MICHAEL J. KUSSMAN, M.D.
DEPUTY CHIEF PATIENT CARE SERVICES OFFICER
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE SUBCOMMITTEE ON TOTAL FORCE
COMMITTEE ON ARMED SERVICES
U. S. HOUSE OF REPRESENTATIVES
HEARING ON FORCE HEALTH PROTECTION AND SURVEILLANCE
February 25, 2004
Mr. Chairman and Members of the Committee, I appreciate the opportunity to appear before you today to discuss efforts of the Department of Veterans Affairs (VA) toward a seamless transition for separating service members from the Department of Defense (DoD) health care system to the VA health care system.
We have been working hard both internally and with DoD to identify the men and women returning from combat theaters and to provide those separated from active duty, particularly those injured or with deployment related illnesses, with world-class VA service. Anyone who has been wounded or injured or has become ill while in defense of our country deserves the highest quality and most timely service possible from their Government.
Working with DoD, VA has accomplished and put into place a number of strategies, policies, and procedures to provide timely, appropriate services to our returning service members.
Seamless Transition Activities
Last August, VA’s Under Secretary for Benefits and Under Secretary for Health created a new VA Taskforce for the Seamless Transition of Returning Service Members to reduce red tape and streamline access to all VA benefits. This taskforce, composed of VA senior leadership from key program offices and the VA/DoD Executive Council structure, focused initially on internal coordination efforts to ensure that VA approaches this mission in a comprehensive manner. In the process, we have improved dialogue and collaboration between our two Departments.
Points of Contact
Through the leadership of the Taskforce, each Veterans Health Administration (VHA) facility and each VA regional office has identified a point of contact to coordinate activities locally and to assure that the needs of returning service members and veterans are met and that additional contact is made should the veteran relocate. VA has distributed guidance on case management services to VHA and VBA field staff to ensure proper coordination processes and that our expectations are communicated and followed. The guidance also addresses the roles and functions of the points of contact and case managers. VHA has recently revised its guidance to reflect recent experiences at field stations. The revised guidance will be distributed this month.
Working in collaboration with the military Surgeons General, the Veterans Benefits Administration (VBA) has detailed two full-time Veterans Service Representatives and VHA has detailed two full-time social workers to the Walter Reed Army Medical Center, the military treatment facility (MTF) receiving the largest numbers of casualties. Beginning in late August 2003, full-time and part-time VHA social workers and VBA Veterans Service Representatives have also been assigned as VA/DoD liaisons to the Brooke, Eisenhower, and Madigan Army Medical Centers, Darnall Army Community Hospital at Fort Hood, and the National Naval Medical Center in Bethesda. They work closely with military medical providers and DoD social workers to assure that returning service members receive information and counseling about VA benefits and programs, as well as assistance in filing benefit claims. They also coordinate the transfer of active duty service members and recently discharged veterans to appropriate VA health care facilities. Through this collaboration, we have improved our ability to identify and serve returning service members that sustained serious injuries or illnesses while serving our country. Over 1,100 hospitalized soldiers have received assistance from VA social workers.
VA actively participates in discharge planning and orientation sessions for returning service members, and we have expanded our collaboration with DoD to enhance outreach to returning members of the Reserves and National Guard. Working with DoD Health Affairs and DoD Reserve Affairs, we developed a new brochure, “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 ensure the widest possible dissemination through VA and DoD channels. It is also available online at http://www.va.gov/environagents/docs/SVABENEFITS.pdf and http://www.defenselink.mil/r2/mobile/pdf/va_benefits_rs.pdf. During FY 2003, VBA conducted over 800 briefings attended by almost 47,000 reserve and guard members. During the 1st quarter of FY 2004, 317 briefings were conducted and were attended by more than 18,000 reserve and guard members.
Outreach activities include the distribution of flyers, posters, and information brochures to VA medical centers, regional offices, and Vet Centers. All of these publications explain VA services available to veterans. As VA becomes aware of service members who are separated from the military, VA contacts them to welcome them home and explain what local VA services are available. Furthermore, in order to make a wide selection of general information available to Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans online, we have created a direct “Iraqi Freedom” link from VA’s Internet page (www.vba.va.gov/EFIF). This new site provides information on VA benefits, including health and mental health 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.
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 recently distributed on 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 hazardous 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 often have questions about their symptoms and illnesses following deployment. VA generally 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 www.va.gov/environagents.
As a new initiative recently requested by Secretary Principi, VA will shortly begin to send “thank-you” letters together with information brochures to each OIF and OEF veteran. These letters will provide information on health care and other VA benefits, toll-free information numbers, and appropriate VA web sites for accessing additional information.
Training and Education
To ensure that our commitment is understood and shared at every level of the Department, the Taskforce developed a number of training materials and other tools for front line staff to ensure that they can identify veterans who have served in a theater of combat operations and take the steps necessary to ensure the veterans receive appropriate care.
To further aid VA employees in their efforts to assist OIF/OEF veterans, we have recently distributed a video entitled “Our Turn to Serve” to all VHA and VBA field facilities. The video helps VA staff better understand the experiences of military personnel serving in Operations Iraqi Freedom and Enduring Freedom and explains how they can provide the best possible service to these newest combat veterans. We have also provided copies of this video to Military Treatment Facilities. Additionally, we have created a web page for VA employees on the activities of the VA Seamless Transition Task Force. Included are lists of points of contact for all VHA health care facilities and VBA regional offices, copies of all applicable directives and policies, press releases, brochures, posters, Task Force minutes, and resource information.
The Veterans Health Initiative (VHI) is a program designed to increase recognition of the connection between military service and certain health effects; better document veterans' military and exposure histories; improve patient care; and establish a database for further study. The education component of VHI prepares VA healthcare providers to better serve their patients. A module was created on “Treating War Wounded,” adapted from VHA satellite broadcasts in April 2003 and designed to assist VA clinicians in managing the clinical needs of returning wounded from the war in Iraq. Modules on spinal cord injury, cold injury, traumatic amputation, Agent Orange, the Gulf War, PTSD, POW, blindness/visual impairment and hearing loss, and radiation are also available. Training modules on infectious disease risks in Southwest Asia and on Weapons of Mass Destruction were released in January 2004. We are developing additional modules on military sexual trauma, traumatic brain injury, and pulmonary diseases of military occupational significance.
In addition to the VHA training modules on PTSD, VA’s National Center for PTSD has developed the Iraq War Clinician’s Guide for use across VA. The website version, which can be found at WWW.NCPTSD.ORG, contains the latest fact sheets and available medical literature and is updated regularly. The first version of the Iraq War Guide was published in June 2003. It is now being revised in collaboration with DoD based on our experience with returning casualties. These important tools are integrated with other VA educational efforts to enable VA practitioners to arrive at a diagnosis more quickly and accurately and to provide more effective treatment.
Mr. Chairman, veterans who have served or are now serving in Afghanistan and Iraq may enroll in the VA health care system and, for a two-year period following the date of their separation from active duty, would 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. Based on lists of separated OIF and OEF veterans received from DoD, we estimate that as of December 2003, 9,753 OIF veterans and 1,798 OEF veterans had received health care from VA for a wide variety of health problems.
For returning service members who are experiencing emotional and behavioral problems, VA has programs specifically developed to assess and address emotional and behavioral problems associated with the military experience. The training programs cited above will ensure that our skilled clinicians will be better able to identify and treat problems presented by the newest generation of combat veterans. The VHI module on PTSD in Primary Care mentioned above is designed to increase recognition of PTSD in medical primary care settings. Within these mental health programs, VA operates a comprehensive continuum of clinical care for posttraumatic stress disorder (PTSD) in its Medical Centers and clinics. This is accomplished both through special PTSD programs and through PTSD specialists in general mental health programs.
VA’s Vet Centers also play an important role complementing VA health care services. Our mental health clinical activities are linked to and supportive of Vet Center activities. Vet Center staff members actively pursue outreach to military installations and family support centers to assist veterans and their families in the veterans’ return to civilian life. Last year, Vet Centers began extending readjustment counseling services to all OEF and OIF veterans. As of December 2003 Vet centers had served 4,300 of these veterans.
Earlier I discussed the Veterans Health Initiative (VHI) as a program designed to increase recognition of the connection between military service and certain health effects.. VA has also developed additional tools to assist the clinician when treating OIF and OEF veterans.
A screening instrument in the form of a clinical reminder triggered by the veteran's separation date is being implemented for returning OIF and OEF veterans who come to VA for health care. This assessment tool will prompt the provider with specific screening requirements to assure that veterans are evaluated for medical and psychological conditions that may be related to recent combat deployment.
VA has also developed evidence-based clinical approaches for treating veterans following deployment. These clinical practice guidelines (CPGs) give health care providers the needed structure, clinical tools, and educational resources that allow them to diagnose and manage patients with deployment-related health concerns. Two post-deployment CPGs have been developed in collaboration with DoD, a general purpose post-deployment CPG and a CPG for unexplained fatigue and pain. Our goal is that all veterans will find their VA doctors well informed about specific deployments and related health hazards. The VA website contains these CPGs as well as information about unique deployment health risks and new treatments.
VA and DoD will release a new CPG on the management of traumatic stress by the end of this month. This guideline pools DoD and VA expertise to help build a joint assessment and treatment infrastructure between the two systems in order to coordinate primary care and mental health care for the purpose of managing, and, if possible, preventing acute and chronic Post Traumatic Stress Disorder (PTSD).
Record Sharing between VA and DoD
VA and DoD are also collaborating to develop the ability to share medical information electronically. Since June 2002, the Departments have successfully been sharing electronic medical information. Key initiatives in the Electronic Health Records Plan are the Federal Health Information Exchange (FHIE) and HealthePeople (Federal). FHIE provides historical data on separated and retired military personnel from the DOD’s Composite Health Care System to the FHIE Data Repository for use in VA clinical encounters and potential future use in aggregate analysis. Patient data on laboratory results, radiology reports, outpatient pharmacy information, and patient demographics are now being sent from DoD to VA via secure messaging. This second phase of FHIE has been deployed and is operational at VA medical centers nationwide. It includes admission, discharge, transfer data, discharge summaries, allergies, and consult tracking. Most recently, additional enhancements were completed to provide retail pharmacy data from the DoD Pharmacy Data Transaction Service. Work on the final release of FHIE is on target to provide Standard Ambulatory Data Record information to VA. FHIE is scheduled to go into maintenance mode at the end of the second quarter FY 2004. The next Phase of the Plan will provide bi-directional exchange of health data between Departments. VA and DoD are developing prototype interoperable data repositories using standardized data that will demonstrate bi-directional data exchange with pharmacy information in October 2004. The Departments will achieve health system interoperability by October 2005.
We are also working with DoD to develop processes whereby pre- and post-deployment health assessments will be available electronically to VA physicians and claims examiners. We are further analyzing the HIPAA Privacy rule and its implications for our health information sharing efforts.
A service member separating from military service and seeking health care through VA today will have the benefit of VA’s decade-long experience with Gulf War health issues as well as the President’s commitment to improving collaboration between VA and DoD. VA has successfully adapted many existing programs, improved outreach, improved clinical care through practice guidelines and educational efforts, and improved VA health provider’s access to DoD health records. Secretary Principi has emphasized VA’s commitment to returning combat veterans. In his words, “We will have failed to meet our very reason to exist as a Department if a veteran is poorly served."
This concludes my statement. My colleagues and I will be happy to respond to any questions that you or other members of the Subcommittee might have.