STATEMENT OF JOHN BROWN, DIRECTOR
SEAMLESS TRANSITION OFFICE
DEPARTMENT OF VETERANS AFFAIRS
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES HOUSE OF REPRESENTATIVES
May 19, 2005
Mr. Chairman and Members of the Subcommittee, I appreciate the opportunity to appear before you today to discuss efforts of the Department of Veterans Affairs (VA) toward effecting a seamless transition for separating service members from the Department of Defense (DoD) to VA.
First, let me assure you that interest in this issue comes from the highest levels of the Department. Though only recently taking office, Secretary Jim Nicholson has reaffirmed VA’s determination to assure that maximum efforts to serve the needs of newly returning service members are undertaken by the Department.
Deputy Secretary Gordon Mansfield is also deeply engaged in this endeavor as he co-chairs VA/DoD Joint Executive Council (JEC) with the Under Secretary for Defense for Personnel and Readiness, Dr. David Chu. In March of this year, Deputy Secretary Mansfield addressed the Joint DoD/VA Conference on Post Deployment Mental Health as they reviewed the potential impact of returning personnel.
Today, my statement will focus primarily on the efforts of VA’s Seamless Transition Office (STO) to achieve a seamless transition for Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans and their families. The STO is one part of the Department’s network of services used to meet these needs.
Before I begin, however, I would like to share with you brief discussions of three issues that play a large role in helping to ensure a seamless transition for returning OIF and OEF service members, the availability of VA health care services, the oversight and guidance of the JEC, and VA/DoD electronic health information exchange. Later in my statement, I will include information about health care utilization of OIF and OEF veterans.
Health Care Services
VA is well positioned to provide health care to returning OIF and OEF veterans. As the largest integrated health care organization in the United States, we can meet their needs through nearly 1,300 health care facilities throughout the country, including 696 community-based outpatient clinics that provide health care access closer to veterans’ homes. We also have 207 Vet Centers, which are often the first contact points for returning veterans seeking health care and benefits near their homes.
VA offers comprehensive primary and specialty health care to our enrollees. The quality of our care is second to none. We are an acknowledged leader in providing specialty care in the treatment of such illnesses as post-traumatic stress disorder (PTSD), spinal cord injury, and traumatic brain injury (TBI). We are now leveraging and enhancing the expertise already found in our four TBI centers to create Polytrauma centers to meet the complex needs of certain seriously injured veterans from all parts of the country. I will have more to say about the Polytrauma Centers later in my statement.
VA/DoD Joint Executive Council
The JEC provides overall support and guidance for the joint VA/DoD initiatives detailed throughout my statement. As stated earlier, the JEC is co-chaired by the Deputy Secretary of Veterans Affairs and the Under Secretary for Defense for Personnel and Readiness and ensures high level attention from both Departments to maximize opportunities to improve service to our mutual beneficiaries. Through this forum, VA and DoD have achieved significant success in improving interagency cooperation in areas such as deployment health, pharmacy, medical-surgical supplies, procurement, patient safety, clinical guidelines, geriatric care, contingency planning, medical education, information management/information technology, financial management and benefits coordination.
VA/DoD Electronic Exchange of Health Information
Our ability to provide care to returning OIF and OEF service members is enhanced to the extent that we can obtain accurate health care information from DoD in the shortest time frame possible. In 2002, VA and DoD gained approval of their Joint Electronic Health Records Interoperability Plan - HealthePeople (Federal). VA began implementation of Phase I of the plan, the Federal Health Information Exchange (FHIE) that same year. The FHIE supports the one-way transfer of electronic military health data on separated service members to the VA Computerized Patient Record System for viewing by VA clinicians treating veterans. Since FHIE implementation in 2002, DoD has transferred records for over 2.9 million unique patients to the FHIE repository, where more than 1 million records have been viewed by VA clinicians. VA and DoD are now developing interoperable data repositories that will support the bidirectional exchange of computable data between the DoD Clinical Data Repository (CDR) and the VA Health Data Repository (HDR), known as Clinical Data Repository/Health Data Repository (CHDR).
Now let me explain the history, operations, and responsibilities of the STO. In August 2003, VA’s Under Secretary for Benefits and Under Secretary for Health created a new VA Taskforce for the Seamless Transition of Returning Service Members. This taskforce was composed of VA senior leadership from key program offices and the VA/DoD Executive Council and focused initially on internal coordination efforts to ensure that VA approached the mission in a comprehensive manner as well as education of VA staff on the needs of returning veterans.
Although the responsibilities and operations of the Taskforce were limited to this comparatively narrow scope, their importance should not be underestimated. By ensuring the success of our initial encounters with returning OIF and OEF service members and veterans, we are establishing a sound basis for an ongoing and long-term positive relationship with our veteran patients and their families. This is especially important for those veterans who have the greatest need for our help, the most seriously disabled combat veterans who transition directly from Military Treatment Facilities (MTFs) to VA medical centers (VAMCs) to continue their care and rehabilitation.
In January of this year, VA established a permanent Seamless Transition Office to assume the duties of the Taskforce. Although the STO administratively reports to the Deputy Under Secretary for Health, it may truly be described as a "One-VA" endeavor. Composed of representatives from the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA), and the National Cemetery Administration (NCA), the STO now coordinates all Departmental activities related to the provision of benefits and health care for those service members transitioning directly from MTFs to VA facilities. The STO also provides coordination within VA for all other initiatives of DoD and the States to provide outreach services to OIF and OEF veterans. The office relies on the expertise of other VA program offices and VA field facilities to support its mission.
Seamless Transition Office Successes
Over the last 2 years, the Seamless Transition Task Force and the STO have achieved many successes in the areas of outreach and communication, trending workload, data collection, and staff education. We have worked hard with other offices in VBA, VHA, and DoD, to identify OIF and OEF veterans and to provide them with the best possible information and access to both health care and benefits. VA has put into place a number of strategies, policies, and programs to provide timely, appropriate services to these returning service members and veterans - especially those transitioning directly from DoD MTFs to VAMCs. The ability to enroll for VA health care and file for benefits prior to separation from active duty is the result of the seamless transition process. Throughout the process, we have greatly improved dialogue and collaboration between VA and DoD to better serve OEF/OIF veterans.
Liaisons and Benefits Counselors at DoD and VA
VA has assigned full-time social workers and benefits counselors to seven major MTFs, including Walter Reed Army Medical Center, the National Naval Medical Center in Bethesda, Brooke Army Medical Center, Eisenhower Army Medical Center, and the Madigan, Ft. Carson, and Ft. Hood MTFs. These VA social workers work closely with MTF treatment teams to ensure that returning service members receive information and counseling about VA benefits and services. They also coordinate the transfer of active duty service members and recently discharged veterans to appropriate VA health care facilities and enroll them into the VA health care system. Through this collaboration, we have improved our ability to identify and serve returning service members who have sustained serious injuries or illnesses while serving our country. VHA staff has coordinated more than 2,000 transfers of OIF/OEF service members and veterans from an MTF to a VA medical facility. VBA benefits counselors are also stationed at MTF’s to provide benefits information and assistance in applying for these benefits. These counselors are generally the first VA representatives to meet with the veteran and family members. From October 2003 through mid-March 2005, VBA benefits counselors interviewed almost 5,000 OIF/OEF service members hospitalized at MTFs.
Points of Contact at Regional Offices and Medical Centers
Each VAMC and VA Regional Office (VARO) has identified a point of contact (POC) to coordinate activities locally and to assure that the health care and benefits needs of returning service members and veterans are met. VA has distributed guidance on the role and functions of case management services to field staff to ensure that the roles and functions of the POCs and case managers are fully understood, and that proper coordination of benefits and services takes place.
Benefits Delivery at Discharge
Many of the OIF/OEF service members who are not seriously injured and therefore do not separate through one the MTFs, participate in VA's Benefits Delivery at Discharge Program (BDD). This program allows service members to begin the VA disability compensation application process 180 days prior to separation. In most cases, disabled service members participating in the BDD Program begin receiving VA disability compensation benefits within 60 days of their separation from active duty, which serves to ease the transition from active duty to civilian status. To expedite claims processing for these service members, VA and DoD have agreed upon a single examination process, using VA's examination protocols, if an examination is also required by the military prior to separation. A memorandum of agreement to establish single examination procedures was signed by VA and DoD in November 2004. The BDD Program is currently offered at 140 military installations. In FY 2004, the BDD Program received approximately 40,000 claims from transitioning service members.
For veterans whom we do not encounter in the MTF’s or the mobilization stations during VA benefits briefings, the STO has worked with VA’s Veterans Integrated Service Networks (VISNs) and VAROs to coordinate other outreach strategies. These individuals may not have the same serious combat-related injuries we have seen in the MTFs; however, they may have other health care, readjustment issues, or benefits needs that require assistance.
VA has developed and distributed pamphlets, brochures, and educational videos ("Our Turn to Serve"), designed for VA employees and others involved in this critical outreach efforts. A second video was developed, entitled "We Are By Your Side," for returning Guard/Reserve members and family to help them through the readjustment period upon returning home. Working with DoD, we developed a brochure entitled "A Summary of VA Benefits for National Guard and Reserve Personnel." The brochure summarizes the benefits available to this group of veterans upon their return to civilian life. We have distributed over a million copies of the brochure to all mobilization stations to ensure the widest possible dissemination through VA and DoD channels. It is also available online at:
I have brought with me copies of several of these products and ask that they be made part of the record.
VA also actively participates in discharge planning and orientation sessions for returning service members. With the activation and deployment of large numbers of Reserve/National Guard members for the onset of military actions in Afghanistan and Iraq, VA, in collaboration with DoD, has greatly expanded outreach to returning Reserve/National Guard members and their family members. National and local contacts have been made with Reserve/National Guard officials to schedule pre- and post-mobilization briefings for their members at the unit level. Returning Reserve/National Guard members can also elect to attend the formal 3-day Transition Assistance Program (TAP) workshops provided by VA personnel at mobilization stations. Knowing that this is an optional program for the Reserve/National Guard, VA has developed strategies to brief family members while the service member is still deployed and has arranged time on the unit training schedule and during reunions and family day activities.
From FY 2002 through the 1ST quarter of the FY 2005, VBA military services coordinators have conducted more than 19,000 briefings, reaching a total of more than 700,000 active duty service members. These briefings include 1,795 pre- and post-deployment briefings attended by over 88,000 activated Reserve and National Guard service members. During FY 2004 alone, VBA military services coordinators provided more than 7,200 benefits briefings to over 261,000 separating and retiring military personnel, including briefings aboard some Navy ships returning to the United States. Almost 1,400 of these briefings were conducted for Reserve and National Guard members. As of January of this year, we had already provided 2,260 briefings to 79,000 returning service members in FY 2005.
Other outreach activities include the distribution of flyers, posters, and information brochures to VAMCs, VAROs, and Vet Centers. VA has, in fact distributed more than 1.5 million brochures to DoD demobilization sites and USO’s. VA has produced and distributed one million copies of a VA health care and benefits wallet/pocket card. The card lists a wide range of VA programs, and provides relevant phone numbers and email addresses.
VA has produced media aimed specifically at OIF and OEF veterans. Examples of these include:
As service members separate from the military, VA contacts them to welcome them home and explain what local VA benefits and services are available. Furthermore, we have made a wide selection of general information available to OIF and OEF veterans online through a direct "Iraqi Freedom" link from VA’s Internet page (www.vba.va.gov/EFIF). This website provides information on VA benefits, including health care services, DoD benefits, and community resources available to regular active duty service members, activated members of the Reserves and National Guard, veterans, and veterans’ family members.
Last year, VA began sending "thank-you" letters together with information brochures to each OIF and OEF veteran identified by DoD as having separated from active duty. These letters provide information on health care and other VA benefits, toll-free information numbers, and appropriate VA web sites for accessing additional information. The first letters and information brochures were mailed in April 2004, and thus far, VA has mailed letters to more than 290,000 returning OIF/OEF veterans. In 2005, letters and educational "toolkit" were sent to each of the National Guard Adjutants General and the Reserve Chiefs explaining VA services and benefits. I am asking that a copy of this letter also be made part of the record.
A critical concern for veterans and their families is the potential for adverse health effects related to military deployments. VA has produced a brochure that addresses the main health concerns for military service in Afghanistan, another brochure for the current conflict in Iraq, and one that addresses health care for women veterans returning from the Gulf region. These brochures answer health-related questions that veterans, their families, and health care providers have about these military deployments. They also describe relevant medical care programs that VA has developed in anticipation of the health needs of veterans returning from combat and peacekeeping missions abroad. These are widely distributed to military contacts and veterans service representatives; they can also be found on VA’s website.
Another concern is the potential health impact of environmental exposures during deployment. Veterans may have questions about their symptoms and illnesses following deployment. VA addresses these concerns through such media as newsletters and fact-sheets, regular briefings to veterans’ service organizations, national meetings on health and research issues, media interviews, educational materials, and websites, like http://www.va.gov/environagents. One major initiative to educate VA and DoD healthcare providers is the Veterans Health Initiative (VHI). Through the VHI, VA has developed training programs for such topics as care of war wounded, TBI, PTSD, and military sexual trauma, among others. This CD-ROM training has been distributed to VA and DoD Healthcare providers. Additionally, we have created a web page for VA employees on the activities of VA’s seamless transition initiative. Included are the points of contact for all VA health care facilities and VAROs, copies of all applicable directives and policies, press releases, brochures, posters, and resource information.
VA Health Care Utilization
Veterans who have served or are now serving in Afghanistan and Iraq may, following separation from active duty, enroll in the VA health care system and, for a two-year period following the date of their separation, receive VA health care without co-payment requirements for conditions that are or may be related to their combat service. Following this initial two-year period, they may continue their enrollment in the VA health care system but may become subject to any applicable co-payment requirements.
As of February 2005, VA had data on 360,674 OIF and OEF veterans who had separated from active duty. Approximately 24 percent of these veterans (85,857) have sought health care from VA. Most of these veterans have received outpatient care, while only a comparatively small number (1,980) have had an episode of hospitalization. Reservists and National Guard members make up the majority of those who have sought VA health care (44,178, or 52 percent). Those who separated from regular active duty have accounted for 48 percent (41,679). However, among separated OIF/OEF veterans eligible for VA health care, a greater percentage of veterans of regular active duty (29 percent) has sought VA health care than have Reservists/National Guards personnel (20 percent).
OIF and OEF veterans have sought VA health care for a wide-variety of physical and psychological problems. The most common health problems have been musculoskeletal ailments (principally joint and back disorders) and diseases of the digestive system, with teeth and gum problems being the predominant complaints. In total, OIF/OEF veterans have accounted for only slightly more than one percent of our total veteran patients (4.9 million in FY 2004).
Mr. Chairman, VA is aware that there has been particular interest about mental health issues among OIF and OEF veterans and VA’s current and future capacity to treat these problems, in particular PTSD. First, I have been asked to assure the Subcommittee that VA has the programs and resources to meet the mental health needs of returning OIF and OEF veterans. Second, in regard to PTSD among OIF and OEF veterans, I have been asked to provide the further assurance that the PTSD workload that we have seen in these veterans has been only a small percentage of our overall PTSD workload. In FY 2004, we saw approximately 279,000 patients at VA health care facilities for PTSD and 63,000 in Vet Centers. Our latest data on OIF and OEF veterans indicate that as of February 2005, 9,688 of these veterans seen as patients at VAMCs carried an ICD-9 code corresponding to PTSD. Additionally, 2,332 veterans received services for PTSD through our Vet Centers. Allowing for those who have received services at both VAMCs and Vet Centers, a total of 11,224 individual OIF/OEF veterans had been seen with actual or potential PTSD at VA facilities following their return from Iraq or Afghanistan. This figure represents only about three percent of the PTSD patients VA saw in FY 2004. It should be noted, however, that some of the 11,224 OIF/OEF veterans may include those with a provisional ("rule-out") diagnosis of PTSD who were being assessed for this disorder or other, unrelated disorders.
Meeting the comprehensive health care needs of returning OIF and OEF veterans who choose to come to VA is one of the Department’s highest priorities. VA is confident that its FY 2005 budget and the Presidents’ FY 2006 budget request contain sufficient funding to allow us to provide for all the health care needs of OIF and OEF veterans. Of course, we will continue to monitor the health care workload associated with OIF and OEF veterans to ensure that VA aligns its health care resources to meet their needs.
One of the harshest realities of combat in Iraq and Afghanistan is the number of service members returning from Iraq and Afghanistan with loss of limbs and other severe and lasting injuries. VA recognizes that it must provide specialized care for military service members and veterans who have sustained severe and multiple catastrophic injuries. Since the start of OIF/OEF, VA’s four regional Traumatic Brain Injury (TBI) Lead Rehabilitation Centers (located in Minneapolis, Palo Alto, Richmond, and Tampa) have served as regional referral centers for individuals who have sustained serious disabling conditions due to combat. These programs are specially accredited to provide comprehensive rehabilitation services and TBI services. Patients treated at these facilities may have a serious TBI alone or in combination with amputation, blindness, or other visual impairment, complex orthopedic injuries, auditory and vestibular disorders, and mental health concerns. Because TBI influences all other areas of rehabilitation, it is critical that individuals receive care for their TBI prior to, or in conjunction with, rehabilitation for their additional injuries.
In accordance with section 302 of Public Law 108-422, VA has developed a plan to expand the scope of care at these four centers and create Polytrauma Centers. This plan builds on the capabilities of the regional referral centers but adds additional clinical expertise to address the special problems that the multi-trauma combat injured patient may face. Such additional services include intensive psychological support treatment for both patient and family, intensive case management, improvements in the treatment of visual disturbance, improvements in the prescription and rehabilitation using the latest high tech specialty prostheses, development of a clinical database to track efficacy and outcomes of interventions provided, and provision of an infrastructure for important research initiatives. Additionally, the plan addresses services for patients in the outpatient setting for ongoing follow-up care not requiring hospitalization. The plan provides for enhancements to existing rehabilitation outpatient clinical services to ensure that necessary services can be provided within easier access to the patient’s home.
On April 7, 2005, VA published a directive that requires the four Polytrauma Centers to assign social worker case managers at a ratio of one case manager for every six patients. These case managers will initiate contact with service members and veterans and their families before they are transferred to the polytrauma centers and will follow them throughout their rehabilitation and treatment. Additionally, VA Voluntary Service (VAVS) Managers at the four polytrauma centers are working with local community organizations and businesses to provide necessary information and services to family members who are staying with their family members. National Veteran Service Organizations (VSOs) have pledged their support to provide phone cards, discount lodging coupons, and local support for transportation of the family members. Each family member will receive a welcome package with information of the local area, coupons for lodging, and area attractions and coupons for the Veterans Canteen Service. In Palo Alto, for example, the Chief VAVS meets with the family members upon arrival and seeks support from area businesses and VSOs based on family needs.
VA’s most important mission is to "care for him who has borne the battle." I am honored to lead an office dedicated to fulfilling this mission. Mr. Chairman, this concludes my statement. I will be happy to respond to any questions that you or other members of the Subcommittee might have.