STATEMENT OF THE HONORABLE W. SCOTT GOULD
U.S. DEPARTMENT OF VETERANS AFFAIRS
U.S. SENATE COMMITTEE ON VETERANS AFFAIRS
MAY 18, 2011
May 18, 2011
Chairman Murray, Ranking Member Burr, Members of the Senate Veterans Affairs Committee, I am pleased to be here today to discuss the progress being made by the Department of Veterans Affairs (VA) and the Department of Defense (DoD) towards meeting the needs of returning and injured Service members and to report on the wide range of VA and DoD collaboration that is ongoing between our two Departments. Secretary Lynn and I have worked together for the past 2 years to confront the major challenges before us. Our goal is to ensure the Service members’ transition between VA and DoD is as smooth as possible and honors the enormous commitment they have made to the country and we have made to them as Veterans. Our Departments understand that we are responsible for the same men and women at different times of their lives and that together our Departments can help improve their transition experience as they move from one stage to the next. Since VA last testified before this Committee on VA/DoD collaboration efforts in 2008 we have made significant progress improving the transition process from military to civilian life, as well as enhancing the collaboration that exists between VA and DoD.
MAJOR INITIATIVES AND IMPROVEMENTS
The two Departments continue to drive toward providing a comprehensive continuum of care to optimize the health and well being of Service members, Veterans, and their eligible beneficiaries. Our joint efforts to provide a "single system" experience of life-time services are supported by three common goals: 1) efficiencies of operations; 2) health care; and 3) benefits. The goal of efficiencies of operations describes the Department’s efforts to reduce duplication and increase cost savings through joint planning and resource sharing. Our health care goal is a patient-centered health care system that consistently delivers excellent quality, access, and value across the Departments. We also strive to anticipate and address Service member, Veteran, and family needs through an integrated approach to delivering comprehensive benefits and services. I will describe the significant VA-DoD collaborative initiatives and programs to achieve these goals. In addition, I will also highlight outreach activities that complement these efforts.
VA and DoD collaboration is governed by two oversight bodies co-chaired at our level called: the Senior Oversight Committee (SOC) and the Joint Executive Council (JEC). As you know, the SOC was created in May 2007 in response to issues raised at the Walter Reed Army Medical Center. Since its inception, the SOC has served as the single point of contact for oversight, strategy, and integration of wounded, ill, and injured (WII) policies by DoD and VA. These efforts are coordinated to improve Service member and Veteran support throughout their recovery, rehabilitation, and reintegration to the Armed Forces and/or civilian life. As the co-chairs of the SOC, Deputy Secretary Lynn and I work together to keep the momentum going on this important work. While the SOC primarily focuses on WII issues, some objectives and initiatives overlap with broader DoD personnel and readiness issues and are, therefore, monitored by the VA/DoD JEC that I co-chair with Under Secretary of Defense for Personnel and Readiness, Dr. Clifford Stanley.
The JEC provides senior leadership for the more expansive issues of collaboration and resource sharing between VA and DoD. The JEC directs appropriate resources and expertise to specific operational areas through its sub-councils, the Health Executive Council (HEC) and the Benefits Executive Council (BEC), and the Interagency Program Office (IPO) and several Independent Working Groups (IWGs). The JEC is also responsible for the preparation of the VA/DoD Annual Report and the VA/DoD Joint Strategic Plan (JSP) that is submitted to this Committee.
The JSP is the primary document through which the Secretaries of the Departments convey the coordination and sharing efforts between the two Departments. The JSP allows VA and DoD to guide and track the progress of interagency collaborative efforts to improve on the delivery of comprehensive benefits, provide patient-centered health care, and deliver effective and efficient delivery of benefits and services. While the JSP is managed by the JEC, it is a multifaceted document that encompasses a wide range of VA-DoD initiatives, some of which are also monitored and tracked in the SOC. Specific SOC initiatives documented in the JSP include the Federal Recovery Coordination Program (FRCP), Integrated Disability Evaluation System (IDES), Integrated Mental Health Strategy (IMHS), Centers of Excellence, and eBenefits. Whereas the SOC focuses on the WII population, the JEC serves as the permanent oversight body for the broad VA-DoD issues affecting all Service members and Veterans.
Many initiatives originating in the SOC are now institutionalized and tracked in the JEC. For example, the SOC aggressively pursued the development of the IMHS to immediately address the growing mental health needs of the WII and their families. After the strategy was approved by the SOC in October, 2010 we transferred it to the HEC under the JEC for permanent oversight and implementation. Similarly, the issue of credentialing and privileging of providers was initially examined in the SOC and transferred to the HEC for permanent oversight and management.
EFFICIENCIES OF OPERATIONS
VA and DoD continue to leverage opportunities to create efficiencies by improving resource and information sharing and enhancing the coordination of business practices through joint planning. Some of these joint initiatives include: data sharing; the Integrated Disability Evaluation System (IDES); the VA/DoD Federal Recovery Care Program (FRCP); and the James A. Lovell Federal Health Care Center (JALFHCC).
Data Sharing Between the Departments of Defense and Veterans Affairs
In the last 2 years, we have made major strides in sharing health and benefits data between our two Departments, and made significant progress toward our long-term goal of seamless data sharing systems. Our objective is to ensure that appropriate health, administrative, and benefits information is visible, accessible, and understandable through secure and interoperable information technology to all appropriate users. For the past several years, we have shared increasing amounts of health information to support clinicians involved in providing day-to-day health care for Veterans and Service members. Our clinicians can now access health information for almost four million Veterans and Service members between our health information systems. Veterans and Service members are able to access increasing amounts of personal health information from home or work sites through our “Blue Button” technology, using VA and DoD secure Web sites.
For the last 2 years, we have worked together on a Virtual Lifetime Electronic Record (VLER). This project takes a phased approach to sharing health and benefits data to a broader audience, including private health clinicians involved in Veteran/Service member care, benefits adjudicators, family members, care coordinators, and other caregivers. We are in the first phase of this project, with five operational “pilot” sites where we are sharing health information between VA, DoD, and private sector health providers.
More recently, Secretary Gates and Secretary Shinseki formally agreed that our two Departments would work cooperatively toward a common electronic health record. We call this effort the “integrated Electronic Health Record,” or iEHR. As I speak to you today, our functional and technical experts are meeting to develop and draft detailed plans on executing an overall concept of operations that the two Secretaries will utilize to determine the best approach to achieving this complex goal. Once completed, the iEHR will be a national model for capturing, storing, and sharing electronic health information.
James A. Lovell Federal Health Care Center
The James A. Lovell Federal Health Care Center (JALFHCC) demonstration project is the culmination of over 5 years of collaboration between VA and DoD. The JALFHCC combines the missions of the Naval Health Clinic (NHC) Great Lakes and the North Chicago VA Medical Center. The JALFHCC is the first clinically and administratively integrated facility of its kind in the nation, highlighted by a single governance structure covering personnel, IM/IT and financial integration. The facility serves both VA and DoD beneficiaries as an integrated entity. The JALFHCC demonstration project held a dedication ceremony on October 1, 2010.
Integrated Disability Evaluation System
In early 2007, VA partnered with DoD to make changes to the DoD’s existing Disability Evaluation System (DES). A modified process called the VA/DoD DES Pilot Model was launched in November 2007, and was intended to simplify and increase the transparency of the DES process for the Service member while reducing the processing time and improving the consistency of ratings for those who are ultimately medically separated. VA/DoD implemented the pilot in response to the issues raised at the Walter Reed Army Medical Center concerning the DoD Disability process in February, 2007, and the subsequent findings of many commissions, studies and reports. The pilot addressed recommendations that could be implemented without legislative change. Authorization for the pilot was included in the National Defense Authorization Act 2008 and further energized our efforts for improving DoD’s DES.
From the outset, the Departments recognized that the VA/DoD DES Pilot Model was preceded by an outdated DoD legacy process that was, in some cases, cumbersome and redundant. The DES Pilot Model was launched originally as a joint VA/DoD process at three operational sites in the National Capital Region (NCR) and was recognized as a significant improvement over the legacy process. As a result, and to extend the benefits of the Pilot Model to more Service members, VA and DoD expanded the Pilot. The DES Pilot Model started in the fall of 2007 with the original three pilot sites in the NCR and ended in March 2010, covering 27 sites and 47 percent of the DES population. In July 2010, the co-chairs of the SOC agreed to adopt the pilot process as the standard business practice, expand the pilot, and rename it the Integrated Disability Evaluation System (IDES). Senior leadership of VA, the Services, and the Joint Chiefs of Staff strongly supported this plan and the need to expand the benefits of this improved DES Pilot Model to all Service members. VA and DoD are now working together to complete the final 50 percent of the system. As a result, in October, 2010 we started the transition from the existing legacy DES to IDES using the DES Pilot Model process. Currently there are 78 IDES sites operational nationwide (which includes the original 27 Pilot Model sites) representing 74 percent of the population. When fully implemented in October 2011, there will be a total of 139 IDES sites.
Through the implementation of IDES, the Departments have created a more transparent, consistent, and expeditious disability evaluation process for Service members being medically retired or separated from military service and provide a more effective transition as they move from DoD to VA. We believe that through the implementation of the DES Pilot Model we have largely achieved that goal. In contrast to the DES legacy process, IDES provides a single disability examination and a single-source disability rating that both Departments use in executing their respective responsibilities. This results in more consistent evaluations, faster decisions, and timely benefits delivery for those medically retired or separated. IDES has enhanced all non-clinical care, administrative activities, case management, and counseling requirements associated with disability case processing. As a result, VA can deliver benefits in the shortest period allowed by law following discharge, thus eliminating the “pay gap” that previously existed under the legacy process, i.e., the lag time between a Service member separating from DoD due to disability and receiving his or her first VA disability payment.
IDES has also eliminated much of the sequential and duplicative processes found in the legacy system. Since the beginning of the pilot, over 5,800 Service members have completely transitioned from referral into IDES to Veteran status. As of April 30, 2011 there were 13,762 active cases in the IDES process. Prior to the roll out of IDES, it took an average of 540 days for the VA and DOD processes to be completed. Now under IDES the goal is to complete the process within 295 days, while simultaneously shortening the period until the delivery of VA disability benefits after separation from an average of 166 days to approximately 30 days (the shortest period allowed by law).
Despite the overall reduction in combined processing time achieved to date, there remains room for significant improvement in IDES execution. VA and DoD recognized that as we expanded outside of the NCR, we did not have robust business processes in place to certify each site’s preparedness before it became operational. Through our analysis of lessons learned, we have developed Initial Operating Capability (IOC) readiness criteria that ensure that future sites are operationally ready for IDES. For a site to be deemed ready it must: 1) provide adequate exam coverage through either the Veterans Health Administration (VHA), Veterans Benefits Administration (VBA) contracted services, or DoD; 2) have sufficient space and equipment for VA and DoD personnel; 3) meet VA information technology requirements; and 4) have local staff who have completed IDES training. If any of these criteria are not met, then the site is not considered certified to implement IDES.
VA and DoD have hosted three joint training/planning conferences to set the stage for the roll-out of IDES sites. The conferences have resulted in improved communications between VA and DoD at each site, individual site assessment analyses and evaluations, and development of joint local plans to meet IOC requirements.
As the Departments continue to move forward, we are aware of the concerns and recommendations of the Government Accountability Office (GAO) in its December 2010 report entitled “Military and Veterans Disability System: Pilot has Achieved Some Goals but Further Planning and Monitoring Needed.” VA and DoD agreed with the GAO recommendations and we are currently acting on those recommendations.
VA and DoD are committed to supporting our Nation’s wounded, ill, and injured warriors and Veterans through an improved IDES. We recognize the requirement to continually evaluate and improve the process, and are constantly working towards that end.
Federal Recovery Coordination Program (FRCP)
In October 2007, the SOC established FRCPas a VA-administered program with joint oversight by VA and DoD. It is designed to coordinate access to Federal, state, and local programs, benefits, and services for severely wounded, ill, and injured Service members, Veterans, and their families. The SOC maintains oversight of the FRCP. The program was specifically charged with providing seamless support from the time a Service member arrived at the initial Medical Treatment Facility in the United States through the duration of care and rehabilitation. Services are now provided through recovery, rehabilitation, and reintegration into the community. Federal Recovery Coordinators (FRC) are Masters-prepared nurses and clinical social workers who provide for all aspects of care coordination, both clinical and non-clinical. FRCs are located at both VA and DoD facilities.
FRCs work together with other programs designed to serve the wounded, ill, and injured population including clinical case managers and non-clinical care coordinators. FRCs are unique in that they provide their clients a single point of contact regardless of where they are located, where they receive their care, and regardless of whether they remain on Active Duty or transition to Veteran status.
FRCs assist clients in the development of a Federal Individual Recovery Plan and ensure that resources are available, as appropriate, to assist clients in achieving stated goals. More than 1,300 clients have participated in the FRC program since its inception in 2008. Currently, FRCP has more than 700 active clients in various stages of recovery. There are currently 22 FRCs with an average caseload of 33 clients. A satisfaction survey conducted in 2010 reported that 80 percent of FRCP clients were satisfied or very satisfied with the program.
National Resource Directory
Also established by the SOC, the National Resource Directory (NRD) is a comprehensive, Web-based portal that provides Wounded Warriors, Service members, Veterans, and their families with access to thousands of resources to support recovery, rehabilitation, and reintegration. NRD is a collaborative effort between the U.S. Departments of Defense, Labor, and Veterans Affairs and has more than 13,000 Federal, state and local resources which are searchable by topic or location. NRD’s success has resulted in more than 3,000 visitors per day to the Web site. NRD is continuously improving and implementing enhancements to the Web site that were identified by recent usability testing. In April 2011, the NRD launched a mobile version of the Web site.
VA and DoD are committed to working together to improve the access, quality, effectiveness, and efficiency of health care for Service members, Veterans and their beneficiaries. Some of our cooperative efforts include the Integrated Mental Health Strategy (IMHS), suicide prevention programs, Polytrauma and traumatic brain injury (TBI) care, Centers of Excellence, Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) Care Management/Coordinators, VA’s liaisons for health care, and joint efforts to address toxic exposures/environmental hazards.
Integrated Mental Health Strategy
The development of the IMHS was a major focus of the SOC in FY 2010 and was finally approved in October 2010. Oversight of the program was then transferred to the Health Executive Council (HEC) under the JEC and the implementation of the strategy was approved at the November 8, 2010 HEC. The IMHS was developed in order to address the growing population of Service members and Veterans with mental health needs. Mental health care provides unique challenges for the two organizations with separate missions in that they serve the same population, but at different times in their lives and careers. As such, the IMHS centers on a coordinated public health model to improve the access, quality, effectiveness, and efficiency of mental health services. Recipients of these services include Active Duty Service members, National Guard and Reserve Component members, Veterans, and their families.
The IMHS derives from joint efforts in 2009 and 2010 between VA and DoD subject matter experts, which included the DoD/VA Mental Health Summit. The Strategy is defined by 28 Strategic Actions which fall under the following four strategic goals: 1) Expand access to behavioral health care in DoD and VA; 2) Ensure quality and continuity of care across the Departments for Service members, Veterans, and their families; 3) Advance care through community partnership and education and reduce stigma through successful public communication and use of innovative technological approaches; and 4) Promote resilience and build better behavioral health care systems for tomorrow.
This collaboration is providing unique opportunities to coordinate our mental health efforts across the two Departments, for the benefit of all of our Service members and Veterans.
Suicide Prevention/ Veterans Crisis Line
The VA Suicide Prevention Program is based on the concept of ready access to high quality Mental Health Care and other services. The Suicide Prevention network of Suicide Prevention Coordinators and Care Managers is based at every Medical Center and at very large Community Based Clinics across the country and provides a wide array of services, tracking, monitoring, and outreach activities. All Suicide Prevention Program elements are shared with the DoD and a conference is held annually to encourage use of all strategies across both Departments including products and educational materials. One of the main mechanisms to access this enhanced level of care provided to our high risk patients is through the Veterans Crisis Line. The Crisis Line is located in Canandaigua, New York, and partners with the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Suicide Prevention Lifeline. All calls from Veterans, Service members, families, and friends calling about Veterans or Service members are routed to the Veterans Crisis Line. The call center started in July of 2007 and the Veterans Chat Service was started in July of 2009. To date the call center has:
• Received over 400,000 calls;
• Initiated over 14,000 rescues;
• Referred over 53,000 Veterans to local Suicide Prevention Coordinators for same day or next day services;
• Answered calls from over 5,000 Active Duty Service members;
• Responded to over 15,000 chats;
The call center is responsible for an average of 300 admissions a month to VA health care facilities and150 new enrollments a month for VA health care.
VA/DoD Collaborations for Polytrauma/Traumatic Brain Injury (TBI)
VA and DoD share a longstanding integrated collaboration in the area of TBI. Providing world-class medical and rehabilitation services for Veterans and Service members with TBI and polytrauma is one of VA’s highest priorities. Since 1992, VA and the Defense and Veterans Brain Injury Center (DVBIC) have been integrated at VA Polytrauma Rehabilitation Centers (PRC), formerly known as Lead TBI Centers, to collect and coordinate surveillance of long-term treatment outcomes for patients with TBI. From this collaboration, VA expanded services to establish the VA Polytrauma/TBI System of Care to provide specialty rehabilitation care for complex injuries and TBI.
Today, this system of care spans more than 100 VA Medical Centers to create points of access along a continuum, and integrates 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 addition to specialty services, Veterans and Service members recovering from TBI receive comprehensive treatment from clinical programs involved in post-combat care including: Primary Care, Mental Health, Social Work and Care Coordination, Extended Care, Prosthetics, Telehealth, and others.
VA’s provision of evidence-based medical and rehabilitation care is supported through a system-wide collaboration with the Commission on Accreditation of Rehabilitation Facilities to achieve and maintain national accreditation for VA rehabilitation programs. Collaboration with the National Institute on Disability and Rehabilitation Research TBI Model Systems Project enables VA to collect and benchmark VA rehabilitation and longitudinal outcomes with those from other national TBI Model Systems rehabilitation centers. With clinical and research outcomes that rival those of academic, private sector, and DoD facilities, VA leads the medical and scientific communities in the area of TBI and polytrauma rehabilitation.
Since April 2007, VA has screened more than 500,000 Veterans from Operation Enduring Freedom (OEF)/Operation Iraqi Freedom/(OIF)/Operation New Dawn (OND) entering the VA health care system for possible TBI. Patients who screen positive are referred for comprehensive evaluation by a specialty team, and are referred for appropriate care and services. An individualized rehabilitation and community reintegration plan of care is developed for patients receiving ongoing rehabilitation treatment for TBI. Veterans who are screened and report current symptoms are evaluated, referred, and treated as appropriate.
Additionally, 1,969 Veterans and Service members with more severe TBI and extensive, multiple injuries were inpatients in one of the specialized VA Polytrauma Rehabilitation Centers between March 2003 and December 2010. VA and DoD collaborations in the area of TBI 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 for 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.
Recent initiatives that have resulted from the ongoing collaboration between VA and DoD include:
• Development and deployment of joint DoD/VA clinical practice guidelines for care of mild TBI;
• A uniform training curriculum for family members in providing care and assistance to Service members and Veterans with TBI (“Traumatic Brain Injury: A Guide for Caregivers of Service members and Veterans”);
• Implementing the Congressionally-mandated 5-year pilot program to assess the effectiveness of providing assisted living services to Veterans with TBI;
• Integrated TBI education and training curriculum for VA and DoD health care providers (DVBIC);
• Revisions to the International Classification of Diseases, Clinical Modification (ICD-9-CM) diagnostic codes for TBI, resulting in improvements in identification, classification, tracking, and reporting of TBI;
• Collaborative clinical research protocols investigating the efficacy of various TBI treatments; and
• Development of the protocol used by the Emerging Consciousness care path at the four PRCs to serve those Veterans with severe TBI who are slow to recover consciousness.
VA Liaisons for Health Care
VA has a system in place to transition severely ill and injured Service members from DoD to VA’s system of care. Typically, a severely injured Service member returns from theater and is sent to a military treatment facility (MTF) where he/she is medically stabilized. A key component of transitioning these injured and ill Service members and Veterans are the VA Liaisons for Health Care, who are either social workers or nurses strategically placed in MTFs with concentrations of recovering Service members returning from Iraq and Afghanistan. After initially having started with 1 VA Liaison at 2 MTFs, VA now has 33 VA Liaisons for Health Care stationed at 18 MTFs to transition ill and injured Service members from DoD to the VA system of care. VA Liaisons facilitate the transfer of Service members and Veterans from the MTF to the VA healthcare facility closest to their home or the most appropriate facility that specializes in services that their medical condition requires.
VA Liaisons are co-located with DoD Case Managers at MTFs and provide onsite consultation and collaboration regarding VA resources and treatment options. VA Liaisons educate Service members and their families about VA’s system of care, coordinate the Service member’s initial registration with VA, and secure outpatient appointments or inpatient transfer to a VA health care facility as appropriate. VA Liaisons make early connections with Service members and families to begin building a positive relationship with VA. VA Liaisons coordinated 7,150 referrals for health care and provided over 26,825 professional consultations in fiscal year 2010.
VHA OEF/OIF/OND Care Management
As Service members recover from their injuries and reintegrate into the community, VHA works closely with FRCs and DoD case managers and treatment teams to ensure the continuity of care. Each VA Medical Center has an OEF/OIF/OND Care Management team in place to coordinate patient care activities and ensure that Service members and Veterans are receiving patient-centered, integrated care and benefits. Members of the OEF/OIF/OND Care Management team include: a Program Manager, Clinical Case Managers, and a Transition Patient Advocate (TPA). The Program Manager, who is either a nurse or social worker, has overall administrative and clinical responsibility for the team and ensures that all OEF/OIF/OND Veterans are screened for case management. Clinical Case Managers, who are either nurses or social workers, coordinate patient care activities and ensure that all clinicians providing care to the patient are doing so in a cohesive and integrated manner. The severely injured OEF/OIF/OND Veterans are automatically provided with a Clinical Case Manager while others may be assigned a Clinical Case Manager if determined necessary by a positive screening or upon request. The TPA helps the Veteran and family navigate the VA system by acting as a communicator, facilitator, and problem solver. VA Clinical Case Managers maintain regular contact with Veterans and their families to provide support and assistance to address any health care and psychosocial needs that arise.
The OEF/OIF/OND Care Management program now serves over 54,000 Service members and Veterans including over 6,300 who have been severely injured. The current caseload each OEF/OIF/OND case manager is managing on a regular basis is 54. In addition, they provide lifetime case management for another 70 Veterans by maintaining contact once or twice per year to assess their condition and needs. This is a practical caseload ratio based on the acuity and population at each VA health care facility.
VA developed and implemented the Care Management Tracking and Reporting Application (CMTRA), a Web-based application designed to track all OEF/OIF/OND Service members and Veterans receiving care management. This robust tracking system allows clinical case managers to specify a case management plan for each Veteran and to coordinate with specialty case managers such as Polytrauma Case Managers, Spinal Cord Injury Case Managers, and others. CMTRA management reports are critical in monitoring the quality of care management activities throughout VHA.
OEF/OIF/OND Care Management team members actively support outreach events in the community, and also make presentations to community partners, Veterans Service Organizations, colleges, employment agencies, and others to collaborate in providing services and connecting with returning Service members and Veterans.
Caregivers are a valuable resource providing physical, emotional, and other support to seriously injured Veterans and Service members, making it possible for them to remain in their homes. Recognizing the importance of providing support and services to the caregivers of certain Veterans and Service members who incurred or aggravated a serious injury in the line of duty on or after September 11, 2001, the new Caregivers and Veterans Omnibus Health Services Act of 2010, signed into law by President Obama on May 5, 2010, enhances existing services for caregivers of Veterans who are currently enrolled in VA care. It also provides unprecedented new benefits and services to family caregivers who care for certain eligible Veterans and Service members undergoing medical discharge who have a serious injury that was incurred or aggravated in the line of duty on or after September 11, 2001 and who are in need of personal care services. These new benefits, which are being implemented through an Interim Final Rule published earlier this month, include, for designated primary family caregivers of eligible Veterans and Service members, a stipend, mental health services, and health care coverage if the primary family caregiver is not otherwise entitled to care or services under a health-plan contract.
Starting in May 2011, we will begin to roll out these services and process applications to ensure delivery of benefits within the next few months. VA already offers a range of benefits and services that support Veterans and their family caregivers. These include such things as in-home care, specialized education and training, respite care, equipment and home and automobile modification, and financial assistance for eligible Veterans. VA is enhancing its current services and developing a comprehensive National Caregiver Support Program with a prevention and wellness focus that includes the use of evidence-based training and support services for caregivers. VA has designated Caregiver Support Coordinators at each VA Medical Center to serve as the clinical experts on caregiver issues; these Coordinators are most familiar with the VA and non-VA support resources that are available. VA has a Caregiver Support Web site (www.caregiver.va.gov) and Caregiver Support Line (1-855-260-3274) which provides a wealth of information and resources for Veterans, families, and the general public.
VA and DoD are also working very closely together on toxic exposure issues. The DoD/VA Deployment Health Working Group (DHWG) under the JEC coordinates VA and DoD responses to toxic environmental exposures, such as exposures to burn pit smoke in Iraq and Afghanistan and to contaminated drinking water at Camp Lejeune. The DHWG facilitates interagency collaboration on surveillance of the potential health effects of environmental exposures, and coordinates communications to ensure consistency between DoD and VA.
VA recognizes that the past methods of assessing specific hazardous exposures for links to adverse health outcomes has its limitations in that other important associations between deployment and adverse health outcomes may not be identified. As a result, VA is planning to expand upon current deployment-specific longitudinal cohort studies of Veterans who were deployed using non-deployed and non-Veteran comparison groups. The intent is to track, observe, compare, and analyze health outcomes in each group over time. This approach allows for examination of differences in health outcomes between those who were deployed to a combat theater of operations with those who were not deployed. An advantage of these studies is that they allow for a determination of the contribution of deployment to adverse health effects, as well as the examination of possible associations between potential environmental exposures and adverse health effects.
In addition, VA recognizes the need to collaborate with DoD, to plan for future studies of deployed personnel from the time of deployment through the life span of all deployed Veterans. These studies would involve a cohort of deployed personnel, and non-deployed personnel and non-Veterans for purposes of comparison. This approach would allow for the examination of differences in all health outcomes and allow for the attribution of possible adverse health effects that may have resulted from a specific assignment or deployment. VA is currently evaluating opportunities for such studies.
From the 1950s through the mid-1980s, persons residing or working at the U.S. Marine Corps Base Camp Lejeune, North Carolina, were potentially exposed to drinking water contaminated with volatile organic compounds (including industrial solvents and benzene from underground storage tanks). VA takes the health concerns of Veterans and their family members who were stationed at Camp Lejeune during this period very seriously. To provide fair and consistent decisions based on service during the period of potential exposure, VA has centralized Camp Lejeune-related claims processing at its Louisville, Kentucky, Regional Office.
The Agency for Toxic Substances and Disease Registry (ATSDR) is conducting ongoing research related to the potential exposures. Current ATSDR research is concentrating on refining hydrological modeling to determine the extent of benzene contamination. This information will then be used along with results from ongoing population studies to determine if the potentially exposed population at Camp Lejeune has experienced an increase in adverse health effects such as birth defects, cancers, and mortality. VA will closely monitor this research and will quickly consider the findings and take appropriate action. In addition, VA will support these studies by acting on ATSDR requests to confirm specific Veteran’s health issues. VA representatives regularly attend the quarterly Community Action Panel meetings hosted by ATSDR. This fosters a close working relationship between ATSDR and VA and allows the Department to stay current with current research efforts.
VA is very concerned about any potential adverse health effects among Veterans as a result of exposure to toxins possibly produced by burn pits. VA has asked the Institute of Medicine (IOM) to review the literature on the health effects of such exposures. While it is possible some Veterans could experience health problems related to exposures to toxins possibly produced by burn pits, the extent of the impact on health is unknown at this time. IOM’s examination of the scientific literature related to the burn pits in Iraq and Afghanistan also will determine what substances were burned in the pits and what byproducts were produced. We expect this study to be completed by early 2012. Other VA actions to address this issue include education of clinical providers and researchers. Experts from VA have provided several environmental exposure workshops to Compensation and Pension examiners, Environmental Health Coordinators, and primary care providers. These workshops address exposures to burn pits, oil fires, and sand and dust. VA researchers are collaborating with DoD and non-governmental experts in designing pulmonary research that will help answer questions in this important area.
Centers of Excellence
The Departments have established several collaborative Centers of Excellence.
DoD Center of Excellence for Psychological Health and Traumatic Brain Injury (DCoE)
In addition to the longstanding affiliation with DVBIC, VA collaborated to help DoD develop and establish the Defense Centers of Excellence (DCoE) for Psychological Health and Traumatic Brain Injury. While DoD has lead Agency responsibility for this Center, with operational oversight assigned to the Assistant Secretary of Defense for Health Affairs ASD(HA), VA provides three staff members to DCoE: the Deputy Director for the DCoE, and two VA Senior Consultant / Liaison subject matter experts – one for TBI (from Office of Rehabilitation Services), and one for psychological health (from Office of Mental Health Services). VA staff members work closely within the DCoE, and their input is highly regarded for all policy recommendations related to TBI and Psychological Health, both within VA and DoD.
DoD Vision Center of Excellence (VCE)
DoD has lead Agency responsibility for this Center, and has assigned operational oversight to the Navy. In September 2010, a contract was awarded for the DoD/VA Vision Registry Pilot. The development of the registry pilot is currently in the test phase with linkages to the VA Data Store expected in the fourth quarter of FY 2011. Once proof of concept of the registry development is validated, the next phase will be to establish the registry as a program and system of record for full implementation. The Registry is being designed to interface with the electronic health records of VA and DoD, including iEHR, and other registries containing information about patient outcomes related to injuries that impact vision care and rehabilitation. The Vision Registry will be the first capability to combine VA and DoD clinical information into a single data repository for tracking patients and assessing longitudinal outcomes.
Located in the National Capital Region, the VCE receives operational support from the Navy, and from the Office of Patient Care Services within VA. Currently, the VCE has a total of 13 permanent government employees (2 military, 6 DoD civilian, and 5 VA civilian employees).
DoD Hearing Center of Excellence (HCE)
The HCE continues to work toward achieving initial operating capability. DoD has lead Agency responsibility for this Center, and has assigned operational oversight to the Air Force. The primary focus of this Center is to implement a comprehensive plan and strategy for a registry for hearing loss and auditory injuries. VA will have access to the registry and the ability to add pertinent information regarding outcomes for Veterans who subsequently receive treatment through VA. The draft functional requirements for a Hearing Loss and Auditory System Injury Registry have been established to identify, capture, and longitudinally manage auditory injury data. Establishing and resourcing the Registry and clinical electronic network will help to prioritize joint collaborations for prevention and health care to improve outcomes for Service members and Veterans with hearing loss and auditory disorders.
An interim director for the HCE has been appointed and a working group of subject matter experts (SME) representing each Military Department and VA was established. The HCE operational plan, facility planning and staffing documents, Registry implementation plan, and proposed budget are pending approval by DoD.
DoD/VA Extremity and Amputation Center of Excellence (EACE)
This DoD Center of Excellence was legislatively mandated to be “jointly” established by DoD and VA. The Deputy Secretary of Defense signed a Memorandum that established the Traumatic Extremity Injuries and Amputations Center of Excellence, and assigned operational oversight to the Army Surgeon General. A joint Memorandum of Understanding (MOU) for establishment of the Center was signed by the Assistant Secretary of Defense for Health Affairs (ASD (HA)) and Under Secretary of Health (VA) on August 18, 2010. A primary focus of this CoE will be to conduct research; there is no requirement for an associated Registry. VA and DoD have continued joint collaboration to meet the responsibility to perform basic, translational, and clinical research to develop scientific information. Continued focus will be on research efforts aimed at saving injured extremities, avoiding amputations, and preserving and restoring function of injured extremities.
A working group comprised of representatives from the Services, VA, and Health Affairs has developed the concept of operations for the structure, mission and goals for the Center. Pending final approval by DoD, this plan will be sent to VHA for review and concurrence. Location of this CoE is yet to be determined. A small administrative staff and team of researchers are planned for this CoE; less than 25 total staff, of which four to six are being requested from VA.
Funding for the EACE in FY11 has been identified, and is being provided through the US Army Office of the Surgeon General. An interim director for the CoE has been appointed, and a working group of SMEs representing each Military Department and VA has been established.
BENEFITS AND SERVICES
Benefits Delivery at Discharge (BDD) and Quick Start
The BDD and Quick Start programs are elements of the Veterans Benefits Administration’s (VBA) strategy to provide transitional assistance to separating or retiring Service members and engage Service members in the claims process prior to discharge. A pre-discharge claim is any claim received from a Service member prior to release from active duty. VBA’s goal is to ensure that each and every Service member separating or retiring from active duty who wishes to file a claim with VA for service-connected disability benefits will receive assistance in doing so.
Participation in the BDD program is open to Service members who are within 60 to 180 days of being released from active duty and who are able to report for a VA examination prior to discharge. BDD’s single cooperative examination process meets the requirements of a military separation examination and a VA disability rating examination. There are currently 96 BDD memoranda of understanding (MOU) covering the 131 military installations throughout the Continental United States, Germany, Italy, Portugal, the Azores, and Korea. The MOUs facilitate the collaboration between local VA Regional Offices (VARO) and local military installations by streamlining processing of pre-discharge claims. The BDD program goal is to provide disability compensation benefits within 60 days of discharge or retirement from active duty. The national average for processing is 92.3 days.
VA introduced the “Quick Start” pre-discharge claims process in July 2008. This provides Service members within 59 days of separation, or Service members within 60-180 days of separation who are unable to complete all required examinations prior to leaving the point of separation, to be assisted in filing their disability claim. Since 2010, the VAROs in San Diego and Winston-Salem process all Quick Start claims. In FY 2010, there were 54,733 claims received at MOU sites. VA and DoD are collaborating to improve the marketing and awareness strategies to increase participation in both programs.
Military Service Coordinators (MSC)
MSCs are located at key MTFs and VA medical facilities to meet with every injured OEF/OIF/OND Service member when medically appropriate. MSCs educate Service members regarding VA benefits and services as well as additional benefits such as Social Security. MSCs assist Service members and Veterans in completing benefits claims and gathering supporting evidence to facilitate expedited processing. VBA has approximately 120 MSCs providing benefits information and assistance in support of approximately 250 military installations.
VBA OEF/OIF/OND Case Managers
VBA places a high priority on ensuring the timely delivery of benefits to Service members and Veterans seriously injured in OEF/OIF/OND. Each VARO has a dedicated OEF/OIF/OND case manager who is responsible for overseeing the OEF/OIF/OND workload and outreach initiatives. The case manager’s responsibilities include working closely with National Guard and Reserve units to obtain medical records and coordinating with VHA case managers for expedited medical examinations.
VBA OEF/OIF/OND case managers work with MTFs to ensure timely VA notification of new OEF/OIF/OND casualty arrivals and schedule inpatient visits by VA representatives. VARO and MTF staffs coordinate procedures at the local level.
VARO employees contact Service members as quickly as possible to provide claims assistance and complete information on all VA benefits. Some benefits, such as home and automobile adaptation grants and vocational rehabilitation benefits, may be used prior to a Service members’ release from active duty.
Social Media (OPIA)
VA has worked with DoD on a number of social media efforts including Facebook, Twitter, and a VA blog to post information relevant to newly separated Veterans. VA launched a Facebook page and Twitter feed aimed at returning Service members that now has 110,000 subscribers and 16,000 followers, respectively. Since early 2010, VA has made a deliberate and concerted effort to reach new Veterans in their own communities through dozens of active VA medical centers on Facebook and Twitter. Currently, 84 of 152 VA Medical Centers operate Facebook pages and 45 operate Twitter feeds which keep Veterans informed and aware of events, changes, and tips for obtaining VA benefits. For example, VA uses both online resources to continually remind Veterans about the extension of retroactive stop-loss special pay. Additionally, VA recently shared information about the new post-traumatic stress disorder (PTSD) application on its blog. The medical centers reach a combined audience of over 37,000 Veterans and their family members annually.
The eBenefits online Web-portal is a joint VA and DoD service that provides resources and self-service capabilities to Service members and Veterans with a single sign-on. eBenefits is evolving as a “one-stop shop” for benefit applications, benefits information, and access to personal information. VA and DoD collaborate in quarterly releases to provide users with new self-service features. Service members and Veterans can access official military personnel documents and generate civil service preference letters using the portal. Additional features allow users to apply for benefits, view the status of their disability compensation claims, update direct deposit information for certain benefits, and obtain a VA-guaranteed home loan Certificate of Eligibility.
In June 2011, VA will enhance eBenefits to allow Service members to participate in the Transition Assistance Program (TAP) online and integrate the VetSuccess portal, thus expanding the services Veterans can receive through a single sign-on. As of March 31, 2011, there were over 278,000 registered eBenefits users. Between July 1, 2010, and March 31, 2011, there were over 2 million unique visits to the eBenefits portal.
Vet Centers are community-based counseling centers that provide outreach counseling and case management referrals for Veterans. Vet Centers also provide bereavement counseling for families of Service members who died while on Active Duty. Through December 2010, Vet Centers have cumulatively provided face-to-face readjustment services to approximately 500,000 OEF/OIF/OND Veterans and their families. As outlined in Section 401 of Public Law 111-163, VA is currently drafting regulations to expand Vet Center eligibility to include members of the Active Duty Armed Forces who served in OEF/OIF/OND (includes Members of the National Guard and Reserve who are on Active Duty).
In addition to the 300 Vet Centers that will be operational by the end of 2011, the Readjustment Counseling Service program also has 50 Mobile Vet Centers providing outreach to separating Service members and Veterans in rural areas. The Mobile Vet Centers provide outreach and direct readjustment counseling at active military, Reserve, and National Guard demobilization activities. In response to the Ft. Hood shooting, VA deployed four Mobile Vet Centers that provided services to over 8,200 Active Duty Services members, Veterans, and families in the Ft. Hood community. In addition, VA’s Secretary is adding licensed family counselors to over 200 Vet Center sites to better assist with military related family problems.
Transition Assistance Program
The Transition Assistance Program (TAP) is conducted under the auspices of a Memorandum of Understanding between the Departments of Labor, Defense, Homeland Security, and VA. The Departments work in conjunction with DoD in scheduling briefings and classes on installations to best serve Service members. There is also a quarterly meeting between the Departments to discuss marketing and improvement of TAP. VA’s MSCs lead regularly scheduled TAP briefings at military installations throughout the country and at overseas locations. VA has streamlined and updated the VA portion of TAP, and in July 2011, an updated online version of the presentation will be available via eBenefits. In addition, VBA provides benefits transition briefings to Service members retiring, separating, and residing overseas, as well as demobilizing Reserve and National Guard members (most demobilization briefings are conducted by VHA). In FY 2010, approximately 207,000 Active Duty, Reserve, and National Guard Service members participated in over 5,000 transition briefings. For the period October 1, 2010, through March 2011, over 83,000 Active Duty, Reserve, and National Guard Service members participated in over 2,000 transition briefings.
Disabled Transition Assistance Program
The Disabled Transition Assistance Program (DTAP) provides Service members with information about VA’s Vocational Rehabilitation and Employment (VR&E) program. DTAP is the first step to ensuring professional and personal success after the military for eligible Veterans with disabilities. DTAP briefings are typically conducted in addition to the TAP briefings for Service members with disabilities. During FY 2010, over 37,000 Service members participated in 1,748 DTAP briefings around the world. Over 19,000 Service members participated in 874 DTAP briefings during the period of October 1, 2010, through April 22, 2011.
Yellow Ribbon Reintegration Program
Through the DoD Yellow Ribbon Reintegration Program (YRRP), National Guard and Reserve units are partnering with VA to increase awareness and utilization of VA benefits, programs, and services. VHA has actively supported the DoD YRRP since the creation of the program in 2008. VHA personnel participate at Yellow Ribbon events across the country by providing: information; live briefings on VA benefits, programs, and services; personal assistance with VA form completion; and referrals to VA facilities for assistance. Representatives from VBA also participate in many Yellow Ribbon events providing information on VA disability compensation, education, loan guaranty, vocational rehabilitation and employment, and insurance.
A growing number of military units are working closely with VA personnel to conduct 90-day post-deployment Yellow Ribbon events in VA Medical Centers (VAMC) in various states, resulting in cost savings and the strengthening of VA-DoD partnership at the local level. Conducting these events in VAMCs facilitates a smooth transition between DoD and VA by getting Service members in the door of the VAMC and establishing a level of comfort with VA care. Service members attending Yellow Ribbon events at a VAMC have opportunities for on-the-spot referrals for VA care, and, in some cases, same day care.
In 2008, VHA’s Office of Interagency Health Affairs placed a full-time VA employee in the DoD YRRP at the Pentagon to assist in coordinating activities and policies. The role of the liaison is to serve as the full-time, on-site source of VA information for Yellow Ribbon specific issues and expedite the exchange of information between VA and the DoD YRRP Office. The liaison assists the YRRP Office with policy and procedure development by providing expertise and information on VA’s structure, benefits, and services. In addition, the liaison works collaboratively with VA staff members to assist with coordination of personnel and resources to support Yellow Ribbon events.
Demobilization Initiative for Returning Veterans
In coordination with National Guard and Reserve units, VAMC and Veterans Integrated Service Network (VISN) staff, along with Vet Center and VBA staff, provide briefings on VA services and benefits. These are conducted at 63 National Guard and Reserve demobilization sites nationwide. VHA staff also facilitate enrollment in VA health care by assisting National Guard and Reserve members with completing VA health care enrollment forms when they choose to enroll on site. The forms are then processed through VHA’s centralized Health Eligibility Center. The National Guard and Reserve members also receive outreach materials and a watermarked letter which serves as a type of temporary ID confirming enrollment in VA Health Care.
The watermarked letter includes the name and phone number of the National Guard and Reserve member’s local OEF/OIF/OND Program Manager and lets VAMC staff know that he or she has enrolled in VA care, thus opening doors to immediate access within VA Health care services at their local VA Medical Center. During
FY 2010, VHA supported 1,339 demobilization events, providing VHA staff with face-to-face interactions for nearly 74,000 Service members. As a result, 70,000 have registered or enrolled in VHA Health care.
Post-Deployment Health Reassessment (PDHRA)
Since 2006, VHA has been focused on managing referrals from Reserve components for Service members and Veterans who have completed the PDHRA. The PDHRA program requires these assessments to be completed at 90-180 days post-deployment. DoD uses a contractor to provide these screenings, either at a face-to-face event or the member may elect to use the on-line assessment, which is followed up by a call with the contractor’s health care provider. When the PDHRA takes place at a face-to-face event, the local VAMC and Vet Center staff, when notified, will provide VA Outreach, education, enrollment, and as needed, referral for clinical services. Referred Veterans have a choice to receive their care at a local VAMC, Vet Center, or if they are a dual beneficiary may receive care for a non-service connected condition via the TRICARE network.
For Service members who request a VHA appointment, the onsite VA staffs are able to schedule appointments for them at their local VAMC. During FY 2010, VHA supported 339 DoD PDHRA events with 44,443 Veterans and 1,319 family members attending. Of these Veterans, 38,059 were OEF/OIF/OND Veterans.
VA and DoD continue to work together diligently to resolve transition issues while aggressively implementing improvements and expanding existing programs. These efforts continue to enhance the effectiveness of support for Service members, Veterans, and their families. While we are pleased with the quality of effort and progress made to date, we fully understand our two Departments have a responsibility to continue these efforts. Through IDES, our goal is to create a less complex process which is more transparent to the Service member. We designed our case management programs to provide seamless support through the duration of care and rehabilitation and we are constantly improving those systems. We continue to explore ways to expand the availability of comprehensive benefits, online resources, and transition education programs to provide Service members and Veterans direct access to the information and benefits they need. In addition, the two Departments are working toward a goal of a fully developed Virtual Lifetime Electronic Record that will provide health and benefits data to all authorized users in a safe, private, secure manner, regardless of the user’s location. Recently, Secretary Gates and Secretary Shinseki formally agreed that our two Departments would work cooperatively toward a common electronic health record. We are looking forward to delivering on this commitment.
Thank you again for your support to our wounded, ill, and injured Service members, Veterans, and their families and your interest in the ongoing collaboration and cooperation between our Departments. Chairman Murray, Ranking Member Burr, this concludes my testimony. I will be happy to respond to any questions that you or other Members of the Committee may have.