DR. LUCILLE BECK
CHIEF CONSULTANT, OFFICE OF REHABILITATION SERVICES
OFFICE OF PATIENT CARE SERVICES
VETERANS HEALTH ADMINISTRATION
U.S. DEPARTMENT OF VETERANS AFFAIRS
COMMITTEE ON VETERANS’ AFFAIRS
UNITED STATES SENATE
MAY 5, 2010
May 5, 2010
Good morning, Mr. Chairman, Ranking Member Burr, and Members of the Committee. Thank you for inviting me here to update the Committee on the Department of Veterans Affairs’ (VA) progress in implementing the wounded warrior provisions in the Veterans Traumatic Brain Injury and Health Programs Improvement Act of 2007. I would like to thank the Committee for its work in passing important legislation, which has enabled VA to establish landmark programs and initiatives to meet the provisions of the title XVI, referred to as the Wounded Warrior Act, and title XVII of Public Law 110-181.
I am accompanied today by Dr. Karen Guice, Director of the Federal Recovery Coordination Program; Dr. Joel Scholten, Associate Chief of Staff for Physical Medicine and Rehabilitation at the Washington, DC, VA Medical Center; and Dr. Sonja Batten, Deputy Director at the Department of Defense (DoD) Centers of Excellence for Psychological Health and Traumatic Brain Injury. I will describe the current state of VA care and services for Veterans and Servicemembers with traumatic brain injury (TBI), as well as discuss the interagency collaborations with DoD to improve the care, management and transition of recovering Servicemembers.
VA has developed and implemented numerous programs that meet legislative requirements and ensure the provision of world-class rehabilitation services for Veterans and active duty Servicemembers with TBI. VA has enhanced its integrated nationwide Polytrauma/TBI System of Care. The VA Polytrauma/TBI System of Care consists of four levels of facilities, including 4 Polytrauma Rehabilitation Centers, 22 Polytrauma Network Sites, 82 Polytrauma Support Clinic Teams, and 48 Polytrauma Points of Contact. The System offers comprehensive clinical rehabilitative services including: treatment by interdisciplinary teams of rehabilitation specialists; specialty care management; patient and family education and training; psychosocial support; and advanced rehabilitation and prosthetic technologies.
In 1992, VA designated four lead TBI Centers as part of the Defense and Veterans Brain Injury Center (DVBIC) collaboration to provide comprehensive rehabilitation for Veterans and active duty Servicemembers. In 1997, VA designated a TBI Network of Care to support care coordination and access to services across VA’s system. In recognition of the high survival rate of severely injured Servicemembers in Iraq and Afghanistan, Congress passed two laws that underscored the need for a specialized system of care that meets the complex rehabilitation needs of Servicemembers and Veterans injured in combat: Public Law 108-422, the Veterans Health Programs Improvement Act of 2004, and Public Law 108-447, the Consolidated Appropriations Act, 2005 (in accompanying Reports S. Rep. 108-353 and H. R. Rep. 108-792 (Conf. Rep.)). These laws directed VA to ensure that severely injured Veterans would benefit from the best of both modern medicine and integrative therapies for rehabilitation. In addition, these laws furthered the development of specialized, interdisciplinary rehabilitation programs to handle the complex medical, psychological, and rehabilitative needs of these individuals. In 2005, VA expanded the scope of services at existing VA TBI Centers, and accordingly renamed them Polytrauma/TBI Rehabilitation Centers, to establish an integrated, tiered system of specialized, interdisciplinary care for polytrauma injuries and TBI.
“Polytrauma” is a new word in the medical lexicon that was termed by VA to describe the complex, multiple injuries to multiple body parts and organs occurring as a result of blast-related injuries seen from Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF). Polytrauma is defined as two or more injuries to physical regions or organ systems, one of which may be life threatening, resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability. TBI frequently occurs in polytrauma in combination with other disabling conditions such as amputation, auditory and visual impairments, spinal cord injury (SCI), post-traumatic stress disorder (PTSD), and other medical problems. Due to the severity and complexity of their injuries, Servicemembers and Veterans with polytrauma require an extraordinary level of coordination and integration of clinical and other support services.
The VA Polytrauma System of Care currently provides specialty rehabilitation care across 108 VAMCs to create points of access along a continuum, and integrating services available at 4 regional Polytrauma/TBI Rehabilitation Centers (PRC), 22 Polytrauma Network Sites - one in each Veterans Integrated Service Network (VISN) and one in San Juan, Puerto Rico - and 82 Polytrauma Support Clinic Teams.
PRCs provide the most intensive specialized care and comprehensive rehabilitation care for Veterans and Servicemembers with complex and severe polytrauma. PRCs maintain a full staff of dedicated rehabilitation professionals and consultants from other specialties to support these patients. Each PRC is accredited by the Commission on Accreditation of Rehabilitation Facilities, and each serves as a resource to develop educational programs and best practice models for other facilities across the system. The four regional Centers are located in Richmond, VA; Tampa, FL; Minneapolis, MN; and Palo Alto, CA. A fifth Center is currently under construction in San Antonio, TX, and is expected to open in 2011.
VA’s Polytrauma System of Care strongly advocates family involvement throughout the rehabilitation process, and VA strives to ensure that patients and their families receive all necessary support services to enhance the rehabilitation process while minimizing the inherent stress associated with recovery from TBI and polytrauma. VA offers multiple levels of clinical, psychosocial and logistical support to ensure a smooth transition and continuous care for patients and their families. VA assigns a dedicated case manager to each patient and family at a PRC. These case managers maintain workload levels of six patients each. Families can access this case manager for assistance 24 hours a day, 7 days a week.
Since 2007, VA has placed Polytrauma Nurse Liaisons at Walter Reed Army Medical Center and National Naval Medical Center (at Bethesda, MD) to support coordination of care, patient transfers, and shared patients between DoD and VA PRCs. Whenever an injured Veteran or Servicemember requires specialized rehabilitative services and enters VA health care, the Polytrauma Nurse Liaison maintains close communication with the admissions nurse case manager at the VA PRC, providing current and updated medical records. Before transfer, the Center’s interdisciplinary team meets with the DoD treatment team and family by teleconference as another way to ensure a smooth transition.
The four VA Centers typically have between 12- and 18-inpatient beds staffed by specialty rehabilitation teams that provide acute interdisciplinary evaluation, medical management and rehabilitation services. Occupancy rates at these Centers fluctuate over time and location. The average length of stay is currently 30 days, but the average for the most severely injured is 67 days. Upon discharge from a VA PRC, patients may be transferred to another facility, although over 70 percent are discharged to their home.
A total of 1,736 inpatients with severe injuries have been treated at these Centers from March 2003 through December 2009; 879 of these patients have been active duty Servicemembers, of which 736 were injured in OEF or OIF. VA continues following these patients after their discharge from a VA PRC to assess their long-term outcomes. Data available for 876 former patients indicate:
• 781 (89 percent) are living in a private residence;
• 642 (73 percent) live alone or independently;
• 413 (47 percent) report they are retired due to age, disability or other reasons;
• 206 (24 percent) are employed;
• 90 (10 percent) are in school part-time or full-time; and
• 59 (7 percent) are looking for a job or performing volunteer work.
As patients recover and transition closer to their homes, the Polytrauma/TBI System of Care provides a continuum of integrated care through 22 Polytrauma Network Sites, 82 Polytrauma Support Clinic Teams, and 48 Polytrauma Points of Contact, located at VAMCs across the country.
The Polytrauma Network Sites develop and support a patient’s rehabilitation plan through comprehensive, interdisciplinary, specialized teams; provide both inpatient and outpatient care; and coordinate services for Veterans with TBI and polytrauma throughout the VISN.
In 2008, the Polytrauma Support Clinic Teams expanded to 82 VA facilities. These interdisciplinary Teams of rehabilitation specialists provide dedicated outpatient services closer to home and manage the long-term or changing rehabilitation needs of Veterans. These Teams coordinate clinical and support services for patients and their families, conduct comprehensive evaluations of patients with positive TBI screens, and develop and implement rehabilitation and community reintegration plans.
VA Polytrauma Points of Contact are available at 48 VAMCs without specialized rehabilitation teams. These Points of Contact, established in 2007, are knowledgeable about the VA Polytrauma/TBI System of care and coordinate case management and referrals throughout the system.
Throughout the Polytrauma/TBI System of Care, we have established a comprehensive process for coordinating support efforts and providing information for each patient and family member. Specialized rehabilitation initiatives at the PRCs include:
• In 2007, VA developed and implemented Transitional Rehabilitation Programs at each PRC. These 10-bed residential units provide rehabilitation in a home-like environment to facilitate community reintegration for Veterans and their families, focus on developing standardized program measures, and investigate opportunities to collaborate with other entities providing community-based reintegration services. Through December 2009, 188 Veterans and Servicemembers have participated in this program spending, on average, about 3 months in transitional rehabilitation. Almost 90 percent of these individuals return to active duty, or transition to independent living.
• Beginning in 2007, VA implemented a specialized Emerging Consciousness care path at the four PRCs to serve those Veterans with severe TBI who are slow to recover consciousness. Patients with disorders of consciousness (e.g., comatose) require high complexity and intensity of medical services and resources in order to improve their level of responsiveness and decrease medical complications. To meet the challenges of caring for these individuals, VA collaboratively developed this care path with subject matter experts from DVBIC and the private sector. VA and DVBIC continue to collaborate on research in this area, and incorporate improvements to the care path in response to advances in science. From January 2007 through December 2009, 87 Veterans and Servicemembers have been admitted in VA Emerging Consciousness care. Approximately 70 percent of these patients emerge to consciousness before leaving inpatient rehabilitation.
• In October 2008, all inpatients with TBI at VA PRCs began receiving special ocular health and visual function examinations based upon research conducted at our Palo Alto PRC. To date, 840 inpatients have received these examinations.
• In April 2009, VA began an advanced technology initiative to establish assistive technology laboratories at the four PRCs. These facilities will serve as a resource for VA health care, and provide the most advanced technologies to Veterans and Servicemembers with ongoing needs related to cognitive impairment, sensory impairment, computer access, communication deficits, wheeled mobility, self-care, and home telehealth.
• VA continues to optimize its Polytrauma Telehealth Network to facilitate provider-to-provider and provider-to-family coordination, as well as consultation from PRCs and Network Sites to other providers and facilities. Currently, about 30 to 40 videoconference calls are made monthly across the Network Sites to VA and DoD facilities. New Polytrauma Telehealth Network initiatives in development include home buddy systems to maintain contact with patients with mild TBI or amputation, and remote delivery of speech therapy services to Veterans in rural areas.
• The PRCs have been renovated to optimize healing in an environment respectful of military service. Military liaisons located at the centers help to support active duty patients and to coordinate interdepartmental issues for patients and their families. Working with the Fisher House Foundation, we are also able to provide housing and other logistical support for family members staying with a Veteran or Servicemember during their recovery at one of our facilities.
• In fiscal year (FY) 2009, 22,324 unique outpatients had 83,794 total clinic visits across the Polytrauma Support Clinic Team sites; an increase of over 30 percent from FY 2008.
In addition to improvements in the Polytrauma/TBI System of Care, VA developed and implemented the TBI Screening and Evaluation Program for all OEF/OIF Veterans who receive care within VA. From April 2007 through February 2010:
• 397,904 OEF/OIF Veterans have been screened;
• 54,675 who screened positive have been evaluated and received follow-up care and services appropriate for their diagnosis and their symptoms;
• 29,819 have been confirmed with a diagnosis of having incurred a mild TBI;
• Over 90 percent of all Veterans who are screened are determined not to have TBI, but all who screen positive and complete a comprehensive evaluation are referred for appropriate treatment.
VA developed and implemented a national template to ensure that it provides every Veteran receiving inpatient or outpatient treatment for TBI, who requires ongoing rehabilitation care, an individualized rehabilitation and community reintegration plan, as required by section 1702 of Public Law 110-181 (38 U.S.C. § 1710C). VA integrates this national template into the electronic medical record, and includes results of the comprehensive assessment, measurable goals, and recommendations for specific rehabilitative treatments. The patient and family participate in developing the treatment plan and receive a copy of the plan. Since April 2009, 8,373 of these plans have been completed and documented for Veterans who receive ongoing rehabilitative care in VA.
Section 1703 of Public Law 110-181 (38 U.S.C. § 1710E) permits VA, in implementing and carrying out § 1710C of title 38, to provide hospital care and medical services through cooperative agreements with appropriate public or private entities that have established long-term neurobehavioral rehabilitation and recovery programs. VA continues to increase collaborations with private sector facilities to successfully meet the individualized needs of Veterans and complement care in cases when VA cannot readily provide the needed services, or cases where the required care is geographically inaccessible. VA medical facilities have identified private sector resources within their catchment area that have expertise in neurobehavioral rehabilitation and recovery programs for TBI. In FY 2009, 3,708 enrolled Veterans with TBI received inpatient and outpatient hospital care and medical services from public and private entities, with a total disbursement of over $21 million.
VA has developed, and continues to enhance, policies regarding comprehensive long-term care for post-acute TBI rehabilitation that includes residential, community and home-based components utilizing interdisciplinary treatment teams. In 2007, VA chartered the Polytrauma Rehabilitation and Extended Care Task Force, to address the long-term care needs of seriously injured OEF/OIF Veterans, including rehabilitative care. As a result of this Task Force, VA developed approaches to meet the long-term care needs of Veterans with TBI through enhancements to the current spectrum of long-term care programs and services. Changes implemented include expansion and age-appropriate modifications in Home-Based Primary Care (HBPC) and Adult Day Health Care, development of volunteer home respite, geographic expansion and staff training for HBPC, implementation of Medical Foster Home for Veterans with TBI, and integration of home Telehealth. Lastly, TBI was a Select Program in VA’s budget request, as directed in H.R. Report No. 110-775, accompanying Pub. L. 110-329, and VA has noted Congress’ direction to continue this designation. In FY 2010, $231.9 million has been programmed for TBI care for all Veterans; $58.2 million is programmed for OEF/OIF Veterans.
VA and DoD have shared a longstanding integrated collaboration in the area of TBI through the Defense and Veterans Brain Injury Center (DVBIC). Since 1992, DVBIC staff members have been integrated with VA Lead TBI Centers (now Polytrauma Rehabilitation Centers) to collect and coordinate surveillance of long-term treatment outcomes for patients with TBI. Other significant initiatives that have resulted from the ongoing collaboration between VA and DVBIC include: developing collaborative clinical research protocols; developing and implementing best clinical practices for TBI; developing materials for families and caregivers of Veterans with TBI; developing integrated education and training curriculum on TBI, and joint training of VA and DoD heath care providers; and coordinating the development of the best strategies and policies regarding TBI for implementation by VA and DoD.
In addition to the longstanding affiliation with DVBIC, since 2007, VA has collaborated with DoD to develop implementation plans for Defense Centers of Excellence (DCoE) and the associated injury registries, including Centers for Psychological Health and Traumatic Brain Injury, Extremity Injuries and Amputation, Hearing Loss and Auditory System Injuries, and Vision. VA has assigned personnel at the Center for Psychological Health and TBI, and at the Vision Center. VA continues to be involved in working groups with DoD representatives to assist in developing concepts of operations and plans for the Hearing Loss and Auditory System Injuries Center and the Center for Extremity Injuries and Amputation.
VA has also collaborated with DoD to develop and implement several unprecedented initiatives that are improving care and services for those with TBI. VA, in collaboration with DoD and DVBIC, implemented a 5-year pilot program to assess the effectiveness of providing assisted living (AL) services to Veterans with TBI, as required by section 1705 of Public Law 110-181. The AL-TBI pilot program is being administered through contracts with brain injury residential living programs that provide individualized treatment models of care to accommodate the specialized needs of patients with TBI. Currently, four Veterans with moderate to severe TBI have been placed in private facilities that specialize in providing rehabilitation services for TBI (residing in Virginia, Wisconsin, Kentucky and Texas). Up to 26 Veterans are projected to be enrolled in the program in FY 2010 and 14 more in FY 2011. We are collecting and assessing outcome data on health information, functional status, satisfaction with care, and quality of life. VA will submit a final report to Congress at the conclusion of the program in 2013.
VA, in collaboration with DVBIC, developed a uniform training curriculum for family members in providing care and assistance to Servicemembers and Veterans with TBI: “Traumatic Brain Injury: A Guide for Caregivers of Servicemembers and Veterans.” The final version of the curriculum was approved by the Defense Health Board, and dissemination of the curriculum is pending final approval from the Secretaries of DoD and VA. In 2009, VA and DoD collaboratively developed clinical practice guidelines for mild TBI and deployed this to health care providers, as well as recommendations in the areas of cognitive rehabilitation, drivers’ training, and managing the co-occurrence of TBI, post-traumatic stress disorder (PTSD), and pain.
In 2009, the VA-led collaboration with DoD and the National Center for Health Statistics produced revisions to the International Classification of Diseases, Clinical Modification (ICD-9-CM) diagnostic codes for TBI, resulting in significant improvements in the identification, classification, tracking, and reporting of TBI and its associated symptoms.
Finally, VA maintains ongoing collaborations with other Federal agencies to leverage resources and collective efforts in advancing the care and services for those with TBI. The most recent notable collaborations include:
• In 2009, VA began collaborating with the National Institute on Disability and Rehabilitation Research TBI Model Systems to collect and benchmark VA rehabilitation and longitudinal functional outcomes and establish a TBI Veterans Health Registry, as required by section 1704 of Public Law 110-181.
• Since 2009, VA has collaborated with the Centers for Disease Control (CDC), National Institutes of Health (NIH), and DoD in accordance with section 3(c) of Public Law 110-206 (42 U.S.C.A. § 280b-1d), the Traumatic Brain Injury Act of 2008 to: (1) determine how best to improve the collection and dissemination of information on the incidence and the prevalence of TBI among persons who were formerly in the military; and (2) make recommendations on the manner in which CDC, NIH, DoD, and VA can further collaborate on the development and improvement of TBI diagnostic tools and treatments. A report to Congress is being prepared regarding this collaborative effort.
The Federal Recovery Coordination Program
The Federal Recovery Coordination Program (FRCP) serves an important function in ensuring that severely injured Veterans and Servicemembers receive access to the benefits and care they need to recover. Beginning in 2008, FRCP has helped coordinate and access Federal, state and local programs, benefits and services for severely wounded, ill and injured Servicemembers, Veterans, and their families through recovery, rehabilitation, and reintegration into the community. The Program is a joint program of DoD and VA, with VA serving as the administrative home.
The Program has grown since enrolling the first client in February 2008. Not every individual referred to the Program meets enrollment criteria or needs the full services of FRCP. Some individuals are enrolled for a period of time and then determine that they no longer need the Program’s services. Currently, 513 clients are enrolled and another 41 individuals are being evaluated for enrollment, and another 451 have received assistance. Anyone can return for re-enrollment or additional assistance if the problems are not resolved or if new problems develop.
Recovering Servicemembers and Veterans are referred to FRCP from a variety of sources, including from the Servicemember’s command, members of the interdisciplinary treatment team, case managers, families or clients already in the Program, Veterans Service Organizations and other non-governmental organizations. Generally, those individuals whose recovery is likely to require a complex array of specialists, transfers to multiple facilities, and long periods of rehabilitation are referred.
FRCP outreach efforts include brochures, a presence on VA’s OEF/OIF Web site, participation and presentations at local, state and national events. Our 1-800 number, new in April 2009, provides another avenue for referral or assistance. When a referral is made, a Federal Recovery Coordinator (FRC) conducts an evaluation that serves as the basis for problem identification and determination of the appropriate level of service.
FRCs coordinate benefits and services for their clients through the various transitions associated with recovery and return to civilian life. 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 care managers, Veterans Health Administration (VHA) and Veterans Benefits Administration (VBA) OEF/OIF case managers, VBA benefits counselors, and others.
Each enrolled client receives a Federal Individual Recovery Plan (FIRP). The FIRP, based on the goals and needs of the Servicemember or Veteran and upon input from their family or caregiver, is designed to efficiently and effectively move clients through transitions by identifying the appropriate services and benefits. The FRCs, with input and assistance from interdisciplinary team members and case managers, implement the FIRP by working with existing governmental and non-governmental personnel and resources.
FRCP staffing has grown to meet the Program’s needs. Eight FRCs were initially hired in January 2008. We are adding 5 additional FRCs to the 20 current positions in order to meet the growth, and success, of the Program. Most of these new hires will be placed at VA PRCs adding additional support for severely wounded, ill and injured Servicemembers and Veterans. The table below shows the current locations, as well as the locations for the new FRCs.
Facility Name and Location Total FRCs
Walter Reed Army Medical Center, DC 3
National Naval Medical Center, Bethesda, MD 3
Brooke Army Medical Center, San Antonio TX 4
Naval Medical Center, San Diego, CA 3
Camp Pendleton, CA 1
Eisenhower Army Medical Center, Augusta, GA 2
James A. Haley VAMC, Tampa, FL 1
Providence VAMC, Providence, RI 1
Michael E Debakey VAMC, Houston, TX 1
USSOCOM Care Coalition, Tampa, FL 1
Richmond VAMC Polytrauma, VA 2 (new hire)
Palo Alto VAMC Polytrauma, CA 2 (new hire)
Navy Safe Harbor, DC 1 (new hire)
Total (FRC) FTE 25
Administrative staff includes an Executive Director, two Deputies (one for Benefits and one for Health), an Executive Assistant, an Administrative Officer and two Staff Assistants.
The FRCP is VA’s lead for the National Resource Directory (NRD), an online partnership of the U.S. Departments of Defense, Labor and Veterans Affairs for wounded, ill or injured Servicemembers, Veterans, their families, caregivers, and supporting providers. The NRD is a comprehensive online tool available worldwide with over 10,000 Federal, state and local resources organized into nine easily searchable topic areas including: benefits and compensation, families and caregivers, employment, education and training, health care, housing, transportation and travel, and homeless assistance. The NRD has an average of 1,500 visitors a day where they access an average of 15,000 page views. Over 300,000 other Web sites now link to the NRD.
FRCP’s success rests in its extraordinary and well-trained problem solving professional staff. We have learned a great deal over the past 2 years and have been able to respond quickly to developing needs or problems. We are looking forward to the results from a current Government Accountability Office program evaluation and those from our satisfaction survey. This input will guide the Program’s future development and adaptation.
In conclusion, thank you again for the opportunity to speak about VA’s efforts to support injured transitioning Servicemembers and Veterans. This concludes my prepared statement.
U.S. Department of Veterans Affairs - 810 Vermont Avenue, NW - Washington, DC 20420
Reviewed/Updated Date: August 20, 2010