JAMES ORCUTT, MD
CHIEF OF OPHTHALMOLOGY
OFFICE OF PATIENT CARE SERVICES
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
COMMITTEE ON VETERANS' AFFAIRS
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
UNITED STATES HOUSE OF REPRESENTATIVES
April 2, 2008
Good morning, Mr. Chairman and members of the Subcommittee. Thank you for the opportunity to discuss the Department of Veterans Affairs' ( VA's ) provision of care for veterans needing support for visual impairment and traumatic brain injury ( TBI ). I am accompanied by Dr. Barbara Sigford, National Program Director for Physical Medicine and Rehabilitation.
VA and the Department of Defense ( DoD ) have a long-standing memorandum of understanding allowing VA to provide medical care and rehabilitative services for severely injured active duty service members, such as those with blindness, traumatic brain injury, and spinal cord injury. The Veterans Health Administration ( VHA ) has developed one of the most extensive rehabilitation systems in the country for visual impairment, and our work in treating TBI, dating back to the creation of four national TBI centers in 1992, is unmatched. Our Polytrauma System of Care is uniquely positioned to address the complex needs of veterans and service members exhibiting these two conditions, and others, simultaneously. My testimony today will provide an overview of the continuum of care VA provides veterans and service members to ensure they receive the right care, in the right way, at the right time, to further their goals of rehabilitation and reintegration.
VA has developed several initiatives to facilitate the ease of transfer for veterans and service members transitioning from military service in Operation Enduring Freedom ( OEF ) or Operation Iraqi Freedom ( OIF ). For the seriously injured, ill, or wounded, VA and DoD have created a new Federal Recovery Coordination Program ( FRCP ) that will assign Coordinators capable of working within and between VA, DoD and the private sector to monitor and support our severely wounded veterans and service members. VA's OEF / OIF Case Management Program provides a fully integrated team approach at every VA Medical Center ( VAMC ), and includes a Program Manager, Clinical Case Managers, a Veterans Benefits Administration ( VBA ) Veterans Service Representative, and a Transition Patient Advocate. OEF / OIF veterans with severe injuries are automatically provided a case manager; all other OEF / OIF veterans are assigned a case manager upon request. Clinical Case Managers, who are either nurses or social workers, coordinate patient care activities and ensure all VHA clinicians are providing care to the patient in a cohesive, integrated manner. VBA team members assist veterans by educating them on VA benefits and assisting them with the benefit application process.
The Transition Patient Advocates ( TPA s) serve as liaisons between the VAMC, the Veterans Integrated Service Network ( VISN ), VBA, and the patient. TPA s act as communicators, facilitators and problem solvers. The team documents their activities in the Veterans Tracking Application, a web-based tool designed to track injured and ill service members and veterans as they transition to VA. VHA is also using the Primary Care Management Module, an application within VHA's VistA Health Information system, to track patients assigned to an OEF / OIF Case Management team.
VA provides clinical rehabilitative services in several specialized areas employing the latest technology and procedures to provide our veterans with the best available care and access to rehabilitation for Polytrauma, TBI, visual impairment, and other areas. Whenever an OEF / OIF veteran requires specialized rehabilitative services, the assigned OEF / OIF case manager engages with the clinical case manager appropriate for that area of rehabilitation (e.g., Polytrauma, spinal cord injury, blindness) and coordinates with the appropriate clinical case manager regarding the veteran's progress and rehabilitation.
Over the past two years, VA has implemented an integrated system of specialized care for veterans sustaining traumatic brain injury ( TBI ) and other polytraumatic injuries. The Polytrauma System of Care consists of four regional TBI /Polytrauma Rehabilitation Centers ( PRC ) located in Richmond, VA; Tampa, FL; Minneapolis, MN; and Palo Alto, CA. A fifth PRC is currently under design for construction in San Antonio, TX, and is expected to open in 2011. The four regional PRC s provide the most intensive specialized care and comprehensive rehabilitation available for combat injured patients transferred from military treatment facilities. As veterans recover and transition closer to their homes, the Polytrauma System of Care provides a continuum of integrated care through 21 Polytrauma Network Sites, 76 Polytrauma Support Clinic Teams and 54 Polytrauma Points of Contact, located at VAMC s across the country. Throughout the Polytrauma System of Care, we have established a comprehensive process for coordinating support efforts and providing information for each patient and family member. On February 27, 2006, VA established a national Polytrauma Call Center available 24 hours a day, seven days a week, to families and patients with questions. This Center is staffed by health care professionals trained specifically in polytrauma care and case management issues and can be reached by calling 1-888-827-4824.
The care coordination process between the referring DoD military treatment facility and the PRC begins weeks before the active duty service member is transferred to VA for health care. The PRC physician monitors the medical course of recovery and is in contact with the MTF treating physician to ensure a smooth transition of clinical care. The admissions nurse case manager maintains close communication with the referring facility, obtaining current and updated medical records. A social work case manager is in contact with the family to address their needs for psychosocial and logistical support. Before transfer, the PRC interdisciplinary team meets with the DoD treatment team and family by teleconference as another way to ensure a smooth transition. The PRC s provide a continuum of rehabilitative care including a program for emerging consciousness, comprehensive acute rehabilitation, and transitional rehabilitation. Each of our PRC s is accredited by the Commission on Accreditation of Rehabilitation Facilities. Intensive case management is provided by the PRC s at a ratio of 1 case manager per 6 patients, and families have access to assistance 24 hours a day, 7 days a week. The interdisciplinary rehabilitation treatment plan of care reflects the goals and objectives of the patient and his or her family.
From March 2003 through December 2007, the PRC s provided inpatient rehabilitation to 507 military service members injured in combat theaters. The transition plan from the PRC s to the next care setting evolves as the active duty service member progresses in the rehabilitation program. Families are integral to the team and are active participants in therapies, learning about any residual impairments and ongoing care needs. The team collaborates with the family to identify the next care setting, and determine what will be needed to accommodate the transition of rehabilitative care. The consultation process includes a teleconference between the PRC team, the consulting team, the family, and the patient. These conferences allow for a coordinated transfer of the plan of care, and an opportunity to address specific questions.
Before discharge, each family and patient is trained in medical and nursing care appropriate for the patient. Once a discharge plan is coordinated with the family, VA initiates contact with necessary resources near the veteran's home community. Based upon the patient's desired discharge location, a transition plan is prepared with one of the 21 VA Polytrauma Network Sites or another provider in the Polytrauma System of Care within the patient's chosen community. As veterans and service members transition to their home communities, ongoing clinical and psychosocial case management is provided by a rehabilitation nurse and social worker from one of 76 Polytrauma Support Clinic Teams. VA social work case managers follow each patient within the Polytrauma System of Care at prescribed intervals contingent upon need. For example, there are four levels of case management: intensive case management, where contact is made daily or weekly; progressive case management, where VA contacts the patient monthly; supportive case management, quarterly; and lifetime case management, annually. For the many patients who are still active duty service members, the military case managers are responsible for obtaining authorizations from DoD regarding orders and follow-up care based upon VA medical team recommendations.
VA reviews and improves our care for these wounded or injured warriors. VA assembled a national research task force last summer to review and evaluate the long term care needs of our most seriously wounded or injured returning OEF / OIF veterans. This taskforce recently completed its work and made several recommendations, which are being submitted to the Secretary for his review. Also, in compliance with the 2008 National Defense Authorization Act, VA is collaborating with the Defense and Veterans Brain Injury Center to design and execute a five-year pilot program to assess the effectiveness of providing assisted living services to eligible veterans to enhance their rehabilitation, quality of life, and community integration.
We also co-hosted a conference in December 2007 with DoD on the visual consequences of TBI. This conference was attended by members of the visual team for each Polytrauma Rehabilitation Center as well as blind rehabilitation specialists, optometrists, and ophthalmologists from both Departments and provided an opportunity to initiate a consensus validation process, which will identify and disseminate the most effective strategies for treatment and services when they are known or to determine where additional research is needed. VA has also assembled teams of specialists, to develop questions for determining evidence-based treatments; we anticipate this process will be complete in the summer. VA holds an annual conference, portions of which are jointly conducted with Blinded Veterans of America (B VA ), at which our experts and B VA representatives can discuss new treatment methods and further areas of cooperation.
Any OEF / OIF veteran seen at a VA medical facility is automatically screened for TBI. Veterans for whom the screen is positive are referred for a full, in-depth evaluation. The evaluation process includes a standardized evaluation template of common problems following brain injury. This template includes checks for visual impairment. Our visual treatment specialists conduct full visual examinations including but not limited to acuity, full visual field testing, pressures within the eye, and imaging of both the retina and the cornea to assess damage to these structures. In all, this screening process includes a 22-item checklist, including an evaluation for visual impairment and presence of visual symptoms. For veterans and active duty personnel with visual impairment, VA provides comprehensive Blind Rehabilitation services that have demonstrated significantly greater success in increasing independent functioning than any other blind rehabilitation program--anywhere. Currently, 164 Visual Impairment Service Team ( VIST ) Coordinators provide lifetime case management for all legally blind veterans, and all OEF / OIF patients with visual impairments. Additionally, 38 Blind Rehabilitation Outpatient Specialists ( BROS ) provide blind rehabilitation training to patients who are unable to travel to a blind center. These Polytrauma Blind Rehabilitation Specialists have certification in two areas, low vision rehabilitation and orientation and mobility training. They work in close collaboration with our neuro-ophthalmologists and low vision optometrists who evaluate, diagnose, and recommend treatment for our patients with visual impairments. Each Polytrauma Rehabilitation Center and Polytrauma Network Site has dedicated funding for a BROS on the Polytrauma team.
Blind Rehabilitation Service involvement often begins while the injured service member is still a patient at a military treatment facility. The patient is transferred to a VA Blind Rehabilitation Center as soon as it is medically needed and at the patient's request. There is no waiting time for OEF / OIF veterans for this service.
The VA Blind Rehabilitation Continuum of Care, first announced in January 2007, further extends a comprehensive, national rehabilitation system for all veterans and active duty personnel with visual impairments. Program expansion during 2008 will add 55 outpatient vision rehabilitation clinics, 35 additional BROS at VAMC s currently lacking those services, and 11 new VIST positions. The continuum of care will provide the full scope of vision services - from basic, low vision services to blind rehabilitation training - across all Veteran Integrated Service Networks (VISNs ).
This continuum of care will allow early intervention for patients whose vision loss results from progressive eye degeneration. Providing services at the earliest point in the continuum will maximize independence and substantially reduce demands on the family, community and VA. Providing a wider array of outpatient services across the continuum of visual impairment, coupled with the ability for a veteran to move through the continuum of care based on individual visual and psycho-social needs will reduce wait times for rehabilitation services. The continuum of care provides basic low vision services, intermediate low vision services, and advanced ambulatory low vision services in all VISNs. Advanced blind rehabilitation services are provided in all VISNs that do not already have an inpatient blind rehabilitation center.
VHA is expanding our capacity to provide care for the growing number of veterans returning from service in Iraq and Afghanistan with wounds and trauma resulting in blindness and visual impairment. We have provided additional funds to ensure visually impaired veterans receive appropriate care and the latest technological devices when needed and in locations convenient to them. To date, VA has provided inpatient blind rehabilitation services to 53 veterans and active duty service members from OEF / OIF, while 156 OEF / OIF veterans and service members have received some level of care from VHA Blind Rehabilitation Service.
VA has consistently been a leader in the development of sensory and prosthetic research aids. Each Blind Rehabilitation Center is actively involved in research, development and evaluation of devices. Many devices that were involved in research programs in past years are now regular features of service at our Blind Rehabilitation Centers. As new devices are crafted, VA will be among the first to evaluate them. Our goal in research and treatment is to improve the quality of life for all blind or visually impaired persons, veterans and non-veterans alike.
VA has been a national leader in the care and rehabilitation of veterans with TBI and visual impairments, and we are committed to maintaining that status. Thank you again for you the opportunity to meet with you today. I would be pleased to address any questions that you have at this time.