case managers to a single case manager responsible
for the entire claim process.
employment
Many have recognized the need for purposeful activity for those
assigned to the various wounded programs to promote recovery and
prevent disciplinary problems. Fortunately, many local companies and
organizations would like to hire wounded/ill/injured servicemembers for
internships while they are healing. These internships can provide a
sense of purpose and provide work experience that can be helpful if and
when the servicemember leaves the military. The DOD operates a program
called Operation Warfighter which places injured servicemembers within
the National Capitol Region into internships at locally based Federal
agencies. This is a successful program but is very limited.
Allowing this program to expand across the country as well as
allowing individuals to intern or have temporary assignment at a local,
State, or Federal agency or even a private company would provide a
significant benefit to those assigned to one of the military Services'
wounded warrior units. From my personal experience, I didn't start
feeling like my ``old self'' until I started an internship at the
Pentagon working 20-25 hours a week in the time between physical
therapy appointments.
summary
As the next panels of witnesses come up to testify, you know that
they are well intentioned and have our best interests at heart. I
respectfully request that you keep in mind two questions as you listen
to their testimony:
1. How is effectiveness measured in each of the different
programs?
2. How do you ensure that programs within each of the
military departments and among different Federal agencies are
compatible with each other?
The senior leadership in the DOD and the Veterans Administration
have done a remarkable job in breaking down institutional barriers in
the last 2 years to provide the best access to services and address
difficulties with case management. Unfortunately, this level of
cooperation has not yet been institutionalized at the end-user level--
that of the recovering servicemember--and many issues remain at that
level with respect to access to services and case management. Effective
oversight of interagency coordination is essential as we move forward
so that the men and women who have sacrificed so much are best equipped
to recover, rehabilitate, and reintegrate as productive members of our
society.
Thank you, Senator Nelson and Senator Graham for the invitation to
appear before you today. I appreciate the opportunity to be a part of
our American process . . . to come before you and present my
perspective to an elected body that has the opportunity to make a
difference for so many. I look forward to answering any questions you
may have.
Senator Ben Nelson. We thank you very much, Lieutenant
Kinard.
We've had join us, since we began, Senator Hagan from North
Carolina, Senator Begich from Alaska, Senator Chambliss from
Georgia, Senator Thune from South Dakota, and Senator Wicker
from Mississippi. Why don't we ask if there are any comments
that you'd like to make before we turn to questions. [No
response.]
I guess we're ready to turn to some questions. We will do
6-minute rounds.
Some of these questions will, in one way or another, be
comparable to some of the testimony you've already made. But,
perhaps it'll be a little bit different. For example, this one.
Where you had care managers, and they were working with you, do
you think they were effective in getting you better care?
We'll start with you first, Lieutenant.
Lieutenant Kinard. The question, sir, is were the case
managers effective in delivering? Yes and no. I feel that the
sheer volume alone of case managers, the number of case
managers there are available, creates a diffusion of
responsibility within the overall system. Having the RCC
program and the FRCP, which are relatively new--what they do
is, they bring all those together to one person that I can call
and say, ``Let's figure this out together.'' I think that is
certainly a great improvement that DOD and VA have made. I
can't say, in every single case, that the case managers dropped
the ball, but it certainly will make it easier having these
programs in place with effective oversight and coordination
between the two departments to allow us to achieve the maximum
medical benefit.
Senator Ben Nelson. What we did see, though, is, in
bringing a case manager in, at least it appears that we got
over the hurdle that we had, where people were unaccounted for.
Wounded warriors were unaccounted for. At least was it
effective in having you accounted for? Did we make any progress
there?
Lieutenant Kinard. I think the individual Services have
made tremendous efforts in accountability. At the end of the
day, just looking at this issue through the lens of your
average patient, the 18- to 24-year-old male, he's going to
trust that guy in uniform. He's going to go to the sergeant,
he's going to go to his noncommissioned officer. I think we've
done a tremendous job, and the Services ought to be commended
for how they've really stepped up to the plate with case
management and with accountability.
Senator Ben Nelson. Thank you. Dr. Noss?
Dr. Noss. I was very fortunate to have the SOCOM Care
Coalition manage--and continue to manage--Scot's care and his
Active Duty status, and know that he will be a part of the
SOCOM Care Coalition for life. If we're trying to have a system
to be modeled by, I really do think it's the Care Coalition.
They have done a fabulous job ever since General Brown started
the organization.
I have not had any bad experiences when it comes to case
management, because of the Care Coalition.
Senator Ben Nelson. Mrs. Rivas?
Mrs. Rivas. We haven't had any bad experiences, either. The
case manager, in fact, saved us. When he first arrived at
Brooke Army Medical Center (BAMC), he just sat there in a room,
and, at that point, he didn't have a case manager. When they
assigned him a case manager, that's when things started moving
along. With the TBI, he couldn't remember anything. She
coordinated everything and made sure that he got to where he
needed to be and that all of his care was taken care of. We had
a wonderful experience.
Later on, SOCOM came in, the Care Coalition. At first, they
didn't realize he was there; he was kind of in limbo. When they
found him, that's when the ball started rolling. They have
stayed with us afterwards and made sure that we are up on any
new care issues that arise. They've both been wonderful.
I need to add this, too. The case manager, she was the one
that was able to get his outpatient farmed out to the
Rehabilitation Institute of San Antonio. It's an institute that
helps with mild to severe brain injuries. If it wasn't for
that, he wouldn't be where he is today. The outpatient care has
been wonderful.
Senator Ben Nelson. Such a simple concept, but an essential
part of the tracking and keeping care appropriate and constant
so that something doesn't lose its momentum.
Mrs. Rivas. It's made all the difference in the world to
us, to where he is today and to where he was. He couldn't do
simple things like get dressed and feed himself, and he
stuttered terribly, he couldn't carry on a conversation. They
worked with him on every aspect, and he is so much better
today. I have to say, we have a wonderful VA vocational
counselor that we've been put in touch with, and she got him
involved in the Easter Seals program. It's just having that
contact.
Senator Ben Nelson. Thank you.
Colonel Gadson?
Colonel Gadson. Yes, sir. I would echo what Lieutent Andrew
Kinard said. The multiple case managers can be a bit confusing,
and I personally have raised a question as to why--in fact, in
Andrew's case and my case, because we're amputees, we have a
specific amputee case manager, and then we have another case
manager, and he may even have some additional ones.
I guess the frustration is, where is the accountability?
Even to this point, I would say that I don't understand what
the clear delineation between responsibility is, and so,
there's a potential gap, not that I've had any personal issues
with it. You have to be on your game and understand what's
going on, and make sure that doesn't happen. I feel like I've
been able to, for the most part, advocate for myself. I think
there's room to streamline that, and I think they recognize
that, but we haven't gotten there yet.
Senator Ben Nelson. Senator Graham.
Senator Graham. Thank you, Mr. Chairman. I thank the panel
for sharing your experiences with us.
Make sure I get this right. You get wounded, you get back
home, your Active Duty pay continues until you're medically
discharged. Is that right?
Colonel Gadson. Correct.
Senator Graham. Now, in terms of support for the spouse
who's life has changed as much as yours has, there is a
compensation stream, is that right, Colonel Gadson?
Colonel Gadson. Sir, first I'd like to say that they have
the Traumatic Servicemembers' Group Life Insurance, which is
the traumatic insurance that you get.
Senator Graham. How much is that?
Colonel Gadson. It really depends on your injury. There's
no set amount.
Senator Graham. Okay. But, you get a payment.
Colonel Gadson. You get a payment. That can, in some cases,
be used to offset that, but I can tell you certain
circumstances where people have had to move and they haven't
been able to sell their house, and it starts eating into money
that wasn't necessarily designed for that.
Senator Graham. But, my question is, a family member is
going to, maybe, have to quit their job----
Colonel Gadson. Yes, sir.
Senator Graham.--or certainly, their life is affected
dramatically. What income stream is available to them? Dr.
Noss?
Dr. Noss. Right now, through VA benefits, they have a small
portion--it's called aid and attendance--which is to pay for
caregiving hours or to be utilized by the family member who's
doing the caregiving.
Senator Graham. How much money did that mean for you?
Dr. Noss. $580 a month.
Senator Graham. Okay. Andrew, you're not married, I know.
Your dad's a doctor, and your mom--are fairly well off, but
there are a lot of guys your age that don't have that--what do
single guys get?
Lieutenant Kinard. Single guys, with the family members
coming to take care of them? I am not familiar with the
compensation, sir.
Colonel Gadson. Senator Graham, I believe, right in the
Washington, DC, area, the per diem for a caregiver--or
nonmedical attendant would have been about $30 a day.
Senator Graham. Okay. Your concern is, it shouldn't be
based on where you're located, it should be a flat rate, where
they bump up based on location, right?
Colonel Gadson. Plus per diem, yes, sir.
Senator Graham. Mrs. Rivas, did you get any income support?
Mrs. Rivas. I'm not aware of any of this. We lived off his
retirement pay and savings so this is new information to me.
Senator Graham. All right. That's why we have these
hearings.
The point that I'm trying to make is that the country needs
to come to grips with the fact that the moment the person is
catastrophically, devastatively injured, the family changes,
and I think most Americans would like an income stream
available to family members who provide that support that
otherwise would be given by the Government. But, the one thing
highly unlikely, the Government caretaker's not going to live
with you 24-hours-a-day, maybe, like a family, so that's
something, Mr. Chairman, I think we can look at, is finding a
revenue stream.
Now, Dr. Noss, how old are you?
Dr. Noss. I'm 28 years old.
Senator Graham. What's your educational background?
Dr. Noss. I have a doctorate in chemical engineering. I
actually just graduated, this past semester.
Senator Graham. How old is your husband?
Dr. Noss. He's 31. He's an E-7.
Senator Graham. As Andrew said, most of these wounded are
young people right?
Dr. Noss. Yes.
Senator Graham. What have you found, in terms of their
spouses' capability or family members' capability to survive
these injuries, financially?
Dr. Noss. Actually, the 2 years that I have been inpatient
with my husband, because Scot is still inpatient at the VA in
Tampa, a majority of the families are very young. Most of the
wives who come with their injured husbands don't have jobs.
They were stay-at-home mothers, they are 17-, 18-, 19-year-old
high school-educated, young women.
Senator Graham. Andrew, what would you have done if you
didn't have the family you have?
Lieutenant Kinard. Sir, I would have been by myself. My dad
left his practice for 2 months, came up to Washington, DC,
moved up here. My mom lived with me for over 7 months until I
was discharged from the hospital and able to take care of
myself.
Senator Graham. Colonel Gadson?
Colonel Gadson. Senator, the tough task, as you're saying
and alluding to, is that these are young families. I was a
senior officer, and I had the revenue to be able to withstand
my wife not being at work as a professional schoolteacher. But,
even that, that took about a third of our income away from us.
Senator Graham. I think this is something the committee can
work on.
You're still on Active Duty is that right, Colonel?
Colonel Gadson. Yes, sir.
Senator Graham. They're going to let you stay on Active
Duty, it looks like?
Colonel Gadson. They are.
Senator Graham. I want to congratulate the Service for
doing that.
Andrew, I know you're going to Harvard Law School. To those
that helped Andrew, look what you've done. He's going to
Harvard and has a great life ahead of him.
It took you 9 months to get from one medical evaluation to
the other? Tell me about that again. What's the 9 months?
Lieutenant Kinard. Sir, I actually did most of that when I
was a congressional fellow in your office.
Senator Graham. Yes, I know. [Laughter.]
You've gone Hollywood on me, now, I see you on TV all the
time. [Laughter.]
Lieutenant Kinard. No comment. [Laughter.]
Sir, that was one of the big issues that was highlighted.
The inadequacies with the flexibility and the speed.
Senator Graham. You were medically discharged from the
Marine Corps about a month ago, is that right?
Lieutenant Kinard. That's right.
Senator Graham. Now, you're 100 percent disabled by VA?
Lieutenant Kinard. Yes, sir.
Senator Graham. What took 9 months to figure out that your
legs weren't going to grow back? Tell me what you mean by that.
Lieutenant Kinard. There were actually two different boards
that I went through. There's the Medical Evaluation Board
(MEB), which is the DOD evaluation of your fitness to continue
service in the military in the job in which you were assigned,
or they can find you another job. Then, once they determine
that you are no longer fit to continue serving, they refer you
over to VA to a Physical Evaluation Board (PEB) that rates the
amount of compensation you are owed for your injuries. It's
going from that one board, where they have to prepare all the
materials, hand it to the next board; if there's anything
wrong, it gets sent back. Then, that other board sits on it and
they----
Senator Graham. Is that still the case today?
Lieutenant Kinard. It is. I hate to say that every case is
9 months, but I think I fell within about an average period of
time for the DES.
Senator Graham. Thank you.
Colonel Rivas. Senator, if I can make a comment?
Senator Ben Nelson. Yes.
Colonel Rivas. My situation is a little different from the
other individuals here. I was retired at 100 percent from the
military, 100 percent from VA. I was a civilian engineer with
DOD, with the Army. I was medically retired from that, at a
significantly reduced income. I was a licensed law enforcement
police officer in the State of Texas, was retired from that,
with no retirement income. So, we've seen significantly reduced
income from my retirement. The issue I have is with the
concurrent receipt law, the way it's currently written. Even
though I had 35 years of military service, both Active and
Reserve, I lose all my VA to get my military retirement. I
think that's a real injustice, because if I had 20 years, the
way the law is written, I would receive both of those. I didn't
choose to get blown up before I made sure I had 20 years of
Active Duty, so I could get both of those. We have to wait
until I'm age 60.
Senator Graham. You were injured when you were a Guard
member or a Reserve----
Colonel Rivas. Reserve. Since then, I've come down with
some secondary issues with kidney failure and some other
issues. My family's concern is I may not live long enough to
see my concurrent receipt.
Senator Graham. Thank you.
Senator Ben Nelson. We've been working on that program,
making some improvements, but we still have a long way to go to
get that fair and equitable. Thank you.
Senator Hagan.
Senator Hagan. Thank you, Mr. Chairman.
First, I want to thank each and every one of you for all of
your service, and the wives, you, too, are to be complimented
for all of your extended care that you've been giving.
Dr. Noss, I have question for you. Your husband is
currently--I think you said, is in Tampa; he's still in care.
Dr. Noss. Yes. He is still an inpatient at the Tampa VA,
the Polytrauma Unit.
Senator Hagan. Will he leave? Will he be sent someplace
else? What's his long-term prognosis, as far as where he might
go?
Dr. Noss. He's going home with me.
Senator Hagan. He'll be able to come home?
Dr. Noss. We're going to make it where he can come home. I
don't believe in putting him in a nursing facility for long
term.
Senator Hagan. Then, from the standpoint of any sort of
financial help to you at that point in time, what has VA
established for that?
Dr. Noss. They do have a benefit package that Scot will
receive every month, and it is a substantial amount of money.
However, the net income will be small because you have to take
into consideration our bills that we will incur each month. For
example, I know of a family who has a quadriplegic and he's on
a ventilator. Because of needing a 24-hour power source, their
power bill is over $1,000 a month. This is due to the
ventilator, and his bed--he has to have a special type of bed
that's hooked up to power. Because of the special care that
Scot is going to receive because of his injuries, we're going
to have to pay for large bills. Despite the substantial amount
of benefit money that will come in per month, the net is going
to be small.
Senator Hagan. You mentioned one other comment. I believe
it was the cognitive rehabilitative therapy, that if--as long
as he was considered active military, he would receive that,
but then, once he became veteran status, it was not funded.
Dr. Noss. Yes, ma'am, that's correct.
Senator Hagan. Is he currently getting that?
Dr. Noss. Yes, he is receiving cognitive therapy at the VA,
at the Polytrauma Unit, which I have to say is absolutely
fabulous. I just love them down there. However, my concern is
if we need to take him to a private-sector rehabilitation
center. TRICARE, as it is stated right now, will not pull from
the supplemental fund that they have set aside for Active Duty
soldiers to pay for cognitive rehab for veteran status.
Senator Hagan. I see.
Dr. Noss. So, right now they are not covered for cognitive
rehab.
Senator Hagan. It feels like we ought to be doing something
about that, too.
Dr. Noss. Right. I really hope you can.
Senator Hagan. Lieutenant Colonel Rivas, I hear, all the
time, your concern on the concurrent receipt issues. That's
something I'm glad to hear Senator Nelson say we've been
working on for a long time, but it seems like we certainly need
to be moving forward, because it doesn't make a lot of sense to
me at all.
Thank you, Mr. Chairman.
Senator Ben Nelson. Thank you, Senator.
Senator Thune.
Senator Thune. Thank you, Mr. Chairman.
Let me also add my deep appreciation to all of you for your
great service to our country and the sacrifices that you and
your families have made. We are, as a Nation, enormously
grateful. Please know how much we appreciate that.
In his prepared testimony, Major General Meurlin outlined
several improvements that DOD and VA have made to DES through
the pilot program. He also says that more should be done and we
need to ``shift away from a focus on pay entitlements to one of
recovery, rehabilitation, transition, and making the
servicemember a viable member of society.''
I guess what I would ask any member of the panel to answer
is, in your opinion, what steps can DOD or VA and this
committee take to improve the system and focus more on
recovery, rehab, and transition?
Colonel?
Colonel Gadson. Yes, sir. I have a few suggestions.
The first is--and I know we're working toward that--is
getting VA and DOD together at the highest levels. The Army--I
was fortunate enough to have the Army to send me to graduate
school, and I'm finishing up my graduate degree at Georgetown
now, while I am recovering. But to illustrate this, in terms of
VA benefits, there are some VA benefits that I don't have
access to unless I retire. By staying on Active Duty, I'm only
authorized a one-time $11,000 vehicle grant, because I lost my
legs, and that's to get a new vehicle and modify that vehicle.
Then there is a $60,000 housing grant--again, for the
modification of an existing home or to apply toward a home.
Other than those two benefits, I cannot access my education
benefits for vocational rehabilitation. For instance, my
daughter is a junior in high school, and I will not be able to
use any of my veteran's benefits toward her college, which I
would be able to do if I were to retire.
I think we need to take a comprehensive look at those
benefits, and merge that. Those benefits were built under the
assumption that, when a servicemember was severely injured, he
was going to be out. As we look at our force, as an All-
Volunteer Force, many people still opt to continue to serve, or
would like to continue to serve, and they should be allowed to
have access to a benefit. This is not a benefit to double any
kind of compensation or get something that you're not
authorized, but just giving you access to it when you need to.
I think that's a discussion or a dialogue that needs to take
place as we look at these two things holistically.
Senator Thune. Good.
Dr. Noss?
Dr. Noss. About the rehabilitation for minimally conscious
patients, I really do think that integration into a civilian-
sector rehab would benefit these men and women greatly. There
are four polytrauma centers in the country right now, a fifth
one being built in San Antonio. There's one located in Tampa,
where I'm located now, which I'm so grateful that the Fisher
House was built on its campus. I have been staying at the
Fisher House for a year and a half now. There's one in
Richmond, Minnesota, and Palo Alto.
Now you're having an issue of families relocating from
their strong support systems and from their family in order to
be close to the polytrauma center. That shouldn't be an issue.
The family should be able to relocate to their desired location
and have some sort of rehabilitation in the private sector.
My husband is still Active Duty, and I'm fighting to keep
him Active Duty. It's not about the money. I've been hearing
for 2 years now, ``Now, Mrs. Noss, if you retire him, you'll be
getting more money every month.'' I don't care about the money.
What I'm caring about is the fact that when he retires, he will
lose some of his coverage for his therapies. I am really
fighting to keep him in. I'm so appreciative of DOD for
actually understanding my reasons for wanting to keep him
Active Duty, and they've been very helpful.
For the cases, as my husband, the minimally conscious
patients that are still Active Duty and have retired since,
really need to work on how we can better improve the health
care after veteran status is achieved.
Senator Thune. Anybody else?
Lieutenant Kinard. Senator Thune, very briefly, if we're
shifting away from a focus on pay and entitlements, where are
we shifting to? I think the word is reintegration. Becoming
productive members of our society is essential. Picking back
up, getting back up on our feet, moving forward. We got
injured, but, hey, we still have value and we can be
productive. I think we need to take a look at some of the
employment opportunities available while servicemembers are
recovering in the WTUs.
There's a program here in the National Capital region
called Operational Warfighter. I think it's a fantastic
program. It allows guys at WRAMC and Bethesda to go intern in
any of the Federal agencies in the Washington, DC, area. The
downside is, it's only in the Washington, DC, area, that I know
of. If you're at Fort Bragg, if you're at BAMC, if you're at
any of the other medical military treatment facilities, I don't
know what programs are available to get guys into some sort of
internship, especially for the ones that know that they're
going to be transitioning out of the Service.
In a way, as the old saying goes, ``Idle hands make for the
devil's work.'' Having gainful employment, in whatever
capacity, even looking at perhaps doing something within the
private sector for those that are in more remote locations and
don't have Federal or State agencies right there, I think that
could be a great step forward towards reintegration.
Dr. Noss. May I add one more thing, as well? With the
integration to society for the mild to moderate brain-injured
who fall beneath the realm of the benefits to compensate a
healthy lifestyle, the employment rate is drastically lower
because of their combat injury. For example, I have befriended
a family whose son was in an improvised explosive device blast
in 2003. Because of his injuries, he is not able to have a very
high-stress job. He is able to work produce at a grocery store,
and that's a very healthy transition into society for him. He
feels a part of the society again, he doesn't feel like he's
lost any type of integrity, and he's really proud of that job.
Helping these mild to moderate brain-injured men and women
be able to find something to help them become productive
citizens is very important for them for long-term recovery.
Mrs. Rivas. I'd like to add something to that, too. Our VA
counselor got us involved with the Easter Seals program, and
they've been working with Ray on a daily basis on cognitive
skills and job skills and job training. Outsourcing to the
Easter Seals and other programs like that have been a big help.
Senator Thune. Mr. Chairman, I appreciate very much the
perspective offered here, and I hope that we can use the
insights as we shape policies to deal with these very important
issues. Thank you.
Thank you all very much for being here today and for your
testimony.
Senator Ben Nelson. Thank you.
Senator Begich.
Senator Begich. Thank you very much, Mr. Chairman. Thank
you for holding this hearing.
Thank you all for your testimony, I have learned a great
deal listening. It sounds like you have also learned something
about a program that exists, which I think is part of the
process of this hearing.
I just want to make sure I understand how that works and
how the nonmedical attendants receive pay or don't receive pay.
I want to make sure I understand that clearly. Who can walk
through that with me?
Lieutenant Colonel Gadson?
Colonel Gadson. Yes, sir.
Senator Begich. If you can walk me from the point of when
the injury occurs. What next?
Colonel Gadson. Okay. A soldier is injured, and typically
they will remain in a hospital, in an inpatient status, until
their medical condition gets to a point where they can transfer
or transition to an outpatient status. In the case of these----
Senator Begich. I'm sorry to interrupt you--both of these
facilities, so far, are all military-operated facilities.
Colonel Gadson. I can't speak for anything outside of
WRAMC, but typically WRAMC and BAMC and Palo Alto, out in
California, have them--and Bethesda--have the most severely
injured.
Senator Begich. Okay.
Colonel Gadson. The nonmedical attendant is typically tied
to that. We have TBI, and there are some other situations
wherein--when a soldier is in an outpatient status, but they
cannot perform all the things that they need to do. I couldn't
drive, I couldn't get in and out of a vehicle, I couldn't wash
without assistance. My wife became that attendant for me, she
became that person that did those things for me, and she had to
quit her job. We had to relocate our family to this area, and
she was no longer working.
Senator Begich. Can I interrupt you for a second? So,
during that process, she did receive, or did not receive----
Colonel Gadson. When my house was at Fort Riley, KS, which
is where I was stationed when I got hurt, she received
nonmedical attendant----
Senator Begich. Because she was at the location----
Colonel Gadson. She was there with me.
Senator Begich. Understood.
Colonel Gadson. Then, when we moved here to consolidate our
family, it stopped, because she was in the local area. It
really doesn't make any sense. Another way of describing the
situation would be, if I were stationed in this local area, and
I was stationed at Fort Belvoir and gotten hurt, and the exact
same thing happened to me, she would have never received
nonmedical attendant.
Senator Begich. Oh, really?
Colonel Gadson. Right. Because she's in the local area. The
rule or regulation or policy doesn't--it doesn't----
Senator Begich. Doesn't make sense.
Colonel Gadson.--doesn't make sense. Then, my point is it
pays lodging and per diem for the local area, so someone in San
Antonio probably gets paid less than Washington, DC, because of
the difference in the----
Senator Begich. Sure, the housing costs.
Colonel Gadson.--the cost of living. That was why my
recommendation was there should be a flat rate, regardless of
wherever it's taking place. Then, of course, you cover the per
diem and lodging also.
Senator Begich. Anyone else want to add to that?
Dr. Noss?
Dr. Noss. The transition from your acute military facility,
post-injury, to your acute rehabilitation facility--I'm going
to have to use myself as the experience. When Scot was injured,
he was taken to Bethesda, and we were there for 8 weeks, and
then we transitioned to the VA in Tampa. The nonmedical
attendee status remained with me, and still is, in Tampa. I'll
tell you what, we earn that money whenever we are receiving
that nonmedical attendee, because it is very hard. Being a
caregiver to a 100 percent dependent loved one is the hardest
thing I ever had thought or imagined doing. But, I love him
very much, and that's why I do it. But, that nonmedical
attendee pay will be drastically reduced whenever he is veteran
status. It actually goes away. What everyone continues to tell
me is that, ``Well, his benefits will counteract the nonmedical
attendee's pay, and you will receive more.'' I think people
forget that, because of Scot's status, I had to file for
guardianship for him. Now I have to account for every cent that
I pay for his benefit from his benefit money. When I have no
income coming in, because I'm his 100 percent caregiver, I also
have to have accountability for every cent that's spent out of
his benefit money. It's going to be very stressful. I know I'm
not the only family out there that this is happening to, and it
especially is worse when a soldier's parents receive
guardianship of him. They are watched like a hawk with his--
their money. It is very unfair, in some circumstances.
Senator Begich. Thank you.
Colonel Gadson. Senator, I failed to mention--and the
Doctor reminded me--and my wife would say this if she were
here--that is now a person that is no longer productive in
society. My wife was a full-time teacher. She was working,
being productive, and she's no longer working and being
productive, working toward a retirement, and all those other
things. It's really kind of a double whammy, in terms of, your
ability to produce. I'm not advocating that the Government
should cover all of that. But, you have to understand the scope
is not just someone quitting their job and being compensated,
but they're no longer producing money towards the household and
retirement and all those other kinds of things.
Senator Begich. Thank you very much.
My time has expired, but I want to say, again, thank you
very much. I'm actually very familiar with this from the
Medicaid end. I have a nephew that has spina bifida, and he's
now in his late 20s, and I clearly understand the nonmedical
attendant and what that means, and the stress that does to the
family, and the cost, and the economic costs. Again, I thank
you for being here. The information is very helpful, and it's
helped me think of some ways that maybe we, as a committee--
subcommittee, can move forward. Thank you very much.
Senator Ben Nelson. Thank you, Senator.
Senator Chambliss.
Senator Chambliss. Thank you very much, Mr. Chairman.
Let me thank our witnesses for really excellent testimony.
Thank you for your frankness, too.
I want to particularly say to you spouses how much we
appreciate you. Commitment to the military is a family
commitment, we understand that. We just thank you for your
service, in addition to the service of your spouses.
Andrew, I know, as a marine lieutenant, you have to feel
like you're still in combat every day you work for Graham. I'm
sorry you have to put up with him like you do Senator----
[Laughter.]
I just have one question, and it goes to exactly what you
were talking about, Andrew, with respect to the coordination of
all of these services that you receive. We have a unique
situation down in Augusta that I hope I can stick around and
talk to the next couple of panels on with respect to the
Eisenhower Medical Hospital and the VA and the Medical College
of Georgia, all of which are participating in care for our
wounded warriors. Case management is a key aspect of what
they're doing there. I noted with interest what you talked
about. You have all these business cards, and you didn't know
who to call, although you knew they were all going to help you,
but trying to figure out who you need for the particular
service.
I want you to talk a little bit more about that, as to how
that is working today, versus how it was 2 years ago, a year
ago, or whatever, when you had somewhat of a state of confusion
as to who you should call. If anybody else has any experience
in that same regard, I wish you'd comment on that.
Andrew?
Lieutenant Kinard. Yes, sir. Interestingly enough, the one
single point of contact that I have is based out of Eisenhower
in Augusta. Because I'm from South Carolina, she's the closest
point of contact to me.
She is what's known as a Federal Recovery Coordinator
(FRC), and this program was created in response to some
legislation that was passed in title 16 of the National Defense
Authorization Act for Fiscal Year 2008, 2 years ago. I'd say
that my experience with her has been very positive. I was
referred into this program, just in January of this year, after
struggling through--and, Senator Nelson, part of what I was
talking with Senator Graham about, the 9 months that it took
them to evaluate me--I had reached some walls there. I called
her on the phone. I was referred to the program. Literally the
next day, she had options e-mailed to me, that said, ``If you
want to do it this way, we can do this; if you want to do it
this way, we do that.'' I said, ``I'll take option B.'' She
took care of it, it was done. I said, ``Wow, this, for the
first time, feels great,'' knowing that there's somebody I can
call that I can hold their feet to the fire, saying, ``Why
isn't this done?'' or ``Let's get some answers here.''
A couple concerns of mine are how the FRC program is
coordinated with the RCC program. I don't have any suggestions
for that. I just merely want to highlight that perhaps that
merits some taking a looking at.
Also, the FRC program, which was designed to take care of
the very seriously injured servicemembers, do they have the
right authorities that they need? Do they have enough authority
to take care of the problems? Senator Nelson, I appreciate what
you said in your opening statement, sir, and, as Senator Graham
echoed, as well--that nobody is arguing here about what
servicemembers deserve: the best of the best that our Nation
can provide. I applaud you for that recognition. The question
is, how do we provide that best of the best? I think the FRC
program is a great start.
Dr. Guice, from whom you will hear on the second or third
panel, is the program director of this FRC program. She'll be
testifying here today. I recommend you ask her some questions
about how she feels about the authorities that have been
provided to her, if they can meet the needs of the
servicemembers.
Senator Chambliss. Yes.
Dr. Noss. I'd like to also make another comment. I know
throughout this whole hearing you've heard Care Coalition, Care
Coalition the whole entire time, coming from me and the
Rivases, as well. The Care Coalition is the advocacy group from
SOCOM. As Andrew was talking about the many business cards that
he received, he did not know who to call first. From day one,
the SOCOM Care Coalition was my one point of contact. They have
been able to organize my life when I was not able to organize
my life. They were able to itemize the pros and cons of staying
Active Duty versus retirement. They have been there the whole
entire way and have made my life easier. I can honestly say
that I have never been told ``no'' by the SOCOM Care Coalition.
I've been told ``maybe'' a couple of times on some little
sticky issues, but I really do feel like they have been able to
take me from the most traumatic day of my life and carry me
through to where I was able to graduate with my dissertation
and my Ph.D. I do credit them for doing that for me.
That one point of contact has always been there for me from
day one, and that was from the SOCOM Care Coalition.
Senator Chambliss. Okay.
Mrs. Rivas. It's the same for us with the SOCOM Care
Coalition. Then we have VA, too. But, it's the SOCOM Care
Coalition that has helped us the most.
Lieutenant Kinard. Senator Chambliss, if I might jump in
here and bring one point.
Senator Chambliss. Sure.
Lieutenant Kinard. The SOCOM Care Coalition is a separate
entity in the same scheme as each of the Services have their
own service-oriented and service-specific WTU. Army has the
Army Wounded Warrior Program. Marine Corps has the Wounded
Warrior Regiment. SOCOM has their own. When they show up to
WRAMC, the Special Forces guys, they just disappear, and
they're taken care of. From these two witnesses here, they've
received the highest marks, I think, out of the any service-
specific transition units.
However, what a concern of mine is, is the net effect when
we have DOD-mandated programs and then we have each of the
Service-specific programs. If you're in the Navy, you have a
different one than the Army or your Marine Corps associates.
Where are these being coordinated? Who's taking care of making
sure that we're eliminating redundancies so that the net effect
is felt by the families who get lost.
Dr. Noss. I also would like to make a comment. Even though
Scot is being taken care of by the SOCOM Care Coalition, his
Wounded Warrior project manager from the Army is involved in
his care as an Active Duty and as a veteran status. They
actually work hand in hand at the SOCOM Care Coalition office.
So, I do credit the Army as well for taking really good care of
my husband.
Senator Chambliss. Thank you.
Colonel Gadson. Senator, just one last comment. It has
improved greatly over the last 2 years. I think DOD is working
toward making it more efficient. There is definitely room for
improvement. I think all of us would echo this sentiment, that
there are a whole lot of folks that are out there trying to do
the right thing and trying to do some good. Sometimes they're
just stepping on each other. When you put that in light of
dealing with these traumatic and difficult times, a lot of
times it gets drowned out, and it's too much for folks to
manage. I would say that probably SOCOM Care Coalition again,
does it the best; and that's generically, regardless of the
Service. They're smaller, in a much tighter community, and so I
think that's why they're more efficient.
Senator Chambliss. Thank you very much, all of you, for
your excellent testimony today. Thanks, Mr. Chairman.
Senator Ben Nelson. Thank you, Senator.
I, too, want to add my thanks for your willingness to come
and tell us, as you've seen it and experienced it, and are
continuing to experience it. We want you to know that we're
very interested, not only in what you have to say, but in
finding solutions to the areas that need further work. You can
be sure that we're going to do everything we can to try to plug
those holes and make it work the way Americans want it to work
for our men and women and their families who serve our country
in so many important ways.
Thank you, and may God bless you all. Thank you.
Let's give them a round of applause, shall we? [Applause.]
[The prepared statements of Colonel and Mrs. Rivas follow:]
Prepared Statement by LTC Raymond T. Rivas, USA (Ret.)
I was medically retired from the U.S. Army in September 2008 after
being injured in Iraq in October 2006. When I retired, I had completed
14 years of Active Duty and 20 years of Reserve Duty and served on
multiple Operation Enduring Freedom and Operation Iraqi Freedom
deployments since September 11.
When I was originally injured in October 2006 in Iraq, I was
Medivac'd out of theater and sent to the Landstuhl Regional Medical
Center in Germany for evaluation. My memory is extremely vague about
this. I was told that I spent 7 days there and convinced the
neurological staff that I was fit to return to duty. I returned to
Iraq, of which I do not remember any of this, and spent approximately
10 days there. I was allowed to go out on missions to forward operating
bases, and on mission convoys. It was then reported to my chain of
command that my behavior was extremely ``bizarre'' and I was referred
to the Air Force Expeditionary Hospital neurologist. After being
examined by him, the orthopedic staff, eye specialist and hearing
specialist it was determined that I had a traumatic brain injury, eye
injury, moderate to severe hearing loss, and a fractured right patella
(knee). I was put on priority Medivac to Landstuhl Regional Medical
Center enroute to Brooke Army Medical Center (BAMC). I do not remember
any of this, and have referred to my records for this information.
Based on my records, the Chief of Neurology at the Balad Field
Expeditionary Hospital informed my Command that I did a ``very good
sales job'' of talking myself back to Iraq to rejoin my unit and should
have been sent stateside immediately.
In route from Iraq to Germany I had several ``unresponsive''
episodes during flight. What I do remember about my first few months at
BAMC was that the system was ``overwhelmed'' with the influx of new
patients. I was pretty much on my own for 2-3 months. I had a couple of
``battle-buddies'' who helped me with dressing, bathing, and eating, as
I was not able to do any of these unassisted.
I believe it was approximately 3 months after being there that I
began to work with my case manager, Ella Stiles. She immediately began
to make things happen in a positve way for my health care. About this
same time, I was contacted by the U.S. Army Special Operations BAMC
Liason, Sergeant First Class Craig Coker, who informed me that he had
just found out I was one of his Special Operations Officers that the
``ball'' really began to ``roll''.
Once he got involved, I began to get the care I needed for my
aforementioned injuries. As mentioned I was medically retired from the
Army at 100 percent in September 2008 and am now enrolled full time at
the Easter Seals Hospital Brain Injury program in San Antonio, TX,
where I continue to participate in their Cognitive Rehabilitation
Therapy program.
There are some things that I think must be changed: The Traumatic
Servicemember Group Life Insurance Program (TSGLI) expanded this past
year to include traumatic brain injury (TBI). While implementing these
new changes, the Government Accountability Office contacted my wife and
asked to use my medical records in developing the criteria for
moderate/severe TBI.
When the changes were implemented, the CARE Coalition which is part
of the Special Operations Command submitted my TSGLI Insurance Claim
packet. I met the requirements for the maximum insurance reimbursement
amount of $100,000; however, I was only awarded partial payment with no
explanation of why. I am currenly awaiting word on my appeal that has
been submitted by the CARE Coalition. This program is not user
friendly, if the injured servicemember meets the requirements for a
particular payment amount, he should get it. I feel this is looked at
as a game of ``lets''-only give minimal amounts and make the
servicemember file an appeal, and then we will give a little more, and
if a final appeal is filed we will give some more.
Second, I have great ``heart-burn'' over the concurrent receipt law
as now written. As the law now stands, only a servicemember with 20
active duty years is allowed to get both his/her military and VA
pension simultaneously.
A Chapter 61 (Medical) Retiree with less than 20 active duty years
is not eligible for concurrent receipt; a Chapter 61 National Guard or
reservist with a ``20 year'' letter is eligible, once they turn age 60.
This is a clear case of bias and injustice. The servicemember, and
Guardsman or reservist who is injured in combat in a theater of
operations who was wounded by no fault of his own should not be
penalized for ``getting blown-up'' or ``shot'' prior to serving 20
active duty years. I had served my country for over 34 years and did
not choose to be seriously injured in Iraq in 2006.
This injury has not only ended my military career, but also my
civilian career as an engineer with the Department of Defense for whom
I worked for 18 years and as a licensed peace officer in the State of
Texas where I served as a Reserve Sheriff's Deputy for 8 years with the
Comal County Sheriff's Department. I hope this committee is
instrumental in doing the right thing in helping make the appropriate
changes to the concurrent receipt law to include those such as myself
who received combat injuries and forced to retire prior to serving 20
years of active duty.
I would also like to give accolades to the Disabled Sports USA
program who has been sponsoring me to participate in Adaptive Sports
these past few months throughout the United States the past few months,
and the Department of Veterans Affairs, Frank Tejeda Outpatient Clinic,
Vocational Rehabilitation Counselor who got me enrolled in the Easter
Seals Program.
______
Prepared Statement by Mrs. Colleen O. Rivas
I am Colleen Rivas, the wife of LTC Raymond T. Rivas (Retired). I
would like to share my views and experiences of the past few years as
well as discuss the challenges that lie ahead for my family as we deal
with the traumatic brain injury (TBI) that my husband received 2\1/2\
years ago in Iraq.
One of the issues that I feel very strongly about is the comparison
being made between TBI and post-traumatic stress disorder (PTSD). In my
opinion there are profound differences between these two injuries. TBI
is a physical trauma that can range from mild to severe. PTSD is an
emotional trauma which can have debilitating effects. I have dealt
firsthand with both of these traumas where Raymond is concerned; PTSD
more so after Afghanistan which was in the form of nightmares and some
depression. What we could not deal with on our own he was able to
obtain help with through the VA in the form of counseling. The TBI has
been an entirely different matter. When Raymond first returned to the
U.S. he was sent to Brooke Army Medical Center. He suffered from severe
headaches that painkillers and brain blocks had no affect on. In
addition to the headaches, he had trouble with his balance, his depth
perception, his speech, his eye to hand coordination, his memory, which
included both his long-term and short-term and any task that involved
sequencing. He was unable to go anywhere by himself because he was
constantly getting lost. It took a year for him to regain his balance
and depth perception. Now, 2\1/2\ years later, he still suffers from
daily headaches, however their severity has lessened. He has regained
most of his long-term memory; however he still has trouble with his
short-term memory which includes misplacing items on a daily basis and
constant repetition of subjects previously discussed. In addition, he
cannot follow a detailed set of instructions nor can he multi-task. His
condition is frustrating for both him and our family.
Another issue that I feel very strongly about is the transition of
the soldier from the battlefield back to civilian life. One thing that
I have noticed over the years with Raymond's numerous deployments is
the difficulty of transitioning back to everyday life and the stresses
that go along with family and work. In my opinion, some sort of
decompression time needs to be built in to ``time served'' so that
soldiers can get readjusted to civilian life. I feel like reservists
especially have it hard because their deployments are longer and when
they are released from active duty, they go right back into their
civilian jobs. Some injuries such as mild TBI as well as PTSD may not
be apparent until months later. In addition to an assessment as soon as
the soldier returns home, some type of reassessment should be done
several months later. It is after the soldier returns home and the
honeymoon period is over that a lot of the problems begin. Furthermore,
if any type of combat action was seen then counseling should be
mandatory for the soldier and the family. Soldiers need to understand
that their families will never fully understand what they have been
through because the family member will never have that experience, and
families need to understand that the soldier they sent off to war may
not be the same soldier that they get back. For our family, the worst
adjustment period was after Afghanistan. Raymond saw a lot of action
due to the fact that he was stationed at a Special Forces Fire Base and
when he returned from active duty he went straight back into a
stressful job and a house full of teenagers. The stress of trying to
readjust to civilian life almost destroyed our entire family. I
strongly feel that mandatory counseling for him and our family would
have made the transition much easier.
It has been a long 2\1/2\ years with a lot of ups and downs. Based
on reports from military and VA nuerologists some type of long-term
care will be needed in the next 5 years. Fortunately, we are working
with many good private as well as government organizations that can
help us with what lies ahead.
Senator Ben Nelson. The second panel is comprised of GAO
subject-matter experts: Randall B. Williamson, who is the
Director for Health Care, we welcome you; Valerie C. Melvin,
Director for Human Capital and Management Information Systems
Issues, we welcome you; and Daniel Bertoni, Director of
Education, Workforce, and Income Security, we welcome you.
We look forward to hearing your assessment of the progress
made by the departments, thus far, as well as identification of
areas where work remains to be done. You've had the benefit of
hearing some of our servicemembers and family members express
their concerns, as well as their experiences.
With that in mind, Mr. Williamson, we'll ask you if you
have an opening statement.
STATEMENT OF RANDALL B. WILLIAMSON, DIRECTOR, HEALTH CARE,
GOVERNMENT ACCOUNTABILITY OFFICE; ACCOMPANIED BY DANIEL
BERTONI, DIRECTOR, EDUCATION, WORKFORCE, AND INCOME SECURITY
ISSUES; AND VALERIE C. MELVIN, DIRECTOR, HUMAN CAPITAL AND
MANAGEMENT INFORMATION SYSTEMS ISSUES
Mr. Williamson. Thank you, Mr. Chairman, and members of the
subcommittee. We are pleased to be here today to discuss
actions that VA and DOD are taking to transition our Nation's
recovering servicemembers back to Active Duty or to a veteran
status.
Beyond adjusting to their injuries, recovering
servicemembers may face additional challenges, including
difficulties managing their outpatient recovery process,
navigating the military's DES, and transitioning between care
provided by DOD and VA.
Our testimony today will discuss the progress made by DOD
and VA to jointly develop policies on improvement to the care,
management, and transition of recovering servicemembers, as
mandated by the NDAA for Fiscal Year 2008. We'll also address
challenges both agencies face as they develop and implement
policies on these issues.
With me today are Dan Bertoni, a director overseeing our
work on DOD and VA DESs, and Valerie Melvin, a director who
heads up our work on issues related to information sharing and
DOD and VA health records. NDAA for Fiscal Year 2008 required
DOD and VA to jointly develop and implement comprehensive
policies in four areas: care and management, medical and
disability evaluation, return of servicemembers to Active Duty,
and the transition of the recovering servicemembers from DOD to
VA.
Within these 4 areas, we identified 76 individual
requirements contained in the NDAA for Fiscal Year 2008. DOD
and VA are addressing these areas and requirements through its
Wounded, Ill, and Injured SOC, which was established in May
2007 as a vehicle for jointly addressing issues for recovering
servicemembers. It is staffed with both DOD and VA employees.
Overall, DOD and VA have made good progress in developing
policies spelled out in NDAA for Fiscal Year 2008. They have
completed joint policy development for 60 of the 76
requirements. The remaining 16 requirements are in progress,
and VA and DOD officials expect to complete policy development
for these requirements by midyear.
In developing policies to address NDAA for Fiscal Year 2008
requirements, DOD and VA have faced numerous challenges, and
will continue to do so as they further develop policies and
oversee policy implementation.
For example, improving the DES for recovering
servicemembers poses a major challenge. Numerous studies have
highlighted long delays and confusion that ill or injured
servicemembers face as they navigate the military DES.
To help remedy these problems, VA and DOD initiated a DES
Pilot Program as a test for consolidating the two departments'
DESs. Both agencies have indicated that decisions on the
feasibility of consolidating their disability systems will be
made after the pilot project is completed.
Possible expansion of this pilot is currently being
considered. However, from our perspective, it is unclear what
specific criteria DOD and VA will use to evaluate the pilot and
whether they will have complete information needed for this
evaluation.
Another daunting challenge involved DOD and VA efforts to
share electronic health records, an effort that has been
underway for over a decade. While the departments are making
progress towards increased information sharing, they face
further challenges in managing initiatives required to achieve
this goal.
GAO has recently reported that the two departments' plans
to further increase their electronic sharing capabilities do
not consistently identify results-oriented performance measures
to accurately assess progress toward the delivery of that
capability, nor have the departments completed all necessary
activities to fully set up their Interagency Program Office
(IPO), including hiring a permanent director and deputy
director. Until these challenges are fully addressed, the
departments and their stakeholders may lack the comprehensive
understanding they need to effectively manage their progress
toward achieving increased sharing of information between the
departments.
Finally, recent staff changes and working relationships
within the SOC could also pose a future challenge. Since
January, the SOC has experienced turnover in leadership and
changes in policy development responsibilities. Also, DOD
established two new organizations as a means to establish a
permanent structure to support the SOC.
Some DOD officials consider the changes to be positive
developments that will enhance the SOC's effectiveness. In
contrast, others are concerned with issues related to
communication and interaction among SOC members. Given the
recent organizational changes that have occurred in support of
the SOC, how this plays out in the future is unknown.
Mr. Chairman, this concludes my remarks. We'll be happy to
answer any questions you have.
[The prepared statement of Mr. Williamson follows:]
Prepared Statement by Randall B. Williamson
Mr. Chairman and members of the subcommittee: We are pleased to be
here today as you examine issues related to meeting the critical needs
of recovering servicemembers by reviewing the progress made by the
Department of Defense (DOD) and the Department of Veterans Affairs (VA)
in jointly developing policies mandated by the National Defense
Authorization Act for Fiscal Year 2008 (NDAA 2008).\1\
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\1\ Pub. L. No. 110-181, 122 Stat. 3.
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Over 1.6 million U.S. troops have deployed in Operation Enduring
Freedom (OEF) and Operation Iraqi Freedom (OIF) since October
2001.2,3 In February 2009, DOD reported that over 33,000
servicemembers have been wounded in action since the onset of these
conflicts.\4\ Because of improved battlefield medicine, those who might
have died in past conflicts are now surviving, many with multiple
serious injuries such as amputations, traumatic brain injury (TBI), and
post-traumatic stress disorder (PTSD). Beyond adjusting to their
injuries, recovering servicemembers may face additional challenges,
including difficulties managing their outpatient recovery process,
difficulties navigating the military's disability evaluation system,
and problems transitioning between care provided by DOD and care
provided by VA.
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\2\ Terri Tanielian and Lisa H. Jaycox, Invisible Wounds of War,
Psychological and Cognitive Injuries, Their Consequences, and Services
to Assist Recovery (Santa Monica, CA: RAND Corporation, 2008).
\3\ OEF, which began in October 2001, supports combat operations in
Afghanistan and other locations, and OIF, which began in March 2003,
supports combat operations in Iraq and other locations.
\4\ Department of Defense, Operation Iraqi Freedom (OIF) U.S.
Casualty Status, Operation Enduring Freedom (OEF) U.S. Casualty Status.
www.defenselink.mil/news/casualty.pdf. (accessed Feb. 19, 2009).
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Questions were raised in the media and by Congress about whether
DOD and VA are prepared to meet the needs of the increasing number of
recovering servicemembers and veterans. In February 2007, a series of
Washington Post articles disclosed deficiencies in the provision of
outpatient services at Walter Reed Army Medical Center, including poor
living conditions at Walter Reed, a confusing disability evaluation
system, and servicemembers remaining in outpatient status for months
and sometimes years without a clear understanding about their plan of
care or the future of their military service. Various review groups
investigated the challenges that DOD and VA faced in providing care to
recovering servicemembers and made a number of recommendations to
address the problems they identified. Shortly after the media
disclosures, we testified about the challenges facing recovering
servicemembers during their recovery process.\5\
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\5\ GAO, DOD, and VA Health Care: Challenges Encountered by Injured
Servicemembers during Their Recovery Process, GAO-07-589T (Washington,
DC: Mar. 5, 2007) and DOD and VA Health Care: Challenges Encountered by
Injured Servicemembers during Their Recovery Process, GAO-07-606T
(Washington, DC: Mar. 8, 2007).
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In May 2007, DOD and VA established the Wounded, Ill, and Injured
Senior Oversight Committee (SOC) to address the problems that had been
identified with the care of recovering servicemembers. The committee is
co-chaired by the Deputy Secretaries of DOD and VA and includes
military Service Secretaries and other high-ranking officials within
both departments. One of the SOC's primary responsibilities is to
oversee the development of policies in response to the recommendations
of the review groups that studied the issues associated with recovering
servicemembers' health care and benefits. Generally, senior officials
from the SOC sign and issue interim policy guidance, which is then
vetted through DOD's and VA's internal processes to be finalized as
department policies.
The NDAA 2008, which was enacted in January 2008, requires DOD and
VA, to the extent feasible, to jointly develop and implement a
comprehensive policy on improvements to the care, management, and
transition of recovering servicemembers. Specifically, section 1611(a)
of the NDAA 2008 directs DOD and VA to cover four key areas: (1) care
and management, (2) medical evaluation and disability evaluation, (3)
the return of servicemembers to active duty, and (4) the transition of
recovering servicemembers from DOD to VA. Because of the related
ongoing work of the SOC, it assumed responsibility for addressing these
requirements. The NDAA 2008 also requires GAO to report on the progress
DOD and VA make in developing and implementing the comprehensive
policy.\6\ Our work is focused on the status of the development of the
comprehensive policy, which includes the development of multiple
policies that are further enumerated in sections 1611 through 1614 of
the law.
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\6\ Pub. L. No. 110-181, Sec. 1615(d), 122 Stat. 3, 447.
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In my testimony today, I will discuss our preliminary findings on:
(1) the progress DOD and VA have made in jointly developing
comprehensive policies for recovering servicemembers in the areas of
care and management, medical and disability evaluation, return to
active duty, and transition from care and services received from DOD to
VA as required by sections 1611 through 1614 of the NDAA 2008; and (2)
the challenges DOD and VA are encountering in the joint development and
initial implementation of these policies.
To assess the extent to which DOD and VA have made progress in
developing the required policies, we asked SOC representatives to
report on the status of policy development for the 76 individual
requirements that we identified in sections 1611 through 1614 of the
NDAA 2008, which we grouped into 14 categories.\7\ (See app. I for a
summary of these requirements and categories.) We also asked the SOC
representatives to provide documentation to substantiate the status of
each requirement, and we verified the reported status of each
requirement by reviewing this documentation. We determined whether each
of the requirements (1) had been completed, (2) was in progress, or (3)
had not been acted upon. We considered a requirement to have been
``completed'' if a document had been signed and approved by DOD, VA, or
both, at the SOC level, that contained standards, guidelines, or
procedures that addressed the requirement, even if DOD, VA, or both
plan to issue additional policies on the subject.\8\ We considered a
requirement to be ``in progress'' if documentation demonstrated that
work had been initiated to develop standards, guidelines, or procedures
that addressed the requirement. We considered a requirement not to have
been acted upon if no action had been taken to develop standards,
guidelines, or procedures that address the requirement. We based our
review in part on the interim policy documents signed by DOD and VA
officials working through the SOC. In some cases, interim policy
documents were signed by officials of both departments, and in other
cases, the documents were signed by officials of one department,
depending upon the requirement. Interim policy documents could be in
the form of memoranda of agreement, memoranda of understanding,
directives, decision- or directive-type memoranda, instructions or
policy memoranda, or other guidelines or forms of guidance. In
addition, we conducted follow-up interviews with DOD and VA officials
when we needed clarification on the reported progress or additional
documentation. We did not, however, evaluate the quality of the policy
documents we reviewed. To identify the challenges DOD and VA
encountered in jointly developing and initially implementing the
required policies, we interviewed officials from both departments to
obtain an account of their experiences in the policy development
process. In conducting our work, we interviewed the acting Under
Secretary of Defense for Personnel and Readiness, the Executive
Director and Chief of Staff of the SOC, the departmental co-leads for
most of the SOC work groups, the acting Director of DOD's Office of
Transition Policy and Care Coordination, and other relevant DOD and VA
officials. We shared the information contained in this statement with
DOD and VA officials, and they agreed with the information we
presented.
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\7\ We defined an individual requirement as a provision within
sections 1611 through 1614 related to the policy required by 1611(a)
that directs DOD, VA, or both to take a specific action or to include a
specific criterion in their policy. The SOC's legal counsel reviewed
these requirements and our groupings, and agreed with our approach.
\8\ Completed policy guidance also included interim policy guidance
signed by the SOC.
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We conducted our work from May 2008 through April 2009 in
accordance with all sections of GAO's Quality Assurance Framework that
are relevant to our objectives. The framework requires that we plan and
perform the engagement to obtain sufficient and appropriate evidence to
meet our stated objectives and to discuss any limitations in our work.
We believe that the information and data obtained, and the analysis
conducted, provide a reasonable basis for any findings and conclusions.
background
Over the past 8 years, DOD has designated over 33,000
servicemembers involved in OEF and OIF as wounded in action. The
severity of injuries can result in a lengthy process for a patient to
either return to duty or to transition to veteran status. The most
seriously injured servicemembers from these conflicts usually receive
care at Walter Reed Army Medical Center or the National Naval Medical
Center.\9\ According to DOD officials, once they are stabilized and
discharged from the hospital, servicemembers may relocate closer to
their homes or military bases and be treated as outpatients by the
closest military or VA facility.
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\9\ These servicemembers may also receive care at Balboa Naval
Hospital in San Diego, CA, or at Brooke Army Medical Center in San
Antonio, TX.
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Recovering servicemembers potentially navigate two different
disability evaluation systems that serve different purposes. DOD's
system serves a personnel management purpose by identifying
servicemembers who are no longer medically fit for duty. If a
servicemember is found unfit because of medical conditions incurred in
the line of duty, the servicemember is assigned a disability rating and
can be discharged from duty. This disability rating, along with years
of service and other factors, determines subsequent disability and
health care benefits from DOD. Under VA's system, disability ratings
help determine the level of disability compensation a veteran receives
and priority status for enrollment for health care benefits. To
determine eligibility for disability compensation, VA evaluates all
claimed medical conditions, whether they were evaluated previously by
the military service's evaluation process or not. If VA finds that a
veteran has one or more service-connected disabilities that together
result in a final rating of at least 10 percent,\10\ VA will pay
monthly compensation and the veteran will be eligible to receive
medical care from VA.
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\10\ VA determines the degree to which veterans are disabled in 10
percent increments on a scale of 0 to 100 percent.
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Efforts to Address the Care and Benefits for Recovering Servicemembers
Efforts have been taken to address the deficiencies reported at
Walter Reed related to the care provided and transitioning of
recovering servicemembers. After the press reports about Walter Reed,
several high level review groups were established to study the care and
benefits provided to recovering servicemembers by DOD and VA. The
studies produced from all of these groups, released from April 2007
through June 2008, contained over 400 recommendations covering a broad
range of topics, including case management, disability evaluation
systems, data sharing between the departments, and the need to better
understand and diagnose TBI and PTSD.\11\
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\11\ The reports are as follows: Independent Review Group,
Rebuilding the Trust: Report on Rehabilitative Care and Administrative
Processes at Walter Reed Army Medical Center and National Naval Medical
Center (April 2007); Task Force on Returning Global War on Terror
Heroes, Report to the President (April 2007); Department of Defense
Task Force on Mental Health, An Achievable Vision: Report of the
Department of Defense Task Force on Mental Health (June 2007);
President's Commission on Care for America's Returning Wounded
Warriors, Serve, Support, Simplify (July 2007); Veterans' Disability
Benefits Commission, Honoring the Call to Duty: Veterans' Disability
Benefits in the 21st Century (October 2007); and Inspectors General,
Department of Defense, Department of Veterans Affairs, DOD/VA Care
Transition Process for Servicemembers Injured in OIF/OEF (June 2008).
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In May 2007, DOD and VA established the SOC as a temporary, 1-year
committee with the responsibility for addressing recommendations from
these reports. To conduct its work, the SOC established eight work
groups called lines of action (LOA). Each LOA is co-chaired by
representatives from DOD and VA and has representation from each
military Service. LOAs are responsible for specific issues, such as
disability evaluation systems and case management. (See table 1 for an
overview of the LOAs.) The committee was originally intended to expire
May 2008 but it was extended to January 2009. Then, the NDAA 2009
extended the SOC through December 2009.\12\
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\12\ Duncan Hunter National Defense Authorization Act for Fiscal
Year 2009, Pub. L. No. 110-417, Sec. 726, 122 Stat. 4356, 4509 (2008).
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In addition to addressing the published recommendations, the SOC
assumed responsibility for addressing the policy development and
reporting requirements contained in the NDAA 2008. Section 1611(a) of
the NDAA 2008 directs DOD and VA, to the extent feasible, to develop
and implement a comprehensive policy covering four areas: (1) care and
management, (2) medical evaluation and disability evaluation, (3) the
return of servicemembers to active duty, and (4) the transition of
recovering servicemembers from DOD to VA. The specific requirements for
each of these four areas are further enumerated in sections 1611
through 1614 of the law and would include the development of multiple
policies. Table 2 summarizes the requirements for the jointly developed
policies.
Selected Initiatives of the SOC
Since its inception, the SOC has completed many initiatives, such
as establishing the Defense Centers of Excellence for Psychological
Health and Traumatic Brain Injury and creating a National Resource
Directory, which is an online resource for recovering servicemembers,
veterans, and their families. In addition, the SOC has undertaken
initiatives specifically related to the requirements contained in
sections 1611 through 1614 of the NDAA 2008. Specifically, the SOC
supported the development of several programs to improve the care and
management of benefits to recovering servicemembers, including the
disability evaluation system pilot and the Federal Recovery
Coordination Program. These programs are currently in pilot or
beginning phases:
Disability evaluation system pilot: DOD and VA are
piloting a joint disability evaluation system to improve the
timeliness and resource use of their separate disability
evaluation systems. Key features of the pilot include a single
physical examination conducted to VA standards by the medical
evaluation board that documents medical conditions that may
limit a servicemember's ability to serve in the military,
disability ratings prepared by VA for use by both DOD and VA in
determining disability benefits, and additional outreach and
nonclinical case management provided by VA staff at the DOD
pilot locations to explain VA results and processes to
servicemembers. DOD and VA anticipate a final report on the
pilot in August 2009.
Federal Recovery Coordination Program: In 2007, DOD
and VA established the Federal Recovery Coordination Program in
response to the report by the President's Commission on Care
for America's Returning Wounded Warriors, commonly referred to
as the Dole-Shalala Commission. The commission's report
highlighted the need for better coordination of care and
additional support for families. The Federal Recovery
Coordination Program serves the most severely injured or ill
servicemembers, or those who are catastrophically injured.
These servicemembers are highly unlikely to be able to return
to duty and will have to adjust to permanent disabling
conditions. The program was created to provide uniform and
seamless care, management, and transition of recovering
servicemembers and their families by assigning recovering
servicemembers to coordinators who manage the development and
implementation of a recovery plan. Each servicemember enrolled
in the Federal Recovery Coordination Program has a Federal
Individual Recovery Plan, which tracks care, management, and
transition through recovery, rehabilitation, and reintegration.
Although the Federal Recovery Coordination Program is operated
as a joint DOD and VA program, VA is responsible for the
administrative duties and program personnel are employees of
the agency.
Beyond these specific initiatives, the SOC took
responsibility for issues related to electronic health records
through the work of LOA 4, the SOC's work group focused on DOD
and VA data sharing. This LOA also addressed issues more
generally focused on joint DOD and VA data needs, including
developing components for the disability evaluation system
pilot and the individual recovery plans for the Federal
Recovery Coordination Program. LOA 4's progress on these issues
was monitored and overseen by the SOC. The NDAA 2008
established an interagency program office (IPO) to serve as a
single point of accountability for both departments in the
development and implementation of interoperable electronic
health records.13,14 Subsequently, management oversight of many
of LOA 4's responsibilities were transferred to the IPO. Also,
the IPO's scope of responsibility was broadened to include
personnel and benefits data sharing between DOD and VA.
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\13\ Pub. L. No. 110-181, Sec. 1635, 122 Stat. 3, 460-63.
\14\ Interoperability is the ability of two or more systems or
components to exchange information and to use the information that has
been exchanged.
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dod and va have completed the majority of the requirements to jointly
develop policies on care and management, medical and disability
evaluation, return to active duty, and the transition from dod to va
As of April 2009, DOD and VA have completed 60 of the 76
requirements we identified for jointly developing policies for
recovering servicemembers on: (1) care and management, (2) medical and
disability evaluation, (3) return to active duty, and (4) servicemember
transition from DOD to VA. The two departments have completed all
requirements for developing policy for two of the policy areas--medical
and disability evaluation and return to active duty. Of the 16
requirements that are in progress, 10 are related to care and
management and 6 are related to servicemembers transitioning from DOD
to VA. (See table 3.)
DOD and VA Have Completed More Than Two-Thirds of the Requirements
Regarding the Care and Management of Recovering Servicemembers
We found that more than two-thirds of the requirements for DOD's
and VA's joint policy development to improve the care and management of
recovering servicemembers have been completed while the remaining
requirements are in progress. (See table 4.) We identified 38
requirements for this policy area and grouped them into 5 categories.
Although 28 of the 38 requirements had been completed, one category--
improving access to medical and other health care services--had most of
its requirements in progress.
Most of the completed requirements were addressed in DOD's January
2009 Directive-Type Memorandum (DTM), which was developed in
consultation with VA.\15\ This DTM, entitled Recovery Coordination
Program: Improvements to the Care, Management, and Transition of
Recovering Servicemembers, establishes interim policy for the
improvements to the care, management, and transition of recovering
servicemembers in response to sections 1611 and 1614 of the NDAA 2008.
In consultation with VA, DOD created the Recovery Coordination Program
in response to the NDAA 2008 requirements. This program, which was
launched in November 2008, extended the same comprehensive coordination
and transition support provided under the Federal Recovery Coordination
Program to servicemembers who were less severely injured or ill, yet
who still were unlikely to return to duty and continue their careers in
the military. This program follows the same structured process as the
Federal Recovery Coordination Program. However, DOD oversees this
program and the coordinators are DOD employees.
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\15\ DOD and VA will also be issuing a joint directive regarding
the policies.
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DOD's January 2009 DTM includes information on the scope and
program elements of the Recovery Coordination Program as well as on the
roles and responsibilities of the recovery care coordinators, Federal
recovery coordinators, and medical care case managers and non-medical
care managers. According to DOD officials, DOD took the lead in
developing policy to address the requirements for care and management
because it interpreted most of the requirements to refer to active duty
servicemembers.
According to DOD and VA officials, the January 2009 DTM serves as
the interim policy for care, management, and transition until the
completion of DOD's comprehensive policy instruction, which is
estimated to be completed by June 2009.\16\ This policy instruction
will contain more detailed information on the policies outlined in the
DTM. A VA official told us that VA also plans to issue related policy
guidance as part of a VA handbook in June 2009. The VA official noted
that the final form of the policy document would correspond with DOD's
instruction.
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\16\ DOD issues directive-type memoranda to address time-sensitive
actions that affect current policies or that will be developed into new
DOD policies. A directive-type memoranda establishes temporary policy
and provides DOD the direction to implement the policy when time
constraints prevent publishing a new policy or a change to an existing
DOD policy.
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DOD and VA Have Completed All of the Requirements for Developing Policy
on the Medical Evaluation and Disability Evaluation of
Recovering Servicemembers
DOD and VA have completed all of the requirements for developing
policy to improve the medical and physical disability evaluation of
recovering servicemembers. (See table 5.) We identified 18 requirements
for this policy area and grouped them into three categories: (1) policy
for improved medical evaluations, (2) policy for improved physical
disability evaluations, and (3) reporting on the feasibility and
advisability of consolidating DOD and VA disability evaluation systems.
DOD issued a series of memoranda that addressed the first two
categories starting in May 2007. These memoranda, some of which were
developed in collaboration with VA, contained policies and implementing
guidance to improve DOD's existing disability evaluation system. To
address the third category in this policy area, DOD and VA have issued
a report to Congress that describes the organizing framework for
consolidating the two departments' disability evaluation systems and
states that the departments are hopeful that consolidation would be
feasible and advisable even though the evaluation of this approach
through the disability evaluation system pilot is still ongoing.
According to an agency official, further assessment of the feasibility
and advisability of consolidation will be conducted. DOD and VA
anticipate issuing a final report on the pilot in August 2009. However,
as we reported in September 2008, it was unclear what specific criteria
DOD and VA will use to evaluate the success of the pilot, and when
sufficient data will be available to complete such an evaluation.\17\
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\17\ GAO, Military Disability System: Increased Supports for
Servicemembers and Better Pilot Planning Could Improve the Disability
Evaluation Process, GAO-08-1137 (Washington, DC: Sept. 24, 2008).
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DOD Has Completed Establishing Standards for Determining the Return of
Recovering Servicemembers to Active Duty
DOD has completed the requirement for establishing standards for
determining the return of recovering servicemembers to active duty.
(See table 6.) \18\
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\18\ The NDAA 2008 directed the Secretary of Defense to respond to
this policy requirement. VA does not participate in return-to-duty
decisions.
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On March 13, 2008, DOD issued a DTM amending its existing policy on
retirement or separation due to a physical disability. The revised
policy states that the disability evaluation system will be the
mechanism for determining both retirement or separation and return to
active duty because of a physical disability. An additional revision to
the existing DOD policy allows DOD to consider requests for permanent
limited active duty or Reserve status for servicemembers who have been
determined to be unfit because of a physical disability. Previously,
DOD could consider such cases only as exceptions to the general policy.
According to a DOD official, it is too early to tell whether the
revisions will have an effect on retirement rates or return-to-duty
rates. DOD annually assesses the disability evaluation system and
tracks retirement and return to duty rates. However, because of the
length of time a servicemember takes to move through the disability
evaluation system--sometimes over a year--it will take a while before
changes due to the policy revisions register in the annual assessment
of the disability evaluation system.
Over Two-Thirds of the Requirements for Improving the Transition of
Recovering Servicemembers from DOD to VA Have Been Completed
DOD and VA have completed more than two-thirds of the requirements
for developing procedures, processes, or standards for improving the
transition of recovering servicemembers. (See table 7.) We identified
19 requirements for this policy area, and we grouped them into 5
categories. We found that 13 of the 19 policy requirements have been
completed, including all of the requirements for two of the
categories--the development of a process for a joint separation and
evaluation physical examination and development of procedures for
surveys and other mechanisms to measure patient and family satisfaction
with services for recovering servicemembers. The remaining three
categories contain requirements that are still in progress.
Most of the requirements for improving the transition from DOD to
VA were addressed in DOD's January 2009 DTM--Recovery Coordination
Program: Improvements to the Care, Management, and Transition of
Recovering Servicemembers--that establishes interim policy for the
care, management, and transition of recovering servicemembers through
the Recovery Coordination Program. However, we found that DOD's DTM
includes limited detail related to the procedures, processes, and
standards for transition of recovering servicemembers. As a result, we
could not always directly link the interim policy in the DTM to the
specific requirements contained in section 1614 of the NDAA 2008. DOD
and VA officials noted that they will be further developing the
procedures, processes, and standards for the transition of recovering
servicemembers in a subsequent comprehensive policy instruction, which
is estimated to be completed by June 2009. A VA official reported that
VA plans to separately issue policy guidance addressing the
requirements for transitioning servicemembers from DOD to VA in June
2009.
dod and va officials experienced challenges during joint development
and initial implementation of required policies
DOD and VA officials told us that they experienced numerous
challenges as they worked to jointly develop policies to improve the
care, management, and transition of recovering servicemembers.
According to officials, these challenges contributed to the length of
time required to issue policy guidance, and in some cases the
challenges have not yet been completely resolved. In addition,
challenges have arisen during the initial implementation of some of the
NDAA 2008 policies. Finally, recent changes to the SOC staff, including
DOD's organizational changes for staff supporting the SOC, could pose
challenges to the development of policy affecting recovering
servicemembers.
Various Challenges Arose during Policy Development
DOD and VA officials encountered numerous challenges during the
course of jointly developing policies to improve the care, management,
and transition of recovering servicemembers, as required by sections
1611 through 1614 of the NDAA 2008, in addition to responding to other
requirements of the law. Many of these challenges have been addressed,
but some have yet to be completely resolved. DOD and VA officials cited
the following examples of issues for which policy development was
particularly challenging.
Increased support for family caregivers. The NDAA 2008
includes a number of provisions to strengthen support for
families of recovering servicemembers, including those who
become caregivers. However, DOD and VA officials on a SOC work
group stated that before they could develop policy to increase
support for such families, they had to obtain concrete evidence
of their needs. Officials explained that while they did have
anecdotal information about the impact on families who provide
care to recovering servicemembers, they lacked the systematic
data needed for sound policy decisions--such as frequency of
job loss and the economic value of family-provided medical
services. A work group official told us that their proposals
for increasing support to family caregivers were rejected twice
by the SOC, due in part to the lack of systematic data on what
would be needed. The work group then contracted with
researchers to obtain substantiating evidence, a study that
required 18 months to complete. In January 2009, the SOC
approved the work group's third proposal and family caregiver
legislation is being prepared, with anticipated implementation
of new benefits for caregivers in fiscal year 2010.
Establishing standard definitions for operational
terms. One of the important tasks facing the SOC was the need
to standardize key terminology relevant to policy issues
affecting recovering servicemembers. DOD took the lead in
working with its military services and VA officials to identify
and define key terms. DOD and VA officials told us that many of
the key terms found in existing DOD and VA policy, the reports
from the review groups, and the NDAA 2008, as well as those
used by the different military services are not uniformly
defined. Consequently, standardized definitions are needed to
promote agreement on issues such as
identifying the recovering servicemembers who
are subject to NDAA 2008 requirements,
identifying categories of servicemembers who
would receive services from the different classes of
case managers or be eligible for certain benefits,
managing aspects of the disability evaluation
process, and
establishing criteria to guide research.
In some cases, standardized definitions were critical to
policy development. The importance of agreement on key terms is
illustrated by an issue encountered by the SOC's work group
responsible for family support policy. In this case, before
policy could be developed for furnishing additional support to
family members that provide medical care to recovering
servicemembers, the definition of ``family'' had to be agreed
upon. DOD and VA officials said that they considered two
options: to define the term narrowly to include a
servicemember's spouse, parents, and children, or to use
broader definitions that included distant relatives and
unrelated individuals with a connection to the servicemember.
These two definitions would result in significantly different
numbers of family members eligible to receive additional
support services. DOD and VA officials decided to use a broader
definition to determine who would be eligible for support.
Of the 41 key definitions identified for reconciliation, DOD
and VA had concurred on 33 as of March 2009 and these 33
standardized definitions are now being used. Disagreement
remains over the remaining definitions, including the
definition of ``mental health.'' A DOD official stated that
given the uncertainty associated with the organizational and
procedural changes recently introduced to the SOC (which are
discussed below), obtaining concurrence on the remaining
definitions has been given lower priority.
Improving TBI and PTSD screening and treatment.
Requirements related to screening and treatment for TBI and
PTSD were embedded in several sections of the NDAA 2008,
including section 1611, and were also discussed extensively in
a task force report on mental health.\19\ DOD and VA officials
told us that policy development for these issues was difficult.
For example, during development of improved TBI and PTSD
treatment policy, policymakers often lacked sufficient
scientific information needed to help achieve consensus on
policy decisions. Also, members of the SOC work group told us
that they disagreed on appropriate models for screening and
treatment and struggled to reorient the military services to
patient-focused treatment. A senior DOD official stated that
the adoption of patient-focused models is particularly
difficult for the military services because, historically, the
needs of the military have been given precedence over the needs
of individual servicemembers. To address these challenges, the
SOC oversaw the creation of the Defense Centers of Excellence
for Psychological Health and Traumatic Brain Injury--a
partnership between DOD and VA. While policies continue to be
developed on these issues, TBI and PTSD policy remains a
challenge for DOD and VA. However, DOD officials told us that
the centers of excellence have made progress with reducing
knowledge gaps in psychological health and TBI treatment,
identifying best practices, and establishing clinical standards
of care.
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\19\ Department of Defense Task Force on Mental Health (2007).
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Release of psychological health treatment records to
DOD by VA health care providers who treat members of the
National Guard and Reserves. Section 1614 of the NDAA 2008
requires the departments to improve medical and support
services provided to members of the National Guard and
Reserves. In pursuing these objectives, VA faced challenges
related to the release of medical information to DOD on
reservists and National Guard servicemembers who have received
treatment for PTSD or other mental health conditions from VA.
DOD requests medical information from VA to help make command
decisions about the reactivation of servicemembers, but VA
practitioners face an ethical dilemma if the disclosure of
medical treatment could compromise servicemembers' medical
conditions, particularly for those at risk of suicide. The
challenge of sharing and protecting sensitive medical
information on servicemembers who obtain treatment at VA was
reviewed by the Blue Ribbon Work Group on Suicide Prevention
convened in 2008 at the behest of the Secretary of Veterans
Affairs. DOD and VA are continuing the efforts to develop
policy to clarify the privacy rights of patients who receive
medical services from VA while serving in the military, and a
protecting the confidential records of VA patients who may also
be treat by the military's health care system. The need to
resolve this challenge assumes even greater importance in light
of DOD's and VA's increasing capability to exchange medical
records electronically, which will expand DOD's ability to
access records of servicemembers who have received medical
treatment from VA.
Future Challenges Could Impede the Joint Implementation of Policy
Initiatives
In addition to challenges encountered during the joint development
of policy for recovering servicemembers, additional challenges have
arisen as DOD and VA have begun implementing NDAA 2008 policy
initiatives.
Medical examinations conducted as part of the DOD/VA
disability evaluation system pilot. In 2007, DOD and VA jointly
began to develop policy to improve the disability evaluation
process for recovering servicemembers and began pilot testing
these new procedures in the disability system. One significant
innovation of the disability evaluation system pilot is the use
of a single physical examination for multiple purposes, such as
for both disability determinations and disability benefits from
both departments. In our review of the disability evaluation
system pilot, we reported that DOD and VA had tracked
challenges that arose during implementation of the pilot but
had not yet resolved all of them.\20\ For example, one
unresolved issue was uncertainty about who will conduct the
single physical examination when a VA medical center is not
located nearby. Another challenge that could emerge in the
future is linked to VA's announcement in November 2008 that it
would cease providing physical reexaminations for recovering
servicemembers placed on the Temporary Disability Retired List
(TDRL).\21\ However, VA made an exception to its decision and
will continue to provide reexaminations for TDRL servicemembers
participating in the disability evaluation system pilot. In
March 2009, VA officials told us that they were developing a
policy to clarify this issue.
---------------------------------------------------------------------------
\20\ See GAO-08-1137.
\21\ Recovering servicemembers may be placed on the TDRL if they
are found to be medically unfit for duty and have service-related
illnesses or injuries that are not stable enough for assignment of a
permanent disability rating. Assignment to the TDRL temporarily retires
and provides servicemembers with disability benefits for up to 5 years
while they wait for their disabling medical conditions to stabilize. A
TDRL retiree must undergo periodic medical reexaminations and
evaluations every 18 months. See 10 U.S.C. Sec. Sec. 1202, 1210.
---------------------------------------------------------------------------
Electronic health information sharing between DOD and
VA. The two departments have been working for over a decade to
share electronic health information and have continued to make
progress toward increased information sharing through ongoing
initiatives and activities. However, the departments continue
to face challenges in managing the activities required to
achieve this goal. As we previously reported,\22\ the
departments' plans to further increase their electronic sharing
capabilities do not consistently identify results-oriented
performance measures, which are essential for assessing
progress toward the delivery of that capability.\23\ Further
challenging the departments is the need to complete all
necessary activities to fully set up their IPO, including
hiring a permanent Director and Deputy Director. Defining
results-oriented performance goals in its plans and ensuring
that they are met is an important responsibility of this
office. Until these challenges are fully addressed, the
departments and their stakeholders may lack the comprehensive
understanding that they need to effectively manage their
progress toward achieving increased sharing of information
between the departments. Moreover, not fully addressing these
challenges increases the risk that DOD and VA may not develop
and implement comprehensive policies to improve the care,
management, and transition of recovering servicemembers and
veterans.
---------------------------------------------------------------------------
\22\ GAO, Electronic Health Records: DOD's and VA's Sharing of
Information Could Benefit from Improved Management, GAO-09-268
(Washington, DC: Jan. 28, 2009).
\23\ These plans are the November 2007 VA/DOD Joint Executive
Council Strategic Plan for Fiscal Years 2008-2010 (known as the VA/DOD
Joint Strategic Plan) and the September 2008 DOD/VA Information
Interoperability Plan (Version 1.0).
---------------------------------------------------------------------------
Changes to the SOC's Staff and Scope of Policy Development
Responsibilities Could Pose Future Challenges
Recent changes to staff and working relationships within the SOC
could pose future challenges to DOD's and VA's efforts to develop joint
policy. Since December 2008, the SOC has experienced turnover in
leadership and changes in policy development responsibilities. The SOC
is undergoing leadership changes caused by the turnover in presidential
administrations as well as turnover in some of its key staff. For
example, the DOD and VA deputy secretaries who previously co-chaired
the SOC departed in January 2009. As a short-term measure, the
Secretaries of VA and DOD have cochaired a SOC meeting.
DOD also introduced other staffing changes to replace personnel who
had been temporarily detailed to the SOC and needed to return to their
primary duties. DOD had relied on temporarily-assigned staff to meet
SOC staffing needs because the SOC was originally envisioned as a
short-term effort. In a December 2008 memo, DOD outlined the
realignment of its SOC staff. This included the transition of
responsibilities from detailed, temporary SOC staff and executives to
permanent staff in existing DOD offices that managed similar issues.
For example, the functions of LOA 7 (Legislation and Public Affairs)
will now be overseen by the Assistant Secretary of Defense for
Legislative Affairs, the Assistant Secretary of Defense for Public
Affairs, and the DOD General Counsel. DOD also established two new
organizational structures--the Office of Transition Policy and Care
Coordination and an Executive Secretariat office. The Office of
Transition Policy and Care Coordination oversees transition support for
all servicemembers and serves as the permanent entity for issues being
addressed by LOA 1 (Disability Evaluation System), LOA 3 (Case
Management), and LOA 8 (Personnel, Pay, and Financial Support). The
Executive Secretariat office is responsible for performance planning,
performance management, and SOC support functions. According to DOD
officials, the new offices were created to establish permanent
organizations that address a specific set of issues and to enhance
accountability for policy development and implementation as these
offices report directly to the Office of the Under Secretary of Defense
for Personnel and Readiness. Currently, many of the positions in these
new offices, including the director positions, are staffed by officials
in an acting capacity or are unfilled.
DOD's changes to the SOC are important because of the potential
effects these changes could have on the development of policy for
recovering servicemembers. However, officials in both DOD and VA have
mixed reactions about the consequences of these changes. Some DOD
officials consider the organizational changes to the SOC to be positive
developments that will enhance the SOC's effectiveness. They point out
that the SOC's temporary staffing situation needed to be addressed, and
also that the two new offices were created to support the SOC and
provide focus on the implementation of key policy initiatives developed
by the SOC--primarily the disability evaluation system pilot and the
new case management programs. In contrast, others are concerned by
DOD's changes, stating that the new organizations disrupt the unity of
command that once characterized the SOC's management because personnel
within the SOC organization now report to three different officials
within DOD and VA. However, it is too soon to determine how well DOD's
new structure will work in conjunction with the SOC. DOD and VA
officials we spoke with told us that the SOC's work groups continue to
carry out their roles and responsibilities.
Finally, according to DOD and VA officials, the roles and scope of
responsibilities of both the SOC and the DOD and VA Joint Executive
Council appear to be in flux and may evolve further still.\24\
According to DOD and VA officials, changes to the oversight
responsibilities of the SOC and the Joint Executive Council are causing
confusion. While the SOC will remain responsible for policy matters
directly related to recovering servicemembers, a number of policy
issues may now be directed to the Joint Executive Council, including
issues that the SOC had previously addressed. For example, management
oversight of many of LOA 4's responsibilities (DOD and VA Data Sharing)
has transitioned from the SOC to the IPO, which reports primarily to
the Joint Executive Council. LOA 4 continues to be responsible for
developing a component for the disability evaluation system pilot \25\
and the individual recovery plans for the Federal Recovery Coordination
Program. It is not clear how the IPO will ensure effective coordination
with the SOC's LOAs for the development of IT applications for these
initiatives. Given that IT support for two key SOC initiatives is
identified in the joint DOD/VA Information Interoperability Plan, if
the IPO and the SOC do not effectively coordinate with one another, the
result may impact negatively on the development of improved policies
for recovering servicemembers.
---------------------------------------------------------------------------
\24\ The Joint Executive Council is responsible for addressing
strategic issues affecting both departments and developing a joint DOD/
VA strategic plan.
\25\ LOA 4 is developing a tracking system for the disability
evaluation system pilot that tracks information about servicemembers
such as the assignment of a physical evaluation board liaison officer
and timeframes for completing the disability evaluation processes.
---------------------------------------------------------------------------
Mr. Chairman, this completes our prepared remarks. We would be
happy to respond to any questions you or other members of the
subcommittee may have at this time.
contacts and acknowledgments
For further information about this testimony, please contact
Randall B. Williamson at (202) 512-7114 or [email protected], Daniel
Bertoni at (202) 512-7215 or [email protected], or Valerie C. Melvin at
(202) 512-6304 or [email protected]. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last
page of this testimony. GAO staff who made key contributions to this
testimony are listed in appendix II.
Senator Ben Nelson. Ms. Melvin?
Mr. Williamson. We just have one statement.
Senator Ben Nelson. Thank you very much, Mr. Williamson.
As you look at trying to develop an intercooperative
arrangement between two distinct agencies, did you get a sense
that maybe there is a tendency for an agency to create a silo
for protection or stovepiping, as it's sometimes called? Did
you see an indication that that might be broken down to where
there truly could be a bridge built between the two agencies to
smooth the transition? Obviously, there is a transition in
place today, it's just not smooth. Is it possible to smooth it
to the level we need and want it to be?
Mr. Williamson. Mr. Chairman, the SOC was created to deal
with a crisis situation, and it was created to overcome the
silos that might have existed in both agencies. I think it has
enjoyed some relative success. I think the question now is,
with the new organizations on the DOD side that have been
created to support the SOC, and with certain other changes,
whether that smoothness will continue. Indications that we have
so far is that the changes--and granted, the changes have only
been in place for 4 months--are being accomplished. Again, I
think a large part of the success of the SOC has occurred due
to personality-driven kinds of considerations. The people who
have been there in the past have gotten along, and they've
communicated well up to this point. I think, now, with future
changes looming, in terms of top-level people who are going to
be leaving and others taking their place, it remains to be seen
just how smoothly things will work out.
Senator Ben Nelson. Any comments from either of the other
panelists?
Mr. Bertoni. Sure, I could add something from a disability
determination perspective.
I have followed this pilot from the initial tabletop
exercise through the initial pilot phase with just 3 locations,
to now it's up to 14 locations. I can say for both DOD and VA--
it's a partnership. They're sharing information, they're trying
to flatten the process and the handoff.
I do see an effort to do that, to make it a seamless
process, to view this as a continuum of care from the
battlefield injury to the stabilization of the person. Then
ultimately making a decision on what we will do with this
person's future, whether they go back into the Service and have
the appropriate supports in play, or to transfer that person
into the civilian world and perhaps VA. There's coordination
there between the board liaisons and the military Service
representatives. There is an effort to do that, certainly.
There's always room for improvement, and we can talk about
that.
Senator Ben Nelson. Ms. Melvin, I know that a lot of people
think that information technology is just something that's
essentially mechanical, and if you come up with the same
system, everything will transfer. Is that a misnomer here, as
well?
Ms. Melvin. Yes, it is, sir. There's a big issue, relative
to interoperability, and that's the critical aspect that has to
be into play for VA and DOD to share their electronic health
information. Getting to interoperability requires a lot of
agreement, relative to standards, and those standards relate to
medical terminology, data transfer, just a complex host of
issues that have to be considered. It's not a matter of just
having systems developed. It is a matter of being able to
understand the requirements that each of those departments has.
What are the priorities, relative to their needs, and how do
you build those systems, and build the interoperable
capabilities that will allow the necessary data to be
exchanged?
Senator Ben Nelson. Mr. Williamson, is it possible to get
the two agencies to determine the same level and interest and
need for the same criteria for determination of status of
health and whether you're partially incapacitated or grossly
incapacitated? Are their interests so different that you can't
bring this together with a single set of criteria, or are you
hopeful that it's possible to establish a single set of
criteria, which would mean coming up with the same language,
the same approach, which would make the transfer of records
clearly more doable?
Mr. Williamson. Clearly, Mr. Chairman, the two agencies are
distinctly different, even though they share many of the same
issues. I think, through the SOC and through the Joint
Executive Council (JEC)--which is another DOD/VA coordination
body--they have taken steps to come together. As you saw in our
written statement, there are issues over definitions.
Senator Ben Nelson. Right.
Mr. Williamson. Definitions--one that's still being decided
is, what is ``mental health''? What does it encompass?
Certainly, the scope and eligibility and other issues regarding
servicemembers depends on having a common understanding of
terms.
So, the SOC has worked its way through about three-quarters
of the definitions. They're working on the others, but it's not
easy.
I think the SOC provides a good vehicle for doing that.
Senator Ben Nelson. I was taken by what Mr. Bertoni said
about their willingness to cooperate, and people of goodwill
who desire to cooperate typically find a way to make things
happen. Those who don't, don't. I might ask, do you think that,
in the process, there is a senior partner and a junior partner,
or do we have coequal senior partners between the two agencies?
Mr. Williamson. I think the two agencies would like to view
themselves as equal. There are probably situations where one
takes precedence when you're talking about certain issues. Some
issues relate more to DOD than they do VA, in terms of Wounded
Warrior Units and so on. Naturally, DOD would take the lead in
those situations. On other issues, VA might take a lead. But, I
think when you're talking about transition issues, they both
try to be full partners.
Senator Ben Nelson. I'm encouraged to hear your assurances
that it appears that there's a cooperative spirit and a sincere
and significant effort to make happen what everybody wants to
have happen; a smooth transition for our members and their
families.
Mr. Williamson. One notable thing is that the Secretaries
of both DOD and VA have come together and have been real
participants in this debate, have participated in SOC meetings,
and have participated in JEC meetings. I think that says a lot
for what the agencies are trying to do.
Senator Ben Nelson. It certainly sends the right message
and lends the credibility that's necessary for this to happen.
Thank you.
Senator Graham.
Senator Graham. Thank you, Mr. Chairman.
Mr. Williamson, did you hear the testimony of Lieutenant
Kinard, when he was talking about the GAO report that said a
program existed, but that you really didn't evaluate the
quality of the program. Is that a fair criticism?
Mr. Williamson. We looked at policy. The first step in this
process is, do they have policies in place? I think we said
they're doing a pretty good job. I was listening to that
testimony, and I thought I would get a question on this.
I think that the proof's in the pudding, in terms of
implementation. I think that has to play out for many of these
76 requirements.
There are a couple of things we're going to be embarking on
in the near future. We're going to be looking at the FRC/RCC
process. We're going to be undertaking a review of that, which
is very much akin to implementation. We're going to be looking
at how that's been implemented. Also, we're going to be looking
at the DCoE for Psychological Health and TBI, which, again, the
SOC has been involved in with respect to the TBI/post-traumatic
stress disorder (PTSD) issue. We're going to be looking at
those from the standpoint of implementation.
To look at all 76 requirements, in terms of implementation,
is a big task. We're going to try to zero in on those that we
think are very important and that need to be addressed soon.
Senator Graham. Fair enough. One thing I'd like to just
bring to the committee's attention, and to the public and our
panel members, is that Colonel Gadson's a good example of how
this war is different. He is going to remain on Active Duty it
looks like. That just shows you how far we've come, in terms of
medical technology and the desire of our soldiers to stay
connected to their units and to the military.
There will always be two decisions to be made. The one
thing I don't want to do is rush a decision, because I think if
it's up to Andrew, in many ways, he'd still be on Active Duty,
but he's made the decision to move forward. We have some young
men and women serving on Active Duty. I think there's a blind
captain who's an instructor at West Point. There are some
amputees that are serving. I think that's good.
Just to let my colleagues up here know that there's always
going to be some delay in making decisions, because the first
decision, as to whether or not you can stay on Active Duty, is
an important decision. More times than not, for most of the
people hurt, their goal is not to be discharged. I want to make
sure that we have a system that looks closely at the ability to
continue to serve, and think outside the box, and make places
for people like Colonel Gadson and others.
Now, once the decision has been made that you're not going
to be able to stay on Active Duty, I do believe that we can do
a lot better. The two agencies involved have two different
missions. DOD's mission is to take care of soldiers, their
families, and fight and win this war. VA is to take care of
those who have served. The interim period of time between
medical discharge and evaluation and rehabilitation is always
going to be complex. This idea of having standard definitions,
that mental health services and rehabilitative services, for an
Active Duty member, should not be materially different than
somebody that goes into the VA. That's what Dr. Noss was
telling us, and that's what Colonel Gadson was telling us,
that, ``When I was an Active Duty person, or I lived in this
region, I had certain services available. When I went into this
new system--the VA--all of a sudden, my access to outpatient
services was limited.''
Did you look at that?
Mr. Bertoni. I can talk a bit about that. I've done a lot
of work across a lot of different programs, and I can say in
many respects, the policies and procedures that pertain to the
Guard and Reserve often do put them potentially at a
disadvantage. At least there's a belief in many respects. In
some cases, we've identified that.
The issue here is when you look at DES, one in four folks
coming into that system are either a Guard or Reserve Force
member. A larger portion of our standing military is Guard or
Reserve.
I've brought this up in other testimonies, and it might be
time to start looking at our policies.
Senator Graham. Colonel Rivas was telling us about
compensation. He's a reservist. Not 20 years retirement
eligible. He has to wait until he's 60.
Mr. Bertoni. There are many issues relating to preexisting
conditions and how many guardsmen can get caught in that
situation and be aced out of benefits. I think we have policies
that were set up when we had this traditional army from many
years ago, and we're moving to a new force.
Senator Graham. Do you think both organizations are
sensitive to the Guard and Reserve dilemma?
Mr. Bertoni. Yes, I think they are, and in the case of the
DES, which we have been able to get behind, versus just saying
there's a policy.
Senator Graham. One final area, and I'll yield here. Dr.
Noss was talking about when her husband was Active Duty, that
when he got out of the Active Duty system, there was a
limitation on access to therapy. Did you find that when you
were looking at it, that going from one system to the other all
of a sudden changed the menu you had to choose from, in terms
of therapies?
Mr. Bertoni. No, we didn't look at that specifically.
Again, we were following the pilot.
Senator Graham. I think that's what she said. When her
husband got discharged, some of the therapies that were
available on Active Duty were not available through the VA
system. Thank you very much.
Senator Ben Nelson. Thank you, Senator.
Senator Begich.
Senator Begich. Thank you very much, Mr. Chairman. I want
to follow up on the comment from the lieutenant regarding the
76 policies. That's the magic number, and they've done 60, 70
of these, and that you just confirmed that they have the
policies in place.
Are you planning, or will you be doing any kind of a
measurement of the success of these policies, or is there a
baseline to measure against? In other words, I'm going to speak
for a moment as a former mayor. When we got audited at times by
our internal auditor, we'd write a policy. Satisfied, you check
the box and move on. It's when they came back and said, ``What
did you do?'' that was more important. So what's the plan? Or
is there a plan? If there's no plan, do we need to help you get
a plan on that?
Mr. Williamson. I mentioned two of the things we're going
to be doing.
Senator Begich. I heard those, but on these specific--and
here's why. I'm walking through the steps, 76 new policies. Of
those 76 new policies, what Senator Graham was getting at, and
that is now, there should be some measurable method to
determine if those polices are working or not. In order to
determine that, you have to have a baseline to where they are
on every one of those policies and where they hope to go and if
they achieve that.
I understand the other 2 you mentioned, but specifically
about these 76, who wants to answer? I see Mr. Bertoni.
Mr. Bertoni. I could talk again about this in terms of the
disability program. Right now, we have a disability system, the
current system that nearly all folks are going through. We have
a pilot that we're looking at right now, 14 locations, on its
way up to 21 by June. Potential to roll that out worldwide, so
that is potentially what will be.
We have been able to look at that pilot. We've been
tracking that for over a year, looking at many aspects of what
DOD and VA are trying to do there. In many respects, the
baseline is, is what is now? What is the current system? What
is broken? What are they trying to do? How is the pilot
comparing against that existing system?
That at least in this example, that's a baseline in many of
the policies that Randy referred to. Modifications of the
existing system, and many of the policies that are being folded
into the pilot. In some ways, we had looked at, got behind the
implementation and effectiveness of some of these policies, at
least from the disability standpoint.
Senator Begich. What I would like to see is graphically,
what happens? In other words, if the person used to take this
much time going through the process, how much time does it take
him now? He used to receive this much service. Now they're
receiving this much service. That's something that you could
share at some point, even though it's at a pilot status, of how
that is?
Mr. Bertoni. Certainly. The pilot's ongoing, but we issued
two testimonies and one report on this. Certainly DOD and VA
are tracking timeliness, transparency, customer satisfaction,
and measuring it against the existing system. With 14 sites,
there is some data coming in, and I could say if you looked at
that data, it tends to be trending pretty well.
Our concern is that it is fairly early on. Some of the more
high-risk, more difficult sites won't be rolled out until
around the time they have to cut off data analysis to begin
writing the final report. I don't know if you all will have the
data you're looking for, in terms of the effectiveness of this
pilot relative to the other system as of August 2009.
Senator Begich. Let me follow up on the definition issue.
You mentioned--I don't know who mentioned it--about three-
quarters of the definitions were agreed to, or there's an
understanding. I'm guessing the last quarter is the tougher
group. What's the timetable that you think you'll see
unification of these definitions?
Mr. Williamson. In terms of when they'll be----
Senator Begich. When they have agreed on it?
Mr. Williamson. I don't know. I think that's a good
question for the next panel. They're the ones doing it.
Senator Begich. Next panel, be ready. That's the question.
You might just include it in your opening comments so we
dispense with it. One other idea I'll just put on the table.
Again, I don't know all the technical terms, so I apologize,
and you could clarify them for me. As described by the
lieutenant, as you're being discharged, there's a process of
termination, and then there's a process with the VA. Why not
have one board meeting? Why not just combine them together and
have one review at the same time, even though there may be
differences in some of the questioning, allow that to occur,
and then you're done?
Mr. Bertoni. Again, it is the DES. That's exactly what the
pilot is trying to do. Right now, we have a MEB, an informal
PEB, then the formal PEB, the DOD rating, the decision on
fitness and unfitness.
Senator Begich. All at the same time?
Mr. Bertoni. This is the DOD system. Once that occurs, and
if the person is found unfit, they'll transition into the
civilian world. They'll go through another set of reviews for
VA.
What the pilot is trying to do is to move the person
through concurrently in these two systems, have the MEB, the
PEB, have the VA in there early at the same time doing a
comprehensive physical exam, issuing a rating the DOD can use
to make the fit/unfit decision and VA will use to ultimately
assign a disability rating to the servicemember.
In this situation, the servicemember is going to know
pretty much what he or she will receive as soon as he leaves
the Service. That's the idea, it is to try to compress this and
make separate situations, processes concurrent.
Senator Begich. Last question on that. Based on the pilot--
and, again, because I'm new here, I don't know what the
timetable was. Using just my thinking, it sounds like it's much
better than the existing system, no matter how you cut it.
There are jurisdictional issues, but if the goal is to deal
with the service person as the priority, then the
jurisdictional issues should go by the wayside.
Putting that aside for a second, have you or has someone--
and maybe it's the next panel--laid out a strategy or
timetable, assuming--and that's what I would assume here for a
moment--pilots are working, when do we see them all up and
operational, so the old system is gone? Is that the next panel?
Mr. Bertoni. We have some information on that. I don't know
that we would say it's much better. I think that the jury's
out. We have 14 sites. There's limited data that is coming in.
They haven't stressed the pilot under a range of scenarios that
they could stress it under. There are a number of different
bases with different characteristics, and I think they're
working toward those farther down the line. I do know they'll
be up to 21, I believe, sites by June 2009. They have to issue
a final report in August.
I don't know if they're going to say that at that time,
that this is ready for further expansion. I think there are
another seven sites they might roll out in the fall. But a
timeline for worldwide implementation, I haven't seen anything
to that effect.
My concern is that they have all the data, and that this be
a data-driven decision that they can crank back into any system
that is proposed.
Senator Begich. Thank you very much. My time is up. Thank
you all for your testimony.
Senator Ben Nelson. Thank you, Senator.
Senator Hagan.
Senator Hagan. Mr. Chairman, I'm going to wait for the next
panel, thank you.
Senator Ben Nelson. Thank you. We thank the panel for your
appearance here today, for providing us an update and analysis
of progress, and we hope that this partnership that you're a
part of, as well, will continue into the future. Time is
important, but getting it right is also important. So we thank
you. Thank you very much.
On our third panel, we welcome Gail H. McGinn, Deputy Under
Secretary of Defense for Plans; Ellen P. Embrey, Acting
Principal Deputy Assistant Secretary of Defense for Health
Affairs; Roger Dimsdale, Executive Director, VA/DOD
Collaboration, Office of Policy and Planning for the VA; Major
General Keith W. Meurlin, United States Air Force, Acting
Director of the Office of Transition Policy and Care
Coordination; Rear Admiral Gregory A. Timberlake, United States
Navy, Acting Director of the Joint DOD/VA IPO; and Dr. Karen
Guice, Executive Director of the Federal Recovery Coordination
Program for the VA.
We have many actings here today because of the change in
administrations. We're very fortunate to have your testimony,
because each of you has played an integral role in developing
and implementing these wounded warrior policies. We're
obviously counting on you to give us your honest assessment of
the work that the departments have completed, as well as areas
where problems remain, and work also remains.
We look forward to your statements. Ms. McGinn, if you
would like to begin.
STATEMENT OF GAIL H. McGINN, DEPUTY UNDER SECRETARY OF DEFENSE
FOR PLANS, DEPARTMENT OF DEFENSE
Ms. McGinn. Thank you, Mr. Chairman, Senator Graham,
members of the subcommittee. I'm pleased to be with you today
to discuss DOD's ongoing effort in collaboration with VA to
support America's wounded warriors and their families. I will
be addressing the organization DOD has put in place to continue
building on the partnership between our two agencies.
DOD has made, in my estimation, an extraordinary
organizational commitment to sustaining and enhancing our
structures for continued progress on this front. Two years ago,
when events brought to light the need for focus on wounded
warrior support, the departments moved quickly to put an
organizational structure in place to staff the SOC in its
decisionmaking and oversight role.
Because we needed to move quickly, the structure was of
necessity ad hoc, comprised of borrowed executives, civilian
detailees, borrowed military manpower, and contractors. DOD is
now replacing this ad hoc staff with permanent employees,
including the dedication of three senior executive resources,
and over 50 permanent traditional positions.
These are in addition to the resources dedicated to the
IPO. Our new structure creates a Director of Transition Policy
and Care Coordination and an Office of Strategic Planning and
Performance Management, encompassing an executive secretariat
for managing SOC and JEC matters. This structure continues the
work of the prior organization.
The lines of action continue. Transferred to permanent
executives and the functions of a previous senior oversight
staff office transferred to the executive secretariat. This
organization has several important features.
First, it solves an organizational issue. There was
previously no senior executive charged exclusively with working
with VA to achieve a seamless transition for our
servicemembers, and now there will be.
It enhances our role with the JEC and the development of
the Joint Strategic Plan to drive the improvement and benefits
and healthcare for all veterans, in addition to continuing the
extraordinary efforts in support of the wounded warrior.
These offices of DOD are co-located with the VA office, a
VA/DOD co-location to ensure day-to-day collaboration. In fact,
they recently moved to new permanent office space.
I've worked for DOD for decades, and I've never seen faster
and more committed progress than that embodied in the
accomplishments of the SOC as it addressed the various
recommendations of numerous studies and commissions and the
challenges given to us by your congressional action.
The DES pilot, the revolution in care coordination and
customer care, advances in responding to TBI and PTSD, and
progress and sharing of electronic information. This is not all
of it, but it is impressive. My colleagues will speak to these
and other accomplishments in more detail.
But as you've heard in the first panel, our work on behalf
of the wounded warrior is not done. As the GAO representative
noted, we are creating new organizations. We are completing our
hires and we will ensure that our processes, their
collaboration with VA, and for integration into the priority
work of DOD are accomplished.
We will establish metrics and evaluation processes to make
sure our focus is steady and to make sure that we can see where
our policies and practices may break down now that we've
started to implement them so that we can find the gaps and fix
them.
We will continuously review program implementation to find
those policy and program gaps. We will integrate the strategic
planning for support of the wounded warrior into the overall
plans of the Under Secretary of Defense for Personnel and
Readiness so that all of these plans are embedded in the
essence of what we do every day in Personnel and Readiness.
We will continue to review the support systems for the
wounded and also for their families and loved ones, and
continue our focus on customer care. We will continue our
emphasis on mental health and the need for psychological
fitness.
The commitment of our leadership is unwavering. As noted,
Secretary Gates and Secretary Shinseki chaired the SOC during
the transition so that we could continue the momentum.
Yesterday, Deputy Secretary Lynn and Deputy Secretary Gould
from VA co-chaired their first SOC and made a commitment to go
forward on behalf of wounded warriors.
Mr. Chairman and members of this subcommittee, we thank you
for your continuing support as we strive to work with you to
provide the best possible care and opportunities for our heroic
wounded warriors and their families. Thank you.
[The prepared statement of Ms. McGinn follows:]
Prepared Statement by Gail H. McGinn
Mr. Chairman, and members of the subcommittee, it is my pleasure to
be here today to discuss with you the Department's ongoing aggressive
support of programs for our wounded, ill, and injured servicemembers,
veterans and their families. Secretary Gates has affirmed that next to
the war itself, support for our wounded, ill, and injured is the
Department's highest priority. We have made a lot of progress in the
last 2 years, but our work is not done. We very much appreciate your
support of our ongoing efforts.
I'm here today to relate the Department's recent establishment of a
capability to permanently sustain enhanced joint oversight and
management of wounded warrior matters and to continue supporting
operations of the Department of Defense (DOD)/Department of Veterans
Affairs (VA) Senior Oversight Committee (SOC). Let me first provide
some background to talk about how we organized initially, and then I
will turn to our new alignment, designed to institutionalize and enrich
our oversight and management of wounded warrior matters.
background
Senior Oversight Committee:
In the spring 2007, Secretary Gates requested an oversight
committee of senior military and civilian officials be created to make
certain that recommendations and mandates from a number of sources,
including a Presidential Commission, and legislation were addressed. As
a result, the SOC for the Wounded, Ill, and Injured (WII) was
established. The SOC is co-chaired by the Deputy Secretary of Defense
and Deputy Secretary of Veterans Affairs, and brings together on a
regular basis the most senior decisionmakers from both Departments to
ensure timely decisions and actions. The SOC is the main decision body
for oversight, strategy, and integration of proposed measures for DOD
and VA efforts to improve seamlessness across an injured
servicemember's recovery, rehabilitation, and reintegration continuum.
The two Departments and the SOC have been in the process of
implementing more than 600 recommendations from 6 major studies and the
National Defense Authorization Acts for Fiscal Year 2008 and Fiscal
Year 2009. My colleagues will discuss specific accomplishments, but the
initiatives to accomplish these requirements fit within a context of
the following fundamental changes:
Increasing collaboration between DOD and VA on issues
to deliver a world class continuum of care for our WII.
Revamping the approach to care and case management,
and fully embracing a customer-centered process that includes
involvement of the family and caregivers through the use of the
Recovery Care Program and the Federal Recovery Coordination
Program.
Increasing the sharing of medical and beneficiary
information between DOD and VA.
Recognizing psychological fitness is as important as
physical fitness.
Overarching Integrated Product Team:
The SOC established an Overarching Integrated Product Team (OIPT)
to closely track and coordinate recommendations from studies and
reports for successful implementation of appropriate support and care
for WII servicemembers. The OIPT reports directly to the SOC and is
responsible for coordinating, integrating, and synchronizing actions.
The OIPT's mission is to:
Act as the primary DOD and VA coordinating and
functioning agent for all recommendations from reports by
commissions, task forces, congressional studies, and NDAA
mandates.
Coordinate analysis and review of recommendations and
mandates, and present consolidated decision packages to the
SOC.
Refine strategic program guidance and joint planning
objectives in conjunction with the Joint Strategic Plan of the
Joint Executive Council (JEC).
Approve plans, timelines, and proposed actions, and
report these to the SOC.
Maintain close coordination, and integration where
possible, with the military Services, Joint Staff, and all
pertinent Federal departments/agencies with respect to their
efforts to improve care and benefits for WII servicemembers and
their families.
Coordinate public relations and communications efforts
internal to DOD and VA and external with outside departments/
agencies, Congress, veterans support organizations, the media,
and the public.
Review legislation for actionable and/or reportable
items.
Maintain an electronic database for the complete
tracking of actionable items.
Recommend resourcing solutions.
Lines of Actions:
To organize for responsibility and accountability, the SOC
established eight lines of action (LoAs) and assigned the
recommendations and mandates consistent with the LoAs missions, which
are as follows:
Line of Action 1: Disability Evaluation System. Develop and
establish one solution for a DOD and VA Disability Evaluation
System using one integrated disability rating system that is
seamless, transparent, and administered jointly by both
Departments. That system must remain flexible to evolve and
update as trends in injuries and supporting medical
documentation and treatment necessitates. Streamline the
transition process for the servicemember separating from DOD
and entering the VA system of benefits.
Line of Action 2: Traumatic Brain Injury (TBI) and Post
Traumatic Stress Disorder (PTSD). Address improvements in
consistency and capability surrounding TBI and psychological
health (PH) across the full continuum of care within DOD and
VA. The effort has been on the collaborative development and
continuous improvement of servicemember/veteran-focused
programs dedicated to TBI and PH prevention, protection,
identification, diagnosis, treatment, recovery, research, and
rehabilitation.
Line of Action 3: Case and Care Management. Coordinate
medical and nonmedical care, rehabilitation, benefits, and
delivery of services and support that will effectively guide
and facilitate servicemembers, veterans, their families, and
caregivers throughout the entire continuum of care.
Line of Action 4: DOD/VA Data Sharing. Ensure appropriate
demographic, personnel, and medical information on
servicemembers, veterans, and their family members is visible,
accessible, and understandable through secure and interoperable
DOD and VA information management systems.
Line of Action 5: Facilities. Ensure facilities are provided
that deliver the care servicemembers and veterans have earned
and deserve. In accordance with existing laws and regulations,
establish standards for the inspection of quarters used by WII
servicemembers; conduct an assessment of the existing DOD
medical support infrastructure; and summarize inspection
results to Congress. Finally, examine the process of
establishing and maintaining medical facility design criteria
and make recommendations for improvement.
Line of Action 6: Clean Sheet Review. Provide WII
servicemembers and their families the best quality care with a
compassionate, fair, timely, and non-adversarial disability
adjudication process. An ideal process will be developed for
providing care and benefits to WII servicemembers, veterans,
and their families. The ideal process will not be constrained
by current laws, policies, regulations, organizations,
infrastructure, or resources.
Line of Action 7: Comprehensive Legislation and Public
Affairs. Coordinate the development of comprehensive
legislation that will provide the best possible care and
treatment for WII servicemembers and their families.
Additionally, keep the public informed of significant
accomplishments and events.
Line of Action 8: Personnel, Pay, and Financial Support.
Ensure each seriously wounded, ill, or injured servicemember
has a level of compensation, benefits, and financial support to
maintain their dignity and support their recovery,
rehabilitation, and reintegration.
Wounded, Ill, and Injured Senior Oversight Committee (WII SOC Staff
Office)
Given the scope and magnitude of the issues addressed and the
complexity of integrating recommendations within DOD and VA, the SOC
directed the creation of a full time joint-departmental support staff.
In the interest of time, the WII SOC Staff Office was staffed with
civilian detailees from both DOD and VA, borrowed military manpower,
and contractor personnel. It was led by a senior executive detailed
from the Department of the Army and a VA detailed senior executive as
the Chief of Staff. The WII SOC Staff Office provided assistance,
advice, and expertise to facilitate changes to policies, procedures, or
legislation so that all recommendations relative to the recovery,
rehabilitation, and reintegration of WII servicemembers and their
families were effectively and efficiently resolved or addressed. The
Staff Office served as the integration focal point to both the SOC and
OIPT and tracked the actions overseen by the SOC. The Staff Office was
charged with providing senior level review and advising the SOC on the
progress of the WII program. The SOC delegated authority to the Staff
Office to task deliverables directly to the LoA representatives to
ensure SOC requirements were met. Within the Staff Office, a group of
DOD and VA personnel jointly served as points-of-contact within the
eight LoAs. In this role, LoA liaisons were responsible for
facilitating communication between their LoA and the Staff Office.
While the Staff Office served as the administrative body facilitating
the efforts of the LOAs and ensuring milestones were met, the
substantive work assigned by the SOC was accomplished by the LOAs.
LOA Assignments/Staffing:
When we initially categorized the recommendations to be addressed
within the LoAs, we assigned LOA lead responsibilities to senior
Department officials who, along with VA co-leads, energized their
staffs to meet the requirements of SOC-assignments. In some cases,
lines of action responsibilities were not clearly in any particular
senior official's portfolio, but implementing the recommendations
became a Department priority so we made the best functional fit
possible. For instance, LoAs 1, 3 and 8 were assigned to senior
officials in the Office of the Secretary of Defense, Navy, and Air
Force, respectively, none of whom had complete Department
responsibilities beforehand for oversight and management of WII SOC
recommendations assigned in these LoAs.
As with the WII SOC Staff Office, in many cases, staffing this
newly created organization to support the SOC required detailing
military and civilian help to LOA leads. Of course, the offices from
which these detailees came have had to adjust work and resources
accordingly.
The Joint Executive Council
The SOC and its supporting structure were designed to focus on the
elimination of deficiencies in the wounded warrior continuum of care.
The JEC drives the entire panoply of DOD/VA interagency strategy and
policy interactions. It has been co-chaired by the Deputy Secretary of
the Department of Veterans Affairs and the Under Secretary of Defense
for Personnel and Readiness. It oversees the efforts of a Health
Executive Council, Benefits Executive Council and Interagency Program
Office and all other councils or work groups designated by the co-
chairs. The JEC works to remove barriers and challenges which impede
DOD and VA collaborative efforts, asserts and supports mutually
beneficial opportunities to improve all business practices, ensures
high quality cost effective services for both DOD and VA beneficiaries,
and facilitates opportunities to improve resource utilization. All this
is spear-headed and monitored through a joint strategic planning
process that results in recommendations to the Secretaries on the
strategic direction for the joint coordination and sharing efforts
between and within the two Departments for all overlapping matters.
This year, we ensured that the SOC actions and milestones were laid
into the JEC Strategic Plan.
establishing permanent organizations
After almost 2 years of SOC operations and achieving what we
believe are significant positive outcomes, it became evident that to
further enrich oversight and management of this priority mission and to
posture the Department for sustaining this level of support to our WII
servicemembers and their families, a permanent structure was needed.
The Department did not have full-time executive leaders dedicated to
DOD/VA collaboration and transition. In order to improve on the
integration of DOD and VA into a single team to address wounded warrior
needs as well as the integration of these issues into the management
framework of the Under Secretary for Personnel and Readiness, the
Department has created two new permanent offices in DOD. We believe
that establishing these two offices will keep support of the wounded
warrior at the forefront in our daily efforts and priorities and give
us greater ability to improve the continuum of care with VA for all
servicemembers. Additionally, further teaming with our colleagues,
we've co-located our two new offices with their VA counterpart
liaisons, thereby enhancing our synergistic efforts.
Transition Policy and Care Coordination Office
The Under Secretary of Defense for Personnel and Readiness
established late last year the Office of Transition Policy and Care
Coordination (TPCC). Maj. Gen. Keith Meurlin, USAF, was appointed
Acting Director. The TPCC assumed responsibility for policy and
programs related to disability systems, servicemember transition to
veteran status, separations from the Armed Forces, case and care
coordination, and pay and benefits entitlements for wounded, ill, and
injured servicemembers, veterans and their families. These assigned
responsibilities include the totality of functions assigned to SOC LoAs
1, 3 and 8, which were originally assigned to Deputy Under Secretary of
Defense for Military Personnel Policy, the Deputy Assistant Secretary
of the Navy for Military Personnel Policy, and the Deputy Assistant
Secretary of the Air Force for Force Management and Integration,
respectively. Additionally, subsets of other responsibilities formerly
assigned to Deputy Under Secretaries for Military Personnel Policy and
Military Community and Family Policy are now included in the TPCC's
portfolio. TPCC assumed responsibility for management and monitoring of
performance against DOD/VA Benefits Executive Council (BEC) goals and
for coordinating with VA in support of BEC activities. Additionally,
TPCC has the authority to enter into agreements, within the scope of
assigned responsibilities, with VA and represent OUSD (P&R) as a member
on councils and interagency forums established under the authority of
the DOD/VA JEC, the BEC and the SOC. The TPCC is up and running and
keeping pace with meeting SOC, JEC and BEC requirements. Staffing
military and government civilian positions is ongoing, expecting full
staff to be in place by the end of this calendar year. Thirty-eight
personnel will be reassigned or hired to accomplish these duties.
Office of Strategic Planning and Performance Management/Executive
Secretariat to the SOC/JEC
At the same time the TPCC was formed, the Office of Strategic
Planning and Performance Management/Executive Secretariat to the SOC/
JEC was established. Mr. Clarence Johnson, a Senior Executive
Servicemember, was appointed Acting Director. The Executive
Secretariat, which aligned some DOD staff--mostly temporary contractor
or military--from the WII SOC Staff Office, is up and running as well.
We expect to hire a permanent Senior Executive Service Director and the
office should be fully staffed by the end of this year. We are adding
14 full time permanent personnel to support this function. This office
has many of the responsibilities formerly accomplished by the WII SOC
Staff Office, including tracking progress of SOC-directed actions (LOA
liaison responsibility as before remains); tracking the status and
accomplishment of the more than 600 actions embraced by the two
Departments; and in collaboration with VA counterparts, establishing
SOC and JEC agendas, scheduling SOC, OIPT and JEC meetings and
supporting the oversight functions of the SOC, OIPT and JEC.
Additionally, this Office has broadened responsibility to provide the
planning and management function for DOD's involvement in the Joint
Executive Council, including the Department's role in the development
of the JEC Joint Strategic Plan and ensuring the accomplishment of
actions identified in that plan. Finally, this Office has
responsibility for ensuring the integration of these plans and actions
into the structure of the Under Secretary of Defense for Personnel and
Readiness strategic planning and performance management processes. The
Executive Secretariat reports to the Deputy Under Secretary of Defense
for Plans.
other realignment notes and closing
I earlier spoke about the alignment of LoAs from the initial SOC
support structure to the permanent structure. I indicated that LoAs 1,
3, and 8 were aligned from disparate owners to the TPCC. With the
exception of LOA 6 whose work has been completed, the other LOAs
remained in place with their missions held constant and their
responsibilities captured in SOC LOA assignments.
From the SOC perspective, LOA 4 issues continue to be administered
with representatives from DOD and VA. From the JEC standpoint,
electronic media was highlighted as outlined in Public Law 110-181--
fiscal year 2008, National Defense Authorization Act, Section 1635,
with the establishment of the Interagency Program Office (IPO) to focus
the integration of electronic health information for the DOD and VA.
Rear Admiral Gregory Timberlake has been assigned as the acting
Director with a permanent Senior Executive Service solution being
pursued and the Deputy position is planned to be filled by a VA Senior
Executive Service employee.
As we sustain and enrich our support to the wounded warrior, we aim
to continue to build upon the partnership with VA to jointly tackle
major issues that emerge in the transition of our servicemembers from
active duty to veteran status. Our new structure actually streamlines
our processes for DOD/VA collaboration, and progress continues.
Under this new alignment, the SOC has met twice and dealt with very
substantive issues. Our two cabinet secretaries chaired a SOC in
February. The OIPT continues to meet frequently, bringing key issues to
discuss and prepare for the SOC forum and reporting on SOC milestones
and achievements. In the future our collaboration should be enhanced
through the increased focus on the JEC, made possible by our new
organizational structure, and by implementation of a new concept--a
Principals' JEC, which would be chaired by our two Secretaries when the
business of the JEC requires their personal involvement.
While we are pleased with the quality of effort and progress made,
we fully understand that there is much more to be done. We believe we
have, thus, postured ourselves to continue providing world-class
support to our warriors and veterans while allowing us to focus on our
respective core missions. Our dedicated, selfless servicemembers,
veterans and their families deserve the very best, and we pledge to
give our very best during their recovery, rehabilitation and return to
duty or to the society they chose to defend.
Thank you for your generous support of our wounded, ill, and
injured servicemembers, veterans, and their families. I look forward to
your questions.
Senator Ben Nelson. Thank you.
Ms. Embrey?
STATEMENT OF ELLEN P. EMBREY, ACTING PRINCIPAL DEPUTY ASSISTANT
SECRETARY OF DEFENSE FOR HEALTH AFFAIRS
Ms. Embrey. Mr. Chairman, Senator Graham, members of the
subcommittee, thank you again for the opportunity to discuss
what DOD is doing to improve the quality of care for our
wounded warriors with respect to psychological health needs and
TBI.
I'm very pleased to be here. It has been my great honor and
responsibility over the last 2 years to be the DOD lead in
partnership with my counterparts in the VA, Dr. Lou Beck and
Dr. Ira Katz, to address the work of line of action 2, which
focuses on achieving improvements and help outcomes associated
with psychological health, PTSD, and TBI.
Today I also briefly discussed the role of my office in
overseeing the health-related aspects of line of action 4,
which focused over the last 2 years on DOD/VA sharing of
information technology and information.
Regarding line of action 2, the Department is committed to
ensuring that all servicemembers, especially those with mental
health and TBIs, receive consistently excellent care across the
entire care continuum. For both psychological health and TBI,
our focus has been on building and sustaining physical and
mental resilience and improving the quality and consistency of
prevention, protection, diagnosis, treatment, recovery, and
transition programs for both DOD and VA.
For TBI, this also includes a significant emphasis on
research to clarify and improve clinical diagnostic treatment
and rehabilitation technologies and therapies, especially for
mild TBI, known as concussion, but also moderate, severe, and
penetrating TBIs.
While DOD has been actively expanding and implementing
programs on psychological health and TBI, we also have been
working to evolve and expand the sharing of medical and
beneficiary data as directed by line of action 4. This
collaboration has ensured that information is viewable,
accessible, and understandable through secure and interoperable
information systems and greatly advanced the electronic sharing
of benefit, personnel, and health information between the two
agencies over the last several years.
Details of these efforts have been included in my submitted
testimony for the record. I would also like to add that
recently, we have refocused our efforts to commit to build a
virtual lifetime electronic record to ensure health and benefit
information is available in either system to support the
servicemember, veteran, and their families at any time, from
the point of accession to burial.
Mr. Chairman, DOD greatly appreciates the committee's
strong support and the concern that you have shown for their
health and well-being. I stand ready to answer your questions.
[The prepared statement of Ms. Embrey follows:]
Prepared Statement by Ellen P. Embrey
Chairman Nelson and distinguished members of the committee, thank
you for the opportunity to bring you up to date on what the Department
of Defense (DOD) is doing to improve the quality of care for our
wounded warriors with psychological health needs and traumatic brain
injuries (TBIs). I am pleased to be here.
From other witnesses today, you have heard how DOD has organized to
address the many recommendations offered to improve care for our
wounded warriors. I have had the great honor and responsibility to
lead, in partnership with my counterparts in the Department of Veterans
Affairs (VA), the work of Line of Action 2, which focused on the
recommendations related to psychological health, including post-
traumatic stress disorder (PTSD), and TBI. In addition, because I have
assumed responsibilities as the acting Principal Deputy Assistant for
Health Affairs, I have added oversight of health-related actions of
Line of Action 4, DOD/VA Data Sharing Information Technology. Ms. Norma
St. Claire, the Director of the Joint Requirements and Integration
Office, is the DOD co-lead for DOD's personnel and benefits related
LOA4 actions.
The DOD is committed to ensuring that all servicemembers, but
especially those with psychological health needs or TBIs, consistently
receive excellent care across the entire medical continuum. For TBI,
this continuum includes diagnostic categories from mild TBI (also known
as concussion) to moderate, severe, and penetrating TBI, including
those with the most severe head injuries. For both psychological health
issues and TBI, the continuum of care includes prevention, protection,
diagnosis, treatment, recovery, and transition from DOD to VA.
In 2007, the Department embarked upon a comprehensive plan to
transform our system of care for psychological health and TBI. The plan
was based on seven strategic goals:
Building a strong culture of health leadership and
advocacy;
Improving the quality and consistency of care, across
the country and around the world;
Creating easy and timely access to care, regardless of
patient location;
Strengthening individual and family health, wellness,
and resilience;
Ensuring early identification and intervention for
individual conditions and concerns;
Eliminating gaps in care for patients in transition;
and
Building a network to leverage and/or direct medical
and cross-functional research, including new and innovative
treatments, technologies, and alternative medicine techniques.
Throughout 2008, we made significant progress toward achieving
those goals, and I would like to tell you, briefly, where we are on
each of them.
leadership and advocacy
In November 2007, we established the Defense Centers of Excellence
for Psychological Health and Traumatic Brain Injury (DCoE). In
partnership with VA, academia, and others, the DCoE will lead the
effort to develop excellence in prevention, diagnosis, practice
standards, training, outreach, and direct care for those with TBI and
psychological heath conditions, and provide the nexus for research
planning and monitoring.
Since its inception, the DCoE has focused its efforts on the
development and continuous improvement of a patient-centered network
dedicated to all issues related to psychological health and TBI.
improving the quality of care
To improve the quality and consistency of mental health care, DOD
and VA continue our longstanding effort to develop and update clinical
standards and guidelines, which incorporate lessons learned and best
practices, and establish evidence-based care as the enterprise standard
for acute stress disorder, PTSD, depression, and substance use
disorders.
Over the past year, the Clinical Practice Guideline for depression
has been updated and entered into the final stages of revision, and
revisions to the Guideline on PTSD have been initiated based on
emerging best practices. DOD purchased clinical tools and equipment to
fully enable our clinicians to provide state-of-the-art care. For
example, we have accelerated the purchase of imaging equipment at
medical centers with high concentrations of patients with TBI.
The DOD introduced an evaluation tool, the Military Acute
Concussion Evaluation tool, to assess the likelihood of mild TBI, and
we published clinical guidelines for its management in operational
settings. We initiated a certification process for multi-disciplinary
teams delivery TBI care in medical treatment facilities, and worked
with the United States Central Command to standardize the decision
process for determining when to return a servicemember to full duty or
to the United States for further treatment.
The Department joined with VA to implement a standardized training
curriculum on evidence-based psychotherapy for PTSD. To date, the
DCoE's Center for Deployment Psychology alone, or in partnership with
other organizations (e.g., Services, MTFs, VA), has trained 1,634
providers from DOD, Federal agencies, and the civilian sector in the
use of evidence-based treatments for PTSD (specifically Prolonged
Exposure and Cognitive Processing Therapy). Similarly, the DCoE's
operational arm for TBI (the Defense and Veterans Brain Injury Center),
supported by VA, has trained more than 1,600 medical providers on
evidence- and consensus-based treatments.
To recognize the challenging diagnoses, and unique requirements,
that can accompany psychological health and TBI wounds, the DCoE worked
with the Intrepid Fallen Heroes Foundation to design and begin
construction of a new facility, the National Intrepid Center of
Excellence.
The new center will provide an interdisciplinary team of clinicians
and scientists dedicated to a holistic evaluation and treatment
approach for servicemembers with mental health and TBI conditions, and
it will provide advanced diagnostics and comprehensive treatment
planning for those whose mental health conditions or TBIs are not
responding to traditional methods. When the new center is complete, we
expect that there will be no finer care available in the country, or
perhaps the world, for wounded warriors with these conditions.
In a similar manner, the DCoE, the National Institutes of Health
Office of Research on Women's Health, and VA cosponsored a meeting, in
October 2008, to identify and explore the existing science on trauma
spectrum disorders (such as PTSD and TBI) related to military
deployment and, for the first time, addressed the question of how
personal differences may impact an individual's response to treatment.
We are continuing to work together to further examine outcomes
associated with these different treatment modalities.
In January 2009, also for the first time, DOD and VA co-sponsored a
conference on suicide prevention entitled, ``Building Community
Connections: Suicide Prevention for the 21st Century,'' to foster
partnerships between suicide prevention experts in government,
medicine, and communities. The conference, which featured a wide range
of speakers including psychological health experts, not-for-profit
organizations, community leaders, survivors, mental health specialists,
and chaplains, focused on four tracks: Clinical Intervention, A Multi-
Disciplinary Approach, Practical Applications and Tools, and Research
and Academics.
improving access to care
To improve access to mental health care, regardless of location, we
funded the hiring of additional mental health and other specialty
providers by the Services, and implemented a policy that requires first
appointment access within 7 days for mental health concerns.
DCoE is leading efforts to standardize DOD telehealth services for
psychological health and TBI including the establishment of a Federal
Partners Exploratory Committee on telemental health. The Center is
working with the MHS' Office of the Chief Medical Officer to define
telemental health as a standard of care. Leveraging the capabilities of
the Services, TRICARE, and civilian providers, DCoE had recently begun
serving as a coordinating and resource center for an emerging
telehealth network of systems across DOD. Efforts are focused on
establishing a collaborative network to rural and underserved locations
by connecting various rural patients with treatment facilities via
telehealth technologies, including web-based applications.
strengthening resilience and reducing stigma
To strengthen resilience to psychological stress and traumatic
events, the Department is implementing solid prevention and health
protection policies, including removing or mitigating organizational
risk factors, bolstering resilience characteristics in our Service
personnel, and strengthening family wellness.
To reduce the stigma associated with mental health issues, the
Department is mounting a pro-resilience and anti-stigma campaign, and
has established a number of effective outreach and educational
initiatives. For example, we gained line leadership support for the
effort to increase psychological fitness through resilience-building
programs. We also eliminated the requirement to divulge combat-related
mental health history on security clearance forms.
In November, 2008, with the assistance of the Service Vice Chiefs,
DCoE began development of the ``Real Warriors, Real Battles, Real
Strength'' campaign, which stresses the impact of war on servicemembers
and emphasizes that seeking help for psychological concerns is a sign
of strength. Supporting initiatives already have been implemented
across the Services to target their individual cultures. The DOD-wide
campaign is scheduled to begin in April 2009.
The DCoE also helped develop educational tools, including a project
with the nonprofit organization behind ``Sesame Street,'' to produce
more than 700,000 DVDs to help families, and especially children, cope
with deployed parents or loved ones. To date, more than 350,000 of
these DVDs have been distributed.
One exciting initiative in this area is ``SimCoach,'' a program
currently under development that will allow warriors and families to
electronically query top experts in psychological health and TBI, and
discuss their injuries with their peers.
Specifically targeted to the Armed Forces younger population,
SimCoach will combine the best of simulation, advanced gaming
technology, artificial intelligence, and avatar-based computer
interaction to encourage warriors and their families to initiate
treatment or access educational resources. It will also reduce the
stigma associated with seeking psychological health care.
caring for patients in transition
The DOD is working with its Federal and private sector partners to
eliminate gaps in care as patients transition through the various
health systems, or to different duty locations. For example, we
recently established an assisted living pilot program in Johnstown, PA,
to improve functionality and independent living after TBI. This program
will provide valuable insight for replication in other areas where
appropriate. We also provided significant support to DOD/VA efforts to
establish the Federal Care Coordination program and stood up a TBI care
coordination system to integrate Federal, State, and local resources.
screening and surveillance
To ensure early identification and intervention of mental health
and TBI issues, the Department enhanced post-deployment assessments and
reassessments. Additionally, in July 2008, the Department began
conducting baseline neuro-cognitive assessments on Active and Reserve
personnel prior to deployment. To facilitate the continuity of care for
veterans and servicemembers, we implemented a common DOD/VA post-
deployment TBI assessment protocol, which will allow clinicians, across
the enterprise, to collect and access the same information.
We designed and implemented the Mental Health Self Assessment
Program, which offers Service personnel and their families the
opportunity to identify their own symptoms and access assistance before
a problem becomes serious. The self-assessments address PTSD,
depression, generalized anxiety disorder, alcohol use, and bipolar
disorder, and may be taken anonymously online, over the phone, or at
special events held at installations. After completing a self-
assessment, individuals receive referral information that includes
services provided by TRICARE, Military OneSource, and VA Vet Centers.
medical and cross-functional research
The Department is building a network in which to leverage and
direct medical and cross-functional research that will enhance
prevention, detection, diagnosis, and treatment of combat-related
psychological health and TBI issues. For example, with the support of
the Service Vice Chiefs of Staff and the Surgeons General, DCoE is
sponsoring an expedited, intramural (DOD facilities), multi-center
randomized clinical trial of hyperbaric oxygen (HBO2) therapy for
chronic and mild-to-moderate TBI patients.
The study, which is in the advanced development phase, will answer
important questions regarding efficacy in this population, including
whether HBO2 therapy should be provided to servicemembers when
indicated. Currently, the study is awaiting Investigational New Drug
registration by the Food and Drug Administration (FDA). Once FDA
approval is obtained, we expect the study to be completed in about 18
months.
The DCoE also participated in blast mitigation studies through and
with the United States Army Medical Research and Materiel Command, and
is working with external groups, such research universities as the
Massachusetts Institute of Technology and Virginia Tech and the
National Football League, to explore new ways to mitigate the effect of
blast and blunt trauma on our populations.
Together with ongoing research activities supported by the Joint
Improvised Explosive Device Defeat Organization, and the Institute of
Soldier Nanotechnology, we have learned a great deal about how to keep
our servicemembers safe before, during, and after physically traumatic
events.
In addition, we initiated numerous research projects to enhance the
diagnosis and treatment of TBI and mental health conditions. Indeed,
thanks to the tremendous support of Congress, DOD is now one of the
world's leading sponsors of such research. The Department has initiated
research projects across the continuum of care to further science in
the areas of TBI and psychological health, including:
Basic research directed toward gaining greater
understanding of the brain and how it works;
Applied research to provide more in-depth knowledge of
TBI and psychological health prevention, treatment, diagnosis,
and recovery techniques;
Advanced technology development to create new tools,
technologies, pharmaceuticals and devices, and treatment
protocols to improve prevention, diagnosis, treatment, and
recovery;
Clinical trials to demonstrate the safety, toxicity,
and efficacy of candidate pharmaceuticals, prototype medical
devices, or protocols benefiting patients diagnosed with TBI or
mental health conditions; and
Complementary and alternative medicine approaches to
the treatment of PTSD and TBI, such as yoga or acupuncture.
dod/va data sharing
While Line of Action 2 was actively expanding and implementing
programs on psychological health and TBI, Line of Action 4 was working
closely with our VA partners to evolve and expand the appropriate
sharing of medical and beneficiary data between DOD and VA. We have
worked closely with multiple program offices in both Departments, as
well as the DOD/VA Interagency Program Office, to ensure that
information is viewable, accessible, and understandable through secure
and interoperable information management systems
We have made great strides forward in the electronic sharing of
benefits, personnel, and health information between DOD and VA during
the past few years. Intensive planning and collaboration regarding
health, personnel, and administrative DOD/VA electronic data exchange
continue to enhance the support we provide for our wounded, ill, or
injured servicemembers and veterans. Key LOA4 health data sharing
accomplishments since February 2007 include the following:
Initiated electronic transmissions of DOD digital
radiographs and scanned medical records from three major DOD
Medical Centers to four VA Polytrauma Centers;
Increased data sharing between DOD and VA from a few
DOD sites before July 2007 to all DOD sites today;
Added procedures, inpatient discharge summaries,
Theater clinical data, vital signs, family history, social
history, other history, and questionnaires to the data already
available between DOD and VA for shared patients;
Established the DOD-VA Interagency Clinical
Informatics Board to give clinicians a direct voice in the
prioritization of enhanced health information sharing
capabilities that will enhance care delivery for common
beneficiaries treated by DOD and VA;
Increased the availability of inpatient discharge
summaries shared with VA from 7 percent of DOD inpatient beds
to over 50 percent;
Enabled the exchange of computable outpatient pharmacy
and medication allergy data at all DOD sites; and
Began implementation activities to support National
Guard and Reserve component remote access to AHLTA, DOD's
electronic medical record.
We are committed to continue to evolve and expand the appropriate
electronic sharing of health, personnel, and benefits information to
enhance care delivery and continuity of care for shared patients. In
fact, current health information exchange capabilities between the
Departments are well ahead of those in the private sector both in scope
and scale. The current level of sharing has built a strong foundation
for information interoperability needed to achieve our shared vision.
Today, this shared information supports the delivery of high-quality
healthcare and the administration of benefits to our servicemembers and
veterans. With joint leadership, DOD and VA continue to develop and
implement numerous interoperability initiatives. We are delivering
information technology solutions that significantly improve the secure
sharing of appropriate electronic health, personnel, and benefits
information for our shared beneficiaries and support continuity of care
for servicemembers transitioning to veteran status.
Another witness, RADM Gregory Timberlake, will provide more
information on the Interagency Program Office, which oversees the
development and implementation of electronic health record systems or
capabilities that allow for full interoperability of personal health
care information between DOD and VA.
conclusion
Mr. Chairman, the inspirational author Ralph Marston, tells us that
``Excellence is not a skill. It is an attitude.'' Throughout DOD, we
have adopted an ``excellence attitude'' about psychological health and
TBI and, as a result, we have made remarkable progress in advancing
critical solutions to the problems they present for individuals and
families.
Mr. Marston also reminds us that, ``It takes a long time to bring
excellence to maturity.'' In that regard, he is also right--which means
that, despite the progress, much work remains.
We will continue to work with our private sector care partners to
ensure the quality and consistency of care. We will continue to work to
meet the needs of our Reserve Forces, especially those in rural or
underserved areas. We will continue to do more at the policy level to
adapt lessons learned and eliminate gaps in care for those in
transition. We will continue to improve our efforts to recruit and
retain high quality mental health providers while working with our VA
partners to improve utilization strategies. We will continue to pursue
every avenue to affect the suicide rates. We will continue to improve
our abilities to share and exchange data with VA. We will continue to
seek new ways to expand our knowledge and improve our ability to care
for our servicemembers, veterans, and their families.
DOD greatly appreciates the committee's strong support of America's
Armed Forces and the concern you have shown for their health and well
being. We have made great progress in meeting the challenges on many
fronts and with the committee's continued help and support, we will do
even more.
Thank you for the opportunity to bring you up to date. We look
forward to your questions.
STATEMENT OF ROGER DIMSDALE, EXECUTIVE DIRECTOR, DEPARTMENT OF
VETERANS AFFAIRS/DEPARTMENT OF DEFENSE COLLABORATION, OFFICE OF
POLICY AND PLANNING, DEPARTMENT OF VETERANS AFFAIRS
Mr. Dimsdale. Good afternoon, Chairman Nelson, Ranking
Member Graham, Senator Hagan. I want to thank you for inviting
the VA to participate in this hearing. My name is Roger
Dimsdale and I'm pinch-hitting for Karen Pane, who's the acting
Assistant Secretary for Policy and Planning. She had a family
emergency and was not able to attend.
Before I start with my oral statement, I would like to
thank the members of the first panel. I learned a lot by
listening to what they had to say. It's obvious that we have a
ways to go. We're heading in the right direction, but we
obviously have placed more emphasis on care and case
management. I would also appreciate that my written statement
be entered into the record.
Senator Ben Nelson. It will be.
Mr. Dimsdale. Mr. Chairman, I want to assure you and the
committee that Secretary Shinseki is fully committed to
supporting America's wounded warriors and veterans. As a sign
of that commitment, Secretary Shinseki has already met with
Secretary Gates four times to discuss wounded warrior issues.
As Ms. McGinn brought up today, they co-chaired a SOC meeting
during the transition.
They have recently agreed to establish a joint Virtual
Lifetime Electronic Record (VLER). The latest acronym is VLER,
so I'll use the term VLER as we continue through the testimony
here. On April 9, the President added support to the VLER. He
and the two Secretaries announced the establishment of a joint
virtual electronic record. The VLER will be for all current and
future servicemembers, veterans, and eligible family members,
and will contain all data to uniquely identify them and ensure
the delivery of care and benefits for which they're eligible.
The VLER will begin when an individual enters the Service
and will continue throughout the period of time he or she is in
the Service, into the veteran status, and throughout their
life. It will contain health and administrative data, so the
idea is this will be one single record, one single virtual
electronic record which will track men and women throughout the
life span of their service.
VA and DOD, of course, have been working for years on this
issue and recently have started to see some progress.
Electronic records are a priority of the administration.
Secretary Shinseki intends to do more than talk about it,
and he holds our department accountable to accomplish this
task. Another important example of an area in which DOD and VA
have accomplished joint activity, is the DES pilot. The DES
pilot was a demonstration project initially, then in the
national capital region, to resolve the confusing aspects of
the existing system, and to shorten the overall time required
to complete the process.
The pilot is intended for those servicemembers who are
being medically separated or retired. The processing time for
those currently enrolled in the pilot has been reduced by
greater than 50 percent. Our business rule is that
servicemembers departing Active Duty will receive their VA
disability benefit check the month after they leave Active
Duty.
The pilot is currently conducted at 14 sites, with plans to
expand and enhance the DES process to another 6 by August 31,
2009. DOD and VA will submit a report to Congress on the
lessons learned from the pilot, along with the recommendations
as to the way ahead.
As a result of what we've seen so far, VA and DOD would
like to extend the policies and lessons learned from the pilot
program to additional installations, taking this phased
approach to wider implementation of the enhanced process. We'll
help ensure success by making sure that we have the right
processes in place.
The VA's also very proud of the success of the joint DOD/VA
FRCP. Dr. Karen Guice, the Executive Director of the FRCP for
VA, is here with me to share with you details about the
successes of the FRCP.
We also believe that the successes we have seen in these
joint efforts, as well as others I've listed in my written
testimony, are the direct result of a structure that allowed us
an open dialogue, encouraged collaboration, and focused on
results.
We have not changed our level of support for the SOC since
it was started in May 2007 and will continue to do so. As
you're aware, the NDAA for Fiscal Year 2009, section 726,
requires that both departments write Congress on the way ahead
for the SOC and the JEC, and we fully intend to work with DOD
to submit a joint report.
While we were pleased with the joint efforts and progress
made, there's a good deal more to do. The VA is committed to
providing support for our Nation's wounded warriors and
veterans. As such, we believe that continued partnership with
DOD is critical.
The comment was made earlier in the GAO testimony that
working harmoniously is the way ahead, and we are working
harmoniously. DOD and VA are hand in hand. Certainly there are
issues that take one department's track versus another. But
overall, the cooperation has been great and will continue to be
so.
Thank you, Mr. Chairman and subcommittee members, for the
opportunity. I look forward to answering any questions.
[The joint prepared statement of Mr. Dimsdale and Dr. Guice
follows:]
Joint Prepared Statement by Roger Dimsdale and Karen Guice, MD, MPP
Good afternoon Chairman Nelson, Ranking Member Graham, and members
of the committee. My name is Roger Dimsdale, and I am the Executive
Director of the VA/DOD Collaboration Office for the Office of Policy
and Planning at the Department of Veterans Affairs (VA). I am pleased
to provide the Subcommittee with the accomplishments and challenges
related to implementing the various elements of the Wounded Warrior
Act. I will also discuss the cooperative efforts between VA and the
Department of Defense (DOD) responsible for the progress made to date,
as well as our strategy for continued action. First, however, I would
like to emphasize the administration's level of support for these
activities.
Secretary Gates and Secretary Shinseki have publically articulated
their commitment to continued inter-Departmental cooperation. They are
particularly supportive of joint activities that resolve issues
concerning Wounded Warriors and have met numerous times to affirm their
commitment and provide general guidance to staff.
Successful implementation of the various provisions of the Wounded
Warrior Act is a direct result of the structured interaction between
the two Departments through the Senior Oversight Committee (SOC). The
Overarching Integrated Product Team (OIPT), consisting of eight Lines
of Action (LOA), supports the SOC. Each LOA is co-led by
representatives from VA and DOD. This unique structure coordinates,
monitors, and implements the over 600 recommendations from a variety of
commissions, task forces, and studies. Currently, the two Departments
maintain a collocated staff to support SOC and Joint Executive
Committee (JEC) issues. Section 726 of the Duncan Hunter National
Defense Authorization Act for Fiscal Year 2009 extended SOC operations
until December 31, 2009. VA strictly interprets this mandate and has
not changed its approach or organizational support to the LOAs.
I would like to highlight some of the jointly developed and
implemented accomplishments resulting from the Wounded Warrior Act. I
will focus on the significant improvements to the disability evaluation
system (DES), the collaborative efforts addressing psychological health
and traumatic brain injury (TBI) through the Defense Centers of
Excellence, innovative approaches to care management and coordination,
the shared information technology (IT) efforts directed by the
Interagency Program Office (IPO), and the various co-developed outreach
materials and communication strategies.
disability evaluation system
Improvements to the DES and VA compensation and pension program
include: (1) the pilot program; (2) revisions to the VA Schedule for
Ratings Disabilities (VASRD); and (3) expedited claims processing for
Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) veterans
by VA.
DOD and VA are currently conducting a pilot program to improve the
current disability processes. The project, initially started at the
medical treatment facilities in the National Capital Region, is
expanding to include other facilities around the Nation. Key features
include a single medical examination and disability rating for use by
both Departments, as well as a reduction in the time required to
transition to veteran status and receive VA benefits and compensation.
Updating the VASRD to reflect the best medical information, and the
signature conditions associated with new conflicts, is a priority. New
rating criteria for the assessment of residuals of TBI became effective
on October 23, 2008. The Veterans Benefits Administration (VBA) is
processing claims from very seriously injured and seriously injured
OEF/OIF Veterans on a first priority basis. VBA also conducts priority
claims processing for initial and reopened claims from all in-theater
war veterans received within 6 months after separation from service and
appeals from such veterans of the initial claims decisions following
such service. Subsequent PTSD claims submitted by returning theater
veterans receive priority processing as well.
psychological health and traumatic brain injury
The Defense Centers of Excellence (DCoE) for Psychological Health
and Traumatic Brain Injury is comprised of an active headquarters
element, along with six component centers, including:
Defense and Veterans Brain Injury Center;
Center for Deployment Psychology;
Deployment Health Clinical Center;
Center for the Study of Traumatic Stress;
National Intrepid Center of Excellence; and
National Center for Telehealth and Technology.
Over the past year and a half, the DCoE and its component centers
have participated actively in several joint VA/DOD activities,
including:
Developing training programs for DOD and VA personnel
for the evaluation and follow-up of patients with TBI--1,500
participants have been trained thus far
Developing a coding proposal that addresses
International Classification of Diseases (ICD-9) coding for
TBI, recently reviewed by the National Center for Health
Statistics
Developing Clinical Practice Guidelines for mild TBI,
as well as updating the Clinical Practice Guidelines for
Substance Abuse and PTSD
Cosponsoring the Annual Suicide Prevention conference
in January 2009, bringing together experts from the Federal and
civilian sectors to increase collaboration and communication on
the key topic of suicide prevention
Participating in the Federal Partners Priority Work
Group on Reintegration
Co-sponsoring a scientific conference on gender and
racial issues in Psychological Health and TBI on October 1 and
2, 2008 with NIH.
Separately, DOD has provided $45 million to the DCoE for research
to advance the assessment, treatment, and prevention of TBI and
psychological health conditions. Five million dollars of these funds is
targeted specifically for complementary and alternative medicine
approaches to the treatment of psychological health problems and TBI.
care coordination and management
DOD and VA have made significant improvement to the care and
transition of recovering servicemembers. VA and DOD collaborate on
issues related to mental and psychological health through a number of
interactions, involving the DCoE as well as other mechanisms. Military
liaisons at the four major VA Polytrauma Rehabilitation Centers provide
a direct connection to the various military services. VA provides
liaison officers at selected Military Treatment Facilities (MTF) to
assist in delivery of VA care and benefits. Each VA medical center has
an OEF/OIF team that facilitates transfers and coordinates VA care at
that facility. The military Services have also created service-specific
Wounded Warrior Programs to assist recovering servicemembers at each
MTF. Finally, the Federal Recovery Coordination Program (FRCP), a joint
program of DOD and VA, assists recovering servicemembers, veterans, and
their families with access to care, services, and benefits provided
through the various programs in DOD, VA, other Federal agencies,
states, and private sector.
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
nongovernmental 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.
FRCP clients work with their Federal Recovery Coordinator (FRC) to
create a goal-based Federal Individualized Recovery Plan (FIRP) with
input from their family or caregiver, as well as from members of the
client's multidisciplinary health care team. The FRC implements the
plan by working with existing governmental and nongovernmental
personnel and resources.
Within the overall framework of care coordination and each client's
particular needs and goals, the FRCs work with military liaisons,
members of the Services Wounded Warrior Programs, service recovery care
coordinators, TRICARE beneficiary counseling and assistance
coordinators, VA vocational and rehabilitation counselors, military and
VA facility case managers, VA Liaisons, VA specialty case managers,
Veterans Health Administration and VBA OEF/OIF case managers, VBA
military services coordinators, and others. FRCs do not directly
deliver services; they coordinate the delivery of services and serve as
a resource for enrolled servicemembers, veterans, and their families.
Currently, 14 FRCs are working at 6 military treatment facilities
and 2 VA medical centers. They are supported by a VA Central Office
staff that includes an Executive Director, two Deputies (one for
Benefits and one for Health), an Executive Assistant, and a Staff
Assistant. In addition, the program receives personnel support at VA
Central Office from the U.S. Public Health Service and DOD, with each
sending two individuals on detail.
information technology collaboration
DOD and VA have taken crucial steps toward creating a Joint Virtual
Lifetime Electronic Record (VLER), as announced by President Obama on
April 9, 2009. Both Secretaries are dedicated to ensuring strong
executive oversight with specific attention to the Interagency Program
Office, mandated by the Wounded Warrior Act (title XVI of the National
Defense Authorization Act for Fiscal Year 2008), on behalf of VA and
DOD, to provide oversight for VA-DOD data sharing initiatives. The
emerging vision for the VLER initiative is for all current and future
servicemembers, veterans, and eligible Family Members to have a VLER
that will encapsulate all data necessary to uniquely identify them and
ensure the delivery of care and benefits for which they are eligible.
This proactive delivery begins upon oath of military service and
continues beyond death to survivor benefits. To the user, the
perception will be that one Federal entity delivers all benefits, care,
and support.
DOD and VA will develop workgroups to define the common services
used by information processes in both Departments as well as the common
functional processes within services unique to each Department. Joint
DOD-VA efforts have already begun to define the data and business
processes for this effort. The result will be an unprecedented unified
data sharing between the two Departments.
outreach and communication efforts
The Wounded Warrior Act called for joint outreach efforts to
recovering servicemembers, veterans, and their families. As a result,
web-based applications, assistance centers, and direct outreach
activities were developed.
The web-based National Resource Directory (the Directory) provides
information on services and resources available through Federal, State,
and local governmental agencies, veterans' benefit/service/advocacy-
organizations, professional provider associations, community and faith-
based/nonprofit organizations, academic institutions, employers, and
philanthropic activities of business and industry. The Directory was
developed jointly, and is currently co-managed by DOD, VA, and the
Department of Labor.
Other efforts include the Wounded Warrior Resource Center. This
consists of a DOD website as well as a call center, and serves as a
single point of contact for wounded, ill, and injured servicemembers,
their families, caregivers, and those who support them. A MyeBenefits
portal, currently under development, will provide individualized
information upon login for all servicemembers and veterans.
The National Guard Family Assistance Centers conduct in-person
outreach for National Guard members throughout the 50 States, the
District of Columbia, and U.S. territories. The Centers augment the
support system for geographically dispersed families by providing
information, referrals, and assistance to families during a
servicemember's deployment. They support any military family member
from any military branch or component.
The Yellow Ribbon Reintegration Program provides National Guard and
Reserve members and their families with information about services
throughout the entire deployment cycle. VA participates in this effort
with representation on the Advisory Board and assignment of a VA
liaison within the program office.
A handbook was developed by DOD and VA to help injured
servicemembers and their families navigate the DOD and VA systems. The
handbook is available electronically or in book format.
challenges
Despite our collective success, we recognize that we have more work
to do to implement the Wounded Warrior Act fully. Specifically, we
must:
Maintain a shared structure that continues to provide
guidance and oversight for these efforts;
Continue to work toward one system that supports our
wounded warriors;
Continue to address the unique needs of the National
Guard and Reserve components;
Continue to work toward sharing information between
the two Departments; and
Continue to address the mental health needs, including
addressing the stigma that continues to be associated with
seeking treatment for mental health disorders.
conclusion
Successful collaboration between the Departments is a direct result
of the coordination and oversight of the SOC. Secretary Shinseki and
Secretary Gates continue to promote, support and direct these efforts
through their actions, including their co-chairing of the SOC and the
JEC.
While we are pleased with the joint efforts and progress made,
there is a good deal more to do. VA is committed to providing support
for our Nation's wounded warriors and veterans. As such, we believe
that continued partnership with DOD is critical, and no less than our
servicemembers and veterans deserve.
Thank you again for your support to our wounded, ill, and injured
servicemembers, veterans, and their families.
We look forward to your questions.
Senator Ben Nelson. Thank you.
General Meurlin.
STATEMENT OF MAJ. GEN. KEITH W. MEURLIN, USAF, DIRECTOR, OFFICE
OF TRANSITION POLICY AND CARE COORDINATION, DEPARTMENT OF
DEFENSE
General Meurlin. Chairman Nelson, Senator Graham, thank you
for the opportunity to represent DOD and the Office of
Transition Policy and Care Coordination this afternoon. I would
like to briefly mention a few major areas where my office is
currently engaged.
The Physical Disability Board of Review has been
established and is up and running. Although we encountered some
challenges getting the program started, we're currently making
very good progress. We're in the process of reevaluating our
approach in two areas and expect significant modifications to
be announced in the near future.
The first area pertains to the scope of the review. It is
our current intention to review all findings of the PEB, those
fitting and unfitting conditions, along with the ratings
assigned to those conditions. The second is the service
specific DOD guidance that conflicts with the VA's Schedule for
Rating Disabilities (VASRD) will be disregarded, and the
conditions and rating will be evaluated only with VASRD in
effect at the time the initial findings and determinations were
made.
We believe both of these changes are consistent with
congressional intent, and understand making these changes as
soon as possible is a matter of great concern to the committee.
The Recovery Care Coordination program is up and running,
with the initial cadre of 31 RCCs deployed to 13 military
sites.
My staff is training an additional 100-plus Army AW2
advocates as RCCs using the standard DOD curriculum, which
includes standard assessment tools and a comprehensive recovery
plan for recovering servicemembers assigned an RCC. The Navy,
Marine Corps, and Air Force are assessing how many more RCCs
will be needed to ensure our recovering servicemembers are
supported.
We have issued interim recovery coordination program policy
and the DOD instruction to establish uniform policy--uniform
policy for the program implementation and deployment of RCCs
and the development of a comprehensive recovery plan.
Ongoing site visits, analysis of the standard assessment
tools, and customer satisfaction surveys will allow us to
evaluate the program, to assess the population served, and
placement of additional RCCs. Recent discussions with the
Services indicate that they are on board with these
requirements.
The third thing I'd like to mention is the progress we've
made in regards to the DES pilot program. There will be a total
of 21 sites participating in the program by June and anticipate
starting an evaluation in the near future.
The pilot is due to report to the SOC this coming August,
and it's imperative to note, however, that the DES pilot is not
an end-all solution, but rather a bridge, with the ultimate
goal being in integrating DOD and VA systems at logical nodes.
Ultimately, it is time for a national dialogue on how
America supports its wounded, ill, and injured. We need to
break down more barriers to trust and transparency, and shift
away from a focus on paying entitlements to one of recovery,
rehabilitation, transition, and making the servicemember a
viable member of society.
The Secretary of Defense put in place a voluntary program
that provides the ability to expedite a servicemember through
the DES. The expedited DES process is a special benefit for
those servicemembers who sustain catastrophic injuries or
illnesses from combat or combat-related operations, as defined
in the policy. The establishment of the policy supports the
Department's belief that there must be a special process for
those members who sustain catastrophic disabilities while
participating in combat or combat-related operations, in
contrast with those disabled otherwise.
We are excited about this program because it allows the
early identification of a full range of benefits, compensation,
and specialty care offered by VA.
Finally, in the area of personnel pay and financial
support, I'd like to bring your attention to the concept of
caregiver compensation. The Center for Naval Analyses (CNA) is
completing a study of wounded warrior caregivers, identifying
that mothers and spouses spend on average up to a year, and in
severe cases, much longer, providing physical and emotional
support to their recovering servicemembers.
The final report from CNA will be published shortly. Based
on CNA's preliminary findings which were released in December,
the Department proposed legislation for fiscal year 2010 to
provide catastrophically wounded servicemembers with a special
monthly compensation for their caregivers. The amount of the
compensation would be based on the monthly income of a home
health care aide and would continue until the catastrophically
wounded servicemember transitions to VA.
My bottom line is that America's families turned over their
loved ones to us. We're returning some of them wounded, ill,
and injured. The servicemembers and their families earned and
deserve to have the best that we have to offer. We pledge to
continue the work with your staff, VA, the Department of Labor,
and others, to make that happen.
Thank you for this opportunity. I look forward to your
questions.
[The prepared statement of General Meurlin follows:]
Prepared Statement by Maj. Gen. Keith Meurlin, USAF
Mr. Chairman, subcommittee members, I am pleased to be here today
to discuss with you the Department's continued support of our wounded,
ill, and injured servicemembers, veterans, and their families, and in
particular, the continued work of the Office of Transition Policy and
Care Coordination.
background
On 14 November 2008, the Under Secretary of Defense for Personnel
and Readiness established the Office of Transition Policy and Care
Coordination (TPCC). It's mission is to ensure equitable, consistent,
high-quality care coordination and transition support for members of
the Armed Forces, including wounded warriors and their families through
appropriate interagency collaboration, responsive policy and effective
program oversight. The TPCC assumed responsibility for policy and
programs related to the Disability Evaluation System, servicemembers'
separation from the Armed Forces and transition to veteran status,
wounded warrior case and care coordination, and related pay and
benefits. These assigned responsibilities include the totality of the
Department of Defense (DOD) functions formerly assigned to the DOD and
Department of Veterans Affairs (VA) Wounded, Ill, and Injured Senior
Oversight Committee (SOC) Lines of Actions (LOAs) 1, 3, and 8. The TPCC
also assumed responsibility for management and monitoring of
performance against DOD/VA Benefits Executive Council (BEC) goals and
for coordinating with VA in support of BEC activities. The TPCC has the
authority to enter into agreements with VA and represent the Under
Secretary of Defense for Personnel and Readiness as a member on
councils and interagency forums established under the authority of the
DOD/VA Joint Executive Council (JEC), the BEC and the SOC. A TPCC
Strategic Plan has been created incorporating objectives from the Under
Secretary of Defense for Personnel and Readiness and the JEC.
disability evaluation system (loa-1)
The mission of LOA-1, Disability Evaluation System (DES), is to
develop and establish one solution for a DOD and VA DES that is
seamless, transparent, and administered jointly by both Departments and
uses one integrated disability rating system, streamlining the process
for the servicemember transitioning from DOD to VA. That system must
remain flexible to evolve as trends in injuries and supporting medical
documentation and treatment necessitates. LOA-1 has continued to make
significant steps forward in regards to the DES Pilot to include the
pilot's expansion, the Expedited DES, and the Physical Disability Board
of Review.
Disability Evaluation System Overview
Now, as in the past, the DOD remains committed to providing a
comprehensive, fair, and timely medical and administrative processing
system to evaluate our injured or ill servicemembers' fitness for
continued service using the DES. One way we have honored these men and
women, was to develop and establish a DES pilot that provides one
solution for a DOD and VA DES using one integrated disability rating
system. This system has several key features: simplicity; non-
adversarial processes; single-source medical exam and disability
ratings (eliminating duplication); seamless transition to veteran
status; and strong case management advocacy. The system must remain
flexible to evolve as trends in injuries and supporting medical
documentation and treatment necessitates. LOA-1 has continued to make
significant progress in regards to the DES Pilot to include the Pilot's
expansion, the Expedited DES, and the Physical Disability Board of
Review. However, it is time for a national dialogue on how America
supports it wounded, ill, and injured. We need to break down more
barriers to trust and transparency, and shift away from a focus on pay
and entitlements to one of recovery, rehabilitation, transition, and
making the veteran a viable member of society.
Disability Evaluation System Pilot
During the reporting week ending April 19, 2009, 80 servicemembers
entered the DES Pilot from 14 Military Treatment Facilities (MTFs) for
a cumulative enrollment of 1,929 servicemembers since 26 November 2007.
Of those, 344 servicemembers have completed the DES pilot by returning
to duty, separating from service, or retiring. Seventy servicemembers
were removed from the DES pilot for other reasons such as transferring
to a location outside the DES pilot or case termination for pending
administrative discharge processing. Currently, 1,515 servicemembers
remain enrolled in the DES pilot.
Active component servicemembers who completed the DES pilot
averaged 271 days from Pilot entry to VA benefits decision, excluding
pre-separation leave. Including pre-separation leave, Active component
servicemembers completed the DES pilot in an average of 286 days. This
represents a process which is 47 percent faster than the current DES
and VA Claim process, and 3 percent faster than the 295 days originally
projected for the pilot. Reserve component and National Guard
servicemembers, who completed the DES pilot, averaged 249 days from
pilot entry to issuance of the VA benefits letter, which is 18 percent
faster than the projected 305 day timeline.
DES Pilot Expansion
Based on guidance from the SOC, the DES pilot will expand to a
total of 21 sites by June, 2009. In addition to the locations in the
National Capital Region, which include Fort Belvoir and Fort Meade, the
following expansion sites are now operating or are prepared to commence
DES pilot operations:
Naval Medical Center San Diego, CA and Fort Stewart,
GA, as of November 2008
Camp Pendleton, CA, as of January 2009
Naval Medical Clinic Bremerton, WA, Vance Air Force
Base, OK, and Fort Polk, LA, as of February 2009
Nellis Air Force Base, NV, MacDill Air Force Base, FL,
and Marine Corps Base Camp Lejeune, NC, as of March 2009
Fort Drum, NY, and Fort Richardson, Fort Wainwright,
and Elmendorf Air Force Base, AK, will commence operations on
April 30, 2009
Studies, Reports, and Policy Updates
Data gathering and analysis are ongoing to support an August 2009,
expansion decision by the SOC and delivery of a final report to
Congress as required by National Defense Authorization Act (NDAA) 2008,
section 1644(g)(3). Reports DOD previously delivered to Congress
include:
Feasibility of combining DOD and VA DESs (NDAA 2008,
Sec. 1612)
Report on rating reductions after Physical Evaluation
Board appeals (NDAA 2008, Sec. 1615(e))
Initial and Interim Status reports on the DES Pilot
(NDAA 2008, Sec. 1644)
Initial Report on Army Medical Action Plan action to
improve Army DES (NDAA 2008 Sec. 1645)
Report on the continuing utility of the Temporary
Disability Retirement List (NDAA 2008, Sec. 1647)
Additionally, DOD continues to learn lessons from the pilot and
capitalize on a continuous improvement process. Since August 2007, the
Department, with VA coordination, has published seven policy updates.
We will continue to refine the DES until national reform is complete.
Expedited DES
The Secretary of Defense established a voluntary program that will
expedite a servicemember through the DES. The Expedited DES process is
a special benefit to those servicemembers who sustain catastrophic
injuries or illnesses from combat or combat-related operations as
defined in the policy. The establishment of the policy supports the
Department's belief that there must be a special process for those
members who sustain catastrophic disabilities while participating in
combat or combat-related operations, in contrast with those disabled
otherwise.
To qualify, a servicemember's condition must be designated as
``catastrophic'' and the injuries or illnesses must have been incurred
in the line of duty and received as a result of the causes prescribed
under the statutory definition of ``Combat-Related'' as used in the
combat-related special compensation program. Under the Expedited DES,
servicemembers receive a presumed 100 percent disability retirement
from DOD. The Expedited DES process will allow the early identification
of the full range of benefits, compensation and specialty care offered
by the Department of Veterans Affairs.
Physical Disability Board of Review (PDBR)
On January 12, 2009, the PDBR began accepting applications. As of
April 22, 2009, the board received 306 applications. The board
forwarded 148 cases to the military Services and 117 to the VA for
records retrieval. The board has 19 complete records assembled and
ready for adjudication and has closed 22 cases for administrative
reasons. The board members have been assigned, trained on the PDBR
process, and have received rating training from VA as well as cross
training in other Service disability processes. The Central
Adjudication Unit is 100 percent operational and has been permanently
occupied since February 16, 2009. The Air Force, acting as the lead
component of the PDBR, has negotiated privileges for direct computer
access to VA claims records.
care coordination (loa-3)
The mission of LOA-3, Care Coordination, is to simplify the care
coordination process by providing uniform standards for wounded, ill,
and injured servicemembers and their families throughout their
continuum of care from recovery, rehabilitation, and return to duty or
reintegration into the community.
Comprehensive Policy for Care, Management, and Transition of Recovering
Servicemembers
A DOD Directive Type Memorandum, ``Recovery Coordination Program:
Improvements to Care, Management, and Transition of Recovering
Servicemembers'', was published and implemented by the Services'
Wounded Warrior Programs in January 2009. A working group chaired by
the Care Coordination Office in the Office of Transition Policy and
Care Coordination is now writing the DOD Instruction to fully address
the NDAA fiscal year 2008 requirements to establish Recovery Care
Coordinators (RCCs) and a Comprehensive Recovery Plan for all
recovering servicemembers. Members of the working group include
representatives from the Service Wounded Warrior Programs, Surgeons
General, Assistant Secretaries for Manpower and Reserve Affairs, Health
Affairs and, Family Support Programs, the Joint Chiefs of Staff, Joint
Task Force National Capital Region Medical, OSD Reserve Affairs,
Services' Reserve Components, and the Department of Veterans Affairs.
Recovery Care Coordinators
Currently there are 31 RCCs deployed across the United States at 13
MTFs and installations. The RCCs have been trained using uniform,
standard DOD curriculum, as required by Congress. This week my staff is
training an additional 100 plus Army AW2 advocates as RCCs using this
uniform standard curriculum.
Recovery Coordination Program Evaluation
Preparation for the initial baseline evaluation of the DOD Recovery
Coordination Program (RCP) is well underway. Metrics are currently
being established to evaluate the program, and assess the current RCC
workload. Customer satisfaction surveys will be administered to
recovering servicemembers and families enrolled in the RCP and assigned
an RCC.
Data Collection/Sharing
`The TPCC has instituted a ``strategic pause'' to review all
existing DOD/VA data sharing systems that pertain to the DOD and VA
RCPs. The study is reviewing and cross-walking the Services' Wounded
Warrior Program existing data collection systems.
We are also conducting a review in mid-May of the standardized
screening and assessment tools used to refer recovering servicemembers
into the RCP. The results of this review and the IT Study will be
incorporated into a solution for a data collection/sharing system for
the RCPs. The data collected will be used to help determine workload
and future deployment of RCCs. I've asked for the study results and
recommendations by the end of May.
National Resource Directory
The DOD, VA, and DoL Web site continues to provide services and
resources for wounded, ill, and injured servicemembers, veterans, their
families, and those who support them. It is an online tool for
accessing more than 10,000 services and resources at the national and
State level to support recovery, rehabilitation, and reintegration into
the community. A recent informal survey reported 90 percent of our RCCs
are using the National Resource Directory to assist them in the
establishment of Comprehensive Recovery Plans and providing services
and resources for our recovering servicemembers and their families.
personnel, pay, and financial support (loa-8)
The mission of LOA-8, Personnel, Pay, and Financial Support, is to
ensure each wounded, ill, or injured servicemember has a level of
compensation, benefits, and financial support to maintain their dignity
and support their recovery, rehabilitation, and reintegration.
LOA-8's accomplishments have continued with the launch of the Navy
Wounded Warrior Database on 29 January 2009 and the release of the
updated Electronic Compensation and Benefits Handbook in February 2009.
LOA-8 has orchestrated advancements in data sharing between the VA and
the Defense Finance and Accounting Service for Active Duty
servicemembers who are being treated as inpatients at VA Medical
Centers. Additionally, LOA-8 has continued to work closely in
cooperation with VA in development of the eBenefits portal with the
next two updated releases expected to be delivered in June and
September 2009 respectively.
closing
We are extremely proud of the progress made to date. Our obligation
to our servicemembers, veterans, and their families is a lifetime
pledge which requires our unwavering commitment to complete the work
which has been started. There remains more work to do. Our valiant
heroes and their families deserve our support and dedication to ensure
their successful transition through recovery, rehabilitation, and
return to duty or reintegration into their communities.
Thank you for your generous support of our wounded, ill, and
injured servicemembers, veterans, and their families. I look forward to
your questions.
Senator Ben Nelson. Thank you, General.
Admiral Timberlake?
STATEMENT OF RADM GREGORY A. TIMBERLAKE, USN, DIRECTOR,
INTERAGENCY PROGRAM OFFICE, DEPARTMENT OF DEFENSE/DEPARTMENT OF
VETERANS AFFAIRS
Admiral Timberlake. Senator Nelson, Senator Graham, thank
you for this opportunity to address you on the status of our,
by which I mean DOD and VA, efforts to achieve full
interoperability between the electronic health care records and
those departments by September of this year.
Let me begin with some background on the DOD/VA IPO, which
had its genesis in the language of section 1635 of the NDAA for
Fiscal Year 2008, which mandated that DOD and VA achieve fully
interoperable electronic health record capabilities by
September 2009, and established the IPO to oversee and help
coordinate this effort.
On April 17, 2008, VA and DOD officially formed the IPO.
Within VA, the IPO was set up to report to the Deputy
Secretary. Within DOD, IPO coordinates most of its activities
through the Defense Human Resource Activity and the Office of
the Under Secretary of Defense for Personnel and Readiness.
The IPO receives strategic guidance from the Secretaries of
DOD and VA, as well as from the JEC, which you've heard
described earlier, the Health Executive Council for health-
related data sharing, and the Benefits Executive Council for
personnel and benefits data sharing.
In the early months, IPO was focused on the basics of
acquiring office space, equipment, determining appropriate
staffing levels, and beginning the process in advertising for
personnel. Today, just under half of the permanent staff have
been hired, standard operating procedures are in place, and a
formal charter has been signed by the Deputy Secretary of VA
and the Under Secretary of Defense for Personnel and Readiness,
which specifies the scope of IPO's oversight responsibilities,
and further clarifies the relationship of the IPO to the two
departments.
The current mission of our office is to provide management
oversight of joint activities to accelerate that exchange of
the electronic health care information between the departments.
In this capacity, IPO is responsible for working with the
departments on issues like supporting the definition of DOD and
VA data-sharing requirements and showing that DOD and VA
schedules are coordinated for the technical execution of the
initiatives; assisting in the coordination of funding
considerations; and assisting on obtaining input and
concurrence of the multiple stakeholders.
Originally, we expected to focus our efforts on the
electronic health care record systems and other health care
data-sharing initiatives between DOD and VA. However, the scope
was later expanded at the suggestion of the Wounded, Ill, and
Injured SOC to include personnel and benefits electronic data-
sharing as well.
Responsibility for development of their requirements and
the execution of information technology solutions still
remained with the respective DOD and VA organizations.
Technical execution also remains in the appropriate
departmental offices, using the departments' established
statutory and regulatory processes for acquisition, funding,
management control, information sharing, and other execution
actions, which are significantly different in each department.
For the immediate term, IPO has centered its energies on
ensuring that by September of this year, the systems are in
place to allow for full interoperability of the electronic
personal health information required for clinical care between
DOD and VA. A key to that has been the adoption of a shared DOD
and VA understanding of the meaning of the phrase ``full
interoperability.''
In our view, that phrase is best defined by the people who
are using the systems daily to deliver care. With this in mind,
we turn to the DOD/VA Interagency Clinical Informatics Board
(ICIB), which is composed of clinicians from both DOD and VA.
It is headed by the Deputy Assistant Secretary of Defense for
Clinical and Program Policy and the Chief Patient Care Services
Officer of the Veterans Health Administration (VHA).
This group was given the responsibility for identifying and
prioritizing the types and format of electronic medical
information which clinicians need in order to provide the
highest levels of care. In July 2008, the ICIB delivered these
recommendations to the IPO and the Health Executive Committee
(HEC), Information Management/Information Technology, Working
Group.
The recommendations were subsequently approved at the HEC,
and then passed down to our DOD and VA information technology
teams as they developed the tools and applications to put these
requirements into operation. By leveraging many prior
accomplishments to the departments toward the development of
interoperable bidirectional electronic health records, the IPO
and the departments were able to formulate a plan to achieve
full interoperability for clinical care by the September 2009
target date.
As a part of this plan, VA's and DOD's ability to utilize
well known interoperability systems, like the Federal Health
Information Exchange and the Bidirectional Health Information
Exchange, has been greatly expanded. At the same time, new
systems have been added to the Clinical Data Repository/Health
Data Repository to allow even more medical data to be
transferred between the two departments.
New pilot programs such as the SHIE imaging project, were
developed. This pilot is now deployed and operational at a
number of major military and VA medical centers across the
country.
Today, I'm pleased to report that I feel we are on target
to achieve full interoperability of electronic health records
for the delivery of clinical care by September 2009 as defined
by the ICIB.
But information technology is not static. As new systems
for capturing, storing, archiving, and retrieving patient data
are developed, we need to make sure that those systems are
built in such a way that they allow the data to be fully shared
between DOD, VA, and authorized private sector providers, such
as our TRICARE network and the VA contract care network.
As I've previously mentioned, on April 9, 2009, the
President announced a new vision for how this would be
achieved, centering on the development of a ``virtual lifetime
electronic record,'' which Mr. Dimsdale has already alluded to.
This virtual lifetime record will leverage investments already
made in the existing DOD and VA electronic record systems, as
well as industry best practices, to provide a system that will
network with new and legacy applications.
Right now, we believe it will be based on a ``common
services'' approach that focuses on the development of
standardized software applications to provide links between
health care and benefits databases across the two departments.
Timing is still in the early stages, but the way ahead looks
promising, and I personally would look forward to briefing you
on the progress, our progress on meeting the President's new
initiative in the future.
Thank you, sir. That concludes my statement, and I look
forward to your questions.
[The prepared statement of Admiral Timberlake follows:]
Prepared Statement bt RADM Gregory Timberlake, USN
introduction
Chairman Nelson and distinguished members of the committee, thank
you for the opportunity to discuss the role of the DOD/VA Interagency
Program Office (IPO) in the ongoing effort to achieve fully-
interoperable electronic healthcare information sharing between the
Department of Defense (DOD) and the Department of Veterans Affairs
(VA). We continue to make great strides in sharing electronic
healthcare information, and have plans to do even more in the near
future.
The sharing of electronic health data has made significant progress
in recent years. I will provide a brief historical overview of these
efforts, outline some of the initiatives that form the foundation for
future sharing efforts, and discuss how the IPO has successfully
managed to grow into the institution that is envisioned by Section 1635
of the National Defense Authorization Act (NDAA) for Fiscal Year 2008.
historical overview
The Departments began laying the foundation for interoperability in
2001, when they first shared healthcare information electronically.
Since that time, both Departments have continued to enhance and expand
the types of information that is shared, as well as the ways in which
it is shared. The following examples illustrate some of the successes
of the Departments' ongoing datasharing initiatives:
The Federal Health Information Exchange (FHIE) data
repository allows electronic health information to be shared on
over 4.7 million separated servicemembers.
The FHIE allows DOD and VA providers to access and
view 71 million laboratory results, 11.6 million radiology
reports, 73.1 million pharmacy records, 75.8 million standard
ambulatory records, and 3.1 million consultation reports, and
2.5 million deployment health assessments for shared patients.
The Bidirectional Health Information Exchange (BHIE)
enables bidirectional real-time sharing of readable electronic
health information between DOD and VA for shared patients.
Since July 2007, BHIE data from all DOD and VA medical
facilities are available to VA and DOD providers.
As of February 2009, health data is available through
BHIE for more than 3.3 million shared patients, including over
117,900 Theater patients.
BHIE also provides bidirectional access to inpatient
discharge summaries from DOD's inpatient documentation system.
This capability is operational at some of DOD's largest
inpatient facilities representing approximately 51 percent of
total DOD inpatient beds. DOD will increase the number of sites
with electronic inpatient documentation system in fiscal year
2009.
In addition to sharing viewable test data, DOD and VA
have expanded the BHIE capability to support the sharing of
digital radiology images. The Departments have expanded the
BHIE Image Pilot to support the bidirectional exchange of
digital images at key locations. The technical accomplishments
and lessons learned from the bidirectional image pilot will be
used in broader image sharing planning activities.
Since 2006, DOD and VA have been sharing computable
outpatient pharmacy and allergy data through the interface
between the Clinical Data Repository of AHLTA, DOD's electronic
health record (EHR), and VA's Health Data Repository (HDR) of
HealteVet VistA. This initiative is called ``CHDR''.
CHDR integrates outpatient pharmacy and medication
allergy data for shared patients that is viewable by providers
in both Departments. Exchanging standardized pharmacy and
allergy data on patients supports better patient care and
safety through the ability to conduct drug-drug and drug-
allergy interaction checks using data from both systems.
In December 2007, all DOD facilities received the
capability to initiate the exchange of this data on shared
patients.
By working together with the senior leadership of DOD and VA,
policies have been established that enable each Department to address
its unique requirements while also addressing shared requirements. This
coordination has been furthered through the formation of oversight and
governing bodies that ensure that information sharing efforts move in
the right direction and at a pace that meets or exceeds the
expectations of our stakeholders. Today, these efforts support the
delivery of high-quality healthcare, continuity of care, and the
administration of benefits to our servicemembers and veterans.
the foundation for interoperability
National Defense Authorization Act for Fiscal Year 2008:
Section 1635 of the NDAA of 2008 requires DOD and VA to jointly
develop and implement electronic health record capabilities that allow
for full interoperability of personal health care information by
September 2009. Section 1635 also requires the development of a DOD/VA
IPO to act as a single point of accountability in the rapid development
and implementation of EHR systems or capabilities that allow for full
interoperability of personal healthcare information between DOD and VA.
On April 17, 2008, a major milestone was met when the two
Departments formed the IPO. In December, the DOD Delegation of
Authority Memorandum, Establishment of the DOD/VA IPO within the Under
Secretary of Defense for Personnel and Readiness was signed.
The IPO's original focus was on EHR systems and other healthcare
datasharing initiatives between DOD and VA. The scope of the IPO was
later expanded by the Senior Oversight Committee (SOC) at the
recommendation of the Overarching Integrated Product Team (OIPT) to
include personnel and benefits electronic data sharing. The
responsibility for developing requirements and technical execution of
information technology solutions remains with the respective DOD and VA
organizations. Technical execution will also remain in the appropriate
DOD and VA offices, using the Departments' respective established
statutory and regulatory processes for acquisition, funding, management
control, information assurance, and other execution actions.
The IPO oversees actions to accelerate the exchange of healthcare
information between the Departments. In this capacity, the IPO is
responsible for working with the Departments on joint functional
activities such as supporting the definition of DOD/VA datasharing
requirements, ensuring DOD/VA schedules are coordinated for the
technical execution of the DOD/VA datasharing initiatives, assisting in
the coordination of funding considerations, and assisting in obtaining
the input and concurrence of stakeholders. Additionally, the IPO
monitors and provides input on personnel and benefits electronic
datasharing initiatives between DOD and VA.
In order to provide initial staff for the IPO, an Acting Director
from the DOD and an Acting Deputy Director from the VA were detailed to
the IPO, along with four military personnel. In August 2009, all four
of these military personnel will be retired from active duty service.
In January 2009, I was appointed as the acting Director of the IPO. Mr.
Cliff Freeman is the acting Deputy Director. The IPO's initial full
staffing structure consists of two Senior Executive Service positions,
14 DOD and VA civilian Government Service positions, and a small
contingent of contracted employees (up to 16). Of the government
positions, three VA employees and one DOD employee are now hired and
working. Candidates for four of the remaining position have been
selected, and another six are in the final approval process. Additional
staffing includes the possible hiring of another six contract support
personnel. Ten contracted support staff are currently working on a
full-time basis at the IPO.
Governance:
The mission of the IPO will evolve over time. Currently, it
provides a forum for high level coordination and guidance to ensure
that full interoperability is achieved. In this role, the IPO will work
in parallel with, and build upon the successes already achieved by the
DOD/VA Joint Executive Council (JEC) and the SOC.
The IPO receives guidance from the Secretaries of DOD and VA, and
the JEC. The IPO works collaboratively with the Health Executive
Council (HEC) for health related data sharing and the Benefits
Executive Council (BEC) for personnel and benefits data sharing. The
JEC provides leadership oversight of the HEC and BEC, as well as other
councils or work groups designated by the co-chairs. If the IPO has
issues that cannot be resolved at the HEC and BEC levels, we raise
those issues up to the JEC.
DOD/VA Interagency Clinical Informatics Board:
Early on, the IPO and the Departments agreed to turn to the
Interagency Clinical Informatics Board (ICIB) to assist in the
prioritization of DOD/VA health data interoperability initiatives. The
ICIB is a professional organization comprised of clinicians from both
DOD and VA. The Deputy Assistant Secretary of Defense for Clinical and
Program Policy and the Chief Patient Care Services Officer, Veterans
Health Administration, serve as its lead functional proponents. Through
the ICIB, we enable the clinical community to define the items that
must be shared by September 2009 in order to achieve full
interoperability. Once the ICIB's needs for electronic data sharing are
identified and prioritized, their recommendations are forwarded to the
HEC for review and approval. Upon approval by the HEC, the list of
priorities is handed off to requirements and definition teams, and then
to our information technology teams to develop applications and tools
to put them into operation.
strategy and planning to meet the interoperability deadline
The Departments and the IPO developed two key documents to serve as
guides in our ongoing interoperability efforts. The DOD/VA Information
Interoperability Plan (IIP) was signed September 15, 2008, delivered to
Congress, and released to the Government Accountability Office. The IIP
is updated and resubmitted annually. This document describes the
current state of electronic data sharing between the Departments and
provides the broad, strategic organizational framework for current and
future work. It also establishes the scope and general milestones
necessary to measure progress toward intermediate and long term goals.
As capabilities become approved and funded, definitive milestones are
incorporated into the DOD/VA Joint Strategic Plan (JSP). The JSP
represents an effort to provide a more detailed roadmap for the
Departments' interoperability goals.
Together, the IIP and the JSP provide the Departments with a clear
strategy to achieve our short-term, medium-term, and long-term
electronic data sharing goals. By leveraging the prior accomplishments
of the Departments toward the development of interoperable
bidirectional electronic health records, efforts to achieve full
interoperability of patient healthcare data are currently on track to
meet the September 2009 deadline, in accordance with the plans laid out
in the IIP and the JSP.
conclusion
Beyond the 2009 Target for Interoperability:
Efforts are underway to deliver full interoperability for the
provision of clinical care by September 2009, and expanded
interoperability capabilities beyond September 2009. However, both
Departments and the IPO recognize that ``interoperability'' does not
have a discrete end point, as technologies and standards continue to
evolve. The Departments and the IPO will continue to take a leading
role in the continued development of electronic health records data
sharing.
Looking ahead, the Departments believe that they are close to
settling on a dramatic new approach to information sharing that takes
advantage of cutting-edge developments in the information technology
industry to create a single virtual lifetime electronic record that
captures a servicemember's relevant health and benefits information
from the time of accession to the time of burial. Through the
Departments' joint adoption of a strictly-defined set of uniform
software standards, an architectural framework can be created that is
capable of integrating the best software health information technology
systems from both the private sector and the government. This method of
information-sharing has the potential to revolutionize the way that
health and benefits data is shared between the Departments. Preliminary
strategic-level planning for this effort is now underway.
Thank you for the opportunity to address the committee, and to
provide you with an update on the important work that we are doing to
improve and advance electronic health information sharing between the
DOD and the VA. I look forward to keeping you apprised of our progress
as we move forward in support of our wounded, ill, and injured
servicemembers, veterans, and their families.
Senator Ben Nelson. Thank you, Admiral.
Dr. Guice?
STATEMENT OF KAREN S. GUICE, M.D., M.P.P., EXECUTIVE DIRECTOR
FOR THE FEDERAL RECOVERY COORDINATION PROGRAM, DEPARTMENT OF
VETERANS AFFAIRS
Dr. Guice. Good afternoon, Chairman Nelson, Ranking Member
Graham, and Senator Hagen, Lieutenant Colonel Gadson,
Lieutenant Colonel Rivas, Mrs. Rivas, Dr. Noss, and Lieutenant
Kinard. Your strength and perseverance is a standard for all of
us. Sixteen months ago, the FRCP was created to address
services and benefits coordination problems across two large,
complex systems of care and benefits.
The FRCP is a joint program of DOD and VA, with VA serving
as its administrative home. It is designed to provide oversight
and coordination for very seriously or catastrophically
wounded, ill, or injured servicemembers, veterans, and their
families.
To do so, the FRC develops a customized individual recovery
plan that is used to monitor and track the services, benefits,
and resources needed to accomplish the identified goals. The
goals were those of the servicemember or veteran with input
from their family or a caregiver and members of the
multidisciplinary team. The number and types of goals are
related to the medical problems, the stage of recovery, and the
holistic needs of the family and client.
Developing goals is a methodical process that begins with
evaluation. FRCs review the relevant records and discusses
specific challenges with the various healthcare providers and
case managers. This appropriation allows for a structured
dialogue with the client in developing the plan. The FRC and
the relevant case manager determine responsibility and the
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 the goals
change as the client progresses through the stages of recovery,
rehabilitation, and reintegration.
The FRC provides a single consistent point of coordination
throughout this progression. Accountability for the plan rests
with the FRC. Today, 14 FRCs are located at 6 military
treatment facilities and 2 VA medical centers. All have a
clinical background, with most being nurses or social workers.
One is a vision rehabilitation specialist. All have prior
experience in either the military or VA health care system.
Collectively, they have over 200 years of professional
experience, all at a Master's level, and many have advanced
practice degrees. All have specialized knowledge in either one
or more clinical areas. They frequently consult each other,
bringing their collective knowledge and experience to bear for
their clients.
Currently, 257 clients are enrolled in the program.
Seventy-five percent of these are still Active Duty. Generally,
these clients are very seriously or catastrophically ill or
injured and require a complex array of specialists, multiple
interfacility transfers, and lengthy rehabilitation.
Individuals are either referred to the program or identified by
FRCs from daily census lists and during attendance at specialty
team care meetings or downrange video conferences.
On the back of our newly designed brochures is the new
toll-free number to make it easier to refer potential clients
or get additional information about the program. A description
of the program is on the National Resource Directory's Web site
and the VA's Operation Iraqi Freedom Web site. The program has
a strategy to reach out to those who went through the system
prior to its inception and who might still benefit from a
recovery plan and care coordination.
Care coordination improves service integration among
different delivery systems and eases transition from one system
of care to another. It's not a bandaid or an indication of
failing systems. Instead, it is another step in the evolution
toward a fully integrated system where care and benefits are
organized around the multiple needs of individuals across the
care continuum.
FRCs, in keeping with this concept, coordinate the delivery
of services and resources for servicemembers, veterans, and
their families, in accordance with the goals identified in the
plan. They work with military Services, RCCs, Tricare, VHA,
VBA, other governmental resources, including State and local
agencies, as well as the private sector. For those
servicemembers and veterans not enrolled in the program, there
are a variety of other programs, services, and resources
designed to meet their needs through the DOD and VA. I
appreciate your input and collaboration as the program matures,
and I particularly appreciate your support, and I look forward
to your questions. Thank you.
Senator Ben Nelson. Thank you. You were all here and heard
my comments about stove piping and the silo effect of agencies.
Based on everything that you've heard thus far, and the GAO
report, are you all of the opinion that we're breaking that
down here so we can have a fully integrated system to smooth
the transition and have it for every step along the way,
including every aspect of the servicemember's life, as well as
his or her family's? Is that fair to say, that what might have
been there in the past is not there today?
Ms. McGinn. Senator Nelson, I think we have to be
constantly vigilant because of the nature of our organizations.
I do think in the last 2 years, watching the collaboration
between DOD and VA, at the highest level, not at the patient
care level, has been extraordinary. I think one of the
indications of that is the development of this FRC, where the
SOC decided they wanted there to be one definitive person, and
that person was decided that they would be administratively
done by VA.
I think that at our organizational high level, the co-
location of the offices, the people that we have put in place
in an acting capacity, continue to build relationships with VA.
Going forward, we not only have SOC issues that we work
together on, but also JEC issues, which are the issues that
cover all of the matters between DOD and VA, and we need to
strengthen those relationships.
DOD is leaning forward to do that and avoid having the
kinds of silos that we've had in the past. As I said in opening
remarks, we never really had a senior executive dedicated to
breaking down those silos before, in terms of collaboration
with VA, and now we will, so I'm hopeful for that.
Senator Ben Nelson. Is that generally shared?
Mr. Dimsdale. Sir, I would like to add my comments. It's
not Kumbaya. Nothing is Kumbaya, but we talk daily. We sit
side-by-side and work daily, and so the silos are breaking
down. But there's a lot of work to continue. I want to assure
you that it's an ongoing effort, and we're doing everything we
can to move the ball in the right direction.
Senator Ben Nelson. Are you in a position where if you run
into a question of legal authorities, that you could bring back
to us any kind of statutory change that might be necessary to
further break it down or to establish this integrated system?
Mr. Dimsdale. I believe so, sir.
General Meurlin. Mr. Chairman.
Senator Ben Nelson. Sure.
General Meurlin. To bring it down to a lower level from
what Ms. McGinn was talking about, we recently invited the
Medical Director of the Richmond VA Polytrauma Unit to go over
on a C-17--go over to Landstuhl and look at the operation
there, collaborate with DOD physicians at the receiving point
from the area of responsibility, and then come back in that
operation.
We're going to expand that program to the other VA
Polytrauma Units. We're planning those forces together, which I
think will help out in easing the transition and acceptance of
patients as they come back.
Yesterday, at the SOC that was mentioned earlier, in
reviewing a way ahead for the DES system, the larger look at
it, we saw both Deputy Secretaries, really, I think, in quite
agreement and accord, which set a tone for the rest of the
organization. So as Roger said, we have offices together in the
palatial Hoffman Building down in the south end of Alexandria,
and we're working together with staffs and mixing them. I think
we're making great progress on that.
Senator Ben Nelson. You mentioned on the FRCP that a
decision was made as to which agency would probably be in the
best position to administer this. Are you finding other areas
where assigning one of the agencies the responsibility makes
more sense than both agencies trying to coordinate work
together on it?
General Meurlin. Sir, since Dr. Guice and I have been
working quite closely and commiserating on the two different
bits of law, one that established the FRCs and then, later on,
the NDAA that established the RCCs. Really pretty parallel
programs. The question is, as we work through this, since they
are so parallel, why not bring them both together? I think
probably the initial intent was to have one program cover all
niches, the FRCs for the ones that are most seriously injured
and destined to depart from DOD and move into VA. But also, the
Category 2, the middle level, that really are up in the air
whether they will progress medically to return to duty or then
depart.
So I think there's a lot of questions there. I know that
was the number-one priority or the number-one recommendation of
the Dole-Shalala Commission. It's one that I think we're making
progress in that area. I think it's going to be absolutely
significant to the success of the recovery and reintegration of
our soldiers, sailors, airmen, and marines.
Senator Ben Nelson. Dr. Guice?
Dr. Guice. I'd just agree with him.
[After reviewing the transcript, Dr. Guice submitted the following
change to the previous statement: ``I'd strongly agree with him.'']
Senator Ben Nelson. Other comments that you might want to
make about this progress?
Ms. Embrey. Sir, I think VA has long been a source of
expertise for PTSD and for severe TBIs within the Federal
Government, and DOD has learned from its expertise and has been
partnering with them on a variety of protocols, standards, and
guidelines.
We believe so strongly that when we set up our Center of
Excellence within DOD, we made our deputy for that center a VA
employee who retains employment with VA to ensure close
integration of the programs of care for both DOD and VA through
that Center of Excellence.
Senator Ben Nelson. If the military can have joint
commands, it would seem to me the agencies can find a way to do
some of this jointly as well, recognizing how important it is,
but also how common it can be to have both agencies have
similar responsibilities because of the needs.
Senator Graham.
Senator Graham. Thank you, Mr. Chairman. This has been a
very informative hearing, I think. To all who attended, thank
you. This has helped the committee a lot, and we appreciate
your time.
I think we are making progress. I guess from the 30,000-
foot view of things, number one, you get injured, I want to
make sure that you get a fair evaluation as to whether or not
you're fit for duty. Right, General?
First thing is, can this servicemember return back to
service. Do you agree with that?
General Meurlin. Absolutely.
Senator Graham. Is that kind of a hope and dream of most
people that are injured?
General Meurlin. It is. Most people that are injured, the
different hospitals and patients that I've visited with, that's
their ultimate objective. Now, the question which was brought
up in the first panel is, is that in their best interest?
Even in the expedited process, we made sure that it was a
provision that even though if they're catastrophically wounded,
we expedite the DES process, and they leave the Service, that
if they do retain a level that they can come back, that we
allow for that provision to petition to come back.
Senator Graham. The only reason I mentioned that is the
Colonel Gadsons of the world. There's no other time in American
history that someone like him would be able to serve. The one
thing you want to do is to have a system that can capture
people like him, but realize that a lot of these young men and
women are going to have to move on to civilian life. All of
them can't be integrated back into the military, so let's not
lose sight of that.
One of the goals is to make sure that the Colonel Gadsons
of the world and others have a chance to continue to serve.
Now, once the decision has been made that you're not going to
be able to stay on Active Duty, I think that the goal here,
between the two of you all, is the same. That when you leave
DOD, I just want to make sure that when you go into the VA
system, that whatever rehabilitative services you had as an
Active Duty member, are not lost because your status changes.
But here's the real problem. Most of these services are
provided by centers that are exceptional. The Guard member, the
reservist, or the person being discharged, may go back to a
home area that's not nearly as robust as what WRAMC provides.
That is what Dr. Noss is trying to tell us. Let's make sure
that you could go back to Allendale, SC, for the medical
requirement, where you're a guardsman or reservist. There's
just going to be limitations as to the rehabilitation services
available to you.
What I want to do is make sure that whatever is available,
that it's available as soon as possible, and we think outside
the box. The goal is to reintegrate people in society. To come
up with--I don't know if it's a voucher plan. I don't know
exactly what it is. But the moment you hit medical retirement,
the moment you go back into the civilian community, whether
you're a guardsman or a reservist or medical retired Active
Duty person, you go to a rural area, we want to do as much as
far as you can, understanding there are limitations.
Apparently, there are some areas of improvement there.
The second problem is, General, you were talking about a
report coming out in December, how the Nation can help care
providers, family members who are going to provide care,
income-wise. That is coming out in December. Is that right?
General Meurlin. The preliminary study that CNA did, their
preliminary results came out in December. The final results are
going to be coming up very shortly.
Senator Graham. The final results will suggest to Congress
that we creative a revenue stream greater than we have today?
General Meurlin. Yes, sir. There's proposed legislation
coming forward for compensation for caregivers, that will
provide for a benefit for caregivers equal and approximate to
what a caregiver commercially would be earning.
Senator Graham. That would last for how long?
General Meurlin. As long as the individual requires.
Senator Graham. Okay. I think that is a great idea, because
we focus on the wounded warrior and their family member. They
have to drop most of their hopes and dreams. That's just the
way it is, and we want to help them where we can. Finally, Mr.
Dimsdale, you were talking about standardized definitions.
Mental health services available through DOD should be the same
as VA when somebody falls into these programs. Whatever
rehabilitative services, whatever definitions we have, are we
moving down the road to getting standardization?
Mr. Dimsdale. Yes, sir, but it is not easy.
Senator Graham. I know it would be hard.
Mr. Dimsdale. This is anecdotal, but there were like 45
definitions we were working on, and I think we got agreement on
about 35 out of the 45. There are policies, as far as benefits
are concerned, based on the definitions. We are continuing to
wicker this thing down, but we have a ways to go.
Senator Graham. The category of somebody who's medically
retired, not fit for duty, that, to me, is your first
evaluation to make. Once that happens, what's the problem after
that?
Mr. Dimsdale. I'll give you an example. When you asked the
question, I was writing notes and trying to get some answers.
I'll give you an example. The definition of catastrophically
injured entitles people to different things.
Senator Graham. Based on what organization you're in, DOD
versus VA?
Mr. Dimsdale. As far as the determination of what is
catastrophic? So Joe or Jane get injured, and we call them
catastrophically injured. One agency may say one thing. Another
may say another. What the individual gets is based on the
definitional acceptance.
Senator Graham. Are there differences within the Services,
or just VA/DOD?
Mr. Dimsdale. I cannot answer that, sir. I would have to
get back----
Senator Graham. But you know that is a definitional
problem?
Mr. Dimsdale. Yes, sir.
Ms. Embrey. My sense is that it's a difference between DOD
and VA. The authorization and the way the defense health
program is set out and the benefits and whether we have prime
and basic and different other kinds.
Senator Graham. You're on to the problem. Just keep us
informed. The more standardization, the easier it is for the
case manager and the troops and their family to get through
this thing. I know it's hard, but like Senator Nelson said,
we're joining everybody else. It was hard. I never thought I'd
be in an office.
I went and did some Reserve duty in Iraq, and there was a
coastguardsman there. That's the first guy I met, and he said,
``What the hell are you doing here?'' We had people from
everywhere, every branch of the Service guarding the Service.
You couldn't tell the difference. This stuff does work.
Thank you, Mr. Chairman.
Mr. Dimsdale. Sir, let me do my homework, and we will get
back to you for the record.
Senator Graham. Sure, that's good.
[The information referred to follows:]
On 10 December 2008, the Overarching Integrated Product Team
approved 33 wounded, ill, and injured related standard terms and
definitions. Terms and definitions that have already been defined in
the Code of Federal Regulations must not be used until after
legislative changes have been made. Veterans Affairs and the Department
of Defense continue to work on reaching consensus for additional terms
and definitions that impact the wounded, ill, and injured servicemember
and veteran.
Proposed terms and definitions for major life activities, mental
disorder, recovering servicemember, and serious illness or injury will
require legislation.
Attached is a copy of the signed agreement and the agreed upon
definitions.
Mr. Dimsdale. I don't want to send you a woof ticket. I
want to get something straight.
Senator Graham. I got you. Thank you for participating and
serving our Nation.
Mr. Dimsdale. Thank you.
Senator Ben Nelson. Thank you, Senator. Senator Hagan?
Senator Hagan. Thank you, Mr. Chairman. I can understand
how confusing this would be for the men and women in the
Service who obviously, once they're veterans, they've all been
in DOD or the Reserves or the National Guard. Then it seems
like they're in a different language and a different world
going into VA. I think this committee is excellent, and I
certainly think it is time that we try to mesh the two in a
seamless fashion.
Dr. Guice, I think you were talking a little bit, too,
about some of the case manager aspects, and I know that
Lieutenant Kinard said that he had eight different case
managers. So these pilot programs you're doing now, is that
actually going to solve those issues?
Dr. Guice. The term ``case manager'' is a fairly ubiquitous
and generic term. It is a term used to describe any
organization service delivery system. You have case managers in
the legal system. You have case managers in public assistance
programs. You have case managers in healthcare. In healthcare,
case managers are usually aligned with a service line or a
specialty, but they exist within a single facility; for
example, in a hospital or in an outpatient unit of a hospital.
They are very key in actually organizing the individual's care
in that facility.
When the individual moves to another facility--for example,
if you're at WRAMC and you go down to the polytrauma unit in
Tampa, you would have another set of case managers similarly
aligned because of your constellation of injuries.
Having a care coordinator eases that transition. The care
coordinator in the FRCP, for example, will stay with that
servicemember and family when they transition over to the VA
polytrauma unit, and then when they transition back, and
however many transitions they need to make it through the
medical system because specialized care occurs in a variety of
different places.
Care coordinators can help connect the dots for the
individual, making sure that all the case managers are aware of
any particular needs of that individual or family, and making
sure it is as comfortable a transition as possible. Transitions
are always difficult, but the coordination effort reduces the
challenges veterans, servicemembers, and caregivers face.
Senator Hagan. Do we have enough personnel to do the care
coordinator model?
Dr. Guice. I believe we do. I think it is under continuous
evaluation, it may change tomorrow, depending upon what
happens. It is always something that we are constantly looking
at, recalibrating, and adjusting.
Senator Hagan. Great. Then this is a follow-up to Senator
Graham's question, but I really think that keeping our wounded
warriors employed is critical, if they can be. Obviously, if
it's a catastrophic injury, in many cases, they cannot.
But I encourage the Services to devise road maps to enable
our wounded warriors with additional skill sets, with the
transition into civilian life, or perhaps the Services could
utilize them in another capacity, keeping them on duty.
These wounded warriors, if they could be trained to serve
as administrative personnel, be assigned as case managers, be
assigned as mentors to other wounded warriors. I was just
curious as to what are your thoughts on this, and is this being
done?
General Meurlin. It is. On the first point that Senator
Graham mentioned on Lieutenant Colonel Gadson being retained in
the Service as a double amputee. In the Air Force, we had, a
number of years ago, the first amputee above the knee who's
flying. He's a pilot with the 89th and back on flying status.
We've made a huge change in how we look at injuries.
Part of the RCC program, this is a group that's
administered by DOD that does the care management that Dr.
Guice was talking about, and developing the comprehensive
recovery plan for the individual, looks at where that
individual wants to go, what his ultimate destination is, or
hers, and then programs it along. We work with the Department
of Labor. We work with VA. We work with the Services to see how
they can be retained if they want to or how they want to
transition.
There are a number of programs out there. We've been
working with one in the very infant stages now of training
people to work within the Civil Service, actually leading them
and training them while they're in that recuperative time to
ultimately be employable. All of this, and this larger package
gets taken care of or coordinated by the RCC or the FRCC to
facilitate that smooth transition.
Senator Hagan. Thank you. Thank you, Mr. Chairman.
Senator Ben Nelson. Thank you, Senator. Thank you to all
the panels for your candid and heartfelt testimony today. The
journey has thus far been a long one, but we recognize that
we're not at the conclusion of it yet. Even when we get to the
conclusion, there will be a need to continue to work together
to make certain that the integrated system continues to work
forward. Thank you very much.
The written testimony submitted by all witnesses today will
be included in the record, without objection. Additionally, we
received a statement from the Blind Veterans Association, and
without objection, it too will be included in the record of
this hearing.
[The prepared statement of Dr. Zampieri follows:]
Prepared Statement by Dr. Thomas Zampieri, Ph.D.
introduction
Chairman Nelson, Ranking Member Graham, and members of the Senate
Armed Services Subcommittee on Personnel, on behalf of the Blinded
Veterans Association (BVA), thank you for this opportunity to submit
our testimony for the record regarding the lack of progress on the
implementation of the Wounded Warrior section 1623 of the National
Defense Authorization Act (NDAA) for Fiscal Year 2008 to establish a
program for the large numbers of military vision injured. BVA was
established in 1945, and congressionally chartered in 1958, as the only
Veterans Service Organization exclusively dedicated to serving the
needs of our Nation's blinded veterans and their families, and BVA
finds the bureaucratic problems associated with the slow implementation
of the congressionally mandated NDAA Vision Center of Excellence
section 1623, today demands more oversight by this committee and more
direct questions today. The NDAA section 1623 required establishment of
the joint Department of Defense (DOD) and Department of Veterans
Affairs (VA) Vision Center of Excellence (VCE) and Eye Trauma Registry.
On March 17, 2009, three Operation Iraqi Freedom (OIF) and
Operation Enduring Freedom (OEF) seriously eye injured veterans
recently testified and shared stories before the House VA subcommittee
on Oversight and Investigations hearing on how there was and still is
no Seamless Transition program for them between DOD medical treatment
facilities and VA medical centers. Despite a dedicated working group of
senior military and VA ophthalmologist and optometry professionals
working since November 2007, with specific plans for how the joint
Vision Center of Excellence should be established and operate, for 14
months there has been a lack of administrative support, failure to
approve organizational charter until February 2009, and according to
several senior DOD sources a persistent funding challenge to establish
this VCE. When asked how much has been spent on the Vision Center of
Excellence since October 2008 at the House VA Oversight hearing the
response was incredible low total of ``DOD has spent $7,000 for the
Vision Center of Excellence'' and it was not until March 12,2009 that a
letter was sent to Chairman Mitchell on the VA Oversight Subcommittee
that $3 million had been identified for the VCE 13 months after
congress required the establishment of the VCE.
obstacles to vce implementation
OIF and OEF servicemembers with both penetrating eye trauma and
Traumatic Brain Injury (TBI) visual impairment have had to wade through
a DOD bureaucracy. DOD has given us the impression that, for them, an
entire year's time to create an organizational charter is actually not
that long. Persistent excuses for lack of action range from ``no plan
was approved for VCE'' to, of course, ``no funding has been found to
create VCE.''
When NDAA was enacted in January 2008, an immediate reaction from
some senior level Assistant Secretary of Defense for Health Affairs
officials was that VCE was an ``unfunded mandate by Congress'' that
would cost ``an estimated $5 million that we do not have built into
this fiscal year 2008 year's budget.'' If this were the case, questions
should be asked at Pentagon, ``Why were these funds not requested in
either last year's May 2008 War Supplemental (H.R. 2462) when $162
billion'' was provided for, among other things, ``wounded warrior
care'' or, better yet, in the fiscal year 2009 Defense Appropriations
request to cover this fiscal year 2009 year's start-up costs. Instead,
on April 12, in early June, and again in early August at the Skyline
Drive office of the Assistant Secretary of Defense for Health, then
once again on September 24, senior officials repeated the claim that
finding even the bare minimum of $3 million to fund start-up costs for
the Vision Center of Excellence VCE presented a very significant
funding challenge.
For 4 years, BVA has attempted to bring to the attention of the
Armed Services Committees, the Defense Appropriations Committees, both
VA Committees, DOD Health Affairs, and the Veterans Health
Administration (VHA) the ever-increasing prevalence of combat eye
trauma and TBI visual dysfunction among servicemembers. We have become
increasingly concerned about the growing numbers of both the battle
wounded who have penetrating direct eye trauma (13 percent of all
evacuated wounded have experienced eye trauma) and/or TBI-related
visual complications (64 percent with TBI have tested positive for
visual dysfunction).
Responses to these pleas have included ``the need to wait until the
next plan is approved,'' ``NDAA reports come late for review,''
``inability to find office space,'' and the aforementioned ``lack of
funding.'' The cumulative result of these responses has been delayed
action, scarce resources for establishment of the VCE, no dedicated
space, no request for funding for staffing or construction even today
while witnesses testify before your committee.
The Pentagon did appoint the first Director of VCE in November
2008. Colonel Donald Gagliano is a highly qualified and dedicated 29-
year Army career ophthalmologist who served in Iraq for 1 year. Also
appointed was an equally well-qualified VA Deputy Director of VCE, Dr.
Claude Cowan with distinguished career in ophthalmology research,
education, and clinical practice here in Washington DC VA medical
center. BVA fully supported both of these appointments. The two
directors of the VCE have entered these challenging positions with
virtually no office space, little staffing support, funding for 3 onths
of $7,000, no organizational charter until February 2009, and thousands
of combat eye-wounded servicemembers and veterans spread across various
military medical facilities and VA medical centers. Thanks to MILCON/VA
Appropriations Chairman Chet Edwards, VA received a $2 million
appropriation for IT Registry support for fiscal year 2009. Although
Senate MILCON/VA Appropriations Chairman Tim Johnson also helped
provide an additional $6.9 million to VHA, questions persisted for
months regarding a plan on how to use these funds because of lack of
implementation of the VCE within DOD.
The OIF and OEF eye wounded who have recently enrolled in the VA
health care and benefits system never should have encountered this
difficult process. Quick action by Secretary Gates, in cooperation with
Secretary Shinseki and with the full attention of the Senior Oversight
Committee, is now vital to correct this mess and these witnesses must
explain why this process has been delayed.
BVA emphasizes that the clinical skills of the DOD professional eye
care providers, both ophthalmology and optometry, have been excellent.
In many cases, they have been no less than outstanding. Ophthalmology
surgery not possible during previous wars has saved the vision of many
soldiers and marines. Nevertheless, the system that organizes and
administers such treatment must become accountable for all battle eye
wounded and TBI patients affected. It must answer for the lack of
action inherent in its failure to begin staffing procedures that will
eventually reach 12 positions, failure to locate office space, and
failure to address the issue of construction renovation funding for the
National Naval Medical Center.
prevalence and incidence of visual impairments
As of September 2008, VHA reported 8,747 diagnoses of TBI with
approximately 7,500 in diagnostic testing for possible TBI. Improvised
Explosive Device (IED) blasts contributed to more than 60 percent of
these injuries. As of January 30, 2009, a total of 33,993
servicemembers had been wounded or injured by accidents in Iraq. The
number of those wounded in hostile operations and requiring air medical
evacuation from Iraq between March 19, 2003, and January 30, 2009, from
one early report was 9,375, of which an estimated 13 percent (1,219)
had sustained combat penetrating eye trauma. Some 135 of this number
blinded have enrolled in VA Blind Rehabilitation Service (BRS)
programs. This past November, however, the Military Surveillance
Monthly Report contained an article from DOD on eye injuries among
members of Active components (U.S. Armed Forces, 1998-2008) that
detailed, by ICD, diagnostic code searches turning up 4,970 perforating
and penetrating eye trauma cases, 4,294 chemical or thermal burns, and
686 damaged optic nerves, most of which were from among OIF and OEF
injured.
The number of direct battle eye injuries does not include estimates
of all moderate-to-severe TBI servicemembers or veterans who have
visual dysfunction, according to VA research of those tested by either
neuro-ophthalmologists or low-vision optometrists at a few military and
VA centers. We stress that while only a small percentage of the eye
injured meet the legal blindness definition of 20/200 or less of visual
acuity, those with neurological vision dysfunction from mild, moderate,
or severe TBI will require long-term VA eye care follow-up in low-
vision clinics. Veterans with a history of ocular battle injuries are
also at high risk of developing retinal detachments, traumatic
cataracts, glaucoma, and other delayed TBI neuro-visual complications
that can occur years after the initial injury.
The top three contributors to combat eye injuries have been
Improvised Explosive Devices (IEDs), Rocket-Propelled Grenades (RPGs),
and Mortars, with IEDs causing 56.5 percent of all eye injuries in
Iraq. Just how many servicemembers have actually sustained moderate-to-
severe TBI injuries to the extent that they are experiencing neuro-
sensory visual complications is anyone's guess. The estimates in
professional journals and other publications indeed change from month
to month. The 64 percent figure (those with TBI who have experienced
visual dysfunction) represent those with associated neurological visual
disorders of diplopia, convergence disorder, photophobia, ocular-motor
dyshnction, color vision loss, and an inability to interpret print.
Some TBIs result in visual field defects with enough field loss to meet
legal blindness standards. We are also finding ever increasing numbers
of TBI-caused ``functionally blinded'' OIF and OEF veterans who, while
not legally blind, are unable to perform normal daily activities
because of loss of vision. More TBI visual screening, diagnosis,
treatment, and new outcome studies should be initiated without delay.
One early VA research study (2005) of OIF and OEF servicemembers
who had entered the VA system with an ICD-9 (diagnostic code) search
found 7,842 individuals with a traumatic injury of some kind.
Consistent with recent media articles and VA reports, the most common
traumatic injury diagnoses were hearing loss and tinnitus (63.5
percent). We now know that 94,191 of the more than 1.5 million troops
who have served in OIF and OEF are now service-connected for tinnitus
while 78,076 are service-connected for hearing loss. A major cause of
this hearing loss (60 percent of the cases) is exposure to IEDs. The
second most common VA diagnostic code was for visual impairment (27.9
percent). We submit to this subcommittee that the cases of sensory loss
of hearing and visual impairment as a result of TBI constitute has been
a ``the sensory silent epidemic'' not widely reported by DOD or the
media. They are, nevertheless, the #1 hearing loss, and #2 vision
injuries from OIF and OEF combat injuries.
neurological impact of tbi dysfunction
Perception plays a major role in an individual's ability to live
life. Although all senses play a significant role in perception, the
visual system is critical to perception, providing more than 70 percent
of human sensory awareness. With hearing being another critical
component, IED blast injuries can obviously impair markedly these two
key sensory systems.
Vision provides information about environmental properties. It
allows individuals to act in relation to such properties. In other
words, perceptions allow humans to experience their environment and
live within it. Individuals perceive what is in their environment by a
filtered process that occurs through a complex, neurological visual
system. With various degrees of visual loss comes greater difficulty to
clearly adjust and see the environment, resulting in increased risk of
injuries, loss of functional ability, and unemployment. Impairments
range from loss in the visual field, visual acuity changes, loss of
color vision, light sensitivity (photophobia), and loss of the ability
to read and recognize facial expressions.
Although one can acquire visual deficits in numerous ways, one
leading cause is injury to the brain. Damage to various parts of the
brain can lead to specific visual deficits. Some cases have reported a
spontaneous recovery but complete recovery is unlikely and early
intervention is critical. Current complex neuro-visual research is
being examined in an attempt to improve the likelihood of recovery.
Nevertheless, the extent of the recovery is often limited and will
usually require long-term follow-up with specialized adaptive devices
and prescriptive equipment.
The brain is the most intricate organ in the human body. The visual
pathways within the brain are also complex, characterized by an
estimated two million synaptic connections. About 30 percent of the
neocortex is involved in processing vision. Due to the interconnections
between the brain and the visual system, damage to the brain can bring
about various cerebral visual disorders. The visual cortex has its own
specialized organization, causing the likelihood of specific visual
disorders if damaged. The back of head, the occipitotemporal area of
the brain is connected with the ``what'' pathway. Thus, injury to this
ventral pathway leading to the temporal area of the brain is expected
to affect the processing of shape and color. This can make perceiving
and identifying objects difficult. The occipitoparietal area (posterior
portion of the head), is relative to the ``where,'' or ``action''
pathway. Injury to this dorsal pathway leading to the parietal lobe
will increase the likelihood of difficulties in position (depth
perception) and/or spatial relationships. In cases of injury,
individuals find it hard to determine an object's location and may also
discover impaired visual navigation.
It is highly unlikely that a person with TBI will have only one
visual deficit. A combination of such deficits usually exists due to
the complexity of the organization between the visual pathway and the
brain. The most common cerebral visual disorder after brain injury
involves visual field loss. The loss of peripheral vision can be mild
to severe and requires specific visual field testing to be correctly
diagnosed. In turn, a number of prescribed devices are frequently
necessary to adapt to this loss.
Accompanying such complex neurological effects on the patient is
the overwhelming emotional impact of brain injury on the patient and
hislher family. BVA would ask the Senate Armed Services Committee
members to seriously consider the ramifications of such visual
injuries. Brain injuries are known for causing extreme distress on
family members who must take on the role of caregivers. According to a
New England Journal of Medicine report of January 30, 2008, TBI
``tripled the risk of PTSD, with 43.9 percent of those diagnosed with
TBI also afflicted with PTSD.''
At present, the current system of screening, treatment, tracking,
and follow-up care for TBI vision dysfunction is inadequate across the
systems. Adding visual dysfunction to this complex mix of other
physical and mental injuries, especially if undiagnosed, makes attempts
at rehabilitation even more daunting and potentially disastrous unless
there are significant improvements in the screening, treatment,
tracking, and follow-up care through the proposed and legislated Vision
Center of Excellence.
vce to address critical issues
BVA believes that the VCE Eye Trauma Registry is where vital
components for research, best practices, outcome measures, and
education can be developed and refined for the eye trauma wounded and
those with TBI vision dysfunction. Critical vision research coordinated
with the Defense Veterans Brain Injury Centers and Defense Centers of
Excellence for TBI can facilitate effective eye trauma research between
DOD and VA. We predict that the number of TBI-injured will again
increase beginning this spring as the troop surge into Afghanistan gets
underway.
BVA wishes to clear up false misinformation about VCE that has
recently become commonplace: First, VCE is not to be one large clinical
eye treatment center for all combat eye injured. It is better
understood as ``a virtual center with connectivity'' to the four major
military trauma centers identified last June in testimony before VA
Committee as (Bethesda National Naval Medical Center, Brooke Army
Medical Center, Madigan Army Medical Center, and San Diego Naval
Medical Center), the soon-to-be five VA Polytrauma Centers. The VCE
will connect there and the hundreds of other military or VA medical
centers where the highest proportion of eye-injured and TBI-wounded are
already receiving specialized eye surgery care and low-vision
optometric services.
Second, VCE is not a DOD blind center or rehabilitation facility.
It will, however, coordinate its work with the already existing,
skilled, multidisciplinary VA Blind Rehabilitation Centers (BRCs) and
low-vision clinics with decades of experience treating blinded
veterans. The VCE Eye Trauma Registry will track all eye injured and
TBI visually impaired, coordinate joint vision research, promote best
practices, and develop educational information on vision services for
both providers and families.
va brs and low-vision services
A positive note is that the challenges inherent in the growing
number of returning OIF and OEF servicemembers needing screening,
diagnosis, treatment, and a coordinated Seamless Transition of services
can be met by the existence of world-class VA BRCs. The programs
provided at such centers now have a 60-year history. In the larger
picture of VA programs for blind and visually impaired veterans, BVA
began working more than 4 years ago to ensure that VA expand its
current capacity to serve blinded veterans. Such expansion became
necessary as the aging population of veterans with degenerative eye
diseases requiring specialized services has continued to increase.
As a result of efforts to broaden and increase services, 54 new
outpatient intermediate low-vision and advanced blind rehabilitation
outpatient programs already have specialized staffing in place. Many of
these new programs are opening with veteran-centered, low-vision
specialized teams providing the full range of basic, intermediate, and
advanced rehabilitation services. Accompanying these gains is special
VA emphasis on outcome measurements and research projects within VHA.
The VA approach of coordinated team methods for rehabilitation care has
unlocked strategies for new treatments and provided the most updated
adaptive technology for blinded veterans. The new, specialized low-
vision and blind programs already existing within the VA system must be
utilized by DOD through VCE. The eye injured must receive high quality
health care with proven outcomes that include constantly emerging
vision research.
The mission of each Visual Impairment Services Team (VIST) program
is to provide blinded veterans with the highest quality of vision loss
services and blind rehabilitation training that truly help them adjust
to the major changes they have experienced in their lives. To
accomplish this mission, VISTs have established mechanisms to
facilitate more completely the identification of blinded veterans and
to offer a review of benefits and services for which they are eligible.
The VIST concept was created in order to coordinate the delivery of
comprehensive medical and rehabilitation services for blinded veterans.
VIST Coordinators can assist not only newly blinded veterans with
timely and vital information leading to psychosocial adjustment, but
can also provide similar assistance to their families.
Seamless Transition from DOD to VA is best achieved through the
dedicated work of VIST Coordinators and Blind Rehabilitation Outpatient
Specialists (BROS) but many DOD case managers are unaware of these key
contacts. They are in a unique position to provide comprehensive case
management services to returning OIF/OEF service personnel for the
remainder of their lives if consulted. VIST Coordinators are now
following the progress of 135 recently OIF or OEF blinded veterans who
are being served on an outpatient basis and 585 low vision veterans.
The VIST system currently employs 112 full-time and 43 part-time
Coordinators. There are 39 full-time BROS/VIST teams who also manage
these cases and VA is process of recruiting another 28 BROS for these
clinics for veterans.
The VA BROS is a highly qualified professional. Many BROS hold
Masters Degrees in both Orientation and Mobility and Rehabilitation
Teaching. BROS also receive extensive cross-training at 1 of the 10
BRCs nationwide. The training prepares such individuals to provide, in
the veteran's home environment, the full range of mobility, living,
adaptive, manual, and other skills essential to blind rehabilitation.
VIST/BROS teams are also well equipped to provide excellent local
services on a continuing basis when a veteran returns home from an
inpatient stay at a BRC.
Advanced Outpatient Rehabilitation Programs occur in ``Hoptel''
settings, as VA calls them. Hoptel sleeping arrangements function
perhaps more like hotels than hospitals. Such programs offer Skills
Training, Orientation and Mobility, and Low-Vision Therapy for veterans
who need treatment with prescribed eye wear, magnification devices, and
adaptive technology to enhance remaining vision.
A VIST Coordinator manages the blind programs with other key staff
consisting of certified BROS, Rehabilitation Teachers, Low-Vision
Therapists, and a part-time Low-Vision Ophthalmologist or Optometrist.
Medical, surgery, psychiatry, neurology, rehabilitative medicine,
pharmacy, physical therapy, and prosthetics services can all be
consulted as needed within the VA Medical Center, effectively providing
the full continuum of care for the OIF and OEF veterans. DOD and VA are
in the process of developing a bi-directional electronic eye trauma
Registry that exchanges eye surgery records and clinical eye
examinations case information. BVA warns that Private agencies that
offer blind rehabilitation would rarely have full on site consultative
medical services, surgical subspecialties, and psychiatry all co-
located within one facility, meaning veterans and their families would
have to travel additional distances to obtain needed outpatient care
for other conditions, adding to wait times for consultants, delays in
obtaining prescribed medications, or waiting on new treatment plans and
disrupting critical training time for orientation or mobility blind
training. BVA strongly recommends that private agencies utilized for
any services provide evidence of peer reviewed outcome studies, quality
assurance standards, research experience, and information technology
systems that can exchange records to VA system. We also recommend that
they be accredited by the Commission on Accreditation of Rehabilitation
Facilities CAW, that they are required to utilize VA electronic health
care records for clinical standards of care, and that they meet
specific outcome measures for contracts.
Another important model of service delivery that does not fall
under VA BRS is the VICTORS program, or the Visual Impairment Center to
Optimize Remaining Sight. VICTORS is an innovative program that has
been operated by VA Optometry Service for more than 18 years. The
program consists of specialized services to low-vision veterans who,
though not legally blind, suffer from visual impairments. Veterans must
generally have a visual acuity of 20/70 through 20/200 to be considered
for VICTORS. The program, entirely outpatient, typically lasts 3-5
days. Veterans undergo a comprehensive, low-vision optometric
evaluation. They receive prescribed low-vision devices and are trained
in the use of adaptive technology to optimize functional independence.
The Low-Vision Optometrists employed in the Intermediate Low-Vision
programs are ideal for the highly specialized skills necessary for the
assessment, diagnosis, treatment, and coordination of services for Iraq
and Afghanistan returnees with TBI visual symptoms. This is because
such veterans often require long-term follow-up services. The programs
also assist the aging population of veterans with degenerative eye
diseases. Such programs often enable working individuals to maintain
their employment and retain full independence in their lives. They also
provide testing for and research into the effectiveness of adaptive
low-vision technology aids that have recently become available through
training, review, and research. In conjunction with a wide network of
VA eye care clinics existing in VA medical centers nationwide, combined
VIST/BROS teams and Intermediate/Advanced Outpatient programs can
provide a wide network of specialized services for these OIF and OEF
veterans and their families once the VCE is fully operational.
These new VA Advanced and Intermediate rehabilitative low vision or
blind out-patient programs, are cost effective for high-need, low-
vision OIF/OEF veterans with residual vision from TBI. Combined VIST/
BROS teams and IntermediateIAdvanced Outpatient programs can provide a
wide network of specialized services for servicemembers and their
families in coordination with existing VA Eye Care clinics within VA
medical centers. VCE is critical to the success of all of the
aforementioned specialized VA services.
conclusions
Serious combat eye trauma and visual dysfunction associated with
TBI among OIF and OEF service personnel have become the second most
common injury resulting from the two conflicts. More than 9,940 visual
injuries have occurred and unknown thousands more have TBI visual
dysfunction stemming from TBI if Rand Study projections are correct. We
urge members ofthe full Senate Armed Services Committee to demand
compliance with the existing NDAA requirements. DOD should have either
requested from congress, or provided the $5 million funding for the
remainder of fiscal year 2009 from the War Supplemental, for joint
professional and administrative staffing, office space renovation
funds, information technology funding, and the Senior Oversight
Committee should have coordinated and complied with of all
congressionally directed activities established in section 1623 Vision
Center of Excellence and Eye Trauma Registry. The establishment of the
Defense Intrepid Center of Excellence for Mental Health and the TBI
Center of Excellence had $64 million for fiscal year 2009, but the VCE
had no directed funding source causing delays and frustration between
the two systems. Immediately establishing the VCE would substantially
improve the multidisciplinary coordination, treatment, rehabilitation,
and research into eye trauma and TBI-related visual impairment
experienced by servicemembers and veterans throughout the DOD and VA
systems.
BVA again expresses sincere gratitude to this Subcommittee for the
opportunity to present our testimony. We hope that you understand the
deep sense of frustration we have felt over the course of the 14 months
since NDAA established VCE. Simply put, the time for DOD and VA to
implement the VCE fully as intended by Congress, is now. With the large
numbers ofveterans suffering direct eye injury from battle and TBI
visual dysfunction, further delay is unacceptable. Because the
population of war wounded servicemembers and veterans is widely diverse
geographically, it is not appropriate or reasonable that one military
or VA medical treatment facility become the one eye clinical center for
all eye-wounded servicemembers or for TBI patients with visual
dysfunction. Depending on such an idea would be cost prohibitive and
delay care for literally thousands ofmen and women veterans and having
the VCE connect those various already existing sites ofeye surgery care
is critical now.
We request that the Armed Services Committee require that both
Secretary Gates and Secretary Shinseki get VCEon track again and comply
with all required reports on the implementation ofthis center within 30
days of this hearing. The Defense Appropriations Committee should
ensure in the next War Supplemental later this month that funding be
included for the following necessary items as opportunity to add
additional directed funding to fix this.
recommendations
The Secretary of Defense and Secretary of Veterans
Affairs must immediately direct the Senior Oversight Committee
Executive Director to implement the organizational structure
and staffing for VCE and provide full DOD/VA clinical/
administrative staffing. They must oversee the securing of
temporary office space for at least 12 staff members and see
that financial resources are in place to begin full
implementation of the operations of VCE. Assistant Secretary
Defense for Health Affairs should then report back to this
committee within 30 days. VHA was provided $6.9 million in
fiscal year 2009 for VCE these funds should be utilized now for
at least some of the expenses associated with VCE's
establishment.
The military director of VCE, Colonel Gagliano, and VA
Deputy Director Dr. Cowan need immediate administrative staff
support, office equipment, travel funding, and educational
support resources from both DOD and VHA to implement the new
VCE joint program, with no less than $2,500,000 million to fund
the final quarters of fiscal year 2009 in the war supplemental.
Congressional oversight should ensure that MILCON/VA
and Defense Appropriations Chairmen and Ranking Members review
budgets for fiscal year 2010 to ensure that they provide no
less than $6.8 million for VCE activities All Program
Operational Management initiatives should be funded for fiscal
year 2011, fiscal year 2012, and fiscal year 2013 as mandated
by the reporting clause in the National Defense Authorization
Act of 2009 and reported to this committee within 30 days of
this hearing date.
The information technology Registry will require
$2,000,000 for fiscal year 2009.
Some $2,000,000 million is urgently needed to fund
Navy Medical Center renovation construction project that will
renovate office space and other facilities at National Naval
Medical Center in Bethesda, MD, where VCE Headquarters is to be
located.
VCE must be patient and family centered,
comprehensively coordinated, and compassionate. All DOD/VA case
managers need educational updates on the various VA specialized
vision programs for eye trauma and TBI visual dysfunction.
Veterans and family members need information on all VA
locations of blind services within VA. VIST/BROS teams must be
notified early in the treatment process of transfers to their
local area of any seriously eye-injured servicemember.
It should be a virtual center providing real Seamless
Transition that ensures electronic bi-directional registry
exchange of both inpatient and outpatient eye care clinical
records that both DOD and VA eye care staff can update and
share with the Veterans Benefits Administration so that
benefits for service-connected injuries can be assessed.
Private agency involvement in the treatment and
rehabilitation process should be narrowly limited to those
meeting strict accreditation, CARF accreditation, quality
educational, and university peer-reviewed medical research
criteria. Such agencies should be equipped with
multidisciplinary staff support and meet all Health Insurance
Portability and Accountability requirements required in
existing DOD policy.
VCE should become involved in the DOD peer-reviewed
Congressionally Directed Medical Research Program (CDMRP) in
order to encourage additional TBI visual dysfunction research.
More eye trauma research in conjunction with DOD, VA, NIH, and
universities with VA academic affiliations is desperately
needed now. Potential long-term consequences of mild-to-
moderate TBI in OIF/OEF veterans are still unknown. Discoveries
of such consequences will require new technology and diagnostic
research support. BVA, supported by the current Veterans
Service Organization Independent Budget, requests $10 million
for CDMRP in fiscal year 2010 as directed vision research.
disclosure of federal grants or contracts
Blinded Veterans Association
The BVA does not currently receive any money from a Federal
contract or grant. During the past 2 years, BVA has not entered into
Federal contracts or grants for any Federal services or governmental
programs.
BVA is a 501c(3) congressionally chartered, nonprofit membership
organization.
Senator Ben Nelson. This hearing is adjourned. Thank you.
[Questions for the record with answers supplied follow:]
Questions Submitted by Senator E. Benjamin Nelson
electronic health records
1. Senator Ben Nelson. Ms. Melvin, one of the keys to seamless
transition between the Department of Defense (DOD) and the Department
of Veterans Affairs (VA) health care systems is the ability to share
medical records of servicemembers who receive care through both medical
systems. The Wounded Warrior Act required the Secretaries of DOD and VA
to develop and implement electronic health record systems that would
allow for full interoperability of personal health care information by
September 30, 2009. What is your assessment of the progress of DOD and
VA have made in development of fully interoperable electronic health
care record systems?
Ms. Melvin. DOD and VA have taken important steps toward the
development of fully interoperable electronic health care record
systems; however they have more to do--not all electronic health
information is yet shared. As we have previously reported,\1\ the
departments have achieved certain levels of interoperability (that is,
the ability to share data among health care providers). This includes
sharing pharmacy and drug allergy data at the highest level of
interoperability--that is, in computable form, a standardized format
that a computer application can act on, as well as structured and
unstructured data in viewable form. As of January 31, 2009, the
departments reported that they were exchanging computable outpatient
pharmacy and drug allergy data on over 27,000 shared patients--an
increase of about 9,000 patients since June 2008.\2\ Nonetheless, the
departments were not sharing all electronic health data, such as
immunization records and history, data on exposure to health hazards,
and psychological health treatment and care records. In addition, while
VA's health data are all captured electronically, information is still
captured on paper at many DOD medical facilities.
---------------------------------------------------------------------------
\1\ GAO, Electronic Health Records: DOD's and VA's Sharing of
Information Could Benefit from Improved Management, GAO-09-268
(Washington, DC: Jan. 28, 2009).
\2\ GAO, Information Technology: Challenges Remain for VA's Sharing
of Electronic Health Records with DOD, GAO-09-427T (Washington, DC:
Mar. 12, 2009).
---------------------------------------------------------------------------
DOD and VA have indicated that they have plans to further increase
health information sharing. In this regard, they have identified the
Joint Executive Council Strategic Plan and the DOD/VA Information
Interoperability Plan as defining their planned efforts to provide
interoperable health records. However, as we testified in March
2009,\3\ neither plan identified results-oriented (i.e., objective,
quantifiable, and measurable) performance goals and measures that are
characteristic of effective planning and can be used as a basis to
track and assess progress toward the delivery of new interoperable
capabilities. Accordingly, we recommended that the departments develop
such goals and measures to be used in reporting of interoperability
progress.\4\ In the absence of results-oriented goals and performance
measures, progress reporting is largely limited to describing
activities completed and increases in interoperability over time.
---------------------------------------------------------------------------
\3\ GAO-09-427T.
\4\ GAO-09-268.
2. Senator Ben Nelson. Ms. Melvin, what are the challenges DOD and
VA are facing in the development of interoperable electronic health
care records?
Ms. Melvin. In their development of interoperable electronic health
records, DOD and VA face challenges in the areas of performance
measurement, standards setting and compliance, and program office
operation. These areas are essential to effectively increasing
electronic health information sharing. First, as mentioned previously,
our March 2009 testimony \5\ noted that the departments'
interoperability plans lacked the results-oriented (i.e., objective,
quantifiable, and measurable) performance goals and measures that are
characteristic of effective planning. Specifically, of 45 objectives
and activities identified in the plans,\6\ only 4 were documented in
results-oriented terms. Thus, the extent to which the departments'
progress could be assessed and reported was limited to reporting on
activities completed and increases in data exchanged (e.g., increases
in the number of patients for which certain types of data are
exchanged). Second, while DOD and VA have agreed on numerous common
health information technology standards that allow them to share health
data, the departments must also ensure that their health information
systems are aligned with national health information technology
standards. Any level of interoperability depends on the use of agreed
upon standards to ensure that information can be shared and used.
However, Federal standards are still evolving, which could complicate
VA's and DOD's efforts to maintain compliance. The need to be
consistent with emerging Federal standards adds complexity to the task
faced by the two departments of extending their standards efforts to
additional types of health information. Third, we noted that the
departments had not completed all necessary activities required for the
Interagency Program Office to be fully operational. Department
officials stated that this office will be crucial in coordinating VA's
and DOD's efforts to accelerate their interoperability initiatives.
However, the departments have yet to complete key activities to set up
the office. For example, they have not yet hired a permanent Director
and Deputy Director. Until the departments complete key activities to
set up the office, it will not be positioned to be fully functional, or
accountable for fulfilling the departments' interoperability plans.
---------------------------------------------------------------------------
\5\ GAO-09-427T.
\6\ The plans are the November 2007 VA/DOD Joint Executive Council
Strategic Plan for Fiscal Years 2008-2010 (known as the VA/DOD Joint
Strategic Plan) and the September 2008 DOD/VA Information
Interoperability Plan (Version 1.0).
3. Senator Ben Nelson. Ms. Melvin, will DOD and VA be able to
achieve the requirement for fully interoperable electronic health care
records by September 2009, as required by the Wounded Warrior Act?
Ms. Melvin. It is uncertain as to whether DOD and VA will achieve
fully interoperable electronic health care records by September 30,
2009. Specifically, in order to meet the September 2009 requirement,
the departments have identified six objectives to increase their
sharing of electronic health information.\7\ However, five of the six
objectives are not documented in terms that allow the departments to
measure and report their progress toward delivering new capabilities.
For example, DOD identified an objective to increase sharing of
inpatient discharge summaries with VA; however this objective does not
reflect a need to report progress in quantitative terms (e.g.,
interoperability levels to be provided, locations and types of medical
facilities to be included, and number and types of patients for whom
data is to be shared). Without measurable objectives, the ability to
ensure that the departments are taking the necessary steps to achieve
their interoperability goals is limited.
---------------------------------------------------------------------------
\7\ These six objectives are identified in the September 2008 DOD/
VA Information Interoperability Plan (Version 1.0).
vision center of excellence
4. Senator Ben Nelson. Ms. McGinn, the Wounded Warrior Act required
DOD to establish a Center of Excellence in prevention, diagnosis,
mitigation, treatment, and rehabilitation of military eye injuries. How
much money has been spent to date in support of this Center of
Excellence and what progress has been made to establish the Center?
Ms. McGinn. DOD is committed to improving the quality of vision
care for our wounded warriors and veterans, who deserve the very best
for the sacrifices they have made for our Nation. During the past year,
Optometry and Ophthalmology Consultants from the DOD and the VA created
the plan that laid the foundation for the Vision Center of Excellence
(VCE). DOD analyzed and reviewed the necessary requirements and
identified $3 million in funding that was available at the beginning of
fiscal year 2009 to commence initial operating activities.
Colonel Donald Gagliano, VCE Executive Director, and Dr. Claude
Cowan, VCE Deputy Director, were appointed in November 2008 and have
made significant progress in strategic planning to achieve the
objectives of the VCE. The VCE leadership have identified primary
resource requirements, including personnel, registry, facilities, TDY,
equipment, and operational support to appropriately obligate the
funding available. $20,000 has been obligated to date, however, the VCE
is expediting the expenditure of the remaining funds as our resource
requirements are now clearly defined and we expect to obligate most of
the remaining funds by the third quarter of fiscal year 2009.
The VCE has also made significant progress to fulfill its mission
to improve the health and quality of life for members of the Armed
Forces and veterans through advocacy and leadership in the development
of initiatives focused on the prevention, diagnosis, mitigation,
treatment, and rehabilitation of disorders of the visual system. The
VCE is taking the steps outlined below to ensure members of the armed
services and veterans who are visually impaired receive appropriate
blind/vision rehabilitation quickly and effectively:
Operations
DOD and VA officials have been meeting since last year to help
shape initial operations. They have developed enabling documents, DOD
Directive and VCE Charter, to establish the Center. The VCE acquired
short-term space near TRICARE Management Activity headquarters in Falls
Church, VA, to begin initial operations and is working to secure
funding for a long-term facility at the Walter Reed Naval Medical
Military Campus. This location allows for collaboration and synergies
with the vision care providers and patients in the National Capital
Region and will allow the VCE to best meet its congressional mandate by
being in close proximity to the new National Intrepid Center of
Excellence for TBI, the National Eye Institute of the National
Institutes of Health (NIH), the Uniformed Services University, and the
National Military Advanced Training Center, a facility for the
reintegration and rehabilitation of injured servicemembers.
Registry
The Defense and Veterans Eye Injury Registry (DVEIR) will provide
data necessary to measure rates of injuries and longitudinal outcomes.
This will support the VCE's efforts to ensure the ongoing improvement
in care and care processes and to foster consistency of care across the
entire continuum of care. Under an initiative led by the VA, an
Ophthalmology, Optometry, and Information Technology workgroup from the
VA and the DOD has been meeting since March 2008 and has developed a
concept of operations for the DVEIR. The concept of operations, already
approved by the VA, examines development options and details a
recommended approach to implementing the DVEIR. A joint effort is now
in place to identify the specific technical requirements for
interoperability, develop a strategic plan and outline milestones for
implementation of the registry. The VA initiated a Memorandum of
Understanding (MOU) with the Joint Theater Trauma Registry for data
exchange and they expect to have developed a mutually satisfactory
strategy to populate the registry by the end of fiscal year 2009.
Research
Research will also help the VCE accomplish its goals. VCE
leadership established research priorities for the congressional
Special Interest Vision Research Programs and the congressionally
directed Medical Research Program through collaboration with health
professionals from the DOD, VA, NIH, Food and Drug Administration,
other Federal health entities, and the private sector. Grant funding
will be awarded based on those priorities. The VCE will continue to
work with DOD, VA, and other outside entities to move research forward
and assist those in need.
Outreach
Outreach is central to the VCE mission. VCE staff members will
interact with visually impaired warriors and veterans to identify
unaddressed needs and help close those gaps. Colonel Gagliano and Dr.
Cowan have visited wounded warriors and veterans at Walter Reed Army
Medical Center and other vision care centers and listened to their
concerns and experiences. The VCE leadership has solicited input from
other centers of excellence, related Federal health agencies, multiple
vision/veterans advocacy organizations, and affected members of the
armed services and veterans for the VCE way ahead. They have
participated in numerous meetings and conferences on visual impairment
for warriors, including the Defense Centers of Excellence Strategic
Planning Summit. To expand the centers' outreach efforts, the VCE
Executive Director was appointed as the DOD ex officio member of the
NIH National Eye Advisory Council. Additionally, the VCE is
coordinating with the VA Blind Rehabilitation Service to establish an
MOU.
5. Senator Ben Nelson. Ms. McGinn, is development of the VCE on par
with the development of the Centers of Excellence for PH and Traumatic
Brain Injury (TBI)? If not, why not?
Ms. McGinn. The VCE and the Defense Centers of Excellence (DCoE)
for PH and TBI have similar missions: to improve the health and quality
of life for members of the Armed Forces and veterans. Pentagon
surveillance data indicates there are approximately 40,000 veterans
that have sustained a TBI from January 2003-March 2009. Due to the
number of people affected and a gap in addressing TBI and PH, Congress
established the DCoE and appropriated initial funding for the effort in
the Fiscal Year 2007 Supplemental Appropriations bill. The DCoE has
made significant advances in education, training, research, and
treatment.
Some of these TBI injuries result in visual disorders. Visual
dysfunction caused by TBI may be difficult to recognize due to the non-
specific nature of many of these symptoms. In addition, visual symptoms
may be overlooked during routine medical screenings and the onset of
visual symptoms can be delayed. In addition to TBI-related visual
disorders, the changing military environment and new mechanisms of
ocular injury, such as blast exposure, pose new challenges to vision
care specialists. These facts contributed to the impetus for creation
of the VCE and the DVEIR. The DOD and VA established the
congressionally-directed VCE in recognition of the increased rate of
ocular injuries and visual impairment incurred during the Operation
Iraqi Freedom and Operation Enduring Freedom conflicts. As a result of
collaborative efforts between the VCE and DCoE, initial screening for
TBI now includes screening for vision problems, and the DOD and VA are
collaborating on the development of clinical guidelines, research
priorities, and outreach initiatives. The DVEIR will also help
researchers better understand these injuries by longitudinally tracking
outcomes. Other information gained through the registry will ensure
that affected warriors and veterans are properly diagnosed and treated.
Colonel Donald A. Gagliano, the VCE Director, and Dr. Claude Cowan,
the VCE Deputy Director, were selected in November 2008. The DOD
allocated $3 million in fiscal year 2009 for initial operational
capabilities of the VCE and the DOD and VA have made significant
progress working together to ensure the VCE is fully operational in the
shortest amount of time to assist our warriors and veterans. The
advanced development of the DCoE, due to an earlier recognition of the
urgent need to address PH and TBI, has been an immense help to the VCE.
Efficiencies are being achieved through a robust partnership, and the
DCoE collaborates with the VCE to provide strategic guidance and
lessons learned. This approach has allowed the VCE leadership to be
immediately active in outreach, research, and data collection and the
VCE and DCoE will continue to work together and identify areas where
collaboration will benefit their common mission of improving the health
and quality of life for members of the Armed Forces and veterans.
funding for the defense centers of excellence for ph and tbi
6. Senator Ben Nelson. Ms. Embrey, over the past 2 years a great
deal of money, to the tune of at least $600 million, has been put
toward PH and TBI. Do you have an assessment of how much of these funds
have been directed towards the Centers of Excellence for PH and TBI?
Ms. Embrey. As part of the supplemental funding provided, the
following amounts show the Operation and Maintenance funding allocated
for the DCoE for PH and TBI:
Fiscal Year 2007/2008: $123 million
Fiscal Year 2009: $126 million
The following amounts show the Procurement funding allocated for
the DCoE for PH and TBI:
Fiscal Year 2007/2009: $345,000
The following amounts show the Research, Development, Test, and
Evaluation funding for the DCoE for PH and TBI:
Fiscal Year 2007/2008: $45 million
Fiscal Year 2009/2010: $90 million
7. Senator Ben Nelson. Ms. Embrey, what mechanisms are in place to
vet and execute contracts to conduct research, and are there metrics in
place to maintain timelines for actionable results?
Ms. Embrey. The projects that were selected and funded were vetted
by the U.S. Army Medical Research and Materiel Command's (USAMRMC)
congressionally directed Medical Research Programs. In addition,
USAMRMC manages the research projects, to include grant execution and
project monitoring.
The process includes a review of proposals conducted according to
the two-tier review model recommended by the National Academy of
Sciences Institute of Medicine. This model has received high praise
from the scientific community, advocacy groups, and Congress. The first
tier is a scientific peer review of proposals against established
criteria for determining scientific merit. The second tier is a
programmatic review that compares submissions to each other and
recommends proposals for funding based on scientific merit and overall
program goals. Programmatic reviews of proposals are conducted by the
Joint Program Integration Panel.
Fiscal Year 2009: For the obligation of future PH and TBI research
funding, the DCoE for PH and TBI plans to include language developed by
the U.S. Army Medical Research Acquisition Activity the fiscal year
2009 request for proposals to increase its visibility and oversight of
ongoing and future research TBI and PH projects. This language is in
the process of being finalized.
In support of ongoing research gap analyses and management of the
DOD PH/TBI research portfolio, DCoE endorses the solicitation of
periodic updates from funded research programs. The autonomous
operation of independent research must be carefully weighed against
both the needs of the Department to measure intermediate progress
towards an end state of a particular research product and the
expectation for transparent accountability that comes with public
funding.
8. Senator Ben Nelson. Ms. Embrey, do the DOD and VA maintain
separate peer review processes for the evaluation of research
proposals, or do they work together on proposals in the areas of PH and
TBI?
Ms. Embrey. The DOD and VA do maintain separate peer review
processes for evaluating research proposals; however, the VA advises
DOD research offices to develop program announcements and identify key
research priorities, specifically in the areas of TBI and PH. VA and
DOD personnel often serve as scientific peer reviewers on committees
evaluating proposals, and the respective expertise is invaluable for
determining feasibility and scientific merit. Additionally, VA staff
serves as programmatic reviewers on integration panels to ensure
understanding of each other's research portfolios, programmatic focus,
and to help prevent funding overlap. These efforts help to reduce
unnecessary redundant funding and help the agencies to leverage their
existing resources.
9. Senator Ben Nelson. Ms. Embrey, to avoid duplicative efforts,
who is ultimately responsible to coalesce the projects being performed
by agencies and entities, such as the VA and other Federal agencies,
State and private universities, and nongovernmental organizations to
identify gaps in research or treatment and to ensure we gain economies
of scale in the efforts currently being undertaken to help improve the
diagnosis and treatment of PH issues and TBI?
Ms. Embrey. The DCoE for PH and TBI provides the nexus for research
planning and monitoring across DOD and with other Federal and non-
Federal agencies. In addition, the DCoE engages in activities to
identify gaps in research and to avoid duplication of effort by
building a PH and TBI research community. These efforts include:
Coordinating development of recommended PH and TBI research
strategies, requirements, and priorities jointly across
multiple agencies;
Working with the VA, NIH, and the Department of Education to
define common data elements, definitions, metrics, outcomes,
and instrumentation standards for research in PH and TBI;
Conducting a comprehensive scan for research activities
related to PH and TBI, and integrating research efforts of
component centers, including the Blast Injury Research Program,
VA, Federal agencies, and civilian organizations;
Performing gap analysis using the Joint Process Integration
Panel to define requirements and priorities as inputs to the
overarching Health Affairs biomedical research, development
testing, and evaluation (RDT&E) portfolio, joint development of
requests for proposals, and both programmatic and peer reviews;
Developing PH and TBI research and clinical practice
clearinghouse capabilities;
Consolidating and disseminating best practices and monitoring
clinical investigations (non-RDT&E); and
Translating research into practical tools, technologies,
protocols, and clinical practices.
The DCoE is in the process of planning an interagency PH and TBI
Research Portfolio Coordination Conference for the fall of 2009. This
will help to provide the major Federal PH and TBI research funding
agencies with an opportunity to develop a qualitative and quantitative
understanding of each other's portfolios, and to coordinate them more
strategically in the future.
The DCoE actively collaborates with the following agencies and
institutions:
DOD Agencies:
Bureau of Medicine and Surgery
Office of Naval Research
U.S. Army Medical Research and Materiel Command
Armed Forces Health Surveillance Center
Armed Forces Institute of Regenerative Medicine
Uniformed Services University of the Health Sciences
Center for Neuroscience and Regenerative Medicine
Joint Improvised Explosive Device Defeat Organization
Defense Advanced Research Projects Agency
Federal Agencies:
VA
NIH
National Institute on Disability and Rehabilitation Research
Centers for Disease Control and Prevention
Department of Health and Human Services
Non-Federal Institutions:
Post Traumatic Stress Disorder (PTSD)/TBI Clinical Consortium
Coordinating Center
TBI Multidisciplinary Research Consortium
PTSD Multidisciplinary Research Consortium
virtual lifetime electronic record
10. Senator Ben Nelson. Admiral Timberlake, on April 9, President
Obama announced plans to create a Virtual Lifetime Electronic Record,
which would expand on the idea of fully interoperable electronic health
record capabilities to include personnel, benefit, and administrative
information. Secretary Gates and Secretary Shinseki support this plan,
and I believe they chose the Interagency Program Office to take the
lead on coordinating this initiative. What effect has this decision had
on the Departments' plans to execute a fully interoperable electronic
health record system or capability?
Admiral Timberlake. Regarding the policy guidance provided by the
President and the Secretaries, the DOD/VA Interagency Program Office
(IPO) is establishing a virtual lifetime electronic record working
group to provide a focused requirements and management effort to
accelerate the adoption and implementation of this new virtual lifetime
electronic record approach. We are in the early planning stages for the
virtual lifetime electronic record and will be developing the timelines
as we progress, but it is important to note that this approach will
leverage the Interagency Clinical Informatics Board (ICIB) in
prioritizing common services for clinical care as the process moves
forward. Currently the IPO is only tasked to facilitate the development
of the various working groups and governance structure in determining
the way ahead. Efforts related to the planning for, and implementation
of, the virtual lifetime electronic record are not intended to be a
replacement to our congressionally-mandated objective of achieving full
interoperability for the provision of clinical care by September 2009.
These two very important efforts are aligned and do not conflict with
one another.
11. Senator Ben Nelson. Admiral Timberlake, will this initiative
require a new system platform? If so, how do the Departments plan to
fund it?
Admiral Timberlake. The foundation of the virtual lifetime
electronic record effort is the implementation of a Services Oriented
Architecture (SOA) approach using common services. This provides an
environment in which functions can be standardized and used across
systems and processes. This approach adopts industry best practices to
provide an environment in which data may be accessed through links to
legacy applications. The Departments are working together to identify
what common services are needed, reconcile clinical and business
practices where needed, and prioritize the common services to be built
or acquired. As more common services are used by DOD and VA, the
systems become more interoperable over time, leading to further
interoperability and the effective and efficient sharing of data
between the Departments.
Certain platform changes will need to be implemented to carry out
the virtual lifetime electronic record mission. Such upgrades include
the use of SOA to ensure that both DOD and VA systems are able to
evolve, allowing for the effective and efficient integration of data
sharing capabilities and services that provide the greatest benefit to
our beneficiaries. Utilizing a SOA approach will provide methods for
the development and integration of services by grouping functionality
among common business processes. As the common services to be developed
or acquired are defined, the Departments will need to estimate the
resources needed.
12. Senator Ben Nelson. Admiral Timberlake, are DOD and VA still
separately funding fixes and improvements to the DOD's electronic
health record system, AHLTA, and the VA's health record system, VistA?
How can electronic health record interoperability move forward with
such a disjointed approach?
Admiral Timberlake. The DOD and VA are currently funding fixes and
improvements to their respective electronic health record systems.
Electronic health record (EHR) interoperability at the present time is
accomplished by ensuring the access to data using the Bidirectional
Health Information Exchange (BHIE). The data are shared bi-
directionally, in real time, for patients who receive care from both VA
and DOD facilities and are viewable at all DOD and VA medical
facilities. BHIE permits DOD providers to view BHIE data from all VA
medical facilities and VA to view BHIE data from all DOD facilities.
The Departments will continue to use and upgrade their current EHRs to
provide and document clinical care while the way forward using a common
services approach is being implemented. The evolution to the virtual
lifetime electronic record will be incremental and rely on legacy
systems and new common services.
employment training for transitioning servicemembers
13. Senator Ben Nelson. General Meurlin and Mr. Dimsdale, many of
our service men and women enter the military out of a desire to serve
their country and receive the education, training, and job stability
benefits the military affords. We train them to do their jobs serving
our country, but if they are injured severely enough then we medically
separate them. With growing economic concerns affecting job
opportunities across the country, we owe it to the men and women who
have served and sacrificed for our country to ensure they have the
tools and skills to succeed in the civilian sector once they are
separated from the military. What employment training do we provide for
wounded, ill, and injured troops leaving the military?
General Meurlin. DOD has a longstanding partnership with the
Department of Labor Veterans Employment and Training Service and the VA
Vocational Rehabilitation and Employment Service. DOD, DOL, and VA
along with the Department of Homeland Security, formalized our
partnership with a MOU. The MOU lays out each Department's areas of
responsibility for the deliver of services and programs that fall under
the Transition Assistance Program (TAP) and the Disabled Transition
Assistance Program (DTAP). This includes programs, services, training,
and new initiatives for the wounded, ill, and injured.
DOD and the Military Services Pre-separation Counseling: The
process to inform and educate servicemembers (including wounded, ill,
and injured about employment assistance and job training) begins with
the Military Services' Pre-separation Counseling sessions. During pre-
separation counseling, servicemembers are given an overview of the
employment and training assistance available by DOL and VA, in addition
to other resources and programs. The Military Service Transition
Counselor, Army Career and Alumni Program Counselor, or the Navy
Command Career Counselor schedule the servicemember to attend the next
available 2\1/2\ day DOL TAP Employment Workshop, VA Benefits (4 hours)
and DTAP (2 hour) Briefings as part of the preseparation counseling
process.
DOL TAP Employment Workshops: During the DOL 2\1/2\ day DOL TAP
Employment Workshop, DOL's professional staff provides training and
assistance on resume writing, developing cover letters, job search
techniques, interview skills, and researching the job market (local,
State, and national level), salary negotiation, dress for success and
more. They also get information on translating their military skills
into civilian language. DOL provides employment assistance, job
training assistance and other DOL TAP services and programs which fall
under the purview of the Secretary of Labor to all separating
servicemembers, including our wounded, ill, and injured. DOL
established the Recovery and Employment Assistance Lifelines
(REALifelines) Program dedicated to providing individualized job
training, counseling, and reemployment services to wounded, ill, and
injured servicemembers. DOL has staff at 16 Military Treatment
Facilities (MFTs).
VA Benefits Briefing: During the VA Benefits Briefing sessions,
wounded ill and injured servicemembers are informed and educated about
all VA benefits. These include information on education and training,
health care, home loans, life insurance, vocational rehabilitation and
employment (VR&E), disability benefits, and others. In addition, those
who are wounded, ill, and injured are also scheduled to attend a
separate DTAP Briefing designed solely for servicemembers leaving the
military because of a service-connected disability, injury, or illness
that was aggravated by military service.
Other Support and Employment Programs for Wounded, Ill, or Injured
(WII): The Military Services along with other organizations provide
many great support programs for wounded, ill, and injured. All of them
play a pivotal role in helping our deserving servicemember with
employment assistance and job training. The goal is to help WII
servicemembers fulfill their aspirations and achieve their employment
goals. Several programs and services are: Military OneSource; Army
Wounded Warrior Program; Navy's Safe Harbor Program; Marine Corps
Wounded Warrior Regiment; Air Force Wounded Warrior Program; Heroes to
Hometown (a DOD partnership with the American Legion for WII
servicemembers); DOL's most recent ``America's Heroes at Work'' project
that focus on the employment challenges of returning servicemembers
living with TBI and/or PTSD.
Mr. Dimsdale. The VA Vocational Rehabilitation and Employment
(VR&E) Coming Home to Work (CHTW) program provides career counseling,
training and education, and employment assistance to wounded, ill, and
injured servicemembers. VA has stationed full-time vocational
rehabilitation counselors at major DOD MTFs. These counselors work with
CHTW coordinators at VA regional offices. CHTW coordinators also
provide outreach and counseling services at DOD warrior transition
units, post deployment health reassessment events, and at DOD Yellow
Ribbon events. The CHTW program eases servicemember transition into to
civilian life by providing expedited and comprehensive training and
employment services that lead to suitable employment.
14. Senator Ben Nelson. General Meurlin and Mr. Dismdale, are there
incentives for companies to hire veterans?
General Meurlin. The Department of Labor has the Work Opportunity
Tax Credit (WOTC). The WOTC provides employers with Federal income tax
credits for hiring certain targeted groups. Veterans and disabled
veterans are groups included in the WOTC. Employers can receive up to
$4,800 in tax credits for hiring veterans. The Federal Government also
has Executive Order 13360 which sets goals for Federal agencies to
provide contract opportunities for Service-Disabled Veterans Owned
Small Businesses. The Veterans Benefits Act (VBA) of 2003 established
the set-aside programs for Service-Disabled Veteran-Owned Small
Businesses (SDVOSBs). Under SDVOSB, ``a contracting officer may award
contracts on the basis of competition restricted to'' SDVOSBs if he or
she is reasonably expects that no less than two SDVSOBs will submit
offers and the award can be made at a fair market price.
VA Programs that Offer Incentives:
Special Employer Incentives (SEI) - offers private companies the
opportunities to hire disable veterans who face extraordinary
circumstances to obtaining suitable employment. The VA can pay the
employer up to 50 percent of the veteran's salary for up to 6 months.
This payment is to help the employer recoup losses in production for
having a senior employee assist with training the veteran.
On-the-Job Training (OJT) - OJT is for Federal, State, local
government as well as private sector employers. Employers have the
opportunity to hire veterans that may need additional training on the
job. The employer pays less than the journeyman wage and the VA pays
the veteran a subsistence allowance to bring the salary up to the
journey wage. An OJT may be a maximum of 2 years. Over time the VA pays
less as the employers' portion of the veterans' salary increases. At
the conclusion of the OJT, the employer is paying 100 percent of the
veteran's salary at the journeyman wage.
Non-paid Work Experience (NPWE) - NPWE is for Federal, State, and
local government employers. It allows a servicemember the opportunity
for a smooth transition from military to civilian work by building
confidence as they recover and rehab prior to being released from
Active Duty. Although employment is not guaranteed, the employer is
encouraged to consider hiring veterans when positions open. The
employer may choose to use Federal special hiring authority to hire the
veteran non-competitively: Disabled veterans enrolled in VA Training
Programs or Schedule A. VR&E provides a subsistence allowance to
veterans based on the number of hours worked per week.
Mr. Dimsdale. There are several tangible incentives available for
both Federal agencies and private sector firms to hire veterans. The
VR&E VetSuccess program assists veterans with overcoming obstacles to
employment such as lack of civilian work experience, gaps in
employment, and serious employment handicaps. Federal, State, and local
government employers may hire veterans through the non-paid work
experience (NPWE) program or Federal on-the-job training (OJT) program.
Private sector firms may hire veterans through the OJT program for
nongovernment employers, or through the special employer incentive
program.
The NPWE program is for Federal, State, and local government
employers. This program allows a servicemember or veteran the
opportunity for a smooth transition from military to civilian work by
gaining meaningful work experience. The number of hours worked per week
may be full or part-time depending on the participant's and employer's
needs. However, during the NPWE program, VR&E provides a subsistence
allowance to veterans based on the number of hours worked per week.
Although employment is not guaranteed, the employer is encouraged to
hire veterans when positions are open. The NPWE program provides the
opportunity for veterans to try a new job in a new setting, while
allowing the employer to assess the veteran's work habits in the work
setting. If the employer decides to hire the veteran, the employer may
choose to use a Federal special hiring authority to hire the veteran
noncompetitively: disabled veterans enrolled in VA training programs or
schedule A.
The OJT program may be used by Federal, State, local government, as
well as private employers. Employers have the opportunity to hire
veterans that may need additional training on the job. Through the OJT
program, the employer pays the veteran less than the journeyman wage
and the VA pays the veteran a subsistence allowance to bring the salary
to the journeyman wage. Over time the VA pays less as the employer's
portion of the veteran's salary increases. At the conclusion of the OJT
program, the employer is paying 100 percent of the veteran's salary at
the journeyman wage. An OJT program may be a maximum of 2 years.
Another incentive program that private sector employers may use to
hire veterans is the special employer incentive (SEI). This program
offers private companies the opportunity to hire veterans with
disabilities that face extraordinary circumstances to obtaining
employment. Extraordinary circumstances may be the seriousness of the
veteran's disabilities, training deficits, or significant gaps in
employment. VA can pay the employer up to 50 percent of the veteran's
salary for up to 6 months. This payment is to help the employer recoup
losses in production for having a senior employee assist with training
the veteran.
Additionally, VR&E continues to partner with the Department of
Labor (DOL) Veterans' Employment Training Service (VETS) program to
advance, improve, and expand employment opportunities for veterans with
disabilities. The VETS program is charged to provide training and job
placement services to veterans, with a special emphasis on veterans
with disabilities. The VETS program provides grant programs to States,
which fund local workforce boards to provide services in local
communities throughout the Nation. Services are provided by disabled
veteran outreach and placement (DVOP) coordinators and local veterans
employment representatives (LVER) at local ``one-stop'' workforce board
organizations. The DVOPs and LVERs are also co-located at VR&E offices
throughout the country. DVOPs and LVERs work with veterans in VR&E from
initial orientation through successful job placement by providing labor
market information, job readiness services (interviewing skills and
resume preparation), and job placement assistance for veterans enrolled
in the VR&E program.
15. Senator Ben Nelson. General Meurlin and Mr. Dimsdale, we know
there is a shortage of behavioral health care professionals nationwide.
Would it make sense for the DOD to adopt a program where they retain,
educate, and train behavioral health care professionals for the force?
As in other education programs, the servicemembers would need to apply
and be selected. Could this concept potentially work for those who are
being medically separated?
General Meurlin. All Service components provide career
opportunities based upon level of injuries and aptitude. The Services
have been tasked to give directives and assignment limitations for
wounded warriors with an expected completion date of June.
Additionally, the Department has, over the past 2 years, been
expanding educational programs for non-physician behavioral health
specialties and continues to look at other opportunities to improve
front-line mental health care. We have been working with the University
of Southern California, which has developed a new Military Masters in
Social Work program, as a potential source of new clinical social
workers. We are also considering the development of a scholarship
program for training civilians in behavioral health fields. Advanced
degree programs are also being created. The Uniformed Services
University of the Health Sciences currently has a PhD in Clinical
Psychology program for military students and a similar PhD in Medical
Psychology program with a clinical track for research-oriented clinical
psychologists in the academic tradition. The Army has a Masters program
with Fayetteville State University, NC (taught in San Antonio, TX) that
provides social workers in uniform with a special counseling skill on
deployment issues.
Mr. Dimsdale. This question is specific to DOD and cannot be
addressed by VA.
hiring authority for civilian health care employees
16. Senator Ben Nelson. Ms. McGinn, the Wounded Warrior Act
authorized enhanced appointment and compensation authority for civilian
health care personnel by authorizing DOD to exercise any authority
under chapter 74 of title 38, which covers pay and hiring authorities
of the VA. This would enhance DOD's pay and hiring authorities for
purposes of recruitment, employment, and retention of civilian health
care professionals. Has DOD used these authorities? If not, does it
plan to?
Ms. McGinn. The Department uses recruitment and compensation
authorities for health care practitioners under both the Office of
Personnel Management (OPM) title 38 delegation agreement and the
provisions of the Wounded Warrior Act.
OPM delegated to the Department a number of the VA title 38
authorities via an agreement that was originally issued in 1994, and
which was subsequently updated in July 2002 and July 2006. Incident to
this delegation agreement, the Department has instituted a number of
compensation flexibilities, as described below, to facilitate
recruitment and retention of health care practitioners. These
authorities are working well and do not need any modifications to
improve their effectiveness.
Special Salary Rate Authority: This authority is currently
being used by DOD to set special salary rates. It is used
mainly for nurses and pharmacists.
Baylor Plan: This authority was authorized for use in DOD in
1996, but has had limited application.
Premium Pay: The authority to pay Call Back Premium Pay was
authorized in 1996.
Head Nurse Pay and Nurse Executive Special Pay: Head nurse
pay was authorized in August 2005, and is currently in use in
the Department.
Hours of Employment: There is no evidence that this authority
is being used. This authority may not be necessary given the
higher salary levels provided under the National Security
Personnel System (NSPS).
Under the Wounded Warrior Act, the Department is pursuing two major
initiatives: an expedited hiring authority for healthcare practitioners
and a new compensation system for non-NSPS physicians and dentists. We
expect the expedited hiring authority to be released to the components
by July 1, 2009. The delay in its delegation stemmed from an assessment
of a recent court case on adjudication of certain veterans preference
cases and the impact that ruling would have on the procedures for this
authority. We have received the necessary guidance and have written the
procedures for using the authority. We also need information on what
type of positions should be covered by this expedited hiring authority.
That information has been requested and we expect to have it collected
by mid-June.
The Policy Instruction for the new physicians/dentists compensation
pay system was issued in December 2008. We are currently finalizing the
system procedures and applicable salary survey instruments, with a
scheduled conversion date for late September 2009. This system will be
applicable to non-NSPS physicians and dentists and will enable the DOD
to pay these employees a salary comparable to that paid by VA and under
NSPS.
In addition to the title 38 authorities, DOD has been making very
effective use of the title 5 recruitment, relocation, and retention
incentives. In 2008, DOD spent approximately $46 million on these
incentives for employees in the medical occupations. Over 4,500
incentives were processed, with an average value of over $10,000.
DOD continues to make effective use of the Physicians Comparability
Allowance, and plans to do so until the allowance amount is included
into the physicians' pay under the Physicians and Dentists Pay Plan or
NSPS.
17. Senator Ben Nelson. Ms. McGinn, does DOD need any additional
legislation to implement these hiring authorities?
Ms. McGinn. Not at the present time. The Wounded Warrior Act has
authorized enhanced appointment and compensation authority for civilian
health care personnel by authorizing the DOD to exercise any authority
under chapter 74 of title 38. This enhances DOD's pay and hiring
authorities for purposes of recruitment, employment, and retention of
civilian health care professionals.
wounded warrior information resources
18. Senator Ben Nelson. General Meurlin and Mr. Dimsdale, you both
mentioned the National Resource Directory (NRD) in your written
statements as a jointly developed source of national, State, and local
information for servicemembers, veterans, and their families. How is
the National Resource Center different from the Wounded Warrior
Resource Center that was mandated by the Wounded Warrior Act as a
single point of contact for wounded, ill, and injured servicemembers,
veterans, families, and caregivers?
General Meurlin. The NRD, www.nationalresourcedirectory.org), is an
online tool for servicemembers, veterans, their families, and those who
support them. It provides access to more than 11,000 services and
resources from Federal, State, local government programs and agencies,
as well as philanthropic, academic institutions and professional
associations, nonprofit and community-based organizations, Veteran
Service, and nongovernmental organizations. The NRD offers information
on: Benefits and Compensation, Education, Employment and Training,
Family and Caregiver Support, Health, Housing and Transportation,
Services and Resources, and Key Contact Information.
The NRD, maintained through a collaborative partnership among DOD
Labor and VA, was created to answer the needs identified by wounded,
ill, and injured servicemembers, veterans, and families to provide a
comprehensive online tool available to assist in transitioning into the
civilian community. It is also part of a larger effort to improve
wounded warrior care coordination and access to information on services
and resources, key goals identified by both the President's Commission
on Care for America's Returning Wounded Warriors (Dole-Shalala
Commission) and Title XVI, ``Wounded Warrior Matters,'' of the 2008
National Defense Authorization Act (NDAA). The NRD will also assist
with the MyeBenefits effort.
In April 2009, there were more than 60,000 hits to pages within the
NRD. The TAP received the most hits to a single page; over 20,000 users
accessed some form of information contained with the VA's website.
The Wounded Warrior Resource Center (WWRC) Web site,
www.woundedwarriorresourcecenter.com, meets the requirements of NDAA
for Fiscal Year 2008, section 1616, which states: ``(b) Access. The
center shall provide multiple methods of access, including at a minimum
an Internet website and a toll-free telephone number (commonly referred
to as a hot line) at which personnel are accessible at all times to
receive reports of deficiencies or provide information about covered
military facilities, health care services, or military benefits.''
In response to this mandate, The WWRC Web site, a DOD site,
provides wounded servicemembers, their families, and caregivers with
information they need on military facilities, health care services, and
benefits. It provides access to 1,000 links and supports access to the
WWRC Call Center (also mandated by the NDAA), run by Military OneSource
(MOS) with trained specialists who are available 24 hours a day, 7 days
a week by phone at 1-800-342-9647 or by e-mail at
[email protected].
The WWRC Web site also provides access to FAQs, handbooks, and
checklists for servicemembers, their families, and caregivers.
In April 2009, the WWRC had 1,362 hits.
Mr. Dimsdale. The NRD is an online tool for servicemembers,
veterans, their families, and those who support them. It provides
access to more than 11,000 services and resources from Federal, State,
local government programs and agencies as well as philanthropic,
academic institutions and professional associations, nonprofit and
community-based organizations, veteran service, and nongovernmental
organizations. The NRD offers information on: benefits and
compensation, education, employment and training, family and caregiver
support, health, housing and transportation, services and resources,
and key contact information.
The NRD, maintained through a collaborative partnership among the
DOD, DOL, and VA, was created to answer the needs identified by
wounded, ill, and injured servicemembers, veterans, and families to
provide a comprehensive online tool available to assist in
transitioning into the civilian community. It is also part of a larger
effort to improve wounded warrior care coordination and access to
information on services and resources, key goals identified by both the
President's Commission on Care for America's Returning Wounded Warriors
(Dole-Shalala Commission) and Title XVI, Wounded Warrior Matters, of
the 2008 NDAA.
In April 2009, there were more than 60,000 hits to pages within the
NRD. The TAP received the most hits to a single page; over 20,000 users
accessed some form of information contained with the VA's Web site.
The WWRC Web site meets the requirements of NDAA Section 1616 which
states: ``(b) Access. The center shall provide multiple methods of
access, including at a minimum an Internet website and a toll-free
telephone number (commonly referred to as a hot line) at which
personnel are accessible at all times to receive reports of
deficiencies or provide information about covered military facilities,
health care services, or military benefits.'' In response to this
mandate, the WWRC Web site, a DOD site, provides wounded
servicemembers, their families, and caregivers with information they
need on military facilities, health care services, and benefits. It
provides access to 1,000 links and supports access to the wounded
warrior resource call center (also mandated by the NDAA), run by
Military OneSource (MOS) with trained specialists who are available 24
hours a day, 7 days a week by phone at 1-800-342-9647 or by e-mail at
[email protected]. The WWRC Web site also provides access to
frequently asked questions, handbooks, and checklists for
servicemembers, their families, and caregivers. In April 2009, the WWRC
had 1,362 hits.
19. Senator Ben Nelson. General Meurlin and Mr. Dimsdale, does
having two major similar resources duplicate efforts or risk causing
confusion for wounded servicemembers and veterans and their families?
General Meurlin. We believe that the WWRC Web site is duplicative
of the information contained within the NRD. All of the links found on
the WWRC Web site are also on the NRD. However the NRD, which is a tri-
agency effort between DOD, Labor, and VA, reaches a wider audience and
offers more services and resources than the WWRC Web site.
Mr. Dimsdale. VA believes that the WWRC Web site is duplicative of
the information contained within the NRD. All of the links found on the
WWRC Web site are also on the NRD. Additionally, the majority of the
questions received on the WWRC Web site are similar if not the same as
questions received on the MOS Web site, or received by the wounded
warrior resource call center run by MOS. The NRD, as a tri-agency
effort, reaches a wider audience and offers more services and resources
than the WWRC Web site.
clean sheet review
20. Senator Ben Nelson. Ms. McGinn and Mr. Dimsdale, the Senior
Oversight Committee (SOC) initially established eight lines of action
to address issues regarding warriors in transition. One of these lines
of action, which is now completed, was called a Clean Sheet Design, to
answer the question of what we would do, having reviewed all of the
issues, if we could start over with a clean sheet of paper? Did this
line of action recommend a system that would be different from what we
have today? If so, what would it look like?
Ms. McGinn. Yes. The Clean Sheet Design did recommend a system that
would be different from what we have today.
The major features of the Clean Sheet Design are:
1. Ability Assessment. For both the decisions that determine
whether or not a person is fit to continue in military service
and that determine the level of compensation for those who are
leaving the military, these recommendations would provide for
an ability assessment rather than a disability evaluation. This
is perceived to encourage a focus on rehabilitation, education,
and training to reach full potential rather than a focus on
limitations. The assessment would include a psychological/
physical medical evaluation, a mental acuity assessment, and an
aptitude assessment.
2. Continuation of Military Service (COMS). These
recommendations would streamline and accelerate the process by
which servicemembers are identified as candidates for the
continuation of military service decision and help them move
more quickly to begin their assimilation into a new life (if
appropriate), while ensuring that there is no penalty (in terms
of benefits or compensation) from leaving the service and
providing return rights if full recovery is more extensive than
expected.
3. Compensation. These recommendations provide for three
components of compensation: military service annuity (based on
years of service and base pay); income replacement (may be
permanent, but focused on providing income while recovering and
participating in vocational rehabilitation to transition to a
new career); and WII compensation that would recognize the
significant quality of life impact. (This could be adjusted up
or down throughout the servicemembers or veteran's life,
depending upon significant changes in conditions.)
4. Care. These recommendations would establish open access to
all DOD and VA facilities for all wounded, injured, or ill
servicemembers or veterans to ensure that access to care is not
dependent on military status. (Enable joint facilities in
selected areas and promote the idea of `Federal health care
facilities' to ensure that servicemembers and veterans
understand that they are appreciated by their country and their
government, not just their military service.)
5. Consolidated Access to Benefits. To ensure that
servicemembers and veterans do not have to navigate the myriad
of benefits (and associated paperwork) that may be available to
them, these recommendations would create an expedited,
centralized capability to support the process by which benefits
are identified, obtained, adjusted, and updated and ensure that
servicemembers, veterans, and their families have the correct
benefits available at the correct time.
6. Information Access. These recommendations would promote and
develop capabilities for the seamless exchange of information
across organizations to provide consistent, timely support and
care. The recommendations would enable access to all relevant
records to those who need it to track, update, and retrieve
information about health care and personnel status, provide
health care practitioners with additional insight into the
incident that caused a would, injury, or illness. (The recent
project to develop a Virtual Lifetime Electronic Record
announced by the President and the Secretaries of DOD and VA
would achieve these goals.)
7. Continuous Improvement and Oversight. These recommendations
would establish an oversight body and define metrics to monitor
success. They would also clarify roles, accountability and
reporting procedures.
Mr. Dimsdale. The Clean Sheet Review sets aside all existing
constraints; e.g., Public Law, departmental policy, existing
organizational boundaries, human capital strategies, and budgets, to
portray a holistic, end-to-end support structure. The design addresses
the needs of wounded, injured, and ill servicemembers/veterans and,
from their perspective, provides overlapping, coordinated care from the
point-of-wound/injury or onset of illness through their reintegration
into military or civilian community and beyond. The Clean Sheet Review
recommended:
(1) A continuation of military service decision by three
processes based on severity of injury, similar to the three
categories implemented by the Federal recovery coordinator/
recovery care coordinator architecture;
(2) A conversion from a disability assessment to an ability
assessment that drives the clinical care regimen,
identification of needed benefits, the ability of a
servicemember to continue their military career, and
compensation;
(3) Compensation including a military service annuity based
on time in service and base pay, paid for life, income
replacement and quality of life compensation;
(4) Access to military/VA or civilian medical treatment
facilities (MTFs) that best meet a servicemember or veteran's
relevant clinical needs and are most convenient to where they
work or live without regard to their status as servicemembers
or veterans and at no additional cost;
(5) Consolidation of benefits delivery from a single care
management team that functions as single approval authority for
all Federal benefits;
(6) A convergence of information that supports managed access
to all relevant systems through a centralized portal for all
approved stakeholders and agents of the process; and
7) A continuous process improvement and oversight function to
ensure responsiveness to wounded warriors and their families,
and constant process improvement to changing conditions and
opportunities.
electronic health records of private sector care
21. Senator Ben Nelson. Admiral Timberlake, the Interagency Program
Office has focused a great deal on getting DOD and VA medical records
online and interoperable. However, it is estimated that up to 60
percent of medical care given to all servicemembers and their eligible
dependents is provided by private health care professionals, outside of
military or veterans medical facilities. Is the Interagency Program
Office taking steps to include records of medical care provided outside
of MTFs or VA medical centers, in order to create a truly comprehensive
electronic health record?
Admiral Timberlake. The virtual lifetime electronic record will
foster interoperability and interchangeability through the use of
common services, and support both the health mission of providers and
the health needs of our warfighters. The open standards/open
architecture technologies employed in the structure will facilitate
secure, appropriate, and cost-effective data sharing with DOD, VA, and
DOD managed care support contractors.
The Departments' approach to the virtual lifetime electronic record
will adopt industry best practices to provide an environment with links
to new and legacy applications through service-oriented architecture
using common services. Creating a truly comprehensive EHR will be
accomplished by referencing national standards for health-related data
guided by the Department of Health and Human Services (HHS). The
virtual lifetime electronic record effort will help facilitate the
effort towards achieving President Obama's goal of allowing for data
sharing with the private sector.
Additionally, as the Nationwide Health Information Network (NHIN)
is developed and matures, it will be the means to obtain information
from civilian healthcare providers and for them to gain appropriate
access to the virtual lifetime electronic record. Recognizing that many
private sector care clinical providers are not currently using
electronic health records, DOD is developing the ability to scan paper
records, make them available through AHLTA, and share them with VA. For
example, if a patient is referred to a private sector provider and
returns to the MTF with a consult report, that report can be scanned
with the appropriate identifying information so others will know what
it is and be able to access it.
access to additional behavioral health care providers
22. Senator Ben Nelson. Ms. Embrey, you state in your written
testimony that the Department ``funded the hiring of additional mental
health and other specialty providers by the Services, and implemented a
policy that requires first appointment access within 7 days for mental
health concerns.'' How many additional positions were funded, and is it
enough?
Ms. Embrey. In the past 2 years, Office of the Assistant Secretary
of Defense (Health Affairs) has funded an additional 1,700 positions
for mental health providers, to include contractors, to work in MTFs.
We are also partnering with the Public Health Service to increase our
number of mental health providers. Around each MTF, we have established
a network of private care providers to augment the MTF's capability and
capacity. When an MTF cannot satisfy the demand for mental health
services, it uses the established referral process to obtain timely
care for TRICARE beneficiaries from private care sources. To ensure
availability of providers for this referred care, TRICARE has added
more than 10,000 mental health professionals to the network during the
past 2 years. As a result of the combination of MTF and network mental
health capability and capacity, TRICARE beneficiaries do not currently
encounter any systemic problems in obtaining timely access to mental
health care.
23. Senator Ben Nelson. Ms. Embrey, if additional behavioral health
care positions were authorized, would the Services be able to recruit
and hire them, given the national shortage of these providers?
Ms. Embrey. Yes, the Services would be able to recruit and hire
additional behavioral healthcare providers. National needs for mental
health providers are developed by agencies such as the National
Institutes of Mental Health, the Health Resources and Services
Administration, and the Substance Abuse and Mental Health Services
Administration--they have responsibilities related to mental health
services throughout America. The DOD and VA are working closely on all
aspects of identifying and meeting mental health staffing requirements
for our wounded warriors and veterans; we have established a working
partnership. DOD's mental health provider requirements are based on the
needs of our wounded warriors, their families, and our beneficiaries.
We are constantly adjusting these requirements.
Medical workforce planning efforts throughout the DOD have
streamlined the hiring process of behavioral healthcare providers,
utilizing the appointing flexibilities we have as well as compensation
incentives. We are now much more competitive for scarce and shortage
healthcare providers. As a result, DOD has been able to increase
recruitment and hiring of many behavioral healthcare positions.
24. Senator Ben Nelson. Ms. Embrey, does the Department's policy of
access to mental health care within 7 days apply only to wounded, ill,
and injured servicemembers? Does it apply to family member
beneficiaries?
Ms. Embrey. Access standards apply to all TRICARE Prime enrollees,
including Active Duty servicemembers and their eligible family members,
retirees and their eligible family members, survivors, and certain
other beneficiaries who might be enrolled in Prime.
25. Senator Ben Nelson. Ms. Embrey, are the Services meeting the
Department's policy of access to mental health care within 7 days?
Ms. Embrey. MTFs are meeting this access standard, although not all
MTFs have mental health (MH) specialty services (small units) and some
do not provide MH specialty services to civilian beneficiaries. Ninety-
six percent of those seen in military mental health clinics are seen
initially as ``walk-ins'' at the time of their initial contact with the
clinic. Approximately 80 percent of those seen by appointment are seen
within 7 days. Across the enterprise, more than 99.5 percent of those
seen initially (who have had a minimum of 6 months without previous
contact) for MH specialty care in military clinics are seen within the
access standard.
TRICARE provides Behavioral Health Provider Locators to assist
beneficiaries to receive routine initial access (7 days or less) to
network MH specialty providers. Most beneficiaries report by survey
little to no problems accessing MH providers. Coverage includes up to
eight sessions without a referral or authorization. Families of both
Active Duty and activated Reserve component personnel receive full
health care coverage, including MH benefits. Coverage for Reserve
members continues up to 6 months after deactivation and will continue
beyond that if they enroll in TRICARE Reserve Select.
______
Questions Submitted by Senator Lindsey Graham
congressional efforts
26. Senator Graham. Mr. Williamson, Mr. Bertoni, and Ms. Melvin,
you have heard the concerns of our first panel of witnesses, and
analyzed the government's response. Where are the gaps in policy and
law that Congress needs to fill?
Mr. Williamson, Mr. Bertoni, and Ms. Melvin. During our review of
the status of DOD and VA's efforts to jointly develop the policies
required by the NDAA of 2008),\8\ agency officials described two
instances in which gaps in policy and law may need to be addressed. In
one case, an official from the Wounded, Ill, and Injured SOC told us
that one of the SOC's work groups had been contributing to legislation
for improving support to caregivers of recovering servicemembers. In
January 2009, the SOC approved the workgroup's proposal. A provision
for caregiver benefits based on the SOC's proposal was included in the
NDAA 2010 bill that was introduced in May 2009.\9\ In a second case,
SOC officials told us that legislation may be needed to reconcile some
of the eight outstanding wounded warrior-related definitions between
the departments.
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\8\ Pub. L. No. 110-181, 122 Stat. 3.
\9\ S. 1033, 111th Cong. Sec. 701 (2009).
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Further, our review of the military's temporary disability retired
list (TDRL) identified two gaps in policy or law. First, in April 2009,
we reported that DOD's temporary retirement program did not appear to
be fulfilling one of its original objectives, that is, to return
temporary retirees to military duty.\10\ Currently, only about 1
percent of temporary retirees return to the military, suggesting that
the purpose of temporary disability retirement in today's military may
need to be clarified. Moreover, on average, it took far fewer than 60
months to arrive at permanent disability rating decisions in most cases
we reviewed. As such, the 5-year maximum eligibility period for these
benefits maybe too long, particularly in view of wounded
servicemembers' need for efficient resolution of their disability
cases. Second, according to TDRL administrative staff, delays in
reexaminations for temporary retirees are common because of limited MTF
resources. Yet, staff indicated that the military rarely exercises its
option to use medical reexaminations performed by civilian and VA
physicians. A clearer policy regarding use of nonmilitary medical
resources in these cases could reduce the MTFs' workload and the burden
re-examinations place on temporary retirees.
---------------------------------------------------------------------------
\10\ GAO, Military Disability Retirement: Closer Monitoring Would
Improve the Temporary Retirement Process, GAO-09-289 (Washington, DC:
Apr. 13, 2009).
---------------------------------------------------------------------------
With respect to DOD's and VA's pilot of a joint system for
evaluating disabilities, we did not set out to and therefore did not
identify gaps in policy or law. However, one of the pilot's objectives
is to identify potential legal and policy revisions that could enhance
disability evaluation efficiency and effectiveness. As pilot expansion
continues, and additional experience is gained from implementing the
pilot at different locations, DOD or VA may decide to submit
legislative proposals to Congress to change law or policy related to
disability evaluation.
27. Senator Graham. Mr. Williamson, Mr. Bertoni, and Ms. Melvin,
policies are only as good as the institutions and people whose job it
is to carry them out. Do we have the most effective mechanisms in place
today to monitor how effectively policies are executed?
Mr. Williamson, Mr. Bertoni, and Ms. Melvin. DOD and VA could
benefit from effective mechanisms to monitor and oversee policy and
program execution. In prior work, we have identified various examples
of limitations or shortcomings in the departments' efforts for
monitoring to ensure that policies are effectively executed.
In September 2008, we reported on the joint DOD-VA disability
evaluation pilot, noting that the departments needed to
maintain leadership oversight of the pilot to ensure that
needed resources are identified, implementation challenges are
overcome, and intended results are achieved-facilitating
successful implementation of potential widespread changes to
the disability evaluation process.\11\ Subsequently, DOD
created anew organizational structure--the Office of Transition
Policy and Care Coordination--to oversee transition support for
all servicemembers, including the pilot initiative. However, in
recent testimony, we reported that while some staff believed
this change would provide focus to implementing key policy
initiatives, including the pilot, other staff were concerned
the change may have a negative impact on the unity of command
within the SOC.
---------------------------------------------------------------------------
\11\ GAO, Military Disability System: Increased Supports for
Servicemember and Better Pilot Planning Could Improve the Disability
Evaluation Process, GAO-08-1137 (Washington, DC: Sept. 24, 2008).
---------------------------------------------------------------------------
Beyond the oversight structure, the DOD and VA plan to
leverage other mechanisms to help execute the pilot process;
however, the effectiveness of these mechanisms may diminish
over time. DOD and VA are using local agreement to establish
the pilot in new locations, based on the Benefits Delivery at
Discharge (BDD) model. These agreements reflect local
collaboration on pilot implementation, notably to ensure that
participants receive timely examinations. Nonetheless, while
local agreements may be an effective tool for implementing
change involving many parties, we have found in our review of
the BDD program that their effectiveness may fade over time. In
September 2008, we reported that the departments have relied on
local MOU at 130 military bases to execute the BDD program--a
program intended to expedite the application process for and
receipt of VA disability benefits to eligible
servicemembers.\12\ However, some bases faced difficulties
executing the program as agreed to in local MOUs due to changes
in base command and lack of communication between the agencies
or resource constraints, which negatively affected the
efficiency of and access to the BDD program. As such, we
recommended that VA and DOD take additional steps to ensure
best practices related to the BDD program are disseminated
across locations.\13\ Both agencies agreed with this
recommendation.
---------------------------------------------------------------------------
\12\ GAO, Veterans' Disability Benefits: Better Accountability and
Access Would Improve the Benefits Delivery at Discharge Program, GAO-
08-901, (Washington, DC, Sept. 9, 2008).
\13\ This recommendation was given to VA and DOD under the auspice
of the Chairs of the Joint Executive Council.
---------------------------------------------------------------------------
In addition, our work examining military temporary disability
retirement, found that currently, there are not effective
mechanisms in place to monitor and ensure appropriate placement
on the TDRL or efficient processing of TDRL cases.\14\ DOD does
not use available data on outcomes in past TDRL cases to avoid
unnecessarily placing servicemembers on temporary retirement
whose disabilities are unlikely to change in severity.
Moreover, current quality assurance procedures do not provide
for the systematic monitoring of TDRL placement decision
accuracy and consistency. In addition, DOD does not have an
effective system for monitoring the timeliness of
reexaminations or a clear policy for addressing noncompliance
with TDRL requirements--mechanisms that would help prevent
lengthy delays in final disability determinations in TDRL
cases.
---------------------------------------------------------------------------
\14\ GAO-09-289.
---------------------------------------------------------------------------
Further, our recent study of VA training for disability
compensation claims processors found that the Department does
not centrally evaluate or collect feedback on training provided
to disability claims processors agencywide.\15\ As a result, it
lacks information on the adequacy of this training-information
critical to its efforts to overcome claims backlogs. The
Department concurred with our recommendation that it collect
and review feedback from claims processors on their training
conducted at VA regional offices to determine if the 80-hour
annual training requirement is appropriate and the extent to
which this training is relevant given their duties and
experience.
---------------------------------------------------------------------------
\15\ GAO, Veterans' Benefits: Increased Focus on Evaluation and
Accountability Would Enhance Training and Performance Management for
Claims Processors, GAO-08-561, (Washington, DC: May 27, 2008).
Beyond these examples, our current work has focused on DOD's and
VA's joint development of the comprehensive policies to improve the
care, management, and transition of recovering servicemembers, as
required by the NDAA 2008. While the previous examples address related
topics, our assessments of the status of implementation and the
effectiveness of specific policies required by the NDAA 2008 will be
addressed in future reports. For example, as part of our follow-on
work, we plan to examine VA's and DOD's implementation of the Federal
Recovery Coordination and Recovery Care Coordination Programs, which
would include an assessment of how the departments are monitoring the
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care provided to recovering servicemembers.
28. Senator Graham. Mr. Williamson, Mr. Bertoni, and Ms. Melvin,
how will we know if laws and policies have made a positive difference
for wounded servicemembers and their families, or not?
Mr. Williamson, Mr. Bertoni, and Ms. Melvin. Performance goals and
measures, and other evaluation tools, are key instruments for
determining whether a positive impact has resulted from a given law,
policy, or program. In this regard, NDAA 2008 directed DOD and VA to
enhance their efforts to obtain meaningful feedback from patients and
their families in order to accurately assess the quality of services
provided to recovering servicemembers and facilitate the oversight of
care and services. Additionally, once the departments have implemented
the policies outlined in the NDAA 2008, we and others will be better
positioned to evaluate whether the policy improvements are making a
positive difference for wounded servicemembers.
Nonetheless, our prior work on topics examining the policies
outlined in the NDAA 2008 have identified various instances where the
departments could improve their performance measures and efforts to
evaluate disability evaluations and related programs.
In September 2008, we reported that while DOD and VA had
established measures for the Disability Evaluation System (DES)
pilot's performance, and a mechanism for tracking performance,
they had not established criteria for determining whether the
pilot was successful and should be expanded on a large scale.
For example, they did not establish how much improvement in
timeliness or other indicators would be needed before deciding
that the pilot was successful. The agencies plan to issue their
final report to Congress in August 2009; however, it is unclear
whether they will have identified success criteria or collected
sufficient performance data on key indicators in order to
determine that the pilot was a success and a candidate for
large-scale implementation.
Our September 2008 report also noted that the Army faced
challenges in demonstrating that improvements made to its
disability evaluations process have had an overall positive
impact on servicemembers' satisfaction, because it had not
implemented a survey that adequately targets and queries
servicemembers who are undergoing disability evaluations. We
recommended that the Army administer existing surveys to a
representative sample of servicemembers undergoing the
disability evaluation process, and consider developing
additional questions to better assess outreach and support
provided by Army legal staff throughout the process. DOD
agreed.
With respect to the Benefits Delivery at Discharge (BDD)
program, we reported that DOD lacked sufficient measures to
track outreach to servicemembers about the program.\16\ While
VA and DOD had coordinated to raise servicemembers' awareness
about the program through VA benefits briefings, DOD was using
a flawed measure for determining the extent to which VA
benefits briefings were reaching all transitioning
servicemembers who could benefit from the program. We
recommended that DOD take steps to ensure more accurate
measurement of servicemember participation in transition
briefings and establish a specific plan to meet its goal of 85
percent participation. DOD agreed with this recommendation.
---------------------------------------------------------------------------
\16\ GAO-08-901.
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Also on the BDD review, we found that VA and DOD lacked the
ability to measure the extent to which members of the National
Guard and Reserves have comparable access to programs that
expedite their VA disability benefits relative to other
servicemembers. Due to their rapid demobilization, National
Guard and Reserve members often cannot access the BDD program.
In response, VA established an alternative pre-discharge
program, which allows National Guard and Reserve members to
begin aspects of the application process early to expedite
receipt of their benefits. However, VA does not collect
sufficient data to determine the extent to which National Guard
and Reserve members are participating in and receiving
expedited benefits under either program. We recommended that VA
collect data for all claims filed by component and analyze the
extent to which different components are filing claims and
receiving timely benefits under BDD, predischarge, and
traditional claims processes. VA agreed with this
recommendation.
Beyond DOD and VA disability programs, we also found
opportunities for improvement related to program measures used
in VA's Vocational Rehabilitation and Employment (VR&E)
program. In our January 2009 report, we noted that VA was not
adequately reporting program outcomes, which could limit
understanding of the program's performance. Accordingly, we
recommended that VA separately report both the annual
percentage of those who obtain employment and the percentage of
those who achieve independent living to increase the
transparency of VR&E's program performance.\17\ VA agreed with
our recommendation and indicated it will implement new
performance measures in fiscal year 2010.
---------------------------------------------------------------------------
\17\ GAO, VA Vocational Rehabilitation and Employment: Better
Incentives, Workforce Planning, and Performance Reporting Could Improve
Program, GAO-09-34 (Washington, DC: Jan. 26, 2009).
electronic health records
29. Senator Graham. Mr. Williamson, Mr. Bertoni, and Ms. Melvin,
DOD and VA have been working on interoperable health care records for
nearly a decade. Congress imposed a deadline of September 2009 for a
fully functional, interoperable health care record for military
retirees and veterans. Are they going to make it?
Mr. Williamson, Mr. Bertoni, and Ms. Melvin. It is unclear whether
DOD and VA will meet the September 2009 deadline for a fully
functional, interoperable health care record. As previously mentioned
in our response to question 3, the departments have not developed
results-oriented goals that can be used to measure and report progress
toward delivering new capabilities. As such, there is no basis to
effectively assess the extent to which the departments will achieve
fully interoperable capabilities by September 2009.
30. Senator Graham. Admiral Timberlake, you have until September
2009 to develop and implement a fully interoperable health care
capability for DOD and VA. Are you going to make it?
Admiral Timberlake. The IPO does not currently anticipate any major
impediments to achieving full interoperability for the provision of
clinical care by September 30, 2009. The DOD/VA IPO will provide
management and oversight of potential risks involving the
identification, coordination, and approval of information sharing
requirements and the impact these processes may have on DOD/VA
information sharing milestones.
The Interagency Clinical Informatics Board (ICIB) is a clinician-
led group whose proponents are the DOD Deputy Assistant Secretary for
Clinical and Program Policy and the VA Chief Patient Care Services
Officer, Veterans Health Administration. The ICIB is co-chaired by
designees of the proponents and includes representation from DOD and VA
clinicians, information technology community, interagency sharing
offices, Veterans Benefits Administration, DOD and VA local Joint
Venture sites, Chief Medical Informatics Officers, and others.
The DOD/VA Interagency Clinical Informatics Board defined the
``fully interoperable'' requirements needed by healthcare providers for
the provision of clinical care. Efforts are underway to deliver full
interoperability for the provision of clinical care by September 2009.
31. Senator Graham. Admiral Timberlake, what do you say to skeptics
who believe that you are just playing with semantics when you assert
that the goal will be achieved--skeptics who also question the ability
of DOD and VA to deliver joint electronic capabilities, whether it be
in the battlefield, or back home, where and when they are needed?
Admiral Timberlake. While great successes have been achieved to
date, as we go forward to enhance the interoperability with the vision
for the virtual lifetime electronic record agreed to by the Secretaries
on March 24th, the key interoperability challenges will include:
Developing, adopting, and maturing standards at the national
level to ensure efficient operational use
Updating systems, infrastructure, and technology consistent
with emerging standards
Identifying and prioritizing information requirements as
defined by the business process owners and the functional
community
Identifying, prioritizing, and implementing common services
The departments also face challenges created by: different
acquisition and funding cycles; different contracting processes; and
differences in IA certification processes for VA, DOD, DISA, the
Services, and the local level.
We are working to not only identify areas where potential process
differences may exist, but the departments and the IPO are
collaboratively engaging in efforts to ensure that any impediment that
may arise is resolved in an efficient manner.
wounded warrior act's final vision
32. Senator Graham. Mr. Williamson, Mr. Bertoni, and Ms. Melvin,
what are the biggest pieces of unfinished business that we as a Nation
need to address in order to achieve the vision of the Wounded Warrior
Act?
Mr. Williamson, Mr. Bertoni, and Ms. Melvin. Among the most
significant matters that need to be addressed to achieve the vision of
the Wounded Warrior Act are improving customer-centered care within DOD
and VA, ensuring the continuation of high-level leadership and
attention to wounded warrior matters, improving the management of
disability programs, and sharing electronic health records. For
example, DOD and VA officials told us that the most difficult challenge
in their efforts to improve the care, management, and transition of
recovering servicemembers is to introduce needed cultural changes
within their organizations--for example, to center medical care on the
patient and to make the welfare of recovering servicemembers a higher
priority. These cultural shifts represent a change to the tradition
that the needs of military predominate over those of individuals,
especially individuals who may not be able to return to a combat role.
It is important that DOD's and VA's leaders maintain their focus on
wounded warrior issues so that the processes, services, and benefits
for recovering servicemembers continue to improve. The SOC has provided
high-level leadership and focused attention on the development of
solutions to many of the obstacles confronting recovering
servicemembers. Sustained attention by DOD and VA top leadership is
needed to ensure that as circumstances change and new issues emerge,
actions are taken to address the challenges that remain for recovering
servicemembers and their families.
Further, managing disability evaluation and employment workloads
with finite resources while maintaining accuracy, consistency, and
timeliness of decisions will likely require continued focus on the part
of DOD and VA. For example, in September 2008, we reported that the
Army was experiencing delays in processing disability evaluations due
to a shortage of key personnel and caseload surges, and identified
specific gaps in legal supports, outreach and other supports to help
servicemembers navigate the disability evaluation process. We made
several recommendations to improve the efficiency of the process and
supports to servicemembers. DOD generally agreed with our
recommendations. Also, in February 2008, we reported that VA continues
to face challenges in reducing the number of claims pending, speeding
up the process of deciding claims, and improving accuracy and
consistency of decisions across regional offices.\18\ Despite steps
pursued by VA to improve the process, we reported that more fundamental
reform may be needed. We are currently reviewing VA's disability claims
workload and progress toward addressing these challenges. Further, in
our VR&E report, we noted that the program had not gathered data on the
number of staff it needs and was not using relevant data to identify
future staffing needs.\19\ We recommended that VR&E engage in a
strategic workforce planning process. VA agreed with our recommendation
and indicated that VR&E would complete a study by the end of fiscal
year 2010 to help it determine an appropriate counselor caseload.
---------------------------------------------------------------------------
\18\ GAO, Veterans' Disability Benefits: Claims Processing
Challenges Persist, while VA Continues to Take Steps to Address Them,
GAO-08-473T (Washington, DC: Feb. 14, 2008).
\19\ GAO-09-34.
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DOD and VA also need to complete the DES pilot, and determine
whether the pilot process will become the way disability evaluations
are conducted by both agencies. Once that decision is made, sustained
management focus will be critical to ensuring successful implementation
of any joint DOD/VA disability evaluation process on a large scale.
Implementation of a joint disability evaluation process would address
one of the issues that we have highlighted in our Improving and
Modernizing Federal Disability Programs High-Risk Area--in efficient
processing of disability evaluations.\20\
---------------------------------------------------------------------------
\20\ GAO, High-Risk Series: An Update, GAO-09-271 (Washington, DC:
Jan. 22, 2009).
---------------------------------------------------------------------------
Our work to date has also identified a number of persistent
challenges particular to the National Guard and Reserves community. For
example, in our September 2008 report, we reported that the Army faces
particular challenges in meeting timeliness goals for completing
disability evaluations for reservists--who comprised about 20 percent
of those undergoing disability evaluations in 2007. We recommended that
the Army explore approaches to improving reservists' case development.
DOD agreed with this recommendation. Also, as noted previously, we
recommended that VA needs to take steps to better determine the extent
to which National Guard and Reserves and other components participate
in and benefit from programs--such as BDD and the alternate
predischarge program--intended to expedite receipt, of VA benefits. VA
agreed with this recommendation.
Lastly, we have reported on and identified a number of challenges
related to efforts to achieve the long-term vision of a single
``comprehensive, lifelong medical record'' that would enable each
servicemember to transition seamlessly between the DOD and VA. Our
January 2009 report \21\ noted that while important steps have been
taken, questions remained concerning when and to what extent the
intended electronic sharing capabilities of the two departments will be
fully achieved. We made recommendations that the departments use
results-oriented performance goals and measures as the basis for future
assessments and reporting of interoperability progress. The departments
concurred with our recommendations.
---------------------------------------------------------------------------
\21\ GAO-09-268.
33. Senator Graham. Ms. McGinn, General Meurlin, Ms. Embrey,
Admiral Timberlake, Mr. Dimsdale, and Dr. Guice, would you agree that
in spite of some progress, wounded warriors and their families still
need our help?
Ms. McGinn, General Meurlin, Ms. Embrey, and Admiral Timberlake. We
absolutely agree. Since the incidents at Walter Reed, there has been a
renewed focus on wounded warriors and their families. But there is
still much more to do. One area of interest that you brought up was
support to family caregivers, which as we heard today is a growing
priority. There is a DOD proposal to provide special monthly
compensation for family caregivers paid to servicemembers who elect to
participate in the expedited DES, and we are aware of at least two
legislative proposals that are being initiated by Senators. It would be
in the best interest of all concerned if we could examine all the
proposals and capitalize on the best ideas for formal legislative
action.
Mr. Dimsdale and Dr. Guice. The many efforts of DOD and VA are
making a difference for wounded warriors and their families. From the
testimony of those servicemembers and veterans on the first panel,
those that had care coordination provided by the SOC coalition or the
Federal recovery coordination program had an easier time navigating the
systems of care provided by both departments. The many initiatives
required by the NDAA 2008 legislation are in place and their
effectiveness will need to be measured and tracked. Both departments
are committed to identifying problems and creating durable solutions.
34. Senator Graham. Ms. McGinn, General Meurlin, Ms. Embrey,
Admiral Timberlake, Mr. Dimsdale, and Dr. Guice, do you agree that the
pathway to obtaining needed care remains complex and difficult to
navigate?
Ms. McGinn, General Meurlin, Ms. Embrey, and Admiral Timberlake. In
our opinion, the complexity of injuries these servicemembers experience
as a result of combat make the system of care difficult to navigate,
not the care itself. The particular patterns of injury require numerous
specialists, frequent interfacility transfers, and lengthy periods of
rehabilitation. The challenges are only increased when a family needs
assistance as well. Both departments have worked hard to improve the
coordination of care and benefits, rather than requiring the wounded
warrior, veteran or family manage the transitions and integrate the
different delivery systems alone. The development of a Clinical Case
Management application via Line of Action 3, addresses the case
management workflow process by coordinating collaboratively across
service lines and care locations. These improvements will lead to the
efficient development of collaborative relationships among
servicemembers, case managers, physicians, and other medical
disciplines.
Mr. Dimsdale and Dr. Guice. The complexity of injuries these
servicemembers experience as a result of combat make the system of care
difficult to navigate, not the care itself. The particular patterns of
injury require numerous specialists, frequent interfacility transfers,
and lengthy periods of rehabilitation. The challenges are only
increased when a family needs assistance as well. Both departments have
worked hard to improve the coordination of care and benefits, rather
than requiring the wounded warrior, veteran, or family manage the
transitions and integrate the different delivery systems alone.
35. Senator Graham. Ms. McGinn, General Meurlin, Ms. Embrey,
Admiral Timberlake, Mr. Dimsdale, and Dr. Guice, please address the
concerns that you heard and tell us what more we can expect--or we need
to legislate--to achieve improvements and reform in the year ahead.
Ms. McGinn, General Meurlin, Ms. Embrey, and Admiral Timberlake. A
large part of what we heard today had to do with care coordination
between DOD and VA--streamlining information flow and performing the
hand-off from one department to the other as seamlessly as possible.
The office of Transition Policy and Care Coordination in partnership
with the VA is working to make these two goals a reality.
The information flow is now being managed by DOD/VA Recovery
Coordinators, who, in concert with the medical and non-medical recovery
teams and Services' Wounded Warrior Programs, act as the go-between for
an injured servicemember, veteran, and their family with all the
various case managers who now work for them.
The SOC has directed DOD and VA to identify how to implement the
Virtual Electronic Lifetime Record and streamline the DES, but the work
has not risen above the working group level. Once we have identified
what needs to change, we will come to Congress with a more formal
proposal. We want to make sure we get this right the first time.
Mr. Dimsdale and Dr. Guice. The testimony provided by the first
panel of witnesses reminds us how important it is to ``get it right.''
Many more programs and resources are available today to those returning
wounded or injured. It will be important to evaluate these programs and
to compare the experiences of those returning today compared to those
who returned in earlier years. Effectiveness should not be measured in
the number of new programs or resources, but whether or not the system
is improved as a result.
traumatic brain injuries
36. Senator Graham. Ms. Embrey, what is the Department's estimate
of the number of veterans who have suffered brain injuries in this war?
Ms. Embrey. As of March 31, 2009, there are 40,035 unique patients
in the DOD TBI surveillance database.
37. Senator Graham. Ms. Embrey, do we have sufficient resources to
provide for their care?
Ms. Embrey. Over the past 5 years, we have made tremendous headway
in the care of TBI, especially for chronic symptomatic concussion, also
known as mild-TBI (mTBI). There are numerous TBI clinics located at
different MTFs all over the country. Additionally, ongoing education of
all providers has remained a priority. Since 2007, over 800 providers
per year learn how to diagnose and treat TBI through the Defense and
Veterans Brain Injury (DVBIC) annual military training. DVBIC works
closely with the DCoE for PH and TBI to ensure that providers treating
patients with TBI have the most up-to-date scientific information
available. We currently have no data to suggest insufficient resources
to care for the servicemembers with TBI.
38. Senator Graham. Ms. Embrey, LTC Rivas testified that his brain
injury in 2006 was not diagnosed and he returned to battle. What is
different for a servicemember who is injured on the battlefield today?
Ms. Embrey. DOD has taken many steps to ensure that what happened
to LTC Rivas does not happen to others. Since 2007, several task force
and commission recommendations have been incorporated into the DOD TBI
Action Plan. Specific advancements implemented by the DOD include,
using the Military Acute Concussion Evaluation to help diagnose mTBI
and clinical practice guidelines for detecting and diagnosing TBI in
deployed settings. In October 2007 the DOD published additional
clinical guidance for the care of mTBI in the nondeployed setting and
updated it in May 2008. Also in May 2008, the DOD implemented TBI
assessment questions into the post-deployment health assessment and
post-deployment health reassessment to ensure there was an avenue of
treatment for ongoing symptoms for all servicemembers returning from
deployment. The VA implemented similar questions in April 2007.
39. Senator Graham. Ms. Embrey and Mr. Dimsdale, Congress intended
that wounded servicemembers have the broadest possible options for
brain injury care and rehabilitation, yet we are informed that Federal
rules still limit accessible treatment options. What are the legal or
bureaucratic barriers we need to address?
Ms. Embrey. Active Duty servicemembers do have the broadest
possible options for brain injury care and rehabilitation. The
statutory scope of health care benefits for Active Duty servicemember
is much broader than for all other categories of beneficiaries and does
not limit the care to TRICARE authorized providers. There is no
requirement that the care is medically or psychologically necessary,
and the statute does not specifically prohibit custodial or domiciliary
care. Further, reimbursement is made by using Supplemental Health Care
Program (SHCP) funds to pay for the services. With the exception of
benefit limitations based on Federal statute, any restrictions or
limitations of the TRICARE Basic Program may be waived for Active Duty
servicemembers under the SHCP in order to make available adequate
healthcare services to Active Duty servicemembers or to keep or make
the Active Duty servicemember fit to remain on Active Duty. Moreover,
under section 1631 of the NDAA for Fiscal Year 2008, DOD may authorize
Active Duty servicemember benefits for former members with a serious
injury or illness if the care is not available in the VA. This
authority expires December 31, 2012.
Mr. Dimsdale. This question is specific to DOD and cannot be
addressed by VA.
medical disability evaluations and ratings
40. Senator Graham. General Meurlin, should DOD get out of the
business of evaluating and rating medical disabilities of
servicemembers? If so, what needs to happen to achieve that goal?
General Meurlin. Since the Career Compensation Act of 1949, DOD and
VA have operated independent systems to examine, rate, and compensate
disabled servicemembers and veterans. DOD, VA, congressional, and
presidential commissions all concur on the need to eliminate dual
adjudication of disability ratings by DOD and VA. On April 28, 2009,
the SOC made the decision to establish a senior working group that will
deliver to the SOC the vision, guiding principles, charter, and high-
level options and recommendation for getting DOD to provide a ``fit/
unfit'' finding with VA determining the disability rating and resulting
compensation.
41. Senator Graham. General Meurlin, has the paperwork required for
medical and physical evaluation boards been reduced in the last 2
years?
General Meurlin. The military departments have taken initiatives to
reduce paperwork and evolve archaic systems. For example, the Army has
an initiative for an automated physical profile system that will feed
profile data to the Medical Operational Data System and the Electronic
Health Record AHLTA. The Medical Evaluation Board (MEB) is also being
automated, which will improve MEB case file tracking, decrease process
inefficiencies, and improve data quality. The automated MEB is
scheduled for testing in August 2009 at Brooke Army Medical Center, in
San Antonio, TX. The system is intended to provide an automated MEB
using an interface that will deliver all permanent profiles with a
numerical designator of 3 or 4 directly to the MTF's MEB Physician so
they may validate and initiate disability processing accordingly.
Additionally, based on the SOC's guidance, we are looking at ``Evolving
the Disability Evaluation System'', which will help facilitate
additional improvements over time.
42. Senator Graham. General Meurlin, have the processes been
streamlined or automated?
General Meurlin. With the introduction of the DES pilot, both DOD
and VA have put in place a process that has cut the time from referral
into the DES to receipt of VA benefits by approximately half. The DES
pilot simplifies the process by eliminating duplicate practices of the
two departments. Complementing timeliness is the integration of new
case management features, such as placing VA counselors in MTFs to
ensure a smooth transition for members who must move to the care of the
VA. The features of the DES pilot are the result of the hard work and
excellent recommendations by several commissions and task forces. These
features include: servicemember-centricity; simplicity; reduction of
the adversarial nature of the DES process; faster and more consistent
evaluations and compensation; a single medical exam and single-source
disability rating; seamless transition to veteran status; case
management advocacy; and expectation management.
43. Senator Graham. General Meurlin, if a servicemember is not in
the disability demonstration project--that is, the vast majority of
servicemembers--what has changed since the 1940s when this archaic
system was put into place?
General Meurlin. Since the Career Compensation Act of 1949, DOD and
VA have operated independent systems to examine, rate, and compensate
disabled servicemembers and veterans. Both departments recognized the
need to improve the current DES and stood up LOA-1. The intent was to
develop and establish an integrated DOD and VA DES, one that is
seamless, transparent, and administered jointly by both departments
using one medical examination and one disability rating. In this
regard, the department has published several policy updates to current
suite of DOD regulations. In addition to the significant steps forward
resulting from the DES pilot, the department has also initiated an
Expedited DES, and a Physical Disability Board of Review.
In January 2009, the Department published guidance for an expedited
DES process. Accelerating the process for eligible servicemembers
presumed to be 100 percent disabled allows for early identification and
delivery of the full range of benefits, compensation, and specialty
care offered by the VA to which the servicemember may be entitled. The
goal is to move the member, consistent with medical and recovery care,
to permanent disability retirement so that the member may obtain
benefits from the VA as soon as possible. Participation in the
expedited DES process is strictly voluntary. Members who are eligible
are not required to be brought to maximum medical benefit prior to
receiving their disability rating and retirement disposition provided
the DES process is waived.
The Secretary of Defense established a Physical Disability Board of
Review (PDBR) with the Air Force as the lead agency to review
disability ratings of wounded warriors, honoring the great sacrifices
required of the men and women of our Armed Forces and providing another
avenue of administrative recourse for our wounded veterans. Variances
in disability ratings among the military departments for same or
similar disorders created a perception of unfairness in applying
disability ratings across the Services. Therefore, under the PDBR any
servicemember may have his or her case reviewed by the PDBR if he or
she was separated from the Armed Forces between September 11, 2001, and
December 31, 2009. The PDBR applies to any servicemember separated due
to unfitness for continued military service resulting from a physical
disability under Chapter 61, Title 10 U.S.C., with a combined
disability rating of 20 percent or less.
mental health providers
44. Senator Graham. Ms. Embrey and Mr. Dimsdale, according to your
treatment protocols, how frequently should a soldier or veteran with
PTSD have face-to-face contact with a mental health provider?
Ms. Embrey. DOD strongly encourages the use of the DOD-VA Clinical
Practice Guidelines for the treatment of PTSD by providers treating
servicemembers and veterans. The guideline, which was carefully
developed by a team of subject matter experts from both DOD and VA,
describes in great detail evidence-based assessment and treatment
methodologies for use both in the primary care setting and the mental
health setting. A range of treatments described in the guideline have
extensive bases of support in the scientific literature, ranging from
pharmacological to cognitive therapeutic interventions. While the
guideline does not specify any particular frequency of face-to-face
contact between patient and provider, it does reference specific
treatment regimens widely known and used in the provider community.
Mr. Dimsdale. PTSD is a condition that can have a number of
different clinical courses. It can occur as a single episode, it can
occur with remissions and recurrences, or it can be chronic. At any
given time it could be associated with symptoms, distress, and
impairments, or it could be in full or partial remission. Treatment can
include pharmacotherapy, psychotherapy, and rehabilitation. The
frequency of contact and decisions about face-to-face versus telemental
health contacts must be individualized on the basis of a given
patient's goals and needs at a given point in time.
45. Senator Graham. Ms. Embrey and Mr. Dimsdale, how many more
mental health providers have DOD and VA hired since 2001?
Ms. Embrey. Mental health provider staffing (military and civilian
only):
Fiscal Year 2001 - 2,010
Fiscal Year 2002 - 1,647 (^363)
Fiscal Year 2003 - 1,643 (^3)
Fiscal Year 2004 - 1,967 (+324)
Fiscal Year 2005 - 1,911 (^56)
Fiscal Year 2006 - 1,912 (+1)
Fiscal Year 2007 - 2,530 (+618)
Fiscal Year 2008 - 2,811 (+281)
Fiscal Year 2009 - 3,515 (+704)
Mental health provider staffing has been on a continuous ramp-up
since 2003 and we continue to increase these numbers to meet increased
patient demand. Overall, since 2001, we have increased mental health
providers by 1,505. Although we do not have historical information on
contract mental health providers, we currently have 711 working in our
MTFs.
Mr. Dimsdale. From 2001 to 2005, VA mental health staffing was more
or less stable. However, since then, staffing increased by about 5,000
full time equivalent positions from 13,950 to about 18,844 by the end
of the second quarter of fiscal year 2009.
46. Senator Graham. Ms. Embrey and Mr. Dimsdale, we have been told
that there is a national shortage of mental health providers, is that
correct? If so, are you working together on this national shortage?
Ms. Embrey. National needs for mental health providers are
developed by agencies such as the National Institute of Mental Health,
the Health Resources and Services Administration, and the Substance
Abuse and Mental Health Services Administration--they have
responsibilities related to mental health services throughout the
United States of America.
DOD and VA are working closely on all aspects of identifying and
meeting mental health staffing requirements for our wounded warriors
and veterans; we have established a working partnership. DOD's mental
health provider requirements are based on the needs of our wounded
warriors, their families, and our beneficiaries; we are constantly
adjusting these requirements.
Mr. Dimsdale. Neither VA nor DOD can comment definitively about
whether or not there is a national shortage of mental health providers.
Projecting the needs for the mental health care workforce for the
Nation as a whole is within the responsibilities of agencies such as
the National Institute of Mental Health, the Health Resources and
Services Administration, and the Substance Abuse and Mental Health
Services Administration.
VA has made major contributions toward developing the Nation's
workforce in mental health. VA has long been one of the Nation's
leaders in professional training for health and mental health care.
With its academic affiliates, VA has been involved in graduate training
in psychology and undergraduate medical education in psychiatry, as
well as programs in a number of allied health professions. As a major
provider of graduate medical education, VA makes a major contribution
to work force development in psychiatry. Additionally, through an
expanding array of VA supported internship and clinical post-doctoral
fellowship positions, VA is making substantial contributions to
workforce development in psychology.
Currently, the Veterans Health Administration (VHA) employs over
19,000 mental health workers. With the aid of newly-established
recruitment initiatives, VA mental health staffing levels have
increased by over 5,800 positions since fiscal year 2005, when VA began
implementing its Mental Health Strategic Plan. Putting these figures
into perspective, VA employs about 5 percent of the national pool of
psychiatrists and psychologists.
With staffing as projected, VHA is able to meet the mental health
care needs of the veterans it serves.
It has been VHA's experience that in certain localities,
particularly highly rural regions, there is a limited number of mental
health professionals, particularly psychiatrists. Specific hiring and
retention incentives have been developed and used in such situations.
VHA also has the flexibility to hire providers of other appropriate
disciplines or to use fee-basis or contract care, when indicated, so
that veterans have continuous access to the full continuum of mental
health services. In addition, telemental health options are continually
being expanded so that mental health professionals in areas where
hiring is easier can provide services through video-conferencing to
veterans in more rural sites. Through its recent efforts, VHA has
developed an array of strategies to recruit and retain mental health
professionals. It is currently working with DOD to share lessons
learned, and to collaborate, as much as possible.
47. Senator Graham. Ms. Embrey and Mr. Dimsdale, who monitors the
performance of your health care systems in meeting the necessary
frequency of face-to-face encounters with a mental health provider?
Ms. Embrey. DOD maintains a range of systems and processes for
ensuring the quality of mental health care for our beneficiaries. While
``necessary frequency'' is something that is individually developed
between the patient and provider as part of the treatment planning
process, the overall quality of health care provided is paramount in
the ongoing evaluation process. Quality of patient care is reviewed
regularly through the peer review process in each MTF, so that any
issues can be detected and remedied early on. Additionally, we strongly
encourage the use of the DOD-VA Clinical Practice Guidelines, including
those for major depression and PTSD. Provider adherence to these
evidence-based guidelines increases quality of care and enhance the
likelihood of positive patient outcomes.
The DOD is planning to rollout a Behavioral Health Module as part
of the electronic medical record. This module will include instruments
that will be administered to our patients to measure the outcomes of
their care. Frequency of sessions is less important than establishing
that treatment is resulting in a positive outcome over time, whether
that time is brief or over an extended period. Providers will also use
this process to enhance treatment planning, and thereby facilitate
positive outcomes within shorter periods of time.
The Department closely monitors access to mental health care.
Having moved the 30-day standard for a first mental health appointment
up to a 7-day standard, we are working to ensure that all MTFs comply
with the standard. We have augmented the number of mental health
professionals significantly in order to facilitate such compliance and
to make mental health care more available.
Our Tricare Operations Center is able to monitor on a daily basis
the number of available appointments in each clinic across the system,
helping clinic managers better control patient flow and ensure the
timeliness of mental health appointments.
Mr. Dimsdale. VA uses performance metrics to monitor both access to
mental health care and the continuity of mental health services. The
entities with responsibility for measurement include the Office of
Quality and Performance and the Office of Mental Health Services. The
frequency of face-to-face encounters is based on the clinical needs of
the individual.
48. Senator Graham. Ms. Embrey and Mr. Dimsdale, are the resources
available to meet the demand for care sufficient?
Ms. Embrey. We have sufficient financial resources to meet our
currently identified requirements associated with the demand for mental
health treatment.
Two years ago, Congress authorized special pays to incentivize
recruitment and retention of health care providers, including mental
health care providers. We are publishing a directive-type memorandum
that will provide implementation guidance to the Services for offering
special pays to psychologists and social workers.
Mr. Dimsdale. The proposed VA budget includes adequate resources to
meet the mental health care needs of veterans of all eras.
case managers
49. Senator Graham. Ms. McGinn, General Meurlin, Mr. Dimsdale, and
Dr. Guice, have you ever had a conversation about the problems we have
heard involving the proliferation of case managers in DOD and VA?
Ms. McGinn and General Meurlin. We do have numerous case managers
assisting our recovering servicemembers. Both the President's
Commission on Care for America's Returning Wounded Warriors and the
NDAA 2008 recognized this and required one point of contact to oversee
the recovering servicemember and family through recovery, rehab, and
return to duty or reintegration into the community. This one belly
button is our Recovery Care Coordinators and Federal Recovery
Coordinators (FRCs). They, working with the medical and nonmedical
team, will create a recovery plan for each servicemember and family
with personal and professional goals that will guide them through their
continuum of care. These coordinators work with the existing case/care
managers to ensure the needs of our recovering servicemembers and
families are met.
Mr. Dimsdale and Dr. Guice. There is much confusion about case
management and the number of case managers. The number of clinical case
managers a recovering servicemember will have is related to the types
and number of their injuries and the number of facilities where care is
received. Clinical case managers are critical components of a
multidisciplinary team--they implement the patient's clinical treatment
plan and often serve as the link between the patient and providers.
Non-clinical case managers assist recovering servicemembers and
veterans with access to programs and benefits (childcare, adaptive
housing, disability determinations, et cetera). Many of these non-
clinical case managers are also facility based. A recovering
servicemember who requires care from three different facilities may
have many case managers. Case managers generally assist the
servicemember only while they are at the facility; upon transfer to
another facility, the servicemember will encounter a new set of case
managers.
Care coordination decreases the opportunities for confusion by
providing a single point of contact and coordinator for these
servicemembers and their families. Federal recovery coordinators
actively coordinate the services and benefits, and work with case
managers to meet recovery needs of the servicemember.
50. Senator Graham. Ms. McGinn, General Meurlin, Mr. Dimsdale, and
Dr. Guice, what do you plan to do about the problem expressed by our
witnesses today?
Ms. McGinn and General Meurlin. It is our belief that past issues
with multiple case managers are being resolved as the DOD Recovery
Coordination Program and the DOD/VA Federal Recovery Coordination
Programs continue to take hold. There are currently 147 RCCs working in
27 locations around the country through each military department's
Wounded Warrior Program, and we will continue to bring more on-line
during fiscal year 2009. The RCCs and FRCs are absolutely critical to
identifying issues early and bringing them to resolution as soon as
possible. The work that the RCCs and FRCs are doing permit the wounded,
ill, or injured servicemember and their families to concentrate on
their medical recovery.
Mr. Dimsdale and Dr. Guice. The problems articulated by the
servicemembers and veterans on the first panel require thoughtful
evaluation. Because so many resources and programs are now in place, a
thorough understanding of their effectiveness is needed in order to
better determine what remains to be addressed.
care for returning servicemembers
51. Senator Graham. Dr. Guice, you served on the staff of the Dole-
Shalala Commission on care for returning servicemembers, is that
correct?
Dr. Guice. I served as the Deputy Director of the President's
Commission on Care for America's Wounded Warriors, March 28, 2007-July
31, 2007. My responsibilities included providing direction for 25
researchers, managing relationships with Capitol Hill and Veteran
Service Organizations, assisting Commissioners in developing
recommendations and writing the final report, working with public
relations to develop statements and press advisories, and assisting the
Executive Director with strategic planning. I had primary
responsibility for the recommendations on care coordination and
rehabilitation.
52. Senator Graham. Ms. McGinn, General Meurlin, Ms. Embrey,
Admiral Timberlake, Mr. Dimsdale, and Dr. Guice, from your current
vantage points, and based on what you have heard from our first panel,
what are the biggest pieces of reform and improvement that are still
needed to support seriously injured and ill servicemembers and their
families?
Ms. McGinn, General Meurlin, Ms. Embrey, and Admiral Timberlake.
From a transition and care coordination perspective, we believe there
are two problems being expressed by the previous witnesses. First, the
policy, process, and provisos for getting a servicemember and their
family started on the road to rehabilitation are still not streamlined
enough. Specifically, Senator Nelson stated in his opening remarks that
improvements are still needed in the DES, and we could not agree more.
The SOC has discussed this, and we are responding by expanding the DES
pilot to seven additional sites this year and we have implemented the
expedited DES for those who opt to take advantage of it. Potentially
combining the RCC and FRC programs may provide a more uniform approach
to the servicemember and eliminate some confusion as well as requiring
both the VA and DOD to come even more closely together in coordinating
their care.
Second, we need to do a better job of supporting our family
caregivers. This is the reason DOD has put forth the proposal for
special compensation to servicemembers who participate in the expedited
DES to compensate a family caregiver. Additional bills have been
introduced to address this issue. The need to support caregivers is
there. We need to look at all the ideas, collect the best ones, and
develop the best legislative solution possible.
Mr. Dimsdale and Dr. Guice. Based upon the testimony of the first
panel, once effective care/case management is established, it seems
that the departments are meeting most of the needs of the affected
servicemembers and their families. The challenge that remains is for VA
and DOD to gain a clear understanding of the effectiveness of the new
programs and policies established to support seriously injured
servicemembers and their families. The assessment of the new programs
and policies is an ongoing activity and both departments are committed
to making reforms or improvements as necessary.
53. Senator Graham. Ms. McGinn, General Meurlin, Ms. Embrey,
Admiral Timberlake, Mr. Dimsdale, and Dr. Guice, are the right
mechanisms in place to achieve them?
Ms. McGinn, General Meurlin, Ms. Embrey, and Admiral Timberlake.
The DES pilot and expedited DES are in place and already helping our
servicemembers and their families. We are looking to expand the pilot
as quickly as possible.
For family caregivers, we will need new authority to begin a
program, and look to the committee for assistance with that.
Mr. Dimsdale and Dr. Guice. It would appear that based upon the
testimony from the first panel that the departments are clearly moving
in the right direction by providing effective care and case management,
while improving access to benefits and services. The establishment of
new programs and policies alone does not guarantee success, but must be
evaluated to ensure they are achieving their intended purpose. The
Government Accountability Office (GAO) indicated in its testimony that
this is something it is considering for the near future.
54. Senator Graham. Ms. McGinn, General Meurlin, Ms. Embrey,
Admiral Timberlake, Mr. Dimsdale, and Dr. Guice, what are the obstacles
that we need to overcome?
Ms. McGinn, General Meurlin, Ms. Embrey, and Admiral Timberlake.
While great successes have been achieved to date, as we go forward to
enhance the interoperability with the vision for the virtual lifetime
electronic record agreed to by the Secretaries on March 24, the key
interoperability challenges will include:
Developing, adopting, and maturing standards at the national
level to ensure efficient operational use
Updating systems, infrastructure, and technology consistent
with emerging standards
Identifying and prioritizing information requirements as
defined by the business process owners and the functional
community
Identifying, prioritizing, and implementing common services
The departments also face challenges created by: different
acquisition and funding cycles; different contracting processes; and
differences in information assurance certification processes for VA,
DOD, DISA, the Services, and the local level.
We are working to not only identify areas where potential process
differences may exist, but the departments and the IPO are
collaboratively engaging in efforts to ensure that any impediment that
may arise is resolved in an efficient manner.
Mr. Dimsdale and Dr. Guice. Since the passage of the 2008 NDAA and
its wounded warrior provisions, significant progress has been made in
the support provided to seriously ill and injured servicemembers,
veterans, and their families. The departments remain committed to
eliminating any obstacles that might prevent a truly seamless
transition for the seriously ill and injured.
55. Senator Graham. Ms. McGinn, General Meurlin, Ms. Embrey,
Admiral Timberlake, Mr. Dimsdale, and Dr. Guice, what can Congress do
to help?
Ms. McGinn, General Meurlin, Ms. Embrey, and Admiral Timberlake.
Congress has demonstrated its support by providing appropriate
legislative authority and the resources necessary to establish and
maintain the programs needed to provide for more effective care,
rehabilitation, and transition for seriously ill and injured
servicemembers, veterans, and their families. We look forward to
working with Congress to ensure that we continue to support those who
have born the burden of battle and their families.
Mr. Dimsdale and Dr. Guice. Congress has demonstrated its support
by providing appropriate legislative authority and the resources
necessary to establish and maintain the programs needed to provide for
more effective care, rehabilitation, and transition for seriously ill
and injured servicemembers, veterans, and their families. The
departments look forward to working with Congress to ensure that we
continue to support those who have born the burden of battle and their
families.
______
Questions Submitted by Senator John Thune
implementation of section 703
56. Senator Thune. Ms. McGinn and Ms. Embrey, what steps has the
Department taken to implement section 703 of the NDAA for Fiscal Year
2009?
Ms. McGinn and Ms. Embrey. A chiropractic workgroup was convened
composed of senior service representatives to determine where to expand
chiropractic care to best meet the needs of our Active Duty
servicemembers. The results of their careful deliberations are:
Air Force
1st Special Operations Medical Group, Hurlburt Field
Army
Army Community Hospital Ft Riley
Army Community Hospital Ft Rucker
Army Community Hospital Ft Polk
Army Community Hospital Ft Wainwright
U.S. Army Medical Center Landstuhl
U.S. Army Health Clinic Grafenwoehr
Navy
Naval Medical Clinic Quantico
Navy Branch Health Clinic Groton
Naval Hospital LeMoore
U.S. Naval Hospital Okinawa
These 11 sites will bring the total number of MTFs providing
chiropractic care to Active Duty servicemembers to 60. We anticipate
these new sites will become operational by September 30, 2009.
57. Senator Thune. Ms. McGinn and Ms. Embrey, has the Department
found a need, due to a rise in demand for musculoskeletal services, to
expand the availability of chiropractors or chiropractic services on
military bases, either in the United States or overseas?
Ms. McGinn and Ms. Embrey. This year, we are expanding the number
of MTFs that provide chiropractic care to Active Duty servicemembers
from 49 locations to 60 locations. Chiropractic care is a valued
treatment modality and we think that offering it at 60 locations
provides a good balance.
58. Senator Thune. Ms. McGinn and Ms. Embrey, has the Department
encountered any obstacles in trying to find licensed chiropractors to
be stationed at bases in the United States or overseas?
Ms. McGinn and Ms. Embrey. No, we have not encountered any
obstacles in finding licensed chiropractors willing to work with us to
care for our Active Duty servicemembers.
[Whereupon, at 5:07 p.m., the subcommittee adjourned.]