[House Hearing, 110 Congress]
[From the U.S. Government Printing Office]


 
                  SERVICEMEMBERS' SEAMLESS TRANSITION 
                 INTO CIVILIAN LIFE--THE HEROES RETURN 

=======================================================================

                                HEARING

                               before the

                     SUBCOMMITTEE ON OVERSIGHT AND
                             INVESTIGATIONS

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 8, 2007

                               __________

                            Serial No. 110-7

                               __________

       Printed for the use of the Committee on Veterans' Affairs

                     U.S. GOVERNMENT PRINTING OFFICE

34-309 PDF                 WASHINGTON DC:  2007
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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            DAN BURTON, Indiana
STEPHANIE HERSETH, South Dakota      JERRY MORAN, Kansas
HARRY E. MITCHELL, Arizona           RICHARD H. BAKER, Louisiana
JOHN J. HALL, New York               HENRY E. BROWN, JR., South 
PHIL HARE, Illinois                  Carolina
MICHAEL F. DOYLE, Pennsylvania       JEFF MILLER, Florida
SHELLEY BERKLEY, Nevada              JOHN BOOZMAN, Arkansas
JOHN T. SALAZAR, Colorado            GINNY BROWN-WAITE, Florida
CIRO D. RODRIGUEZ, Texas             MICHAEL R. TURNER, Ohio
JOE DONNELLY, Indiana                BRIAN P. BILBRAY, California
JERRY McNERNEY, California           DOUG LAMBORN, Colorado
ZACHARY T. SPACE, Ohio               GUS M. BILIRAKIS, Florida
TIMOTHY J. WALZ, Minnesota

                   Malcom A. Shorter, Staff Director

                                 ______

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                  HARRY E. MITCHELL, Arizona, Chairman

ZACHARY T. SPACE, Ohio               GINNY BROWN-WAITE, Florida, 
TIMOTHY J. WALZ, Minnesota           Ranking
CIRO D. RODRIGUEZ, Texas             CLIFF STEARNS, Florida
                                     BRIAN P. BILBRAY, California

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
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                            C O N T E N T S

                               __________

                             March 8, 2007

                                                                   Page
Servicemembers' Seamless Transition into Civilian Life--The 
  Heroes Return..................................................     1

                           OPENING STATEMENTS

Hon. Harry E. Mitchell, Chairman.................................     1
    Prepared statement of Chairman Mitchell......................    55
Hon. Ginny Brown-Waite, Ranking Republican Member................     2
    Prepared statement of Congresswoman Brown-Waite..............    55

                       SUBMISSION FOR THE RECORD

Hon. Cliff Stearns, a Representative in Congress from the State 
  of Florida, statement..........................................    56

                               WITNESSES

U.S. Department of Veterans Affairs:
    Michael J. Kussman, MD, MS, MACP, Acting Under Secretary for 
      Health, Veterans Health Administration.....................     4
        Prepared statement of Dr. Kussman........................    57
    Shane McNamee, MD, Director, Hunter Holmes McGuire Richmond 
      Veterans Affairs Medical Center, Richmond, VA..............    25
        Prepared statement of Dr. McNamee........................    65
    Steven G. Scott, MD, Medical Director, Tampa Polytrauma 
      Rehabilitation Center, James A. Haley Veterans' Hospital, 
      Tampa, FL..................................................    27
        Prepared statement of Dr. Scott..........................    67
    William F. Feeley, MSW, FACHE, Deputy Under Secretary for 
      Health for Operations and Management, Veterans Health 
      Administration.............................................    41
        Prepared statement of Mr. Feeley.........................    69
    Edward C. Huycke, MD, Chief Department of Defense 
      Coordination Officer, Veterans Health Administration.......    43
        Prepared statement of Dr. Huycke.........................    70
    Ira R. Katz, MD, PhD, Deputy Chief Patient Care Services 
      Officer for Mental Health, Veterans Health Administration..    45
        Prepared statement of Dr. Katz...........................    72
U.S. Government Accountability Office, Cynthia A. Bascetta, 
  Director, Health Care..........................................    10
    Prepared statement of Ms. Bascetta...........................    59

                                 ______

Lain, Kimberly, Millersville, MD.................................    33
Pearce, Kathy, Mesa, AZ..........................................    46
Sullivan, Paul, Cedar Park, TX...................................    30
Walter Reed Medical Center/Bethesda Naval Hospital:
    Kathy Dinegar, Social Worker Liaison for Seamless Transition.    34
    Sherry Edmonds-Clemons, Social Worker Liaison for Seamless 
      Transition.................................................    35

                   MATERIAL SUBMITTED FOR THE RECORD

Letter dated March 7, 2007, from U.S. Department of Veterans 
  Affairs Secretary Nicholson to Congresswoman Ginny Brown-Waite, 
  regarding the ability of DOD and VA to provide world-class 
  health care to servicemembers and veterans.....................    73
U.S. Government Accountability Office Letter dated June 30, 2007, 
  from Cynthia A. Bascetta, Director, Health Care, to Congressman 
  Michael Bilirakis, regarding Transition of Care for OEF and OIF 
  Servicemembers (GAO-06-79R)....................................    78
U.S. Government Accountability Office Report entitled, 
  ``Vocational Rehabilitation--More VA and DOD Collaboration 
  Needed to Expedite Services for Seriously Injured 
  Servicemembers,'' dated January 2005 (GAO-05-167)..............    94

                 POST-HEARING QUESTIONS FOR THE RECORD

Response to Questions for the Record from Paul Sullivan, Cedar 
  Park, TX, and former Project Manager for the U.S. Department of 
  Veterans Affairs, dated March 27, 2007 [The exhibits submitted 
  by Mr. Sullivan are being retained in the Committee files].....   111


                  SERVICEMEMBERS' SEAMLESS TRANSITION

                INTO CIVILIAN LIFE--THE HEROES RETURN

                              ----------                              


                        THURSDAY, MARCH 8, 2007

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
              Subcommittee on Oversight and Investigations,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 3:43 p.m., in 
Room 334, Cannon House Office Building, Hon. Harry E. Mitchell 
[Chairman of the Subcommittee] presiding.

    Present: Representatives Mitchell, Space, Walz, Rodriguez, 
and Brown-Waite.

    Also Present: Representatives Filner, Hare, Buyer, 
Bilirakis, and Lamborn.

             OPENING STATEMENT OF CHAIRMAN MITCHELL

    Mr. Mitchell. Welcome to the Oversight and Investigations 
Subcommittee of the Committee on Veterans' Affairs March 8, 
2007, hearing entitled, Servicemembers' Seamless Transition 
into Civilian Life--The Heroes Return. I want to thank everyone 
for being here today. Two weeks ago, the American people 
learned that some of the most seriously wounded warriors were 
recovering in dilapidated conditions at the Walter Reed Medical 
Center, supposedly the Army's premier medical facility.
    These conditions are absolutely unacceptable and the 
American people are rightly outraged. Sadly, it appears the 
buildings are just the tip of the iceberg. Reports have been 
filtering in about a labyrinth of bureaucratic red tape our 
returning soldiers are having to navigate to get the basic 
health care benefits they need and deserve. These problems have 
a direct impact on these men and women as they transition from 
the military's health care system to the VA. We have a 
responsibility to investigate how issues at the Department of 
Defense affect soldiers as they become veterans. We have a 
responsibility to make sure that the Department of Veterans 
Affairs is doing its job to make the transition as easy as 
possible.
    I am not convinced that the U.S. Department of Veterans 
Affairs (VA) is doing its part. Last night, ABC News reported 
that a proposal to keep seriously wounded vets from falling 
through the cracks of the bureaucracy was shelved in 2005 when 
Jim Nicholson took over as VA Secretary. I am deeply troubled 
when wounded soldiers say in news reports that the VA has made 
them feel horrible. That is unacceptable and embarrassing and 
the American people deserve answers. Today, we hope to get to 
some of them. In today's hearing, we will hear from witnesses 
who have seen and experienced firsthand the difficulties 
veterans face when they transition from the DOD health care 
system to the VA. Their stories are compelling, and I am eager 
to learn how the VA is responding to their concerns as well as 
the health care needs of their fellow veterans who have taken 
time to come to observe our hearings.
    In particular, I would like to recognize Specialist Greg 
Williams, Corporal Noel Santos, Sergeant Frank Valentine, Staff 
Sergeant Danny Vega. We are honored to welcome these young 
heroes here today. At this time, I ask unanimous consent that 
Mr. Filner, Mr. Buyer, Mr. Hare, Mr. Lamborn, and Mr. Bilirakis 
be invited to sit at the dais for the Subcommittee hearing 
today. Hearing no objections, so ordered.
    [The prepared statement of Chairman Mitchell appears on pg. 
55.]
    Mr. Mitchell. Before I recognize the ranking Republican 
Member for her remarks, I would like to swear in all of our 
witnesses. And at this time, if you would please stand, we will 
swear you in.
    [Witnesses sworn.]
    Mr. Mitchell. Thank you. Now I would like to recognize Ms. 
Brown-Waite for her opening remarks.

          OPENING STATEMENT OF HON. GINNY BROWN-WAITE

    Ms. Brown-Waite. I thank the Chairman. And I apologize both 
to the Chairman and to the Members for my tardiness. It was an 
issue relating to a sexual predator in my district who was 
found guilty yesterday, and I was speaking to the family and to 
some Members of the press about it. And I thank the gentleman 
for yielding. The Committee on Veterans' Affairs has been 
conducting oversight reviews of the seamless transition issue 
for our Nation's servicemembers for the past several 
Congresses.
    In the last Congress alone, the Committee and its 
Subcommittee held 10 hearings on the transition of our 
servicemembers. I believe that I speak for all of us when I say 
that this is a top priority issue, that despite our best 
efforts has not always been entirely resolved. Congress 
codified the concept of DOD-VA sharing, now known as seamless 
transition, in 1982, with the passage of the Veterans 
Administration and the Department of Defense Health Resources 
Sharing an Emergency Operation Act. This Act created the VA 
Care Committee to supervise and manage opportunities to share 
medical resources. Now, 25 years later, we are still discussing 
this issue. Some progress has been made in the area of 
transitioning servicemembers back to the workforce.
    Last Congress, Public Law 109-461 was enacted which 
included various transition assistance initiatives ranging from 
health care needs to education and employment needs. During the 
last Congress, Members and staff from the Committee conducted 
numerous field and site visits at the VA and military treatment 
facilities and military bases to review efforts on the seamless 
transition, and held oversight hearings in May and September of 
2005. The transition and integration back into civilian life 
should be transparent and effortless for our servicemembers.
    However, this apparently does not always seem to be the 
case. More often than not, the handoffs have been fumbles. In a 
GAO report prepared for this Subcommittee on June 30, 2006, it 
was found that the VA has taken many aggressive actions to 
provide timely information to OEF and OIF servicemembers and 
their families, especially in their critical time of need. The 
report also noted the positive steps taken to increase the 
awareness training and sensitivity of staff and medical 
providers on the needs of OIF and OEF servicemembers and 
veterans. The report also found the VA continues to have 
problems assessing real-time medical information from DOD 
treatment facilities. Mr. Chairman, I ask unanimous consent 
that a copy of this report be inserted in the official hearing 
record, and I will be happy to hand that to you.
    Mr. Mitchell. So ordered.
    [The referenced GAO Report entitled, ``Vocational 
Rehabilitation--More VA and DOD Collaboration Needed to 
Expedite Services for Seriously Injured Servicemembers,'' (GAO-
06-79R), appears on pg. 78.]
    Ms. Brown-Waite. I appreciate that.
    We know that we have witnesses from Walter Reed Army 
Medical Center, and I want to make it clear that today's 
hearing is not about the conditions at Walter Reed, but about 
the transition of our servicemembers and how they are making it 
from DOD to VA care, how the process works, are there any gaps 
in care, and is VA getting the information that it needs from 
DOD in a timely manner to ensure the continuity of care for 
these new veterans, so that waiting periods for care do not 
extend for months after separation from active duty. And why to 
this day is information on DOD personnel being cared for at the 
VA's polytrauma centers still not being electronically 
transmitted? Is there a difference between DOD electrons and VA 
electrons? Again, Mr. Chairman, I thank you and I yield back 
the balance of my time.
    [The statement of Congresswoman Brown-Waite appears on pg. 
55.]
    Mr. Mitchell. Thank you. At this time, I am asking Members 
to submit their opening statements. We have 13 people on three 
panels that we are going to hear today. So it will take quite a 
while. If you could submit them for the record, I would 
appreciate that.
    We will now proceed to panel one, we are pleased to welcome 
Dr. Michael Kussman, the acting Under Secretary of Health for 
VA. Dr. Kussman has had a long and distinguished military 
career beginning with his service in the 7th Infantry Division 
in Korea. He has held leading medical positions at multiple 
facilities while on active duty, such as serving as commander 
of the Walter Reed health care system.
    As the Director of Health care at the GAO, Ms. Cynthia 
Bascetta provides our Subcommittee with a major service not 
only in her ability to provide independent assessment of VA 
program performance, but also to place the performance of VA's 
seamless transition programs in a historical context. As many 
of you are aware, last night, Mr. Paul Sullivan appeared on ABC 
News to discuss a data tracking system, which would have made 
the seamless transition of new veterans much more efficient. We 
are pleased to welcome him here today to answer questions and 
share his knowledge and experience on this issue.
    Finally, Private First Class Kimberly Lain who has recently 
gone through the transition process to the VA from the Walter 
Reed Medical Center is here to share her experiences with us.

 STATEMENTS OF MICHAEL J. KUSSMAN, MD, MS, MACP, ACTING UNDER 
  SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. 
   DEPARTMENT OF VETERANS AFFAIRS; AND CYNTHIA A. BASCETTA, 
  DIRECTOR, HEALTH CARE, U.S. GOVERNMENT ACCOUNTABILITY OFFICE

    Mr. Mitchell. Dr. Kussman, if you would please. If everyone 
could please, in front of you is a little clock with a green 
light, a yellow light and a red. And if we could keep that, 
keep it in line with that, I would appreciate it. Dr. Kussman?

                STATEMENT OF MICHAEL J. KUSSMAN

    Dr. Kussman. Good afternoon Mr. Chairman and Members of the 
Subcommittee. I would like to submit the written record for the 
record if that is okay, Mr. Chairman. Thank you for this 
opportunity to comment on VHA's seamless transition efforts. 
Before I begin, however, let me address an issue with which was 
discussed in the news media last night. In 2003, VA developed a 
contingency tracking system to meet the Veterans Benefits 
Administration, not the VHA's immediate need to track their 
benefits, assistance activities in support of seriously injured 
servicemembers as they transition from MTFs to our health care 
facilities.
    The VA employees who worked on the system hoped that it 
would evolve to meet the VHA. Unfortunately, it could not meet 
VHA's needs or even all of VBA's needs without additional 
development costs, and in February 2005, our Department decided 
to consider other ways to accomplish this task.
    Because VHA's case management needs were not met by the 
system, we developed our own tracking system which is known as 
the MTFs to VA. Last summer, we were briefed on DOD's joint 
patient tracking application, or JPTA system, which provides a 
great deal of information on the progress of seriously injured 
veterans through DOD's health care system.
    Together, DOD and VA realized that enhancing DOD system was 
our best option, providing both departments with a much better 
tool to track case management issues. DOD provided us with the 
capability to look at their records toward the end of last 
year, and earlier this month, we developed the ability to 
enhance the system to enable VA case managers to add their own 
notes and information about phone calls they have made to 
patients.
    Our vision is to create a continuous clinical record of 
transfers and case management activities for all seriously 
injured patients as they progress through both DOD and VA 
systems of care. VHA will continue to use the MTF to VA system 
until JPTA can create such a record for seriously injured 
patients.
    One other thing, before I leave this subject, contrary to 
what was erroneously reported last evening, the decision to use 
one system which was felt better met our needs over another one 
was made appropriately at the administrative level. This was a 
programmatic decision and not one made by the Secretary. VHA's 
efforts to create a seamless transition for men and women as 
they leave the service and take up the honored title of veteran 
begins early on. Our outreach network ensures that returning 
servicemembers receive full information about VA benefits and 
services.
    In each of our medical centers and benefits offices now has 
a point of contact designed to work with veterans returning 
from service in Operation Enduring Freedom and Operation Iraqi 
Freedom. VHA has coordinated the transfer of other 6,800 
injured or ill active duty servicemembers and veterans from the 
Department of Defense to the VA.
    Our highest priority is to ensure that those returning from 
the global war on terror who transition directly from DOD 
military treatment facilities or MTFs to VA medical centers 
continue to receive the best possible care available anywhere. 
This month, we are attempting to call each of these severely 
injured servicemembers and veterans to see if they need 
additional support. And we are directing facilities to provide 
OIF/OEF care coordinators at each facility.
    VA social workers benefits counselors and outreach 
coordinators advise and explain the full array of VA services 
and benefits to servicemembers while they are still being cared 
for by DOD. These employees assist active duty servicemembers 
as they transfer to VA medical facilities from MTFs.
    In addition, our social workers help newly wounded 
soldiers, sailors, airmen, and marines and their families plan 
a future course of treatment for their injuries after they 
return home. Currently, VA social work and benefits counselors 
are located at 10 military treatment facilities. One important 
aspect of coordination between DOD and VA to a patient's 
transfer to VA's access to clinical information. The Bi-
Directional Health Information and Exchange, BHIE, allows VA 
and DOD clinicians to share text space clinical data in a 
number of sites, including Walter Reed and National Naval 
Medical Center and the two military treatment facilities that 
refer them, they are the two military treatment facilities that 
refer the majority of polytrauma patients to the VA.
    Mr. Chairman, case management for our patients begins at 
the time of transition from the military treatment facility and 
continues as their medical and psychological needs dictate. 
Patients suffering severe injuries or those with complex needs 
receive ongoing case management at the VA facility where they 
receive most of their care. VHA has recently determined that 
every medical center will have a full-time case manager for 
OIF/OEF veterans needs and we are in the process of hiring a 
hundred new OIF/OEF veterans to serve as ombudsmen to support 
severely wounded veterans and their families.
    Each VA NC also has a designated point of contact to 
coordinate activities locally for OIF/OEF veterans and to 
ensure the health care and benefits needs of the returning 
servicemember and veterans are fully met. VA has distributed 
specific guidance to field staff to ensure that the roles and 
functions of the points of the contact and case manager are 
fully understood and that proper coordination of benefits and 
services occur at the local level. To ensure that all eligible 
veterans are aware of the services they are entitled to, VA's 
developed a vigorous outreach education and awareness program 
for our returning veterans and their families.
    To allow us to provide coordinated transition services and 
benefits for National Guard and Reservists, a memorandum of 
agreement was signed with the National Guard in May 2005. 
Similar memorandums are under development with the United 
States Reserve and the United States Marine Corps. These new 
partnerships will increase awareness of and access to VA 
services and benefits during the demobilization process as 
former servicemembers return to their local communities.
    VA is also reaching out to returning veterans whose wounds 
may be less apparent. VA's a participant in the DOD's post-
deployment health risks and assessment program. We provide 
information about VA care and benefits, enroll interested 
Reservists and Guardsmen in the VA health care system and 
arrange appointments for referred servicemembers.
    As of December 2006, an estimated 68,800 servicemembers 
were screened under the provisions of this program resulting in 
more than 17,000 referrals to the VA. Finally, VA provides 
outreach to our newest veterans through our readjustment 
counseling service, commonly known to veterans as the Vet 
Centers Program. Vet centers were created by Congress as the 
outreach element in VA's health administration. The approximate 
number of OIF/OEF combat veterans served by vet centers today 
is 180,000. Vet centers have provided bereavement services to 
the families of over 900 fallen warriors. VA plans to expand 
the Vet Center Program. We will open 15 new vet centers and 
eight new vet center outstations at locations throughout the 
Nation by the end of 2008. At that time vet centers will total 
232.
    We also expect to add staff to 61 existing facilities to 
augment the services they provide. Seven of the 23 new centers 
will be opened during calendar year 2007. Mr. Chairman, this 
concludes my presentation. At this time I would be pleased to 
answer any questions that you may have. Thank you.
    Mr. Mitchell. Thank you, Dr. Kussman, for your 
presentation.
    [The statement of Dr. Kussman appears on pg. 57.]
    Mr. Mitchell. The others are here just for questions. We 
will not have an opening statement. But I do have some 
questions I would like to ask of you to start with. I am going 
to ask about the complaint system that is in place that the VA 
has. When a patient approaches the VA with a complaint about 
treatment they have received, how is that complaint handled?
    Dr. Kussman. Sir, there would be multiple ways. We have 
patient advocates at every facility. There are signs up that 
tell the patients that if they are unsatisfied with what they 
have they can go to the patient advocate. They could call the 
IG, they could call our Office of Medical Inspection. They 
could go directly to the hospital director or they could send 
an e-mail directly to me, which people do, as well as the 
Secretary.
    Mr. Mitchell. And is there someone who follows up with this 
after they have made a complaint?
    Dr. Kussman. Yes, sir. Personally, if it is to me.
    Mr. Mitchell. And to follow up with this, the follow-up, 
who follows up with the facility to make sure that they correct 
whatever is wrong? Does anybody follow up? Because it seemed to 
me, you know, when we hear about Building 18 and some other 
buildings out there--I am sorry, that was Walter Reed, not 
under your control. But let's say that there was a facility 
that someone complained about, is there anybody who follows up 
with the facility?
    Dr. Kussman. Yes, sir. Our assistant, I mean, our Deputy 
Under Secretary for Operations and Maintenance, Mr. Bill 
Feeley, is responsible for the upkeep and the services at all 
the facilities and through him and the hospital directors we 
would be sure that things were corrected. We also have a lot of 
inspection teams that come and visit us. If there was an issue 
like that, not only the joint commission, but we have what we 
call our own supports, there are a mini joint commission that 
we do on ourselves. The IG comes and reviews us with their CAP 
reports. We have other outside agencies that review, CARF which 
reviews rehabilitation centers. So there is a lot of review and 
follow up if there is identified a deficiency in any of our 
facilities.
    Mr. Mitchell. What kind of records do you keep on patients' 
complaints?
    Dr. Kussman. Again, I think that would be at the facility 
level. But we also have very elaborate patient satisfaction 
surveys that are done when patients come in, they fill out a 
form, and those are reviewed and kept that, I believe at the 
facility. They are tracked at the facility as part of the 
performance measures for the leaders of the facilities to be 
sure, but we also have the University of Michigan do a consumer 
satisfaction review service every year, and thank goodness 
every year that we have done very well on that is a customer 
satisfaction, and have actually been 10 points higher than 
civilian facilities.
    Mr. Mitchell. What is the process you use for taking valid 
complaints and taking corrective action?
    Dr. Kussman. Well, as I said, sir, hopefully that would be 
handled at the facility level, that if somebody raised a 
complaint about something, that through the patient advocate or 
anybody else who took the complaint, the facility director and 
associate directors would act on that. If the patient doesn't 
get satisfaction, it could be raised through the division level 
or to the central office through an 800 hotline call to the 
Secretary, the IG, or the Office of Medical Inspection.
    Mr. Mitchell. How often do you review these surveys or 
these complaints? Are they done every day? Once a month? Every 
3 months? How often do you review these complaints or these 
satisfaction surveys? Once a year?
    Dr. Kussman. The survey, the large survey, as I mentioned 
from the University of Michigan, is done once a year, but other 
surveys are done on a rotating basis. The IG does--rotates 
through our facilities.
    Mr. Mitchell. Besides surveys about satisfaction, what 
about complaints about service or the care they are getting? 
How often are those reviewed and are there records of those?
    Dr. Kussman. Well, as I said, I think it depends on whether 
the complaint got up to the central office or not, but the 
complaints are generally handled at the local level if they can 
be handled. If the individual doesn't get satisfaction, it 
would bubble up, but that is an ongoing thing. They review 
those complaints and see if there is any pattern.
    Mr. Mitchell. If a patient doesn't feel they have gotten 
satisfactory compliance or haven't had their complaint 
satisfactorily answered, what happens then?
    Dr. Kussman. Well, I would encourage them and they would be 
encouraged to take it to the higher level. They can come to the 
division or they can come to the central offices if they don't 
get satisfaction. That is our job, to take care of veterans and 
if they are not satisfied with what they want, we would 
encourage them to call us.
    Mr. Mitchell. Do you have any idea about how many 
complaints you might get a month?
    Dr. Kussman. No, sir, but I can go back and ask and get it 
to you.
    Mr. Mitchell. All right. Thank you. I yield my time.
    Mr. Buyer. Mr. Chairman, I ask for a parliamentary inquiry.
    Mr. Mitchell. Yes.
    Mr. Buyer. My inquiry is that the witnesses sitting with 
the Acting Under Secretary, the individuals sitting there, are 
they witnesses or are they sitting there in an individual 
capacity?
    Mr. Mitchell. Mr. Buyer, they were sworn in. So they are 
here to answer questions as we try to further this.
    Mr. Buyer. Further parliamentary inquiry. Is it the 
intention of the Chairman to follow rule XI of the House Rules 
when it comes to the rules and procedures of the Committee?
    Second, Mr. Chairman, in the 15 years I have been here in 
Congress, I have never seen a Committee or a Subcommittee ever 
treat an official of the administration without respect and 
dignity of their position and station. And I have been here 
through Republican and Democratic administrations. This is a 
very curious manner in which you are treating the Under 
Secretary of Health for the VA. So I, again, ask you, is it the 
intention of the Chairman to follow the rules and protocols of 
the House under rule XI?
    Mr. Mitchell. We will take a five-minute recess on that.
    [Recess.]
    Mr. Mitchell. We will reconvene. Mr. Buyer recommends that 
having Mr. Sullivan and Ms. Lain appear with Dr. Kussman on the 
panel does not show proper respect. So, we will ask Ms. Lain 
and Mr. Sullivan if they would step down and join the second 
panel. If you would do that, please.
    Mr. Sullivan. Yes, Mr. Chairman.
    Mr. Mitchell. That's the only way I guess we can get proper 
respect. Thank you.
    Mr. Buyer. I thank the Chairman.
    Mr. Mitchell. Ms. Brown-Waite?
    Ms. Brown-Waite. I would address this to Dr. Kussman. Today 
I received a letter from Secretary Nicholson addressing what 
the VA has done and what they are doing, and what they're going 
to do in the future to ensure that the wounded veterans receive 
everything that they need as a transition from DOD medical 
facilities to the VA. If you would please talk about that, I'm 
sure that you were involved in that letter. Is that correct?
    Okay. If you would just please discuss that, and I think 
that every Member here does plan, you know, holding the 
Secretary's feet to the fire to make sure that those promises 
made in the letter, and I think everyone received one, I think 
the Chairman received a letter today, that that really does 
take place. I think regardless of the party affiliation, every 
Member here wants to make sure that our veterans are well taken 
care of, and in response to the Chairman's question about what 
happens when the number of complaints pile up, I can just tell 
the Chairman that I'm aware of at least one hospital 
administrator who was removed from that post in my district, 
and I am sure that the freshman Members here will learn and 
that we will be also contacted when the VA is not responsive.
    The families and/or the veterans and military people won't 
hesitate to also let us know. So if you would just elaborate a 
little bit on that letter, I would appreciate that very much.
    Dr. Kussman. Congresswoman, I don't have the letter right 
in front of me, so I didn't have it memorized, but obviously I 
am aware of the content of the letter. We believe very strongly 
in our responsibility to veterans and their families for care, 
and I believe that we have done that, as mentioned with the 
satisfaction surveys that we have. But I believe this was just 
another way of energizing and reminding our people and our 
facilities of our obligation to do the things that we need to 
do. We are hoping we will accept responsibility when things 
don't go well, and we pledge to fix them when they're not, and 
so we want to be sure that we've assessed everything that we 
are doing, and be sure that we can raise the bar as 
appropriate.
    Ms. Brown-Waite. You know, when I first ran for office, I 
thought it was a really good idea to virtually have the 
veterans be able to go to non-VA hospitals. I really thought 
that was a good idea until I really got to know the veterans 
population both in my district and the organizations that are 
represented up here. And I learned what a very high 
satisfaction level that the clear majority of veterans have and 
also the very good survey results that the virtual--the 
customer satisfaction survey that takes place. I know I don't 
have a VA hospital in my district.
    I have three great ones around me, and we're going to hear 
later from the head of the polytrauma unit there. But I get 
great results and the veterans who aren't happy also contact 
us, you know, I would be interested in the number of 
complaints. I think maybe we should--every Member should have 
that information available, and how many of them were resolved. 
You know, so that we can also assure the veterans that if they 
do have a question, or a complaint, that their complaint is 
taken seriously, and is resolved.
    Dr. Kussman. Yes, ma'am.
    Ms. Brown-Waite. Mr. Chairman, I would also request that 
Secretary Nicholson's March 7 letter addressed to me and to you 
regarding the VA's efforts to ensure the seamless transition 
into the VA system from DOD, that that can be also submitted 
for the record.
    Mr. Mitchell. Without objection, so ordered.
    [The March 7, 2007, letter from Secretary Nicholson appears 
on pg. 73.]
    Ms. Brown-Waite. I appreciate that. In the letter it also 
said that every VA medical center now has specialty PTSD 
treatment capability. Would you elaborate a little bit on that? 
And how recent is it that the PTSD treatment availability has 
been available?
    Dr. Kussman. Thank you for the question. The VA, as you 
know, has been the leader in the treatment evaluation and 
research of PTSD ever since the diagnosis was first used in 
1980, and we have a national center in White River Junction and 
other research sites that are seen as international resources 
for the treatment research and evaluation of PTSD. We, in 2004, 
developed a very thorough and elaborate mental health strategic 
plan to look at where we were at the time and what are the 
things that we could do better. And one of those things we 
realized that we could do better was to be sure there was PTSD 
treatment teams at all our facilities and there are over 200 of 
them and that is more than just our facilities, because as you 
know, we have about 155 hospitals. We've also put PTSD 
treatment teams in large clinics as well to meet the needs of 
people who have PTSD or are being looked at for PTSD. And so 
this is really part of our mental health strategic plan to 
enhance the services available.
    Ms. Brown-Waite. I thank the Doctor, and I yield back the 
balance of my time.
    Mr. Mitchell. Thank you, and just one follow-up question 
real quick. What is the waiting time for a person to receive 
treatment in these centers?
    Dr. Kussman. Sir, obviously our goal, first of all, if 
anybody has urgent or emergent care, they get in right away. 
Our goal is that if it is not urgent or emergent the person 
should be seen within 30 days of the request.
    Mr. Mitchell. How long?
    Dr. Kussman. 30 days.
    Mr. Mitchell. Thank you. Mr. Space?
    Mr. Space. Thank you, Mr. Chairman. I understand that Ms. 
Bascetta is available for questioning?
    Mr. Mitchell. Right.
    Mr. Space. I hope I have pronounced your name correctly.
    Ms. Bascetta. Bascetta.
    Mr. Space. Thank you. And I apologize.
    Ms. Bascetta. That's okay.
    Mr. Space. Ms. Bascetta, you, in your work for the GAO, 
obviously have invested many hours in researching, in 
documenting matters concerning seamless transition. My question 
is to what extent--I am assuming you have made recommendations. 
And I am curious to what extent those recommendations have been 
followed, and if there have been matters that you have 
recommended, issues that you have suggested that have been 
ignored.

                STATEMENT OF CYNTHIA A. BASCETTA

    Ms. Bascetta. I wouldn't say that the VA has ignored any of 
our recommendations in this regard. I can't say, however, that 
the two departments working together have followed our 
recommendations so far to the extent that we'd want them to. 
And the one that I'm most concerned about is that VA and DOD do 
a better job collaborating on rehabilitation so that veterans 
or servicemembers, for that matter, who need services get them 
as early as possible. Our work has shown that if there is a 
delay in getting rehabilitation, there can oftentimes be 
deficits that can't be made up. And one of our most significant 
concerns is that, of course, all veterans start in the DOD 
system. And if they don't work together early, meaning that DOD 
at times would have to let VA in early, it could happen that 
when VA has a veteran arrive for care in their system, you 
know, there could be deficits that VA can't make up.
    I'd also say that with regard to the seamless transition, 
it remains a work in progress rather than a fully implemented 
reality, but I think that because of the complexity of the 
process, there will always be room for continuous improvement. 
When we reported on it in 2006 to this Committee, we did not 
make recommendations because in the course of our work when we 
found problems to VA's credit, they corrected them while we 
were completing our work. Most of those were problems with 
regard to individual patients. So we would have to do more work 
at this time to look systematically to reassess how well it is 
working.
    [The statement of Ms. Bascetta appears on pg. 59.]
    Mr. Space. Thank you. Have you made specific 
recommendations concerning the fashion in which these delays 
can be eliminated, specifically with respect to rehabilitation? 
And if so, can you provide us with a copy of those specific 
recommendations?
    Ms. Bascetta. I can submit our report for the record. The 
recommendation was a conceptual one that the two departments 
collaborate to come up with a plan and an agreement as to when 
it would be appropriate for VA to have data about 
servicemembers. And that through the course of them working out 
the details early intervention could become a reality.
    [The GAO report (GAO-05-167) reference by Ms. Bascetta 
appears on pg. 94.]
    Mr. Space. Thank you. I yield back the balance of my time.
    Mr. Mitchell. Thank you. Mr. Buyer?
    Mr. Buyer. Mr. Chairman, I will follow the protocols of the 
Committee and I will go at the end of the sitting Members of 
the Committee for questions. Thank you.
    Mr. Mitchell. Thank you. Mr. Walz.
    Mr. Walz. Thank you, Mr. Chairman. And thank you, Dr. 
Kussman, for being here. Ms. Bascetta, I appreciate the 
opportunity to speak with you, and I want to thank you for the 
work you've done for our veterans. I said I do think that is 
critically important that we keep that in mind, and having 
spent a lot of time in our polytrauma center in Minneapolis, I 
know the quality of care and the professionalism there is 
something that I am very proud of.
    My constituents demand that we get this right and we're 
here today to question and to look ahead and I think that is a 
healthy exercise, I think it is one we need to do and we can 
get this right. We must get it right. I would associate myself 
with the Ranking Member Ms. Brown-Waite when she said, that 
this is a priority. This is one that we have to get right. I 
feel it is a moral imperative to take care of our wounded 
warriors when they return home, but I also think that it is a 
national security issue.
    We need to make sure this is part of what we're doing so 
soldiers know they're being taken care of. Results matter in 
this, and it is one of these situations that I think we have to 
shoot for. You're right, it is always going to be a continuing 
process. But this is a zero sum proposition. One mistake is too 
many in this. One soldier left untreated is too many.
    And I think all of us agree with that, and the goal is to 
try to get it to zero. If we ever get there, we must continue 
to try. So just a couple of questions, Mr. Kussman. How long 
have you been with the VA--I'm not sure if I got that--have you 
been working in your current position, sir?
    Dr. Kussman. In my current position? Since 12 August 2006.
    Mr. Walz. How long have you been with the VA in general, 
Dr. Kussman.
    Dr. Kussman. I first came to the VA on 24 September 2000.
    Mr. Walz. Very good. My first question on this is do you 
believe there were substantial changes made or substantial 
preparations made starting in about March of 2003 when this 
current conflict in Iraq got started? Were there preparations 
made for the influx of wounded veterans that we would see?
    Dr. Kussman. We always, sir, are ready to take whatever we 
need. I think that the thing that surprised everybody was the 
type of injuries that we were seeing, not necessarily the 
volume, although no one could predict how long the war was 
going to go on, and that is a different issue. But what we have 
seen is that there are certain signature injuries of this war. 
One is PTSD, particularly for the National Guard and Reserves 
because I am not trying to minimize the active component, but 
they do have a cocoon around them, and in my previous life I 
appreciated that. But what do you do with the people who then, 
when they get discharged, don't have that same type of cocoon?
    The other thing is because of the body armor and the far-
forward surgical care, servicemembers are surviving with much 
more complicated wounds. So that was one of the things that 
drove us very quickly to build on our four TBI centers that we 
have in Palo Alto, Minneapolis, Tampa and Richmond. And we have 
two of the directors here that will be on a follow-up panel. We 
put in place there, the full multidisciplinary approach for 
things, not just TBI. But TBI is another signature injury that 
is occurring, partly because I think when we went into the war, 
we thought that we would see the more traditional types of 
casualties, gunshot wounds, shrapnel, the usual thing.
    The enemy is taking a different tact in using IEDs and car 
bombs that create blast injuries, and one of the blast injuries 
among others is the traumatic brain injury which is--not to 
minimize it, it is head rattle that occurs inside the helmet, 
the brain floats and things in the brain, it is not locked in. 
So there is a whole spectrum of mild to moderate traumatic 
brain injuries to severe traumatic brain injuries.
    Mr. Walz. And just using the last bit of my time, do you 
feel like we're prepared for the large number that are going to 
be diagnosed as we start to check everyone now the traumatic 
brain injury? Sometimes it's not so visible, vision, different 
things like that, and PTSD. Do you feel like we're prepared? 
And you are absolutely right, in my former life, it was 24 
years in the National Guard. And I know when they go out to 
rural Minnesota, it is a lot different than when we're on an 
active military base. Are we prepared for these soldiers today, 
tomorrow and 5 years and 50 years down the road?
    Dr. Kussman. Sir, as you know, I can't read a crystal ball, 
but I think right now we put in place the procedures and 
processes that we can take care of this group of patients. As 
you know, of the 613,000 servicemembers that have transitioned 
out of the active component since the OIF/OEF started, some are 
active component people who have left, others are transitioned 
back to the National Guard or Reserve or just get out of that 
as well. We've seen 205,000 of those people with a myriad of 
differing complaints. We see--we project that number--that was 
out at the end of FY 06. We project that number in FY 08 to be 
263,000.
    We project that we will see 5.8 million veterans. So it is 
a relatively small number of our total force, but they have 
certain needs, and we believe with our four polytrauma centers, 
our 17 additional level two centers and teams and all our 
facilities, we are ideally poised to be able to take care of 
the patients as they transition out.
    Mr. Walz. Thank you. And I yield back, Mr. Chairman.
    Mr. Mitchell. Mr. Rodriguez?
    Ms. Bascetta. Mr. Chairman, may I add something? I'm sorry.
    Mr. Mitchell. Go ahead, ma'am.
    Ms. Bascetta. I would just like to elaborate a little bit 
on what Dr. Kussman said. And that is, we did some budget work 
for this Committee last year and reported in September 2006 
that one of the factors that caused one of the problems in VA's 
budget estimation was underestimating the cost of serving 
veterans returning from Iraq and Afghanistan. And part of that 
was due to the fact that their data largely predated the 
conflict. But the other part was--and I can't make this point 
too strongly--that they have had trouble getting data from DOD 
that they need for planning purposes. So it is another example 
of the need for these two agencies to work together.
    Mr. Mitchell. Thank you. Mr. Rodriguez?
    Mr. Rodriguez. Thank you very much. I wanted to follow up 
with the GAO. And you answered one of my questions because I 
recall some time back, we pushed an effort in terms of trying 
to get both the active-duty soldier and the VA working together 
more and it seems based on the GAO report that there are still 
some serious problems in communication and, in fact, some even 
questioning the part of the DOD about the fact that they have 
concerns that they might even provide services to them while 
they're still in the military. And I was wondering, why would 
they be concerned about that?
    Ms. Bascetta. They told us--and this was about a year and a 
half ago now--that they were concerned about their retention 
goals.
    Mr. Rodriguez. They were concerned about their retention 
goals?
    Ms. Bascetta. Yes.
    Mr. Rodriguez. And not necessarily concerned about their 
health, I gather.
    Ms. Bascetta. They didn't say that.
    Mr. Rodriguez. They didn't say that.
    Ms. Bascetta. They were worried about VA coming in too 
early and giving servicemembers the idea that they might want 
to leave the military. And our concern was that these 
servicemembers needed rehabilitation from VA, from DOD, from 
the private----
    Mr. Rodriguez. Whoever can provide it, I agree.
    Ms. Bascetta. So they could fully recover both medically 
and vocationally and have the option to, you know, work to 
their fullest potential, either in the military or in the 
private sector, in the civilian sector and many of them, I 
think, might have opted to stay in the military and many are 
because it is their career, and they're dedicated to it. Others 
have told us that they don't want to leave the military because 
their families need health care, health insurance.
    Mr. Rodriguez. And I know that doesn't have anything to do 
with VA, but you also, in the GAO report, talk about our 
military soldiers having difficulty paying, or when creditors 
go after them, when they're unable to get their loans, unable 
to buy a car, and mainly, because they're being harassed by 
credit agencies and going after them for fees?
    Ms. Bascetta. Yes, sir. There are long-standing problems 
with the military pay system that have not been fixed. And it 
aggravates an already antiquated system. If I might add too, 
there are other problems that we noted in the course of the 
seamless transition work. It was done for the VA Committee. So 
we didn't report these findings in the report, and we didn't 
make recommendations to DOD because they weren't within the 
scope of our reporting. But some of them had to do with other 
bureaucratic problems that the family members and the 
servicemembers get caught up in.
    For example, in one case, a disabled servicemember was to 
be discharged from a PRC to a VA nursing home. And DOD refused 
to pay to have the wheelchair transported. It didn't fit in the 
ambulance, and they refused to have it transported separately 
until a cost analysis could be done. They told the VA social 
worker that would take several weeks. The VA social worker, to 
her credit, found donated post funds, not appropriated funds, 
and used them to have the wheelchair shipped to the nursing 
home so the servicemember would not be confined to his bed.
    Mr. Rodriguez. My God. You know, and I know that, you know, 
I had left for 2 years from Congress, but I remember prior to 
leaving, we were working hard at trying to establish a system 
where the soldier automatically leaves the military and can be 
picked up as quickly as possible. Now you also mention that the 
VA is still having difficulty getting the prognosis and 
diagnosis, and the medical history, because it isn't 
electronically done?
    Ms. Bascetta. That's correct.
    Mr. Rodriguez. What can we do from the VA perspective in 
terms of trying--because that is part of--you know, and the 
other part, and I know you have only been there a short time 
and I know the responsibility falls with all of us. I don't 
like the idea of coming down--this I am referring to the 
administration--firing the commander at Walter Reed who has 
only been there for 6 months when in all honesty, that 
responsibility falls with all of us in ensuring that they have 
the resources that are needed, and I know that we haven't 
provided that, and I know that with a large number, some 23,000 
soldiers that are coming back seriously injured, we need to 
beef up on funding. I was pleased to see on the CR, that $3.6 
million, and I want to get your feedback on it, and we're 
hoping to add some additional supplemental funding, but not 
only to the VA, but also to the active soldier.
    And in saying that, we had talked about seeing how we can, 
you know--and maybe you can guide us from the VA perspective. 
What do we need to do to make sure that we accomplish that goal 
that when that soldier leaves the military and the VA picks him 
up, how can we make sure we don't have to reduplicate 
everything and retest everything in terms of the soldier?
    Dr. Kussman. Sir, is that a question to me?
    Mr. Rodriguez. Yes, sir.
    Dr. Kussman. We are working very closely with DOD, 
particularly with the more seriously injured people. And let me 
just add to what Ms. Bascetta said. The two health care 
systems, by their nature, have been complementary, that the VA 
does some things and DOD does others. I mean, we don't do 
pediatrics and things of that sort. She is exactly right, that 
when people have multidisciplinary problems, you need to get at 
them all quickly because you can then lose some momentum with 
one thing if you are only focused on one. So we have moved to 
put a blind rehabilitation specialist into Walter Reed, a 
spinal cord specialist coming out of the Washington VA, because 
those are the two things that----
    Mr. Rodriguez. If I can, what else do we need to do to try 
to correct some of those things that were mentioned by the GAO 
from the VA perspective?
    Dr. Kussman. Well, I think that we have done a lot of the 
things that the GAO mentioned, and Ms. Bascetta said that. What 
we did is we realized that we have those four wonderful centers 
that we have, and I think they're state of the art and 
multidisciplinary, but people leave those centers. They don't 
live near there, so we put 17 additional--there are really 21 
level II sites, one for each of our divisions. But the 17 are 
additional. The four that we already have in VISNs, we didn't 
see any reason to duplicate on top of the level I. So there is 
a total 17 new, but a total of 21 centers as well as putting 
resources at our facilities to try to provide the full depth 
and breadth of services close as we could.
    Mr. Rodriguez. Did I hear you saying that we don't need to 
do anything else, that you have established the things that are 
there in order for us to--for the service person to be able to 
be picked up? Is that what I am hearing?
    Dr. Kussman. We can always do better. We appreciate your 
assistance.
    Mr. Rodriguez. The question is how can we do better? What 
do we need to do to help to you do better? Because apparently 
we're not doing----
    Mr. Mitchell. Mr. Rodriguez, your time has expired.
    Mr. Rodriguez. Thank you.
    Mr. Mitchell. Thank you. Mr. Buyer?
    Mr. Buyer. Thank you very much. Ms. Bascetta, I was sitting 
here trying to think how many years we have been on this issue. 
I can't even remember. It has to go back 12 or 13 years. It is 
not nice to talk about age with a lady, but it has been a long 
time. I can't even begin to count the number of GAO studies 
you've done and supervised over the years. You know, this is 
20-plus years in the making, trying to get DOD and VA to 
coordinate and cooperate.
    And Dr. Kussman, I've got history with you too, even back 
when I was on the Armed Services Committee and you were a 
commander at Walter Reed, which a lot of people may not even 
realize, back in the nineties. And you know what--pardon?
    Mr. Filner. Now we know who is responsible.
    Mr. Buyer. Well, if you want to know who is responsible, 
let's go back and do a little history. I remember--let's do 
this, Dr. Kussman, because you were a senior officer then in 
the medical corps. In the nineties, we would come out of two 
rounds of base closures, back then the defense budgets were 
about $270 billion, and we were doing everything we could to 
try to downsize everything from wings and ships and divisions, 
and were trying to make it work, and then that is when I had 
the supervision over the military to help the delivery system.
    So what was the response? The response was that if we had 
less dollars, we'd create centers of excellence. Remember? So 
we created Brooke, Bethesda, and Walter Reed as centers of 
excellence because there weren't enough dollars to go around 
out of those budget years to fund all of those hospitals at all 
the ports or all of the bases and forts. So we create the three 
centers of excellence. And we had this belief coming out of the 
first gulf war that, gee, we weren't going to have as many 
wounded, we wouldn't be in a continuous war for a long period 
of time. It was challenging for me when Walter Reed came out on 
the BRAC. I was pretty surprised by that. I knew it was an 
aging facility. But at a time of war, for us to put one of our 
centers of excellence on the BRAC was bothersome to me.
    Now I no longer had served on the Armed Services Committee, 
so I have a void in my background in intellect here as to 
exactly what happened and transpired over the last 5 years. But 
even to say we're going to transition it all over to Bethesda 
is a pretty heavy burden. So as we had a surge of wounded and 
other than hospitals were not able to accept those capacities, 
we had a problem.
    And I also, then, add to this Congress, GAO, and Inspectors 
General have put a lot of pressure on commanders of bases that 
have been BRAC'ed about what moneys you are going to spend on 
facilities that are about to be closed. And so, what an 
untenable and difficult position we put a commander in at 
Walter Reed by squeezing him from both ends. We're going to 
maintain the standard and quality of care, and at the same 
time, by golly, you'd better be careful what dollar you spend, 
and the worst, horrible things that happened is, I can almost 
see an individual thought they would make a well-intentioned 
decision by saying, let's keep these unmarried soldiers in 
close proximity to the care giver and they made a bad judgment 
by putting them in an unhealthy building.
    So when they talk about who is responsible, well, Congress 
is on the list. Because what did we do BRAC'ing one of our 
centers of excellence during a time of war? So I'm going to 
turn it over to you. I have a lot of history with you, General, 
and Dr. Kussman, and I would, from a historical perspective, be 
interested in your comments on mine.
    Dr. Kussman. Well, sir, I think--thank you for the 
question. And Mr. Filner said maybe I am responsible for what 
happened. It was 10 years ago, Mr. Filner. So thank you. But 
having been a commander of other facilities when they were 
targeted to be closed, it wasn't when I was at Walter Reed, but 
I've been there at other times. It is a big challenge because 
psychologically, the place closes very quickly with the ability 
to do the nonrecurring maintenance, the other things that you 
would like to have done as well as maintaining an adequate work 
force, because if people look ahead and they know there is a 
good chance that they will not have a job 2, 3 years from now, 
the real good ones in particular start looking for new things. 
So it is a great challenge to be in charge of a facility that 
has been earmarked to close.
    Mr. Buyer. So with the personnel challenge, then what 
commanders have to do is do contracting, try to fill in the 
gaps or holes where they can. And now we have soldiers waiting 
on their disability ratings and therein lies the tremendous 
challenge that we have for them, as that begins to back up and 
now that they gain rehab and convalescent care. Well, thank you 
very much. Thank you, Mr. Chairman.
    Mr. Mitchell. Thank you. Mr. Filner?
    Mr. Filner. Thank you, Mr. Chairman. And thank you for 
allowing those of us who are not on this Subcommittee to visit 
with you today. It is a very important issue, and I appreciate 
your leadership on this, and I appreciate the job you are 
doing. I apologize, Dr. Kussman. I did not hear your opening 
statement, but I did hear answers to some questions. What I was 
surprised about when Mr. Walz asked are you prepared? I think 
it was in the context of the traumatic brain injury. But I 
probably enlarged that to PTSD also. And you said, we are 
ideally poised. Those were your words.
    I find that, that kind of--I don't know, misplaced optimism 
or defense of where we are to be at the cause of a lot of 
things we are hearing today, whether it was at Walter Reed, 
whether--if you read the cover story from Newsweek on veterans 
falling through the cracks, to see the situation that Bob 
Woodruff portrayed on ABC, I don't believe we're ideally 
poised. I don't think we're handling what we're doing now, let 
alone the tens of thousands, maybe several hundred thousand 
returning vets. This injury, as you, I assume, pointed out is 
not always recognizable at the beginning. You said that. So, we 
got probably thousands of kids coming back that have brain 
injuries that we don't know about, they don't know about, that 
it is our obligation to follow as long as they are alive. The 
stress on this system right now is very tough.
    I mean, we are not handling the veterans who get out today 
and who have been out. We have a 600,000 claim backlog. Does 
that mean we're ideally poised? We have got veterans waiting 
weeks and weeks, if not months, for their first appointment. Is 
that ideally poised? We have people sitting in waiting rooms 
for hours because there is not enough doctors or there is not 
enough nurses. Is that ideally poised? Come on. Let's be frank 
and candid about the situation. The VA is being stressed to the 
limits. I'm not blaming you.
    I'm blaming you for the defensiveness and the cheery 
optimism you have instead of telling us the truth. Because we 
are asking you to do more and more with fewer and fewer 
resources. It is our job to give you the resources, but if you 
say you don't need them, I mean, that is ridiculous. I will 
tell you, by the way, by the work of the people from Mr. 
Mitchell and Mr. Space, Mr. Walz, Mr. Rodriguez, and Mr. Hare 
and myself, and a couple people who aren't here, we convinced 
our leadership to add in the supplemental that is coming to the 
floor, $3.5 billion of additional resources, primarily aimed at 
traumatic brain injury and PTSD. That is going to be a big 
item.
    But you will probably give it back because you are so 
ideally poised to deal with these issues. Listen, we have an 
incredible obligation here. We have an incredible obligation. 
There are so many with brain injuries, there are so many with 
PTSD, we are not diagnosing them. Kids want to get home. 
They're not checking anything. Marines say if you check 
anything, that is a weakness. The American public doesn't 
understand PTSD, doesn't understand traumatic brain injury. We 
got a lot of work to do.
    You guys had the nerve last year, when there were sudden 
upticks of diagnoses of PTSD, you had the nerve to say--instead 
of saying to Congress, we need more resources to handle all 
these diagnoses, you said, let's investigate these doctors and 
why they're giving out this diagnosis so freely. That is the 
problem. You guys keep not saying what--that we have an 
extensive situation. We have got to take--our obligation, these 
kids have done everything we've asked them to do. It is our job 
to treat them with the--to extent worthy of the sacrifices they 
have made. And I will tell you, we're not doing it, Dr. 
Kussman. And you are not doing us any good with this cheery 
optimism saying that, ``we can handle it.'' We are not handling 
it today. You tell me how we are handling it if a young Marine 
goes to one of your facilities in Minnesota who says he thinks 
he has PTSD and he has suicidal thoughts and they tell him he 
is 26th on the waiting list. Come back in a few months and he 
goes home and commits suicide. Are we ideally poised, Dr. 
Kussman?
    Dr. Kussman. Sir, can I respond to that particular case?
    Mr. Filner. No. Respond to the whole thing.
    Dr. Kussman. No one is more committed than I am of taking 
care of veterans. I am a veteran and a retiree and I am very 
proud of it. So I wasn't trying to be glib when I said ideally 
suited. I meant from a clinical perspective, when we have the 
resources, we are looking at TBI. No one really knows how 
common mild to moderate TBI is. We put in a screen that we are 
going to evaluate everybody who comes in, and we do that same 
thing with PTSD, our outreaches.
    Mr. Filner. You tell me you are diagnosing every single 
returnee with PTSD and TBI? You are telling me you are doing 
that right now? You are not doing it. Let these guys tell me if 
they are doing it. They check a questionnaire, and that is what 
the thing is.
    Dr. Kussman. That is not what I am talking about, sir. I am 
talking about when somebody comes to the VA not some screen 
that is being done someplace. This is part of when----
    Mr. Filner. Oh, they have to come in first. Well make that 
clear.
    Dr. Kussman. When they come in to the VA for whatever their 
problem is, they get screened for PTSD and now we're screening 
for TBI as well.
    Mr. Filner. Thank you.
    Mr. Mitchell. Thank you. Mr. Bilirakis.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it. 
Dr. Kussman, GAO testimony last Monday at the Walter Reed field 
hearing indicated medical information of patients being 
transferred to the VA is less than adequate. I want to know why 
there is no transfer electronically. It requires a very time-
consuming process of multiple phone calls and faxes. Doesn't 
this become a safety issue, a serious safety issue?
    Dr. Kussman. I think there is more progress that needs to 
be done, obviously in the transfer of information. We are 
working together, our IT people, to develop that seamless flow 
of information. As you are probably aware of, it recently was 
announced last month that we are going to move toward a single 
inpatient electronic health record that would be the same in 
DOD and VA.
    Mr. Bilirakis. Okay. Thank you. Ms. Bascetta, TBI patients 
and their families at the polytrauma centers complained that 
while they were on lengthy administrative hold, awaiting 
military disability process up to 6 months, no brain 
rehabilitation was given until they arrived at the VA. I 
understand early intervention would help, most definitely. Can 
you comment on this, please?
    Ms. Bascetta. Absolutely. That is one of our biggest 
concerns. I should emphasize, we don't have work on the DOD 
rehabilitation side of the story, medical or vocational. But we 
have heard this repeatedly, and, you know, it is great that VA 
is going to start screening for PTSD and brain injury, but it 
has to start earlier. It has to start at DOD. And that 
information has to be shared with VA as early as possible. 
Otherwise, I don't understand how servicemembers or veterans 
will get the care that they need when they need it.
    Mr. Bilirakis. Thank you. I yield back.
    Mr. Mitchell. Thank you. Mr. Hare?
    Mr. Hare. Thank you, Mr. Chairman. I don't know really 
where to begin here. I share Congressman Filner's anger and 
frustration. I have been sitting here during this hearing. I 
look out and I see those brave people sitting there, and for 
the life of me, I cannot understand why we cannot get two 
agencies to talk to each other to do something that makes some 
sense to help these people out. And I know that might be 
oversimplification on my part. But you know, this is another VA 
hearing that I sit in, and I listen to testimony about things 
that have been going on for years, and I'm not blaming the 
witnesses even for this.
    I am talking--I think this problem is just built in, 
inherent, and I don't see any movement on it or I see 
discussions on it, and I see a lot of rhetoric. But you know, 
it is like the old commercial, ``Where's the Beef?'' There has 
to come a time, it seems to me, where we have to make treating 
these people, our finest, in the finest possible fashion that 
we can. I am just so incredibly tired of what I consider to be 
lip service.
    I think the hammer has got to be dropped, and I think this 
Walter Reed thing is just systemic. I think we fight like--
sometimes like children on a playground to figure out if we're 
going to have funds, to be able to give the kind of care that 
we have while we spend $11 million an hour on a war, and we're 
not nearly prepared for the people that are coming back, not 
nearly prepared to take care of them.
    And we shrug our shoulders and wonder, well, we hope we can 
get some continuity and some cooperation between DOD and the 
VA, and in the meantime, while that goes on, we have people 
going home that are hurt, people, you know, I don't even know--
I'm beyond the point of being angry about this.
    And just when you think it gets bad, it keeps getting 
worse. I think we have to put our money where our mouth is. I'm 
glad that we got the additional funds, but I share this 
frustration. I have a vet center two blocks from my district 
office. They do a wonderful job and you're right, we need more 
of them. And we need to do everything we can, and we have to 
back up what we're doing with a lot more--I think--I think 
maybe you folks ought to be angry, if you are not already 
there, maybe a little bit more.
    Maybe we have to figure this out because what we've been 
doing hasn't been working, quite candidly. I said this before, 
I'm the new kid on the block. I'm a veteran and a freshman on 
this Committee, but you know, I don't get it. And perhaps maybe 
you folks can enlighten me at another point. I just wanted to 
say a couple things. Why is it the case that servicemembers who 
are transitioning to veteran status still have to make hard 
copies, if that is the case, of the medical records and hand-
deliver them to the VA? Is that still the practice? Do they 
still have to do that?
    Dr. Kussman. I believe for the benefits, that is true, sir.
    Mr. Hare. Okay. How long do you folks see an integration of 
these two systems so that we can put an end to this once and 
for all? And from your perspective, what can we do? What can I 
do or what can this Committee do or what can this Congress do 
to move this along and put an end to this once and for all to 
put an end to it and to do what needs to be done from your 
perspective, I would be very interested in hearing what you 
think.
    Dr. Kussman. I think there are several things that are 
being done, as I hope you know that we have VA personnel full 
time in the military facilities. We have military people in the 
VA facilities. I think Congressman Filner and the Secretary 
just visited north Chicago as an example of partnering. We hope 
to be able to do more things like that in a more integrated 
system. There are a lot more things to be done.
    Mr. Hare. Can you maybe describe what actions are being 
done to improve the sharing the medical records between the VA 
and the DOD. I think you did. I apologize if I didn't get it.
    Ms. Bascetta. We characterize it really as a work in 
progress. They clearly are better off at the polytrauma centers 
than elsewhere because they do have some access to the 
electronic records. DOD actually installed computers in the VA. 
They're not VA computers that have access to DOD computers. 
What bothers us is that, you know, a year ago when we showed up 
in one of the PRCs to make sure that the electronic access was 
working, it wasn't.
    As recently as 3 weeks ago DOD unilaterally cut off the 
access of the physicians in one of the PRCs because the two 
bureaucracies had failed again to reach a data sharing 
agreement. That is inexcusable. And the potential adverse 
effect on patient care could have been a significant problem. 
In a larger sense, sometimes I think that if the servicemembers 
on medical hold were not discouraged and were getting the kinds 
of rehabilitation services that they needed, maybe the mold in 
Building 18 wouldn't have caused as much of a problem.
    And where I've seen VA and DOD sharing work the best it has 
been when the two departments or the people in the departments 
at the local level have taken the approach of focusing on the 
patient, not their own bureaucratic rules and regulations.
    Mr. Hare. Hopefully that is--I know my time is up, and I 
thank you, but hopefully that is something we can all improve 
on and get that cooperation. So that the men and women that are 
sitting here are the beneficiaries of that cooperation. I yield 
back. Thank you.
    Mr. Mitchell. Thank you. I would like to ask Dr. Kussman 
just a couple of other questions. Are you familiar with the 
contingency tracking system that has been talked about?
    Dr. Kussman. Yes, sir.
    Mr. Mitchell. And one of the purposes of that tracking 
system was to supposedly track the status of wounded soldiers 
throughout their medical treatment in Defense and VA 
facilities. In your view, why was this canceled?
    Dr. Kussman. It is my understanding, sir, that when the 
program was developed it was tried to be used. It didn't meet 
the needs of particularly the VHA. It was a system that was 
localized to a military treatment facility, and the input would 
have had to be done at the military treatment facility. It 
didn't integrate itself with the CPRS Vista or the DOD system, 
and it was felt it wouldn't meet the needs of particularly VHA 
in the longitudinal following of patients, because when they 
transferred out of the MTF, the data didn't go anywhere.
    Mr. Mitchell. Okay. One last question. Did social workers 
who are liaisons at Walter Reed, did they ever report any 
concerns about the conditions that the servicemembers were 
living under at Walter Reed?
    Dr. Kussman. Are you talking specifically, sir, about 
Building 18?
    Mr. Mitchell. That or any other buildings, any of your 
social workers.
    Dr. Kussman. They didn't report that to us. Actually when I 
heard about it, I called them over to have a meeting of what 
was their assessment of what was going on. You know, they don't 
have the visibility of the actual physical plant. They're 
working generally in the hospital with servicemembers who are 
transitioning.
    Mr. Mitchell. They were not working with those who were 
outpatients, for example?
    Dr. Kussman. Well, the individuals, as they're working 
through the disability process in the military, they would be 
talking to them as needed to be sure that if they chose to use 
the VA when they left then some of them are direct transfers, 
others would be patient that are going back home and we would 
get them enrolled in appointments at a local VA but we're not 
involved the MEB/PEB process that is going on in the military.
    Mr. Mitchell. So if you know that someone who is a multiple 
amputee is obviously not going to be in the military very long, 
and will be transitioned into your service, you don't do 
anything with them until they report back home to the hospital?
    Dr. Kussman. No, sir. The people who are entering into the 
disability process, someone like you just described, we then 
approach them and work with them to determine what their 
benefits might be and where they would like to get their health 
care. As you know, someone who is leaving the military, 
particularly if they're being medically discharged have 
basically three options of their care. They can come to the VA 
if they choose and we would encourage them to do so and have 
them seen. They can use TRICARE or they can use the military 
treatment facility. The more severely injured ones, as you go 
from Walter Reed to Bethesda or Brooke to one of our four 
polytrauma centers.
    Mr. Mitchell. Thank you. Yes, Ms. Brown-Waite?
    Ms. Brown-Waite. Thank you Mr. Chairman. I have another 
question for Ms. Bascetta and I know also that Mr. Buyer has a 
question also.
    Ms. Bascetta, were you able to ascertain why the joint 
patient tracking application system was turned off so that the 
VA did not have information about the patients?
    Ms. Bascetta. My understanding is that a decision was made 
at TMA and DOD by their attorneys that the data sharing 
agreement had not been signed, and that is why the access was 
cut off.
    Ms. Brown-Waite. Are you aware if any efforts are ongoing 
to resolve any issues so that that access can be turned on so 
that there can be continuity of care and information sharing?
    Ms. Bascetta. I don't know what was done systemically, and 
I am not current on whether they have a data sharing agreement 
at this point. But I know that the access was restored. I think 
it was cut off on a Friday and it was restored that Saturday 
morning.
    Ms. Brown-Waite. Doctor, could you respond?
    Dr. Kussman. Yes. There is a data sharing agreement, and it 
was restored.
    Ms. Brown-Waite. So it has been fully restored?
    Dr. Kussman. Yes, ma'am.
    Ms. Brown-Waite. Thank you.
    Mr. Mitchell. Thank you. Mr. Buyer, you had a question?
    Mr. Buyer. Yes. Thank you, Mr. Chairman. What I realize 
quickly is that, you know, many soldiers, Dr. Kussman, they 
will be very complimentary of their care for the military 
treatment facilities or the actual medical care at the VA. But 
they have real challenges when they're facing the discharge. 
Over the years, we talked about this in doing the Benefits 
Delivery at Discharge (BDD), identified the 142 sites. Ms. 
Bascetta, you went out there and visited some of those a couple 
of years ago, you identified 20, went to 10 I think. And so, as 
we try to do this, one physical that will apply to that VA 
disability, Dr. Kussman, right there is the sandpaper to the 
skin. I think that is the beginning of a lot of irritation for 
soldiers in ``how my government is treating me, do they 
appreciate my sacrifice, am I being fairly treated with regard 
to my rating,'' and it just rips them from the inside of their 
gut.
    And I think that is where this one really begins to 
identify itself. And so, if there is a weakness that I see in 
our system in the total chain of mercy, it is right here. And 
so let me ask now, Ms. Bascetta, whether or not you have looked 
at this. Since you looked at it 2 years ago, have you had any 
advance look with regard to the BDD and the sites and whether 
or not we've improved ourselves?
    Ms. Bascetta. No. Unfortunately we don't have updated work 
on that, but we have overall work on modernizing disability, 
which is at a much higher level than you were talking about, 
but I think it speaks volumes that if soldiers are feeling as 
though they're discouraged, they don't really want to be 
boarded out, and the system becomes more adversarial than it's 
intended. It's not surprising we have these kinds of outcomes. 
And the systems are geared in VA, DOD, Social Security, you 
name it, the Federal disability programs are cash benefit 
programs. And the incentive is to minimize the payments, and 
that is part of what creates the adversarial atmosphere.
    Our view is that a better system would focus on 
rehabilitation first because it is in the interest of the 
government, if not the servicemembers, to get everybody 
rehabilitated so that they can work either in the military or 
in the civilian labor force to their fullest potential. If we 
had a system that focused on rehabilitation, what people can do 
instead of what they can't do, and compensated them afterward 
for their residual impairments, it could really help reduce a 
lot of the animosity.
    Mr. Buyer. Dr. Kussman, your thoughts?
    Dr. Kussman. Sir, I am aware--we've had this discussion 
before. Right now, we have two types of seamless transition. 
There is the little seamless transition that we've been talking 
about about patients who are severely injured or going from one 
facility to another. The large--what I call big seamless 
transition, is the average servicemember who is getting out 
through the BDD process. And we have, as you know, worked for a 
long time to focus on a single physical exam. I think the thing 
that we've learned is that it is really a comp and pen exam 
because routine discharge physicals are not actually done in 
the military.
    And so what we have to do is be sure that we start with 
this process at these 144 sites up to 6 months before if 
somebody is getting out to help them work through the process, 
encourage them if they have a problem to request a CMP exam, 
and the whole idea is to get that done expeditiously so that 
when they do separate, because as you know, we can't provide 
anything for anybody until they get a DD-214 from a disability 
perspective, that we would be prepared to provide them that 
disability for whatever it is determined to be.
    Mr. Buyer. All right. Thank you, Dr. Kussman. Thank you for 
your courtesy, Mr. Chairman. Okay.
    Mr. Mitchell. If there are no other questions, we want to 
move to the second panel. Thank you for coming today. We 
appreciate you answering questions and your statements. Thank 
you.
    Ms. Bascetta. Thank you.
    Dr. Kussman. Thank you, sir.
    Mr. Mitchell. At this time we'll take a 5-minute recess. 
And let me just mention that I will read the panel as they get 
their name tags up there. Go ahead. Thank you.
    [Recess.]
    Mr. Mitchell. If everyone will be seated, we can get 
started. If those witnesses that were not sworn in at the very 
beginning, if they would please rise and raise their right 
hand.
    [Witnesses sworn.]
    Mr. Mitchell. Let me just very quickly introduce this 
panel, and I will reintroduce two that were on the last panel. 
As many of you may be aware, last night, Mr. Paul Sullivan 
appeared on ABC News to discuss a data tracking system which 
would have made the seamless transition of new veterans much 
more efficient, and we're pleased to welcome him here today to 
answer questions. He shares his knowledge and experience on 
this issue. Also Private First Class Kimberley Lain who has 
recently gone through the transition process to the VA from 
Walter Reed Medical Center is here to share her experience with 
us.
    We also have Ms. Kathy Dinega and Ms. Sherry Edmonds-
Clemons, who are VA social work liaisons to Walter Reed Medical 
Center and Bethesda Naval Hospital. We have asked Mr. Dinegar 
and Ms. Edmonds-Clemons and what the options are once they 
transition into the system at the local level. Dr. McNamee is 
the director of VA Polytrauma Center in Richmond, Virginia, and 
we welcome his input on the challenges facing the VA as it 
attempts to move seriously wounded servicemembers into these 
facilities. At this time--let me--I want to defer to Ms. Brown-
Waite and ask her to introduce Dr. Scott, and let me do that 
now. I'm sorry.
    Ms. Brown-Waite. I thank the Chairman very much. It is my 
very distinct pleasure to introduce Dr. Steven Scott. Dr. Scott 
heads up the polytrauma unit at Haley Hospital, and there is 
something we didn't know until today when I actually had time 
to fully read his resume, and that is, he is graduate of 
Springfield College from Springfield, Massachusetts, where he 
got his original bachelor's degree, and I taught at 
Springfield, but at the Tampa campus. And he went on to 
Pennsylvania State University, did his graduate school of 
medicine at Mayo Clinic in Rochester, Minnesota with a 
residency in physical medicine.
    He also was recently nominated to be the VA employee of the 
year. We don't know yet, the votes aren't counted, but that 
certainly is a great honor for him to be nominated. And I visit 
the hospital regularly, and talk to the family members, and 
also to some of the patients and let me just tell you that Dr. 
Scott is held in very high esteem. He is passionate about 
quality care for those who need the polytrauma rehabilitation 
center. And I thank the gentleman for allowing me to introduce 
him.

   STATEMENTS OF SHANE McNAMEE, MD, DIRECTOR, HUNTER HOLMES 
MCGUIRE RICHMOND VETERANS AFFAIRS MEDICAL CENTER, RICHMOND, VA; 
    STEVEN G. SCOTT, MD, MEDICAL DIRECTOR, TAMPA POLYTRAUMA 
   REHABILITATION CENTER, JAMES A. HALEY VETERANS' HOSPITAL, 
   TAMPA, FL; PAUL SULLIVAN, CEDAR PARK, TX (FORMER PROJECT 
  MANAGER, U.S. DEPARTMENT OF VETERANS AFFAIRS); AND PRIVATE 
     FIRST CLASS KIMBERLY LAIN, MILLERSVILLE, MD (RECENTLY 
  TRANSITIONED VETERAN FROM WALTER REED AND DISABLED AMERICAN 
                            VETERAN)

    Mr. Mitchell. Thank you. We're going to have two 
statements, five minutes each. Dr. McNamee, is that how you 
pronounce it?
    Dr. McNamee. It is McNamee, sir.
    Mr. Mitchell. Thank you. And if you would start, I would 
appreciate it.

                   STATEMENT OF SHANE McNAMEE

    Dr. McNamee. Good afternoon, Mr. Chairman and Members of 
the Committee. Thank you for the opportunity to discuss the 
transition of our wounded heroes with the Veterans and Health 
Administration. My name is Dr. Shane McNamee, and I will be 
testifying from the perspective of a clinician as well as in my 
role as the medical director of the Richmond polytrauma 
program. To frame the issue appropriately, I will describe the 
typical transition process of severely wounded heroes and their 
family Members in the military treatment facilities through our 
programs and into their communities. It is my firm belief that 
this highly coordinated effective system is unparalleled in 
this Nation's medical system for those who have suffered a 
traumatic brain injury.
    The key concepts of seamless transition I will be 
discussing are as follows: Number one, the significance of 
medical record access, the continuum of care; number two, the 
importance of relationship-based medicine; and number three, 
the recognition of the family as part of the injury complex and 
the integration of families into the therapeutic plan of care. 
Our four polytrauma rehabilitation centers are consulted by the 
military treatment facilities when a wounded hero screens 
positive for a traumatic brain injury. The referrals that come 
to Richmond are processed by our nursing admissions 
coordinator. Following collection and analysis of clinical and 
family information, we provide the military treatment facility 
a decision on the referral within 24 hours of the DOD's 
original request for this referral.
    At the earliest possible time, the family Members of the 
severely wounded are contacted by myself, the nursing 
admissions coordinator, and the social worker assigned to the 
case. This step has proved essential for several reasons. For 
the family, the transition of a wounded hero between medical 
facilities creates anxiety due to the unknown. Importantly, 
this contact provides an early opportunity to build a 
relationship with key family Members. This relationship with 
the patient and the family Members forms the basis of a 
successful rehabilitation plan. The family also serves as an 
invaluable resource in the recognition of personality and 
cognitive changes that are common after a traumatic brain 
injury. Numerous systems are used to develop an individualized 
plan of care prior to admission to our polytrauma 
rehabilitation center. Medical records are obtained through our 
direct access of Walter Reed Army Medical Center and Bethesda 
national Naval Medical Center.
    Up-to-date information about medications, laboratory 
studies, results of imaging and daily progress notes are 
reviewed to determine the individual case parameters. We access 
the Web-based joint patient tracking application to gain 
further understanding of the patient's clinical status, 
specifically the field notes from Balad, Iraq, and follow up at 
Landstuhl, Germany, are indispensable in determining severity 
of TBI and associated injuries.
    Our nursing admissions coordinator also takes specific 
documentation through the DOD liaison personnel stationed at 
both Walter Reed Army Medical Center and Bethesda national 
Naval Medical Center. As medical director, I contact referring 
physicians and discuss the particulars of the case. Our 
facilities have scheduled video teleconferences to discuss the 
referral and to meet the wounded hero and family Members face 
to face. These are essential in developing intensive 
individualized rehabilitation medicine plan for each wounded 
hero before admission. This also includes coordination of 
resources necessary for the family including housing, 
transportation, meals and psychosocial supports. Upon admission 
to our facility, each Member of our rehabilitation team 
individually evaluates the wounded hero within 24 hours and 
pays particular attention to the functional needs.
    Our team meets three times weekly to discuss each patient 
and continually adjust the therapeutic plan of care. Each 
patient undergoes 3 to 6 hours of therapy a day tailored 
specifically to their functional and cognitive needs, we 
actively work to reinstitute the roles that previously defined 
our wounded heroes. As mentioned earlier, it is not just an 
individual who suffers a traumatic brain injury, rather, the 
entire family's structure is affected and requires attention. 
The literature relating to TBI is very clear on the fact that 
those individuals with strong psychosocial supports are more 
successful over time.
    Our support is multi-modal and includes health information 
through site specific literature, informal education sessions, 
formalized lecture series and intensive discharge planning. We 
also provide professional support, emotional support, 
logistical support, involvement in the care processes, and the 
support of a military liaison officer.
    To further support the families, we have instituted a pager 
and cell phone system that are covered 24 hours a day by 
Members of our social work team. This allows yet another level 
of support for our families. And importantly, in a very real 
sense, the family Members become an integral part of our team. 
This program serves to educate families, decrease their anxiety 
of the unknown and prepare them to care for their loved one. In 
recognition of this, we have developed the model of care 
appropriately referred to as relationship-based medicine.
    We have found that it is this relationship with those 
involved in the continuum of care that drives our success. 
Initially, we intensively worked with the families and patients 
to gain their trust and instill recognition that we are on 
their side indeed. Once this level of trust has been 
established, we can develop an effective treatment plan and 
approach. It is important to point out that this relationship 
does not end once discharged from our facility. Patients are 
followed at regular intervals by the social work case manager 
along with the physiatrist.
    Intensive discharge planning is the cornerstone of any 
successful rehabilitation plan. Our discharge plans are 
initiated the moment a patient is admitted to our facility. On 
a weekly basis, we discuss the discharge needs and timelines 
necessary for success. These are communicated with the family 
and aligned with their needs. Once a disposition is provided by 
the family, we begin to contact necessary resources in the 
community. Based upon location, a consult is opened either with 
one of the polytrauma network sites or----
    Mr. Mitchell. Doctor, could you summarize very quickly?
    Dr. McNamee. The integrated transition plan of care from 
the military treatment facility to the PRC into the community 
is paramount to the success of our wounded heroes and families. 
The systems set up throughout the VA is world-class and has no 
equal for those suffering from traumatic brain injury. Across 
the system, we continually monitor and incorporate 
improvements. I am proud to be a part of an exceptional 
rehabilitation staff who are fully dedicated in their mission 
to serve those who sacrifice so much. Thank you, Mr. Chairman 
and members of the Subcommittee for your time.
    [The statement of Dr. McNamee appears on pg. 65.]
    Mr. Mitchell. Thank you. Dr. Scott?

                  STATEMENT OF STEVEN G. SCOTT

    Dr. Scott. Mr. Chairman and Members of the Subcommittee, 
thank you for the opportunity to discuss our experience as it 
relates to the Servicemember's Seamless Transition Into 
Civilian Life, Our Heroes Return. My name is Dr. Steven Scott, 
and I have been a specialist in physical medicine 
rehabilitation since 1980. I have been employed at the James A. 
Haley Veterans Hospital in Tampa, Florida, since 1990 and have 
directed both the spinal cord and traumatic brain injury 
programs.
    I would like to provide you with a brief history of the 
development of polytrauma rehabilitation care. In the summer of 
2003, we began to receive these unique patients who had been 
evacuated from the battlefield following improvised explosive 
devices blasts and injuries.
    Due to tremendous advancement in military care, we now have 
the opportunity to rehabilitate young men and women who in 
years past would not have survived. These patients are 
medically complex and have sustained numerous injuries which 
are complicated by serious TBI or traumatic brain injury. The 
primary focus of the polytrauma system of care has been to 
provide rehabilitation care to the most seriously injured. A 
typical patient has traumatic brain injury, vision or hearing 
loss, pain, wounds, burns, orthopedic problems including 
amputations. We deal with extended families in crisis including 
spouses, children of all ages, parents and siblings, as well as 
care givers.
    The stress and the sacrifice of these families frequently 
takes its toll, sometimes resulting in conflict and serious 
marital issues.
    The complexity of injuries of these combat veterans wasn't 
like those seen previously. The unique needs of these patients 
required rapid realignment of our delivery of health care 
systems to routinely include such things as our 
multidisciplinary team of medical specialists. In addition to 
our team of physiatrists or rehabilitation doctors, specialists 
in the areas of surgery, neurosurgery, internal medicine, 
psychiatry, infectious disease, prosthetics, orthotics, and 
spinal cord injury are a part of the day to day planning and 
patient care treatment program. The physiatrist or rehab doctor 
also runs the interdisciplinary team which is quite large and 
includes speech therapists, kinesiotherapists, vocational 
therapists, social workers, neuropsychologists, psychologists, 
advanced nurse practitioners, wound care nurses, respiratory 
therapists, recreational therapists, rehabilitation counselors, 
military liaisons, chaplains, blind occupational therapy case 
managers, physical therapists amputation case managers, social 
worker case managers, educational specialists, and veteran 
benefit specialists.
    Each one of these medical specialists and health care 
disciplines have a specialized expertise in caring for the 
polytrauma patient and their family and are essential to be 
sure that their comprehensive care results in excellent 
outcomes.
    As we developed the program it became quite apparent that 
we needed to establish a mechanism to exchange medical 
information. Initially we established physician to physician 
phone conferences to the National Naval Medical Center in 
Bethesda and the Walter Reed Army Medical Center in Washington. 
Videoconferencing with the patient and family in attendance was 
established with Brooke Army in San Antonio, National Naval and 
Walter Reed. A military treatment referral form was completed 
by the military and sent to our onsite case manager DOD VA 
military liaison social worker.
    This form initiates the referral to the polytrauma system 
of care. Medical records and exchanges occur between the Tampa 
VA and the military treatment facilities.
    This practice was new to us, and we have progressively 
improved this practice over the years. We continue to work on 
improvements in the transfer of radiological images and 
microbiology lab results. The VA polytrauma rehabilitation 
centers have been an active participant in videoconferencing 
with the DOD Trauma of Continuing Care that has been 
established to improve practices in care and transportation of 
trauma patients.
    In addition, we've been able to connect and actually 
participate with the joint patient tracking system that allows 
us to get more detailed medical information.
    Most polytrauma patients remain on active duty during the 
entire stay at the Tampa Polytrauma Center. Therefore, ongoing 
sharing of information between the VA and DOD is necessary. The 
military liaisons assigned to our center assist the patient and 
family with military issues and assist with maintenance of 
nonmedical orders for the family.
    Patients are frequently referred back to the military 
treatment facilities from the VA for follow-up surgery and 
placement in medical hold.
    When the individual comes to Tampa, a military greeting 
team and case manager meets the patient and their family. 
Community volunteers arrange free housing and transportation 
for families through the Haley House Fund. Our 7-day a week 
program for both patients and families always has the emphasis 
of community re-entry as our primary goal. Our staff and 
volunteers provide family educational classes, family support 
groups, planned family activities such as spouses day out, 
trips to NASA and to the space shuttle, and others. Our 
Internet Cafe provides activities outside our structured 
therapy program and recreational therapy provides community re-
entry such as shopping and recreational activities. As the 
patients and families advance in rehab, they go to day passes, 
then overnight passes to practice their independent living 
skills. We also have----
    Mr. Mitchell. Dr. Scott, could you wrap it up?
    Dr. Scott. I will wrap it up for you. In summary, basically 
we work on a continuing care to get the individual home, that 
is our goal. And it is in my conclusion that I am honored to 
serve these courageous young men and women and their families. 
And I look forward to working with DOD, Congress, our VA 
leaders, advocacy groups and private citizens to continue to 
provide the excellent care and improve the function of their 
future lives throughout the lifespan of the American wounded 
heroes. Thank you.
    [The statement of Dr. Scott appears on pg. 67.]
    Mr. Mitchell. Thank you very much. I have a couple 
questions. First to Dr. Scott. It has been reported recently in 
the news that VA physicians have been cut off from relevant DOD 
data on injured patients and the VA inspector general, the GAO 
have reported that there have been incomplete transfers of 
medical records when soldiers are transferred from DOD to the 
VA medical centers. Do you currently have any reliable access 
to relevant DOD medical records for the OIF and the OEF 
veterans and active duty men and women who are in your wards?
    Dr. Scott. Presently this morning in Tampa we have access 
to Bethesda, Walter Reed, as well as Brooke Army and also have 
access with the Joint Patient Tracking System. The only system 
that was down that I am aware of is the Patient Joint Tracking 
System. When I became aware of it I called the help line and 
within 12 hours--I think 24 hours that was back online. So that 
was the only down time that I experienced during this time.
    The record system itself is cumbersome in the military, to 
get into those cumbersome records, but we can do it on a 
regular basis, we have done it, and it is working at the 
present time.
    Mr. Mitchell. Dr. Scott, you were reading all of the 
different kinds of therapists and the specialists. There is a 
whole list of them. Do you have a proper mix of all of these 
specialties?
    Dr. Scott. Presently based on our outcomes it appears that 
we have a proper mix. But as the injuries change and as 
individuals and new things come up, we may need different and 
newer specialists in the future. This is an ongoing change. As 
we follow the war, the injury patterns sometimes change. We 
have seen where the injuries were first fairly minor and then 
more complex. We saw mild burns, now there are major burns.
    So sometimes our team management has to change according to 
the needs of the patient. All this program is and all this team 
structure is, is focused to meet the needs of those injured 
from the war. Whatever those needs are, we try to meet them 
directly with the highest quality of care.
    Mr. Mitchell. One follow-up. Have you had to turn anybody 
away because you just didn't have the space or the beds?
    Dr. Scott. In my 16 years at the James A. Haley Veterans 
Hospital I have never turned a patient away, and I never will 
in the future. I will always find space for that individual, 
wherever that might be. And with these returning individuals I 
will also find space wherever that might be within our 
facility.
    Mr. Mitchell. Thank you. I have a question for Mr. 
Sullivan. Could you please explain to us your role in the 
Seamless Transition Task Force? Not only your role but what did 
you do on the task force and what data did you brief your 
supervisors on while you were at the VA?

                   STATEMENT OF PAUL SULLIVAN

    Mr. Sullivan. Yes, Mr. Chairman. Thank you for having me 
here today. My role on the Seamless Transition Task Force 
created by Secretary Anthony Principi in 2003 was as staff 
support to one of the full Members of the Committee. That was 
my Assistant Director, Susan Perez.
    I attended the task force meetings with her and when we 
were requested to create the contingency tracking system, I 
became the project manager for that system. There was a person 
also for a while who was the project manager on this before me. 
He was deployed to Afghanistan. That is the other reason why I 
picked up the project. That was my role with the Seamless 
Transition Task Force.
    What did I report to my supervisors regarding what was 
going on and what was I seeing with the data? I can tell you, 
Mr. Chairman, that one of my other responsibilities at the 
Veterans Benefits Administration was to monitor the claims, 
health care and counseling use of gulf war veterans and thus I 
was asked to monitor the claims activity of the new Iraq and 
Afghanistan war veterans.
    So what I did is designed along with the team of computer 
programmers and analysts a method to use the Pentagon data to 
see how many Iraq and Afghan war veterans had filed claims. 
Then we would take that information and sort it. We would sort 
it and see how many of those claims were still pending, how 
many were approved, and how many were denied. Then I would 
prepare reports and I would brief my supervisor, the Assistant 
Director, as well as other executives within VBA about our 
findings.
    I can tell you that starting in March of 2005, we started 
to notice some very significant events and if you would like I 
can actually read you some of the e-mails that I sent issuing 
what I thought were warnings that there would be a surge in 
disability compensation claims among the Iraq and Afghanistan 
war veterans. I made those concerns known several times in 
several briefings.
    [The additional information from Mr. Sullivan was supplied 
in a March 27, 2007, letter, and the attachments are being 
retained in the Committee files.]
    Mr. Mitchell. My time has expired. Maybe somebody else will 
follow up on that.
    Ms. Brown-Waite.
    Ms. Brown-Waite. I would encourage Mr. Sullivan to submit 
the information to the Subcommittee so that we could all have 
it. I think that would be appropriate, Mr. Chairman.
    Dr. Scott, I know from talking to so many families that the 
reputation that James Haley Polytrauma Unit has is superior, 
and Dr. McNamee, I am sure it is the same with your facility. I 
just have a little more familiarity with the facility in Tampa.
    I would like to know what else can we do here, including 
appropriating more money, to make your job a little bit easier 
when you see the young people coming back with these traumatic 
brain injuries and I know the great work that is done, the 
great rehab work that is done. Tell us what we can do. I know 
last year, Dr. Scott, for the Haley Hospital I think we 
provided more money for spinal cord injury, and are you going 
to be--so that they could expand. Are you going to get some 
more beds also when that expansion takes place? I know the 
funding was there but it takes a while for that construction to 
take place.
    Dr. Scott. Presently we do have a space problem on our 
polytrauma unit. The VA leadership is trying to do its best to 
create more space for our unit at the present time as well as 
expand the bed situation too. Our space problem is serious. I 
would have to say this because I have a strong compassion to 
those who come back. We basically put them in rooms 10 by 10, 
about 100, 110 square feet. That is just not--we should not do 
that. We need to change that, and I think we will change that 
very shortly and with the support of our leadership.
    But we also probably need to expand more beds than we 
currently have because of the increased amount of attention, 
awareness of traumatic brain injury. We are not sure exactly 
what numbers they are, we are not sure exactly how many are out 
there. We know this is an invisible, hidden type of wound. We 
know that by creating more attention and more awareness this is 
going to create more individuals referring not only the active 
duty individuals but also our veteran population who also 
sustained TBI or have had previous TBIs in the past. I might 
add there is an unknown population group that we haven't 
really----
    Ms. Brown-Waite. Doctor, I am confused. When the Chairman 
asked you, you said that you never turned anybody away, and I 
believe that because I have been there. But is the issue that 
you don't turn anybody away in a response to the Chairman, but 
you are telling me that they are in inadequate rooms for the 
equipment that is needed. That is question number one. And 
question number two is: Making room for somebody, and, Dr. 
McNamee, you probably have exactly the same problem and I would 
like to hear from you too, making room for somebody and making 
sure that the room is adequate are really two different things.
    So, Dr. Scott, could you just clarify that?
    Dr. Scott. We do make room, it may not be adequate, as you 
mentioned. One of the lessons learned is that our whole 
hospital is involved in the polytrauma system and so we use all 
the hospital beds in our facility, and so when we run out of 
rehab beds we will use medical/surgical beds.
    Another one of the lessons learned, we also have done, is 
we admit people right on our medical/surgical floors directly 
and make sure that they are medically and surgically stabilized 
before we move them to rehab. If we don't have rehab beds at 
that time, we keep them off-floor and we start the rehab off-
floor. That allows us to again keep that open door and be able 
to serve those in need.
    Ms. Brown-Waite. How many in Haley are not on the 
polytrauma unit floor, but rather are elsewhere in the 
hospital?
    Dr. Scott. We usually have several over in the spinal cord 
unit that we use and we may have one or two in our intensive 
cares or even off-floor because of the nature of these complex 
injuries. So when we make our multi-disciplinary rounds, it is 
almost like hospital rounds because we are all over the 
hospital. And that is why we do it in a multi-service type 
fashion, not just one service. We have all the services 
involved because we basically cover most areas of the hospital.
    Ms. Brown-Waite. I thank the doctor.
    Mr. Mitchell. Thank you. Mr. Walz.
    Mr. Walz. Thanks, Mr. Chairman. I would say I am lucky 
enough in Minnesota, we have one of the four polytrauma centers 
in Minneapolis and in my district the Mayo Clinic. I would 
argue that we have two of the finest medical facilities in the 
world. So I am very familiar with the polytrauma centers.
    The work that has been done there has been nothing less 
than stellar. That is verifiable, that is not anecdotal. We are 
seeing some incredibly impressive work being done there. So, 
see, I do applaud you on that and we are here to be proactively 
preparing for the needs of our returning veterans to make sure 
that we are carrying forward lessons learned maybe over at 
Walter Reed and the DOD system and making sure we are getting 
them into the VA system.
    I want to make very clear especially to the two directors 
the work you are doing is absolutely stellar in that regard. We 
need to make sure the work that Congress is doing in oversight 
is equally stellar in preparing for that. That is part of our 
leadership responsibility.
    I have two questions, the first one was to Mr. Sullivan, I 
know you are going to submit it to the record, about this data 
you are providing to the VA. I want to know a bit about it if 
you could summarize that quickly and when you were giving that 
to the VA, what you knew about what was coming.
    Mr. Sullivan. Here is a briefing from August 2005 and it is 
just a couple of sentences of summary: In summary, these 
analyses that I gave provide a strong warning of a current and 
future increase in the surge of claims activity among global 
war on terror veterans. VBA is now beginning to observe the 
initial yet tremendous and sustained impact of more than 1.1 
million recent war servicemembers discharging from the military 
and promptly filing substantial numbers of complex multi-issue 
disability compensation claims. The risk of an increased claim 
workload and delays in processing claims based on the 
continuing surge in VBA claims activity among new war veterans 
can be mitigated with immediate and proper staffing, training 
and funding at central office and at regional offices.
    That is my summary.
    Mr. Walz. That is what we are here to do. What was done 
with this data as far as you know?
    Mr. Sullivan. I am not aware of anything that was done.
    Mr. Walz. Is it possible, do you think this data is solid 
enough that you could extrapolate and project needs into the 
future that we would have then an idea of what we could see on 
maybe a yearly basis or specifically a monthly basis? Is that 
possible?
    Mr. Sullivan. Yes, Congressman. I was fortunate enough to 
use the Freedom of Information Act to get this information and 
provide it to Harvard Professor Linda Bilmes, who prepared and 
delivered a report that estimated the number of patients and 
the cost of the war. She was estimating hundreds of thousands 
of claims and patients and she estimated between $350 billion 
and $700 billion in costs for VA for the war for the next 40 
years.
    Mr. Walz. In your mind, Mr. Sullivan, how was the VA making 
these projections if they are not using quantifiable data? How 
are they making projections on needs when the President tells 
us how much he needs in the future? How are they doing it?
    Mr. Sullivan. That wasn't done in my office, Congressman. 
You would have to ask the Department of Veterans Affairs 
actuary. You may want to ask the former chief actuary, Mr. 
Steven Meskan, about what he was trying to do at VA to make 
those kinds of projections, sir.
    Mr. Walz. Because their projections are quite a bit lower 
than what you are projecting and what the Harvard study is 
projecting.
    Mr. Sullivan. That is correct.
    Mr. Walz. We will look at those, you can rest assured. My 
last question is to PFC Lain. First, I would say as a retired 
enlisted soldier I know they moved you off that first panel; I 
would proudly sit with you on that panel. So there was no 
disrespect there sitting with a PFC in a military uniform.
    I would ask as comfortable as you are, I know these are 
private matters, if you could summarize just briefly from your 
impact in your wound to where you are at today, how would you 
summarize your care?

                   STATEMENT OF KIMBERLY LAIN

    Ms. Lain. Actually, I just joined the military back in July 
of 2005 and I was injured in basic. I ended up here at Walter 
Reed in September of 2005 and the care--the doctors are great. 
There's awesome doctors there. When I was finally discharged 
from the hospital and sent on my way, I grew up in Baltimore so 
I knew the area, I ended up at home with family, and when I 
finally ended up back for checkups and everything, I really--
there was no direction on where to go from the doctor to med 
hold. I eventually did find my way to med hold and then from 
there it was one appointment after the other until eventually 
they said okay, we are going to discharge you, and then once I 
was told that, I had to start the MEB process.
    The MEB process was--I wasn't very involved in it, it was 
basically give your documents to your counselor, they will get 
them to where they need to go. The problem with the documents 
is we are moving into a paperless society. There is no physical 
documents unless you ask your doctor for them, and a lot of the 
soldiers aren't told that so they go back and ask for these 
documents that the doctor can't access any more because they 
have been filed and gone wherever they need to go.
    Once I finally did get my MEB back I was given 3 days to 
look over it and decide whether or not I agreed with the 
findings or wanted to submit something else. Actually, I agreed 
with mine and I submitted them to the PEB as they were and once 
they finally made it over to the PEB I was given a rating 
according to their standards, and it came back and I was told 
that I then had 10 days to decide whether I agreed with the PEB 
findings of what they were going to discharge me with, either 
medical separation or medical retirement, depending on the 
severity of what they felt my injuries were.
    Once I had decided that I didn't agree with what they had 
rated, they had rated a condition that I didn't have, that 
there was a mix up somewhere in paperwork, and so I submitted 
an appeal for that. When I first decided to submit my appeal, I 
had no idea how to go about doing it. I didn't know who to go 
to.
    Luckily, in my platoon I had been hearing the phrase DAV 
being thrown around and I finally was put in contact with the 
DAV. There's one person on post operating from the DAV, and he 
submitted my appeal, he started my VA claim. Actually, he's 
helped me through the entire process of the PEB. Actually, I 
signed it this morning for a medical retirement. And I have 
already--with his help submitting my information to the VA I 
have already seen all of the initial doctors I need to see for 
the VA. They just have to wait for my orders to finally get me 
completely into the VA system to be discharged from the 
military.
    Mr. Walz. Thank you.
    Mr. Mitchell. Mr. Rodriguez.
    Mr. Rodriguez. We have large caseloads of veterans that we 
do the casework for because the VA doesn't have sufficient 
workers to help them out in the process of doing the casework 
that is needed. I know we have handled a large number of VA 
requests, and it is unfortunate.
    Let me ask the two social workers, do you all have the 
tools that are necessary, and the staffing that is required to 
handle the so-called surge or the injuries that I know has got 
to be there because there have been some 23,000 soldiers that 
have been seriously injured that have been coming in and I 
wanted to see if you could react to that.
    Ms. Dinegar. I think so. Our program has really grown. We 
started with one VA at Walter Reed.
    Mr. Rodriguez. One?
    Ms. Dinegar. We started with one back in August of 2003. We 
now have two full time at Walter Reed, one full time at 
Bethesda, and I think it is 12 VA social work liaisons at 10 
MTFs across the country. So the resources have been given to us 
to grow and try and meet the need of the servicemembers who are 
returning and getting off of active duty.
    Mr. Rodriguez. What's your caseload?
    Ms. Dinegar. We have transferred out of--well, I can speak 
to Walter Reed and Bethesda, we have transferred, transitions 
health care, about 11,000 referrals out of Walter Reed and I 
believe Bethesda's number is somewhere around 500, just 
transitioning of health care from those two facilities. I know 
Dr. Kussman had some more numbers about how many nationwide we 
have transitioned through our social work liaisons at the MTFs.
    Mr. Rodriguez. The most common problems that you see coming 
toward you, and the question is to both of you, the most common 
problems that you see coming to you in terms of from the 
soldiers. Do you want to react?
    Ms. Dinegar. In terms of injuries and illnesses?
    Mr. Rodriguez. Yes.
    Ms. Dinegar. Sir, that varies from a broken foot, an injury 
in basic training, to your most severe traumatic brain injury, 
to your triple amputee. We see all ranges of severity of 
illnesses and injuries.
    Mr. Rodriguez. Now you heard the comments by the soldier in 
terms of her difficulty. As social workers do you have a 
responsibility there?
    Ms. Edmonds-Clemons. Can you repeat that, sir?
    Mr. Rodriguez. You heard the soldier talk about her 
difficulties in terms of trying to figure out what you needed 
to do next and where she was going to get access to services 
and those kind of things. Is that part of the role of the 
social worker in terms of helping out?
    Ms. Edmonds-Clemons. Yes. We become involved with the 
soldiers at the point that they are referred to us from their 
treatment team, and that would be their teams at, say, Walter 
Reed or Bethesda. The part that she was involved in with the 
MEBs, we generally are not directly involved in that until 
which time the case manager or one of the treatment team 
Members refers the soldier to the VA.
    Mr. Rodriguez. Do you know what kind of caseloads the case 
managers might have? No?
    Go ahead, ma'am.
    Ms. Lain. The case managers that we have, in the active 
duty med hold side, we have one case manager per platoon and 
the platoons usually have 55 to 60 soldiers in the platoon and 
that one case manager is responsible for coordinating all their 
doctors visits, their meetings with their PEBLO counselors, any 
other kind of meeting they have. The case manager keeps track 
of them and it is their responsibility to make sure the soldier 
gets there.
    I know with the med holdover, which is the Reserve/National 
Guard component, the med holdover side, which is Reserve/
National Guard component they--I believe they have six--they 
have six platoons and their six platoons have anywhere between 
30 to 40 soldiers. The Active duty side has eight platoons.
    Mr. Rodriguez. I guess on the VA side in terms of casework 
I know that as a Member of Congress we have a large number of 
veterans that come to see us when they have difficulty getting 
access either because of the waiting list or because of a 
variety of different decisions are made. Is there any attempt 
in terms of the VA maybe taking on the responsibility? Of 
course they are always welcome to run to their Congressman, but 
is there an effort in terms of beefing up on the case managers? 
I am talking to the two directors of the hospitals.
    Dr. McNamee. Sir, are you specifically speaking about the 
case managers on the Department of Defense side or on the 
Veterans Affairs side?
    Mr. Rodriguez. Am I making a mistake on this? DOD then?
    Dr. McNamee. With Veterans Affairs.
    Mr. Rodriguez. I apologize. Because we do get the ones----
    Mr. Mitchell. Mr. Rodriguez, your time has expired. Thank 
you. Mr. Bilirakis.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it.
    Dr. Scott, I know you worked very well with my father, 
Congressman Bilirakis, in the 109th Congress when he Chaired 
the Oversight Subcommittee. I look forward to working with you 
as well and I will see you next week at Haley. I have a couple 
questions here. Are you still having problems receiving 
complete medical records from military treatment facilities?
    Dr. Scott. We receive them, and I think I can say from our 
facility it is always an effort to get everything because we 
have to make sure with this complex injury that every 
microbiology report, every x-ray, ever--we can't miss one 
thing. And I think that is what makes this very complex and why 
the medical records system has to be a perfect system almost 
because if anything is lost in that exchange it could affect 
the outcome of that individual, and it has affected the outcome 
of the individual. And so we are able to get them; it takes a 
lot of effort. It has improved and it is going to continue to 
improve as we all continue to work together to make it better.
    Mr. Bilirakis. So it is improving and you are receiving 
them in a timely manner?
    Dr. Scott. I think we are like Richmond, too; we try to get 
a response back once the individual is referred within about a 
day, if possible. If we have all the medical information, we 
can make that response. If it's anything longer than that, then 
we have to get updated medical records because that morning or 
that last 4 hours it may change completely, the medical status. 
That is why it is important that we do things in a very timely, 
orderly way.
    Mr. Bilirakis. Dr. McNamee, do you want to comment on that?
    Dr. McNamee. We definitely get full records from our DOD 
facilities and, as Dr. Scott and I both had mentioned, we get 
them in multiple different fashions. We get them through our 
direct access, we get them through the incredible work of our 
VA-DOD liaisons, we get them through the joint patient tracking 
application, and go figure, you can pick up a phone and call 
someone as well. That to me has been the piece that is probably 
the most appropriate because even when you look at a hospital-
to-hospital transfer and if you have someone coming from one 
floor to another, typically the most appropriate way to 
understand a case and to transfer a case is for the two 
clinicians to sit down and discuss the complexities of the case 
and work it through.
    As I had mentioned earlier, the term relationship-based 
medicine that we preach, that isn't just with the families and 
the patient, but that is with our referers and the clinicians 
on the other end.
    In my cell phone in my bag I have the phone numbers of two 
of the major referers from Walter Reed and Bethesda and we talk 
on a very frequent basis. This on its own has really led to a 
tremendous level of care and handoff and even more so the 
ability to plan care over time for these individuals. So yes, I 
do believe we get access to the data and we get it from a lot 
of different ways. Sometimes it takes some effort but I don't 
think people are being in any way cut out from the highest 
quality of medical care because of it.
    Mr. Bilirakis. Thank you very much. I yield back the 
balance.
    Mr. Mitchell. Thank you. Mr. Filner.
    Mr. Filner. Thank you, Mr. Chairman. Thank you all for 
being here and helping us understand this issue. To the two 
medical directors, thank you for providing a good survey of 
what you are doing and the passion which you bring to the job. 
I have questioned the VA bureaucracy and their seeming lack of 
passion for the veterans because it comes through that way 
sometimes. So we appreciate your passion.
    On the medical records, you say you are able to get them, 
but the two systems electronically can't communicate with each 
other, is that correct?
    Dr. Scott. Yes, they do not connect. Actually, there is a 
two-step approach, the other one takes three different steps to 
go through.
    Mr. Filner. You have to go through each system to get those 
records. That is the kind of thing we need you to point out to 
us. Is there a plan to bring them into one system as far as you 
know?
    Dr. Scott. My understanding from the previous testimony and 
my reading is there is a plan to have one medical records 
system. That is I think the long-term plan.
    Mr. Filner. That is very long-term, unfortunately. It is 
probably not going to help any of your patients in the next 10 
years. It's a question of programming and software, and if we 
put the resources into it we could do it. It is not 
conceptually a difficult problem. I was at North Chicago, as 
one of the witnesses said, and there the military clinic and 
the VA are trying to figure this out and they are making some 
progress. But even bringing this together is difficult.
    Again, I think you would be helped tremendously by having 
that access, and it's not just at Walter Reed; it's also what's 
happened on the battlefield in Iraq. In the most advanced 
society in the world, we can't get these two systems to 
communicate. It's beyond my comprehension. But it takes 
resources to do it. How many actual patients do you have right 
now, sir?
    Dr. McNamee. We currently have 11 on our unit, in our 
active unit.
    Mr. Filner. How many would you deal with in a year?
    Dr. McNamee. In the last year the number of specifically 
OIF/OEF injured on our last count was 56 for fiscal year 2006.
    Mr. Filner. Similar or more?
    Dr. Scott. We have 11 now, we had over 100 this past year.
    Mr. Filner. In four polytrauma centers, 44 people we are 
treating right now. You have painted an incredibly good picture 
but we are doing only a couple hundred, maybe 350 a year 
compared to the needs that we are going to have. It seems to me 
that we are so far from where we need to be. You don't turn 
anybody away, but are there a lot more cases out there that 
would profit from being at your polytrauma center?
    Dr. McNamee. Sir, the numbers that we quoted are the 
individuals who are on the inpatient unit, and they are the 
most severely wounded of the polytraumatic injuries. The large 
numbers that we will see will be the mild to moderate injuries 
that will not need intensive neuro-cognitive and behavioral 
training on an inpatient unit.
    Mr. Filner. Based on what you know at this moment. Three 
years from now, they may.
    Dr. McNamee. It is from the knowledge that we have gained 
in the last 30 years with traumatic brain injury 
rehabilitation.
    Mr. Filner. If you have mild brain injuries that do not 
need that kind of care, they may need it in a decade.
    Dr. McNamee. The care we provide is in the outpatient 
setting. Currently, at Richmond, the outpatient caseload for 
these individuals is 75 and growing rapidly every month as we 
are beginning to screen these individuals. So this care----
    Mr. Filner. Are you in charge of the outpatient, too?
    Dr. McNamee. I have a large hand in the outpatient setting.
    Mr. Filner. It seems at Walter Reed the problem was in the 
outpatient situation, not necessarily in the hospital. It looks 
like to me we have much greater needs. You are doing a great 
job with the 11 you have, but we've got hundreds of thousands 
coming back and, Paul, you told me what percentage might have 
brain injuries?
    Mr. Sullivan. According to a document from the Defense and 
Veterans Brain Injury Center, it was about 10 to 12 percent. So 
if you do the math on 1-1/2 million servicemembers deployed, 
that could be about 150,000. And most of those overwhelmingly 
are going to be in the mild, is that right, Doctor?
    Dr. Scott. If you compare the report, A Mild Head Injury in 
2003, and that would be a good one for everyone to review, 
about 75 percent of all head injuries in this country are mild 
head injuries. So if you just multiply basically what we have 
for moderate to severe and then multiply it by again times 
four, you can probably get just a rough estimate.
    Mr. Filner. What's the estimated number of polytrauma 
centers we need or will need next year? Probably dozens I would 
think, offhand. We've got four.
    Dr. Scott. We just don't really know what the number is out 
there. We could estimate, we could draw some things here and 
there, but what we do know is that our troops over there are 
under a lot of these IED blasts and they are being redeployed 
multiple times. So they are going to have increased chances of 
having these injuries.
    Mr. Filner. One last question if I may, did you watch the 
Bob Woodruff interview? It seemed to me, that one of the main 
problems there was in the discharge to the local home area, 
where there was not the same expertise that you have.
    Is that a legitimate concern, and how do we deal with it? 
Woodruff showed several people who went backward in their 
movement toward health because there was just not the expertise 
and the records got lost.
    Dr. McNamee. What we are doing at this point in this, and 
obviously there are 21 outpatient polytrauma network sites, and 
to develop a system of care that crosses the country for 
traumatic brain injury has never been done in the history of 
this society and what we are doing with that is to provide the 
appropriate levels of education, support and direction. We have 
the video teleconferencing abilities with all these sites, we 
have frequent conferences. There is a system-awide TBI 
initiative to cover this as well. We are all here to cover each 
other, and I don't think anyone would say that any system is 
anywhere near perfect, particularly with one that is this wide 
ranging and this large, but we are doing our best to make sure 
that all of these individuals receive the highest level of care 
that we have.
    That issue that you talk about is true with any system of 
care within this country for any specific injury. It is about 
building the appropriate system.
    Mr. Filner. You are ready for a promotion to the 
bureaucratic staff if you look at what you just said. Instead 
we need answers of how we are going to prepare for all these 
people. I need numbers of centers, number of beds, what you're 
telling me is not going to help in getting the job done. You 
have to be more simple with us.
    Mr. Mitchell. Thank you. Mr. Hare.
    Mr. Hare. I am going to ask a quick question, then yield my 
time to Mr. Filner.
    What measures and accountability practices are you 
implementing when you work with the Department of Defense to 
ensure that the rehabilitation of TBI patients is initiated 
when it's clinically indicated?
    Dr. Scott. We have our own outcome and quality management 
that we do on every individual that enters our program. It is 
based on an outcome-based program. It's very comparable to the 
private sector, too. It is based on functional gains, 
accessibility, amount of disability, amount of impairment, and 
we can follow that individual within the hospital and also on 
follow-up, too, in that fashion and we roll up those data on a 
regular consistent basis with what we call performance 
improvement plan, and with that we then look at that and see 
which areas we can improve upon and from that improvement we 
can advance forward.
    I am also a principal investigator of the Defense and 
Veterans Head Injury Program and we have regular contact every 
other week. We have phone conferences in which we bring up key 
issues on head injury management between DOD and VA, and from 
that we can problem solve and identify certain key areas that 
we can contribute and improve upon.
    Also the international trauma continual care, that we 
actually follow the individuals. This is a V-Tel that goes from 
the battlefield all the way over. We also are an active 
participant in which we can contribute information back to 
those at the warfront or back to those that actually can 
improve and identify head injuries or problems that we see at 
our end that they can help at the other end, and that also 
improves the quality of care, too.
    Mr. Hare. Let me just if I can, Mr. Filner, would you 
like--I am going to yield the balance of my time to Mr. Filner.
    Mr. Filner. Again, we need some help. And you are on the 
front lines. There is a disconnect, and it's especially 
pronounced when you're in the bureaucratic hierarchy here, as 
you saw with the previous panel. From your perspective, you are 
doing everything really well with what you have and the people 
you have to see.
    Ms. Lain, did I get that right? Ms. Lain's testimony was 
the frustration felt from the patient end. There is a 
disconnect here. You are doing great work, yet we have 
hundreds, if not thousands, of people feeling very frustrated 
with the system. You have to help us bridge that and you have 
to be honest with us and straightforward, and if you said, ``I 
have 11 beds but if I had 50 I could really do something,'' or 
``their caseload is 1,600,'' and I don't know how many social 
workers have to handle those 1,600 referrals. It's not just the 
two of you, is it?
    Ms. Dinegar. There are three of us that have transitioned 
1,600. They are not all currently active.
    Mr. Filner. That is a big load. We need people to say, if I 
had half I could really help people. So we need to hear that. 
Apparently the upper bureaucrats don't want us to hear. They 
are instructed not to tell us.
    We want to help you. We are all committed on both sides of 
this Committee to helping you serve our veterans better, but 
we've got to know what's going on. Paul has been sort of the 
designated guy on some of the TV shows where he's telling us 
what's going on. That's been very helpful watching you, Mr. 
Sullivan. I really appreciate what you have been saying.
    But we all have to be honest and straightforward. We need 
to know what you want because we control the money. Help us 
help you because you are doing a great job with what you have. 
But we are going to have thousands, if not tens of thousands 
more to deal with.
    So I'll leave it open. Anything that you would like us to 
know right now about what you need in the current budget?
    Dr. McNamee. I think one of the initiatives that the VA is 
working on right now, which is tremendously important, is the 
transitional care and the transitional living care piece for 
those individuals with traumatic brain injuries. These are 
individuals again with moderate to severe brain injuries. The 
things that we look at that are the greatest success for these 
individuals is to transition back into a community setting and 
potentially transition back into a work setting.
    There has been a model of this developed in the community; 
however, there is a bit of disconnect with it over time.
    Mr. Filner. You mentioned 21 centers; what was that 21?
    Dr. McNamee. 21 polytrauma networks. These transitional 
care units will be developed at the polytrauma rehabilitation 
centers and will be set up to transition these individuals back 
into active duty to re-establish those roles I talked about or 
back to home with their family.
    Mr. Filner. What would you tell the veteran on the Bob 
Woodruff show in some rural town that didn't have access? What 
do they do?
    Dr. McNamee. We need to continue to case manage these 
individuals and allow them every opportunity to get back into 
our system and work with them and deliver the kind of care that 
they absolutely deserve. We are responsible for that and we are 
responsible to deliver that care to those individuals and 
responsible to develop programs to support these individuals.
    Mr. Filner. Thank you, Mr. Chairman.
    Ms. Brown-Waite. Mr. Chairman, a little bit of 
housekeeping. I don't believe that it was mentioned, so I would 
ask for unanimous consent that all members would have 10 
legislative days to submit statements.
    Mr. Mitchell. Without objection, so ordered. Thank you. 
Thank you very much. I really appreciate you taking your time 
to come here and give us your expertise and your testimony. 
Thank you all very much.
    Ms. Brown-Waite. Keep up the good work.
    Mr. Mitchell. As they leave would the next panel please 
position yourselves so we can keep going? It's getting late. 
We've got a few more things to hear. Thank you.
    Take your seats so we can get started. Thank you all for 
being here and the rest of you for sticking with us. I would 
like to introduce panel three. Mr. William Feeley is the Deputy 
Under Secretary for Operations and Management; Dr. Edward 
Huycke, the DOD-VHA Coordination Officer; Dr. Ira Katz, the 
Director of Mental Health Services, are all here courtesy of 
the VA. I would like to also welcome their thoughts on the 
seamless transition process. In addition to these three 
gentlemen we have Mrs. Kathy Pearce, who is here to tell us 
exactly what she and her son have faced on the personal level 
in making the transition from DOD care to the VA system. We 
welcome her and thank her for appearing at such short notice to 
answer questions.
    I would also like to note, due to unforeseen circumstances, 
Mr. Todd Bowers was unable to appear at the last minute, and we 
are very sorry for the confusion.
    My understanding is that Mr. Feeley, Dr. Huycke and Dr. 
Katz have a statement, a 5-minute statement, and that Mrs. 
Pearce also would like to be here for questions, is that 
correct? Thank you.
    Mr. Feeley, if you would start.

   STATEMENTS OF WILLIAM F. FEELEY, MSW, FACHE, DEPUTY UNDER 
 SECRETARY FOR HEALTH FOR OPERATIONS AND MANAGEMENT, VETERANS 
  HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
EDWARD C. HUYCKE, MD, CHIEF DEPARTMENT OF DEFENSE COORDINATION 
  OFFICER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
 VETERANS AFFAIRS; IRA R. KATZ, MD, PhD, DEPUTY CHIEF PATIENT 
   CARE SERVICES OFFICER FOR MENTAL HEALTH, VETERANS HEALTH 
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND KATHY 
       PEARCE, MESA, AZ (MOTHER OF TRANSITIONING VETERAN)

                 STATEMENT OF WILLIAM F. FEELEY

    Mr. Feeley. Good afternoon, Mr. Chairman and Members of the 
Committee. My statement is in the record but I would like to 
read my comments. I want to thank you for the opportunity to 
discuss ongoing efforts in the Veterans Health Administration 
to improve the quality of care we provide to veterans returning 
from Operation Iraqi Freedom and Operation Enduring Freedom. 
VHA is committed to providing comprehensive, quality primary 
and specialty care to all enrollees with an emphasis on 
exceeding the expectations of veterans. When we don't, our 
leaders want to know about it and make it right.
    My comments will focus on the operational facility aspects 
of the organization. Related to the access of care issue, the 
quality of care VHA provides to our veterans is widely regarded 
as exceptional. Offering veterans access to VA care when and 
where they need it is key to this excellent clinical care.
    VHA monitors how long veterans must wait for appointments, 
including the time it takes for an OEF/OIF veteran to be seen. 
The waiting times are reported every 2 weeks and are 
distributed to network and facility leadership. Waiting times 
are a key performance element in network and facility 
directors' performance plans.
    VHA has employed system improvement strategies in recent 
years to reduce clinic wait times and help to ensure that our 
clinic processes are streamlined. Some examples of these 
efforts include group visits. People with diabetes or 
congestive heart failure, rather than seen on an individual 
appointment are seen in group teaching sessions, extended hours 
in clinics, including Saturday clinics. Normal lab work, an x-
ray reporting is reported to the veteran via phone rather than 
have them return for a medical visit.
    And one of the issues that was discussed today is we have 
clinical office space renovation providing two exam rooms for 
every physician as a goal. Dr. Scott did identify space 
challenges at the polytrauma center in Tampa, and we are 
currently looking at a $7 million minor renovation project that 
will enable him to enlarge those rooms.
    I would like to talk a little bit about the polytrauma 
centers. In order to meet the needs of our most severely 
injured veterans, VA has created this polytrauma system of 
care, which includes a phased approach to providing care for 
seriously injured veterans returning from Iraq and Afghanistan. 
The most intense phase, Level I, consists of four centers that 
provide acute comprehensive medical and rehabilitation care for 
the most complex and severe polytraumatic injuries. Each 
maintains a full staff of dedicated rehabilitation 
professionals and consultants from numerous specialties. The 
centers serve as resources for other VA facilities and are 
active in the development of educational programs to spread 
national learning across our system.
    These four trauma centers are located in Tampa, Richmond, 
which we heard from the two physicians today, Minneapolis and 
Palo Alto.
    In my statements there are detailed explanations of 
polytrauma that I am going to skip because I think Dr. Scott 
has adequately addressed those. I would like to comment on a 
point Dr. McNamee made. VHA is recognizing that severely 
injured veterans may require extensive rehabilitation therapy 
to successfully reintegrate back into the community, and thus 
the Department is developing four transitional rehabilitation 
programs collocated with the Level I polytrauma rehabilitation 
centers. The activation date for these four new residential 
transitional programs is July of 2007.
    A transitional rehabilitation program offers additional 
time to improve a veteran's physical, cognitive, communicative, 
behavioral, psychological and social functioning under the 
necessary scope and supervision. The goal of these programs is 
to return servicemembers to the most independent status 
possible, whether that is return to active duty, work, school 
or independent living in the community.
    Palo Alto's transitional housing is now complete. The other 
three sites we are currently working on them. The Level II 
sites which we have heard about exist in 17 locations, one in 
each network. These sites are responsible for coordinating 
lifelong rehabilitation services for patients within each 
network. Level II sites provide a high level of expert care, a 
full range of clinical and ancillary supports, and serve as a 
resource for other facilities within the network. They provide 
continued management of patients referred from the Level I 
polytrauma sites and evaluate patients referred directly to the 
Level II sites.
    Mr. Mitchell. Could you summarize pretty quickly?
    Mr. Feeley. Yes. The last comment I would make is the 
extensive polytrauma network was created to adapt VHA's 
existing health care system to provide care for these severely 
wounded veterans. I would be happy to entertain any questions.
    [The statement of Mr. Feeley appears on pg. 69.]
    Mr. Mitchell. Thank you. Dr. Huycke.

                 STATEMENT OF EDWARD C. HUYCKE

    Dr. Huycke. Thank you, Mr. Chairman, distinguished Members 
of the Committee. Thank you for the opportunity to speak to you 
about the progress the Department of Veterans Affair and the 
Department of Defense have made in improving the delivery of 
health care and benefits to our Nation's veterans. I think you 
have my statement for the record, and so I will just orally 
talk about some of the highlights if I can in the interest of 
time.
    Veterans Health Administration staff has coordinated the 
transfer of care for more than 6,800 injured or ill active duty 
Members and veterans from DOD to the VA, specifically those 
injured or ill as part of the global war on terrorism in Iraq 
and Afghanistan and in particular those transitioning directly 
from the DOD treatment facilities to the VA medical centers.
    In partnership with DOD, VA has implemented a number of 
strategies and innovative programs to provide timely, 
appropriately and seamless services to the most seriously 
injured OEF/OIF active duty Members and veterans. The 
centerpiece of the program supporting the seamless transition 
of the seriously injured servicemembers and veterans involves 
the placement of the VA social work liaison, the DOD liaisons, 
VA benefit counselors and outreach coordinators at the military 
treatment facilities to educate servicemembers about VA 
services and benefits. These VA employees assist active duty 
servicemembers during their transfer to VA medical centers and 
ensure that returning servicemembers receive information about 
VA benefits and services.
    Currently VA social work and benefit liaisons are located 
at 10 medical treatment facilities, including of Walter Reed 
Army Medical Center, National Naval Medical Center, the Naval 
Medical Center at Balboa, and Womack Army Medical Center.
    In addition to the social work and benefits liaison a VA 
certified rehabilitation registered nurse was assigned to the 
Walter Reed Army Medical Center in September of 2006 to assess 
and provide regular updates to the VA polytrauma centers to 
which these patients may be transferred. They provide education 
to the families about VA benefits and services and prepare the 
active duty servicemembers for the transition to the 
rehabilitative phase of their recovery.
    Once the MTF team notifies VHA of its plan to transfer the 
patient, the VA social work liaison and the certified 
rehabilitation nurse begin to coordinate the care and 
information transfer. The VHA social worker liaison begins 
meeting with the patient and the family to educate them about 
the patient's transition from the DOD health care system to the 
VA's health care system.
    The VHA social work liaison also registers the active duty 
servicemember or enrolls the recently discharged veteran in the 
VA health care system and begins the process of coordinating a 
transfer to the VA health care facility most appropriate for 
the services they need or to a location that is closest to 
their home.
    In the case of a polytrauma patient transfer, both the 
registered nurse and the social work liaison remain an integral 
part of the treatment team at the medical treatment facility 
while providing input to the VHA care plan and collaborating 
with the patient and the family throughout the remainder of the 
health care transition process. VA case management for these 
patients begins at the time of the transition from the medical 
treatment facility and continues as their medical and 
psychological needs dictate. Once the patient is transferred to 
the receiving VA medical center or reports to his or her home 
VA medical center for care, the VA social work liaison at the 
medical treatment facility follows up with the receiving VAMC 
to address any issues and to ensure the patient is attending 
appointments.
    Patients with severe injuries or those that have complex 
needs will receive ongoing case management at the medical 
center where they receive most of their care.
    An important part of the coordination of the care between 
the DOD and VA prior to transfer is the access to the clinical 
information, including viewing of electronic medical 
information using remote access capabilities. Video 
teleconference calls are routinely conducted between the DOD 
medical treatment facility team and the receiving VA 
polytrauma----
    Mr. Mitchell. Could you wrap it up?
    Dr. Huycke. --enabling a face-to-face transfer, discussion 
of the polytrauma patient's care prior to transfer.
    I think I will conclude my oral statement at this point and 
thank the Chairman and the Subcommittee. Meeting the 
comprehensive health needs and benefits of our Nation's 
veterans is our Nation's highest priority, and we are proud of 
the progress we have made in the seamless transition process.
    Thank you, Mr. Chairman. I would be happy to answer any 
questions.
    [The statement of Dr. Huycke appears on pg. 70.]
    Mr. Mitchell. Thank you, Dr. Huycke. Dr. Katz.

                    STATEMENT OF IRA R. KATZ

    Dr. Katz. Thank you. Mr. Chairman and Members of the 
Subcommittee, I am pleased to be here today to discuss the 
ongoing steps that the Department of Veterans Affairs is taking 
to meet the mental health needs of our Nation's returning 
veterans. Care for Operation Iraqi Freedom and Operation 
Enduring Freedom veterans is among the highest priorities in 
VA's mental health care system.
    For these veterans, VA has the opportunity to apply what 
we've learned through research and clinical experience about 
the diagnosis and treatment of mental health conditions; to 
intervene early; and to work to prevent the chronic or 
persistent courses of illness that have occurred in veterans of 
prior eras.
    Since the start of the global war on terrorism until the 
end of 2006, over 631,000 veterans have been discharged. About 
a third have sought care from VHA; and, of these, 35.7 percent 
have had diagnosis of a possible mental health condition. This 
makes mental health second only to musculoskeletal conditions 
among the classes of conditions seen in returning veterans.
    Somewhat less than half of the returning veterans with a 
mental health condition have a possible diagnosis of post-
traumatic stress disorder, or PTSD, making it the most common 
of the mental health conditions. However, PTSD isn't the whole 
story. Among the diagnosable conditions, mood disorders as a 
group, when added together, are almost as common. Moreover, 
many veterans experience nonspecific stress-related symptoms 
that may be viewed more appropriately as normal reactions to 
abnormal situations in combat, rather than any disorder.
    VA, in fact, has two components of its mental health care 
system: mental health services in medical centers and clinics 
and vet centers. In response to the growing number of veterans 
returning from combat, the vet centers have initiated an 
aggressive outreach campaign to welcome home and educate 
returning servicemembers at military demobilization and 
National Guard and Reserve sites. Through its community 
outreach and coordination efforts, vet centers provide access 
to other VHA and VBA programs.
    To augment this effort, the vet center program recruited 
100 OEF/OIF veterans in 2004 and 2005; and just last week 
Secretary Nicholson announced plans to hire an additional 
hundred to conduct outreach at both medical centers and in the 
community. When these outreach activities lead to 
identification of mental health conditions, veterans have 
choices. They may receive care in vet centers, medical 
facilities or both.
    VA's approach to PTSD is to promote early recognition for 
those who meet formal criteria for diagnosis and those with 
partial symptoms. The goal is to make evidence-based 
treatments--psychological, pharmacological and rehabilitative--
available early to prevent chronicity and lasting impairment.
    Throughout VHA, there is a sense of urgency about reaching 
out to OIF/OEF veterans, engaging them in care, screening them 
for mental health conditions and making diagnoses, when 
appropriate. Screening veterans for PTSD and other stress-
related conditions is a necessary first step to helping to heal 
the psychological wounds of war. In cases where there are 
positive screens, patients are assessed and referred to mental 
health providers for follow-up and treatment, as appropriate.
    However, we recognize that even in America, even in 2007, 
there can still be some degree of stigma associated with mental 
health conditions and their treatment. That is why we offer a 
number of options, for example, for care in mental health 
specialty services, vet centers or, increasingly, for mental 
health services provided in primary care settings. When 
veterans with severe symptoms are reluctant to enter care, 
we're prepared to educate them and their families and to work 
with them to overcome resistance. When veterans with milder 
symptoms are reluctant, we watch over them over time and urge 
treatment if symptoms persist or worsen.
    We're committed to making the best available treatments 
available; and for advancing the nature of the care available, 
VA has been a leader in research as well as clinical services 
for PTSD. Last week, the Journal of the American Medical 
Association included an article based on VA research describing 
the benefits of a specific behavioral treatment for PTSD. 
Before the results were even published, VHA was beginning to 
establish training programs to make this intervention available 
throughout our system to our patients. The translation from 
research into practice won't be instantaneous, but it can be 
accomplished far more readily in VA than in any other clinical 
setting or system. This is how a mental health care system 
should be functioning.
    Thank you again, Mr. Chairman, for the opportunity to be 
here; and I would be pleased to answer questions.
    Mr. Mitchell. Thank you, Dr. Katz.
    [The statement of Dr. Katz appears on pg. 72.]
    Mr. Mitchell. Ms. Pearce, did you want to read your 
statement or did you just want to answer questions?
    You've got a statement here. Please do it.

                   STATEMENT OF KATHY PEARCE

    Ms. Pearce. Thank you, Mr. Chairman and Congress, for 
taking your time to listen to these veterans and these people 
that work with our veterans.
    I would like to say good morning--it is not morning. Good 
afternoon. My name is Kathy Pearce. I am a military mom who 
lives in Mesa, Arizona. I appreciate the opportunity to tell 
you about my story because I believe it is similar to the 
experiences of so many families of seriously wounded soldiers 
across the country.
    My son, Army Sergeant Brent Bretz, was seriously wounded 
during his service in Iraq on December 19 of 2004. Brent was 
driving a supply truck at the time in his Stryker Brigade 
convoy when a remotely detonated IED blast blasted through his 
vehicle. Brent lost both of his legs in the attack. His left 
arm was very seriously injured, his lost his spleen, his lung 
collapsed, and he suffered a head injury.
    But the truth is, we are lucky Brent is alive. I know that 
he would not be with us today without the exceptional medical 
care he received from military doctors in the months following 
his blast.
    After he was stabilized in Iraq and treated at military 
facilities in Germany, Brent was transferred to Bethesda Naval 
Hospital, where he stayed for 5 months. He was then transferred 
to Brooke Army Medical Center at Fort Sam Houston, where he was 
an inpatient for 2 months before he was transferred to 
outpatient status in June of 2005.
    Thankfully, I was able to be with Brent from his care in 
Germany to his transition to outpatient status. Despite his new 
status as an outpatient, he still had unique needs, and I know 
that if I had not been available to help provide care, the 
transition would have been very difficult for Brent.
    Unfortunately, there are many soldiers whose families 
cannot help during that transition; and, as a result, their 
needs are not always being met.
    My experiences with Brent led me to believe that there may 
be a need for many soldiers to have an option of care that is 
somewhere between inpatient and outpatient status. As an 
outpatient, Brent had to wheel himself with one arm severely 
injured the length of three football fields from his barracks 
to his appointments at the hospital and to the mess hall. On 
several occasions Brent was physically unable to get himself to 
appointments or to the mess hall, and he missed meals and 
doctors' appointments accordingly.
    In addition to the distance he had to travel to his 
appointments, he has to wade through an interminable 
bureaucracy that makes it difficult to get the answers he 
needs. Unfortunately, as he is transitioning into a status as a 
veteran, he has encountered the same bureaucracy and red tape 
at the Department of Veterans Affairs.
    I don't think most people know how difficult it can be for 
a wounded soldier to transition into the Department of Veterans 
Affairs and get the benefits and care they need. The 
experiences Brent had with overloaded caseworkers at the 
Department of Defense is similar at the VA, and at times it 
doesn't seem like there is an adequate level of communication 
between the DOD and the VA. At times, the VA counselor has been 
inaccessible, unable to answer many of Brent's questions. He 
frequently fills out paperwork only to be told that he needs to 
secure even more documents and fill out even more paperwork to 
move the transition process forward. It is time-consuming and 
complicated, and it has been very difficult for Brent to get 
the guidance he needs.
    Brent's experience is common for many wounded soldiers. 
While his initial care was world class and our family 
appreciates the work of these doctors, Brent has experienced 
many things no soldier should ever experience. His outpatient 
care has not always met his unique needs, and he is now dealing 
with significant bureaucracy gridlock at the VA.
    We can do better, and our soldiers deserve better. I 
appreciate the Subcommittee's interest in this issue, and I 
hope that you can help military families like mine and soldiers 
like Brent get the services and care they deserve.
    Thank you.
    Mr. Mitchell. Thank you very much.
    Before we open up to questions, I would like to turn the 
gavel over to Mr. Walz. I will be back in just a few seconds, 
but I will have you start with the questions.
    Mr. Walz [presiding]. Well, thank you all for being here. I 
know it is a late hour, and I said there might be a little 
discomfort, but I couldn't help even thinking before Ms. Pearce 
spoke that I don't think it is a bad thing that America feel a 
little discomfort when we're talking about this issue. I think 
it is highly appropriate that we feel a little discomfort.
    We're here today to make sure that we correct and we do 
what is right for these wounded soldiers and that we're 
proactive on this. As I have said, again, the VA and the 
providers inside the VA are doing what they can. They're doing 
a good job. But I said--when I listened to Ms. Pearce, it comes 
back to what I said earlier, this is a zero sum proposition. 
One that goes through this is too much in this Nation, and I 
think we have every expectation in this Nation that we should 
do everything possible to make sure there isn't that one.
    I think it is probably good that Mr. Filner is not here at 
this time because I think he would raise some questions.
    But I'm going to ask the question that I think is on the 
mind of a lot of my constituents; and that is, looking at this 
and looking at the administration level, higher than the 
gentlemen sitting in front of us, but I am going to ask your 
opinion, and I am going to ask what you think when I hear this 
from constituents. Are we getting a rosy picture painted by the 
VA to justify this administration's--the Presidential 
administration's unwillingness to put the money that was 
necessary into the VA and unwillingness to plan for this war?
    When we were told it was weeks and not months, when we were 
told it was over and mission accomplished, was thought put into 
the implications for people like Brent and his mother? Were 
those types of decisions talked about at an administrative 
level? Were they discussed on the level of what you could do to 
change the infrastructure of the organization to prepare for 
that?
    When I hear experts tell me that the numbers are going to 
be larger than the VA is telling me, I have to be quite honest, 
from this administration, I am very skeptical that they are 
planning based on reality. And I ask that question more out of 
frustration for my constituents who are asking it.
    Has this discussion happened at a VA level or an 
administration level? Was there a preparation made? If each of 
you have been there for that long, was preparation made? Was it 
talked about, what the impact would be on the numbers that were 
coming?
    Mr. Feeley. I would indicate--I have been in the position 
13 months, and I believe that this is a daily discussion going 
on the entire time I have been there, and we are constantly 
learning from our experiences as we go along in trying to 
adjust. So that is the best answer I can give to that, 
considering the length of time.
    Now I also was a network director and a director in the 
field, and I think we are making every effort to treat every 
veteran as a family Member. I want Ms. Pearce to know that this 
is my card, and you can e-mail me and call me, and I will do 
whatever I can to make sure your son gets what he needs.
    Ms. Pearce. Thank you.
    Mr. Walz. How do I get that card to the rest of them? That 
is the answer I want to hear. That is the type of reaction I 
want to start seeing.
    But I am feeling right now what I do feel at times. We're 
with you in this. We are partners. We need to figure out how to 
get this. And too many people are afraid of what the political 
fallout will be by admitting that we need help, we need to 
prepare, we need to make sure Brent's needs are met and do 
everything in our power to do that.
    I just want to know what we can do, and I feel like we're 
being told it's okay.
    Mr. Feeley. I think one of the key issues that was 
identified here is the need for these transitional housing 
options that we talked about. Because people need a longer 
runway to heal, and the polytrauma center needs to have the 
ability to handle the most severe injuries. But that next phase 
requires additional support so that young men and women can go 
to school, go to vocational tech school, get a job, test their 
legs at independence.
    This is a learning issue that we found out the hard way, 
and only in the past 6 months has this started to gain 
attention.
    A conference was held in December of last year, and that is 
where the decision was made to build these units. It's 
essentially a halfway house with proper supervision allowing 
people to integrate back in. I think that is a little bit of 
what I hear Congressman Filner raise. That need may get 
greater. We do have options in our system, including the 
veterans domiciliary system, to assist young men and women; and 
we're going to have to gear up for that.
    Mr. Walz. My final question before I turn it over to the 
Ranking Member, and this is to you, Ms. Pearce. You are sitting 
here in front of Congress. I am sitting here as a new Member of 
Congress who was a command sergeant major whose total life was 
devoted to making sure those soldiers get taken care of. What 
do you have to tell us? What would make life easier for you and 
for Brent? What would truly honor that commitment that he made 
to this Nation so that this Nation can pay it back the way it 
should?
    Ms. Pearce. I think that these transitional houses, they 
are really needed. They're needed on the VA side as well as the 
DOD side.
    Brent is still going through his med board, and he has had 
some dealings with the VA, but he's still with the DOD. It is a 
tough--there is a tough line there, and it is like they can't 
take hold of him until the DOD has let go of him. And to get 
that agreement between the DOD and the VA that those medical 
records, that that information, that they can have this 
seamless transition that we keep talking about would really 
help these guys.
    Their everyday lives have changed. What they used to take 
for granted--if I can take a moment here. When Brent first got 
back, a reporter asked him what he missed. It was standing up 
to pee. I mean, that is something so simple. But, for him, it 
was something that he was looking forward to.
    To give him back that dignity by giving them this 
transitional housing--they go from 24/7 care to nobody there, 
nobody to help him, nobody to help him with that transition. A 
lot of these young men and women don't have family that can 
stay with them and help them with that transition.
    And he needs to know that the VA is going to be there for 
the next 20, 30, or 40 years to help him. He made his 
commitment to this country. He gave his all, and he just wants 
to know that they're going to be there to assist him.
    Mr. Walz. Thank you.
    I'll recognize the Ranking Member.
    Ms. Brown-Waite. Thank you very much.
    Ms. Pearce, one of the things that I tell my daughter who 
has teenagers is parenting doesn't end when they're 18 or 20. 
And certainly you are the epitome of the world's greatest mom, 
and I mean that, to be there for your son.
    I'm sorry that the system wasn't there to help your son. 
I'm sorry that DOD just doesn't work well with the VA. It has 
been a system since--I've been here 5 years. It was long before 
I ever got here that these kind of silos buildup with DOD and 
the VA. That's not an excuse that anyone should fall through 
the cracks, as obviously your son did. And thank you so much 
for being there. I have parents in my district, too, who are 
there for their son, move around the country as he transitions 
from James Haley to other units.
    If I may, to ask this question to you, Ms. Pearce. Did you 
bring this to the attention of your Member of Congress? I don't 
even know who your Member of Congress is. But did you contact 
the Member of Congress' office to express these concerns and to 
have somebody work on the issue? And I'll let you answer that.
    Ms. Pearce. I have talked to Members of the Senate. I have 
not talked to my Congressman. But these are issues that I have 
recently noticed as I have spent more time travelling back and 
forth, still spending time with Brent, but I had to go back to 
work. But I see these young men that are in these barracks. 
They're at Brooke Army Medical Center. And just over the months 
of being away from Brent and back and forth, I have realized 
these needs.
    So it is not something that I noticed early on, but I see 
that there is a need there, that they need some kind of 
transitional housing, and I think it needs to be on both sides 
of the fence. Because so many of our young men and women are 
spending time at Bethesda and Walter Reed and Brooke and I know 
Pendleton now as well as Madigan and some of the others, and 
they need something to help them get to the point where they 
can live independently. But I hope that it is something that--I 
did stop by my Congressman's office today. He was out voting. 
So I didn't get to speak with him.
    Ms. Brown-Waite. But, please, as you come in contact with 
any people who have served in the military, whether they're 
still under DOD or whether they're in the VA, have them contact 
their home Member of Congress. Because until we know that there 
is a problem, we can't solve that problem.
    I know in my instance of parents who are with their son 
today, they're actually out in California at a private rehab 
center. I know that they didn't hesitate to contact me so that 
I could make sure that everything that Marine needed, he got.
    So, please, I implore you, let the servicemembers and their 
families that you come in contact with know; and that way we 
can work on coming up with a solution that works not just for 
that one person--because we are not, you know, narrow minded, 
just take care of my constituent--take care of Mr. Rodriguez's 
constituent, too, who may be in exactly the same situation.
    But when we know about the problem, there isn't a Member on 
either side that won't immediately go to work and try to solve 
the problem.
    Again, I commend you for your devotion to your son. You 
ultimately are, you know, the mom of the year.
    I would have a quick question for Mr. Feeley. That is, 
Secretary Nicholson's recent letter making all sorts of 
promises and initiatives, ultimately, you are probably going to 
be the one implementing it. How do you plan on operationalizing 
all of the health care initiatives?
    And the other important question is, will you be adequately 
funded to do these things?
    I know I'm running out of time, so you may have to submit 
the answer, but I think it is an important question.
    Mr. Feeley. We're committed to the transitional housing. I 
think that need is going to be greater; and, frankly, we have 
excellent cooperation with Dr. Katz to help us.
    Ms. Brown-Waite. I think transitional housing is one of the 
issues, but there were far more than that in Secretary 
Nicholson's letter. Did you see the letter?
    Mr. Feeley. I have seen the letter, and there are a lot of 
deployment and execution issues we're going to face, but we're 
going to deal with it. The hiring of the hundred patient 
advocates is something we're putting a plan together on right 
now.
    Ms. Brown-Waite. And you will have enough money for it? 
Because, if not, you need to let us know immediately. The 
Secretary needs to let us know.
    Mr. Feeley. I understand.
    Ms. Brown-Waite. Dr. Katz, you need to let us know.
    I thank the gentleman.
    Mr. Walz. I thank the gentlewoman.
    Mr. Rodriguez, you are recognized for 5 minutes.
    Mr. Rodriguez. Thank you very much.
    Ms. Pearce, thank you very much for your testimony, and I 
would want Dr. Ed Huycke, since you are responsible for--I 
gather you are the one who helps coordinate between VA and the 
DOD--in terms of some feedback from you as to what else can you 
do or that we have to do in order to try to have a better 
transition in that process.
    And, number two, you know--and I was glad to hear in terms 
of that specific recommendation in terms of transition--I'm 
from San Antonio. We have Brooke Army facility there. It is a 
beautiful facility, and I know that we just had the private 
sector come in and do some--for families because we're not 
providing it.
    I was wondering in terms of how we can begin to look at not 
only the soldier but the families. And in that I wanted to see 
if Dr. Katz, I know in the area of mental health, how it 
impacts the entire family, and I wanted to get your feedback in 
terms of what we need to do.
    Once again, I think we're working hard, and I know the 
supplemental had--and I'll say it again--$3.6 billion 
additional moneys that you have for the rest of this year, and 
we're working hard in trying to add another $3-point-something 
on the, you know, supplemental, which is probably the most you 
have ever had. But the key is, now how do you use those 
resources to respond to that?
    And I would ask both of you to see if you might be able to 
respond.
    Dr. Huycke. Thank you, sir, for the question.
    I think at this point in time, working together, the VA and 
the DOD is at its--as good as it has been ever been. It is 
not--I think you've heard that it is not perfect at this point 
in time, and there is still work to do. But I think it would be 
important to state up front that there has been an awful lot of 
work between the DOD and VA to help transition those servicemen 
and women from active duty into veteran status.
    That said, I think the issue of the medical records has 
been brought up. There needs to be continued work on that, and 
I think the departments, both of the departments, are committed 
to that. And that would be my answer.
    Mr. Rodriguez. Okay. I would hope that we would come up 
with something that actually makes it happen. Dr. Katz, on the 
mental health side for families.
    Dr. Katz. For families, that's an excellent question. We're 
authorized to provide care--I'm sorry. We're authorized to 
provide care to help the veteran. In our medical centers and 
clinics, we can provide services to families when it is part of 
the treatment plan to benefit the veteran. That is a major part 
of mental health care, especially with more serious mental 
illness.
    Mr. Rodriguez. Can I interrupt there?
    Dr. Katz. Sure.
    Mr. Rodriguez. In cases of, for example, suicide or serious 
situations, does that trigger the need to bring in the family?
    Dr. Katz. Yes. Yes. And I want to respond in a sidetrack to 
answer about suicide and then go back to talking about 
families.
    We've been following the Joshua Omvig bill very, very 
closely in VA; and I am really very proud to say that, with 
leadership of Dr. Kussman and Dr. Cruas, we're already 
implementing almost all of that bill with existing legislative 
authority. We're committed to doing everything possible to 
prevent veteran suicides.
    About families, working with families as a part of 
benefiting the veteran who is in our care is only part of the 
story. We've been discussing possible legislative proposals to 
you, and one of them is asking for authorization to work with 
the families of people who haven't come to us, families who 
might notice mental illness or suffering or behavioral 
difficulties, dangers. We'll be asking for authorization to 
work with those families to evaluate the symptoms they report, 
to educate them about resources, to talk with them about 
helping to manage the veteran at home, and to collaborate with 
them about a plan to help the veteran engage in care. That is a 
low-cost, small-ticket item, but a kind of authorization that 
could help us reach out and meet needs.
    Mr. Mitchell [presiding]. Thank you.
    Mr. Rodriguez. Thank you very much for the services you 
provide for us.
    Mr. Mitchell. Mr. Hare?
    Mr. Hare. Ms. Pearce, let me just thank you for coming this 
evening. I listened to your testimony. I have a son. I can't 
imagine, you know, what you are going through and have gone 
through. And it struck me, one of the parts of your testimony 
is, you know, you were able to spend time with Brent and the 
numbers of people who may not be able to spend the kind of time 
and get the type of care and be around people who need them the 
most when they need them the most. I just wanted to tell you 
that, from my perspective and hopefully from this entire 
Subcommittee and full Committee's perspective, we've got to put 
an end to this.
    I said this before, and I will continue to say it, as my 
colleague Representative Walz has said, one soldier, one person 
is one too many, and we have a responsibility. I would like you 
to convey to your son and to your entire family, A, that you 
have talked to a lot of congressmen here this evening and, B, 
these Congress people have listened.
    We may be new, as I said before, but the advantage of being 
new is, you know, sometimes you get different ideas and you 
can--you know, I get a little angry, as you can probably tell--
or frustrated. But I'm probably not close to what you've been 
through. So please understand that we're going to work on this, 
and we will get this thing solved one way or another. I don't 
know how long it is going to take, but we're going to do it 
because it is the right thing to do.
    I want to ask Dr. Katz a question, and I'm not sure that we 
do this. For people who come back from the Middle East in 
whatever theater they served in, are all men and women tested 
for PTSD when they exit their tour?
    Dr. Katz. There are a couple levels, three levels at least, 
for testing, for screening to try to observe everyone who is 
suffering. There is the post-deployment health assessment just 
when people are leaving from deployment. There is the post-
deployment health reassessment conducted by DOD and the vet 
centers working with them, outreach to catch symptoms that may 
have emerged over 3 to 6 months after deployment. When people 
come to us, we screen everyone for symptoms of mental health 
conditions, PTSD and others, and follow up on what we find.
    Mr. Hare. And I would assume that by testing everybody or 
having everybody screened, whatever term you want to use, that 
would avoid someone having to feel guilty or someone, you know, 
the stigma that is touched with having a problem that that they 
can't necessarily--that they don't want their family to know 
about.
    But isn't it true that this whole--the post-traumatic 
stress or the disorders people have, it affects the entire 
family, as you mentioned, am I correct?
    Dr. Katz. Right.
    Mr. Hare. And then my other question to you--I'm sorry. I 
didn't want to interrupt your answer. But then the second part 
of that was, for those that don't have the symptoms or may be 
developed later, how do you identify them and reach out to them 
and have them come in and help them and their families?
    Dr. Katz. Yeah. You know, I think because of the experience 
with PTSD and returning veterans, America is learning that the 
strongest, best-trained and most resilient people can still be 
vulnerable to a mental illness. Unfortunately, the last people 
to learn that lesson may be the soldiers, who all too often 
still feel ashamed. So stigma remains a problem, in spite of 
what America is learning about PTSD and other mental health 
conditions.
    I am really proud of the 2-year eligibility without co-
payment in VA. That gives people a chance to come in, to get to 
know us and us to get to know them, to become aware of mild or 
moderate symptoms or to let them grow to trust us enough to 
tell us what they're suffering from.
    Mr. Hare. Is that 2 years enough or should that be extended 
in your opinion, Doctor? Is that 2-year window enough or should 
that be down the road?
    I'm not an expert. Obviously, I wouldn't know how long 
symptoms are going to take before somebody has that or has a 
problem. But is 2 years enough or should it be longer?
    Dr. Katz. Well, symptoms can emerge at any point throughout 
the lifespan, but the overwhelming number will emerge within 
that--you know, the greatest good--the greatest number might 
well be 2 years, although we worry about everyone we miss.
    Mr. Hare. Thank you, Doctor,
    Mr. Mitchell. Thank you.
    I want to thank you all for being here and staying with us 
for this long period of time. What you have given us is very 
important. We're hoping to, as all of us are, to try to make 
the lives of these veterans and these soldiers better. They 
have given a great sacrifice, and I think it is our duty as a 
nation to do everything we can, our utmost, to give them the 
finest care that they can get, and that is the purpose of these 
hearings.
    If there is no other business, this meeting is adjourned. 
Thank you.
    [Whereupon, at 7:04 p.m., the Subcommittee was adjourned.]















                            A P P E N D I X

                              ----------                              

              Prepared Statement of Hon. Harry E. Mitchell
         Chairman, Subcommittee on Oversight and Investigations
    Good afternoon and thank you for being here today.
    Two weeks ago, the American people learned that some of our most 
seriously wounded warriors were recovering in dilapidated conditions at 
the Walter Reed Army Medical Center, supposedly the Army's premier 
medical facility.
    These conditions are absolutely unacceptable--..and the American 
people are rightly outraged.
    Sadly, it appears the buildings are just the tip of the iceberg. 
Reports have been filtering in about a labyrinth of bureaucratic red 
tape our returning soldiers having to navigate to get the basic health 
care benefits they need and deserve.
    These problems have a direct impact on these men and women as they 
transition from the military's health care system into the VA.
    We have a responsibility to investigate how issues at the 
Department of Defense affect soldiers as they become veterans. We have 
a responsibility to make sure that the Department of Veterans' Affairs 
is doing its job to make that transition as easy as possible.
    I'm not convinced the Veterans' Affairs Department is doing its 
part.
    Last night, ABC News reported that ``a proposal to keep seriously 
wounded vets from falling through the cracks of the bureaucracy was 
shelved in 2005 when Jim Nicholson took over as the secretary of the 
Veterans Affairs Department.''
    I am deeply troubled when wounded soldiers say in news reports that 
the VA has made them feel ``horrible.''
    That's unacceptable and embarrassing, and the American people 
deserve answers. Today we hope to get some of them.
    In today's hearing, we will hear from witnesses who have seen or 
experience first-hand the difficulties veterans face when they 
transition from the DOD health care system to the VA network.
    Their stories are compelling, and I am eager to learn how the VA is 
responding to their concerns as well the health care needs of their 
fellow veterans. I am pleased to note the number of new veterans who 
have taken time to come and observe our hearing. In particular, I would 
like to recognize Specialist Gregory Williams, Corporal Noel Santos, 
Sergeant Frank Valentine, and Staff Sergeant Danny Vega. We are honored 
to welcome these young heroes.
    At this time, I ask unanimous consent that Mr. Filner, Mr. Buyer, 
Mr. Hare, Mr. Lamborn, and Mr. Bilirakis, be invited to sit at the dais 
for the Subcommittee hearing today.
    Hearing no objection, so ordered.
    Before I recognize the Ranking Republican Member for her remarks, I 
would like to swear in all our witnesses.
    I ask that all witnesses stand and raise their right hand.
    Do you solemnly swear to tell the truth, the whole truth, and 
nothing but the truth?
    I now recognize Ms. Brown-Waite for opening remarks.

                                 

    Prepared Statement of the Honorable Ginny Brown-Waite, Ranking 
    Republican Member, Subcommittee on Oversight and Investigations
    Thank you, Mr. Chairman for yielding.
    The Committee on Veterans' Affairs has been conducting oversight 
reviews of the seamless transition issue for our Nation's 
servicemembers for the past several Congresses. In the last Congress 
alone, the Committee and its Subcommittees held 10 hearings on the 
transition of our servicemembers. I believe I speak for all of us, when 
I say this is a top priority issue that, despite our best efforts, has 
not entirely been resolved.
    Congress codified the concept of ``DOD-VA Sharing'', now known as 
``Seamless Transition,'' in 1982, with passage of the Veterans 
Administration and the Department of Defense Health Resources Sharing 
and Emergency Operations Act (P.L. 97-174). This Act created the VA-
Care Committee to supervise and manage opportunities to share medical 
resources. Now, twenty-five years later, we are still discussing this 
issue.
    Some progress has been made in the areas of transitioning 
servicemembers back to the work force. Last Congress, P.L. 109-461 was 
enacted, which included various transition assistance initiatives 
ranging from health care needs to educational and employment training 
provisions.
    During the last Congress, Members and staff from the Committee 
conducted numerous field and site visits at VA and military treatment 
facilities and military bases to review efforts made on Seamless 
transition, and held oversight hearings in May and September of 2005. 
The transition and integration back into civilian life should be 
transparent and effortless for our servicemembers. However, this does 
not always appear to be the case. More often than not, the hand-offs 
have been fumbles.
    In a GAO report prepared for this Subcommittee on June 30, 2006, it 
was found that the VA has taken many aggressive actions to provide 
timely information to OEF and OIF servicemembers and their families, 
especially in their critical time of need. The report also noted the 
positive steps taken to increase the awareness, training and 
sensitivity of staff and medical providers on the needs of OEF and OIF 
servicemembers and veterans. The report also found that VA continues to 
have problems accessing real time medical information from DOD 
treatment facilities. These records are instrumental in continuing care 
for servicemembers and veterans receiving treatment at VA facilities.
    Mr. Chairman, I ask unanimous consent that a copy of this report be 
inserted into the official hearing record.
    Mr. Chairman, I know we have witnesses from the Walter Reed Army 
Medical Center. I would like to make it clear that today's hearing is 
not about the conditions at Walter Reed, but about the transition our 
servicemembers are making from DOD to VA Care. How the process works? 
Is there any gap in care? Is VA getting the information it needs from 
DOD in a timely manner to ensure the continuity of care for these new 
veterans, so that waiting periods for care do not extend for months 
after separation from active duty? And, why to this day is information 
on DOD personnel being cared for in the VA's polytrauma centers still 
not being transmitted electronically? Is there a difference between DOD 
electrons and VA electrons?
    Mr. Chairman, I ask unanimous consent that any full Committee 
Members attending this hearing be recognized under the 5 minute rule to 
question the witnesses after the Subcommittee's Members have been 
recognized.
    Again, thank you Mr. Chairman, and I yield back my time.

                                 

Statement of the Hon. Cliff Stearns, a Representative in Congress from 
                          the State of Florida
    Thank you Mr. Chairman,
    For several years now, we have held hearings, heard testimony, and 
listened to a number of recommendations and proposals to make the 
transition of service Members from active duty to the Veterans' 
Administration as smooth as possible. However, here we are again today, 
with many of the same issues outstanding.
    Last year's GAO report on these issues quoted VA officials as 
saying that the transfer of service Members to their system from the 
DOD would be more efficient if the Polytrauma Rehabilitation Center 
(PRC) medical personnel had real time access to the service Members' 
complete DOD electronic medical records from the referral facility. As 
Yogi Berra said, this is Deja-Vou all over again!
    Back in 1982, Congress identified the sharing of medical records as 
a critical need, and passed the ``Veterans Administration and the 
Department of Defense Health Resources Sharing and Emergency Operations 
Act'' that created the first interagency Committee to supervise those 
opportunities to exchange information between the two departments. This 
was the first in a long series of new oversight Committees, interagency 
cooperative Committees, and special task forces that looked into this 
same issue. Back in 2003, President Bush established the Task Force to 
Improve Health Care Delivery for Our Nation's Veterans. The first 
recommendation of this task force 4 years ago was that the VA and DOD 
should ``develop and deploy by fiscal year 2005'' electronic medical 
records that are interoperable for both systems and standards based. We 
are 2 years beyond that deadline and not much closer to its completion. 
Frankly, I am very concerned about the Information Security procedures 
at the VA which have not even implemented basic steps like encrypting 
each laptop. I would insist that those precautions are in place 
immediately and done before we add any more confidential information to 
the system.
    Another concern of mine is the availability of mental health 
services for our service Members returning from Operation Enduring 
Freedom and Operation Iraqi Freedom. It is my understanding that 
initial screenings by both the DOD and VA are conducted in adequate 
time, but the concern is the long wait for follow up appointments. Some 
veterans receiving mental health care for PTSD could be delayed in 
their next appointments by up to 90 days! Currently, VA officials 
report that they are managing the workload of referrals for PTSD 
treatment, but are concerned about the influx of new returning veterans 
from their service overseas which could strain the VA's ability to 
treat them. Over 24,000 service Members have returned from these 
theaters so far, and many more are anticipated over the coming year. We 
need to look into ways to expand the capacity of the VA to provide 
mental health services to our returning service members in a timely and 
efficient manner.

                                 

 Prepared Statement of Michael J. Kussman, MD, MS, MACP, Acting Under 
 Secretary for Health, Veterans Health Administration, U.S. Department 
                          of Veterans Affairs
    Mr. Chairman and Members of the Subcommittee, good afternoon. Thank 
you for this important opportunity to comment on the Veterans Health 
Administration's (VHA) efforts to ensure a seamless transition process 
for our injured service men and women, and our ongoing efforts to 
continuously improve this process.
    VHA's work to create a seamless transition for men and women as 
they leave the service and take up the honored title of ``veteran'' 
begins early on. Our Benefits Delivery at Discharge Program enables 
active duty Members to register for VA health care and to file for 
benefits prior to their separation from active service. Our outreach 
network ensures returning service Members receive full information 
about VA benefits and services. And each of our medical centers and 
benefits offices now has a point of contact assigned to work with 
veterans returning from service in Operation Enduring Freedom (OEF) and 
Operation Iraqi Freedom (OIF).
    VHA has coordinated the transfer of over 6,800 severely injured or 
ill active duty service Members and veterans from DOD to VA. Our 
highest priority is to ensure that those returning from the Global War 
on Terror transition seamlessly from DOD Military Treatment Facilities 
(MTFs) to VA Medical Centers (VAMCs) and continue to receive the best 
possible care available anywhere. Toward that end, we continually 
strive to improve the delivery of this care.
    In partnership with DOD, VA has implemented a number of strategies 
to provide timely, appropriate, and seamless transition services to the 
most seriously injured OEF/OIF active duty service Members and 
veterans.
    VA social workers, benefits counselors, and outreach coordinators 
advise and explain the full array of VA services and benefits. These 
liaisons and coordinators assist active duty service Members as they 
transfer from MTFs to VA medical facilities. In addition, our social 
workers help newly wounded soldiers, sailors, airmen and Marines and 
their families plan a future course of treatment for their injuries 
after they return home. Currently, VA Social Work and Benefit liaisons 
are located at 10 MTFs, including Walter Reed Army Medical Center, the 
National Naval Medical Center Bethesda, the Naval Medical Center San 
Diego, and Womack Army Medical Center at Ft. Bragg.
    Since September 2006, a VA Certified Rehabilitation Registered 
Nurse (CRRN) has been assigned to Walter Reed to assess and provide 
regular updates to our Polytrauma Rehabilitation Centers (PRC) 
regarding the medical condition of incoming patients. The CRRN advises 
and assists families and prepares active duty service Members for 
transition to VA and the rehabilitation phase of their recovery.
    VA's Social Work Liaisons and the CRRN fully coordinate care and 
information prior to a patient's transfer to our Department. Social 
Worker Liaisons meet with patients and their families to advise and 
``talk them through'' the transition process. They register service 
Members or enroll recently discharged veterans in the VA health care 
system, and coordinate their transfer to the most appropriate VA 
facility for the medical services needed, or to the facility closest to 
their home.
    In the case of transfers of seriously injured patients, both the 
CCRN and the Social Work Liaison are an integral part of the MTF 
treatment team. They simultaneously provide input into the VA health 
care treatment plan and collaborate with both the patient and his or 
her family throughout the entire health care transition process. Video 
teleconference calls are routinely conducted between DOD MTF treatment 
teams and receiving VA PRC teams. If feasible, the patient and family 
attend these video teleconferences to participate in discussions and to 
`meet' the VA PRC team.
    I should note that one important aspect of coordination between DOD 
and VA prior to a patient's transfer to VA is access to clinical 
information. This includes a pre-transfer review of electronic medical 
information via remote access capabilities. The VA polytrauma centers 
have been granted direct access into inpatient clinical information 
systems from Walter Reed Army Medical Center (WRAMC) and National Naval 
Medical Center (NNMC). VA and DOD are currently working together to 
ensure that appropriate users are adequately trained and connectivity 
is working and exists for all four polytrauma centers. For those 
inpatient data that are not available in DOD's information systems, VA 
social workers embedded in the military treatment facilities routinely 
ensure that the paper records are manually transferred to the receiving 
polytrauma centers.
    Another data exchange system, the Bidirectional Health Information 
Exchange (BHIE) allows VA and DOD clinicians to share text-based 
outpatient clinical data between VA and the ten MTFs, including Walter 
Reed and Bethesda.
    VA case management for these patients begins at the time of 
transition from the MTF and continues as their medical and 
psychological needs dictate. Once the patient transfers to the 
receiving VAMC, or reports to his or her home VAMC for care, the VA 
Social Worker Liaison at the MTF continues to coordinate with VA to 
address after-transfer issues of care. Seriously injured patients 
receive ongoing case management at the VA facility where they receive 
most of their care. Since April of 2006, points of contact or case 
managers have been identified in every VA medical center. In response 
to the Secretary's request this week, VA is in the process of hiring 
the 100 OIF/OEF veterans to serve as case advocates to support their 
severely injured fellow veterans and their families.
    VA has four Polytrauma Rehabilitation Centers, located at Tampa, 
FL; Richmond, VA; Minneapolis, MN; and Palo Alto, CA. The Army has 
assigned fulltime active duty Liaison Officers to each one in order to 
support military personnel and their families from all Service 
branches. The Liaison officers address a broad array of issues, such as 
travel, housing, military pay, and movement of household goods.
    In addition, Marine Corps representatives from nearby local 
Commands visit and provide support to each of the Polytrauma 
Rehabilitation Centers. At VA Central Office in Washington, DC, an 
active duty Marine Officer and an Army Wounded Warrior representatives 
are assigned to the Office of Seamless Transition to serve as liaisons. 
Both the Army and the Marine Liaisons play a vital role in ensuring the 
provision of a wide bridge of services during the critical time of 
patient recovery and rehabilitation.
    VHA understands the critical importance of supporting families 
during the transition from DOD to VA. We established a Polytrauma Call 
Center in February 2006, to assist the families of our most seriously 
injured combat veterans and service Members. The Call Center operates 
24 hours-a-day, 7 days-a-week to answer clinical, administrative, and 
benefit inquiries from polytrauma patients and family Members. The 
Center's value is threefold. It furnishes patients and their families 
with a one-stop source of information; it enhances overall coordination 
of care; and, very importantly, it immediately elevates any system 
problems to VA for resolution.
    VA's Office of Seamless Transition includes two Outreach 
Coordinators--a peer-support volunteer and a veteran of the Vietnam 
War--who regularly visit seriously injured service members at Walter 
Reed and Bethesda. Their visits enable them to establish a personal and 
trusted connection with patients and their families.
    These Outreach Coordinators help identify gaps in VA services by 
submitting and tracking follow-up recommendations. They encourage 
patients to consider participating in VA's National Rehabilitation 
Special Events or to attend weekly dinners held in Washington, DC, for 
injured OEF/OIF returnees. In short, they are key to enhancing and 
advancing the successful transition of our service personnel from DOD 
to VA, and, in turn, to their homes and communities.
    In addition, VA has developed a vigorous outreach, education, and 
awareness program for the National Guard and Reserve. To ensure 
coordinated transition services and benefits, VA signed a Memorandum of 
Agreement (MOA) with the National Guard in 2005. Combined with VA/
National Guard State Coalitions in 54 states and territories, VA has 
significantly improved its opportunities to access returning troops and 
their families. We are continuing to partner with community 
organizations and other local resources to enhance the delivery of VA 
services. At the national level, MOAs are under development with both 
the United States Army Reserve and the United States Marine Corps. 
These new partnerships will increase awareness of, and access to, VA 
services and benefits during the de-mobilization process and as service 
personnel return to their local communities.
    VA is also reaching out to returning veterans whose wounds may be 
less apparent. VA is a participant in the DOD's Post Deployment Health 
Reassessment (PDHRA) program. DOD conducts a health reassessment 90-180 
days after return from deployment to identify health issues that can 
surface weeks or months after service Members return home.
    VA actively participates in the administration of PDHRA at Reserve 
and Guard locations in a number of ways. We provide information about 
VA care and benefits; enroll interested Reservists and Guardsmen in the 
VA health care system; and arrange appointments for referred service 
Members. As of December 2006, an estimated 68,800 service Members were 
screened, resulting in over 17,100 referrals to VA. Of those referrals, 
32.8% were for mental health and readjustment issues; the remaining 
67.2% for physical health issues.
    Congress created the Readjustment Counseling Service (RCS), 
commonly known to veterans as the Vet Center Program, as VHA's outreach 
element. Program eligibility was originally targeted to Vietnam 
veterans; today it serves all returning combat veterans. The Vet Center 
Program receives high ratings in veterans' satisfaction, employee 
satisfaction, and other measurable indicators of quality and effective 
care.
    The approximate number of OEF/OIF combat veterans served by Vet 
Centers to date is 165,000 (119,600 through outreach; 45,400 seen at 
centers). In February of 2004, the Secretary of Veterans Affairs 
approved the hiring of 50 OEF/OIF combat veterans to support the 
Program by reaching out actively to National Guard, and Reserve service 
Members returning from combat. An additional 50 were hired in March of 
2005. This action advanced the continuing success of our Vet Centers in 
their ability to assist our newest veterans and their families. VA Vet 
Centers have provided bereavement services to 900 families of fallen 
warriors.
    VA plans to expand its Vet Center Program. We will open 15 new Vet 
Centers and eight new Vet Center outstations at locations throughout 
the Nation by the end of 2008. At that time, Vet Centers will total 
232. We expect to add staff to 61 existing facilities to augment the 
services they provide. Seven of the 23 new centers will open this 
Calendar Year 2007.
    In addition, as you know this week the President created an 
Interagency Task Force on Returning Global War on Terror Heroes (Heroes 
Task Force), chaired by the Secretary of Veterans Affairs, to respond 
to the immediate needs of returning Global War on Terror service 
Members. The Heroes Task Force, which had its first meeting on Tuesday, 
will work to identify and resolve any gaps in service for service 
Members. As Secretary Nicholson said, no task is more important to the 
VA than ensuring our heroes receive the best possible care and 
services.
    Finally, The VA is partnering with the State VA Directors in the 
``State Benefits Seamless Transition Program'' in which severely 
injured service Members can release their contact information to their 
home State VA Office to be educated about their State Benefits.
    VA staff assigned to major MTFs are coordinating with Heroes to 
Hometown as a resource to provide to service Members returning to 
civilian life.
    Mr. Chairman, this concludes my presentation. At this time, I would 
be pleased to answer any questions you may have.

                                 

   Prepared Statement of Cynthia A. Bascetta, Director, Health Care,
                 U.S. Government Accountability Office
    Mr. Chairman and Members of the Subcommittee:
    I am pleased to be here today to discuss health care and other 
services for U.S. military servicemembers wounded during Operation 
Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF).\1\ On March 1, 
2007, the Department of Defense (DOD) reported that over 24,000 
servicemembers have been wounded in action since the onset of the two 
conflicts. In 2005, DOD reported that about 65 percent of the OEF and 
OIF servicemembers wounded in action were injured by blasts and 
fragments from improvised explosive devices, land mines, and other 
explosive devices. More recently, DOD estimated in 2006 that as many as 
28 percent of those injured by blasts and fragments have some degree of 
trauma to the brain. These injuries often require comprehensive 
inpatient rehabilitation services to address complex cognitive and 
physical impairments. In addition to their physical injuries, OEF/OIF 
servicemembers who have been injured in combat may also be at risk for 
developing mental health impairments, such as post-traumatic stress 
disorder (PTSD), which research has shown to be strongly associated 
with experiencing intense and prolonged combat.\2\
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    \1\ OEF, which began in October 2001, supports combat operations in 
Afghanistan and other locations, and OIF, which began in March 2003, 
supports combat operations in Iraq and other locations.
    \2\ Charles W. Hoge et al., ``Combat Duty in Iraq and Afghanistan, 
Mental Health Problems, and Barriers to Care,'' The New England Journal 
of Medicine, 351 (2004): 13-22.
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    While servicemembers are on active duty, DOD decides where they 
receive their care--at a military treatment facility (MTF), from a 
TRICARE civilian provider,\3\ or at a Department of Veterans Affairs 
(VA) medical facility. From the OEF and OIF conflict areas, seriously 
injured servicemembers are usually brought to Landstuhl Regional 
Medical Center in Germany for treatment. From there, they are usually 
transported to MTFs located in the United States, with most of the 
seriously injured admitted to Walter Reed Army Medical Center or the 
National Naval Medical Center, both of which are in the Washington, 
D.C., area.\4\ Once the servicemembers are medically stabilized, DOD 
can elect to send those with traumatic brain injuries and other complex 
trauma, such as missing limbs, to one of the four polytrauma 
rehabilitation centers (PRC) \5\ operated by VA for medical and 
rehabilitative care. The PRCs are located at VA medical centers in Palo 
Alto, California; Tampa, Florida; Minneapolis, Minnesota; and Richmond, 
Virginia. While many servicemembers who receive such rehabilitative 
services return to active duty after they are treated, others who are 
more seriously injured are likely to be discharged from their military 
obligations and return to civilian life with disabilities.
---------------------------------------------------------------------------
    \3\ DOD provides health care through TRICARE--a regionally 
structured program that uses civilian contractors to maintain provider 
networks to complement health care services provided at MTFs.
    \4\ Other MTFs that received OEF/OIF servicemembers include Brooke 
Army Medical Center (San Antonio, Texas), Dwight David Eisenhower Army 
Medical Center (Augusta, Georgia), Madigan Army Medical Center (Tacoma, 
Washington), Darnall Army Community Hospital (Fort Hood, Texas), Evans 
Army Community Hospital (Fort Carson, Colorado), and the Naval Hospital 
Camp Pendleton (Camp Pendleton, California).
    \5\ The Veterans Health Programs Improvement Act of 2004, Pub. L. 
No. 108-422,  302, 118 Stat. 2379, 2383-86, mandated that VA establish 
centers for research, education, and clinical activities related to 
complex multiple trauma associated with combat injuries. In response to 
that mandate, VA established PRCs at four VA medical facilities with 
expertise in traumatic amputation, spinal cord injury, traumatic brain 
injury, and blind rehabilitation. A PRC addresses the rehabilitation 
needs of the combat injured in one setting and in a coordinated manner.
---------------------------------------------------------------------------
    Our work has shown that servicemembers injured in combat face an 
array of significant medical and financial challenges as they begin 
their recovery process in the DOD and VA health care systems. In light 
of these challenges and recent media reports that have highlighted 
unsanitary and decrepit living conditions at the Walter Reed Army 
Medical Center,\6\ you asked us to discuss concerns we have identified 
regarding DOD and VA efforts to provide medical care and rehabilitative 
services for servicemembers who have been injured during OEF and OIF. 
Specifically, my remarks today will focus on (1) the transition of care 
for seriously injured OEF/OIF servicemembers--those with traumatic 
brain injuries or other complex trauma, such as missing limbs--who are 
transferred between DOD and VA medical facilities; (2) DOD's and VA's 
efforts to provide early intervention for rehabilitation services as 
soon as possible after the onset of a disability for seriously injured 
servicemembers; (3) DOD's efforts to screen OEF/OIF servicemembers at 
risk for PTSD and whether VA can meet the demand for PTSD services; and 
(4) the impact of problems related to military pay on injured 
servicemembers and their families.
---------------------------------------------------------------------------
    \6\ See, for instance, Dana Priest and Anne Hull, ``Soldiers Face 
Neglect, Frustration at Army's Top Medical Facility,'' The Washington 
Post (Feb. 18, 2007).
---------------------------------------------------------------------------
    My testimony is based on issued GAO work.\7\ The information I am 
reporting today reflects the conditions facing OEF/OIF servicemembers 
at the time the audit work was completed and illustrates the types of 
problems injured servicemembers encountered during their healing and 
rehabilitation process. To complete the work for these products, we 
visited DOD and VA facilities, reviewed relevant documents, analyzed 
DOD data, and interviewed DOD and VA officials. Our work was performed 
in accordance with generally accepted government auditing standards.
---------------------------------------------------------------------------
    \7\ See Related GAO Products at the end of this statement.
---------------------------------------------------------------------------
    In summary, DOD and VA have made various efforts to provide medical 
care and rehabilitative services for OEF/OIF servicemembers. The 
departments established joint programs to facilitate the transfer of 
injured servicemembers from DOD facilities to VA medical facilities, 
assess whether servicemembers will be able to remain in the military, 
and assign VA social workers to selected MTFs to coordinate the 
transfers. DOD has also established a program to screen servicemembers 
after their deployment outside of the United States has ended to assess 
whether they are at risk for PTSD. However, we found several problems 
in the efforts to provide health care and rehabilitative services for 
OEF/OIF servicemembers. For example, DOD and VA had problems sharing 
medical records and questions arose about the timing of VA's outreach 
to servicemembers whose discharge from military service was not 
certain. Furthermore, we found that DOD cannot provide reasonable 
assurance that OEF/OIF servicemembers who need referrals for mental 
health evaluations receive them. Finally, problems related to military 
pay have resulted in overpayments and debt for hundreds of sick and 
injured servicemembers.
DOD and VA Have Taken Actions to Facilitate the Transfer of 
        Servicemembers but Experienced Problems in Exchanging Health 
        Care Information
    In our June 2006 report, we found that DOD and VA had taken actions 
to facilitate the transition of medical and rehabilitative care for 
seriously injured servicemembers who were being transferred from MTFs 
to PRCs.\8\ For example, in April 2004, DOD and VA signed a memorandum 
of agreement that established referral procedures for transferring 
injured servicemembers from DOD to VA medical facilities. DOD and VA 
also established joint programs to facilitate the transfer to VA 
medical facilities, including a program that assigned VA social workers 
to selected MTFs to coordinate transfers.
---------------------------------------------------------------------------
    \8\ GAO, VA and DOD Health Care: Efforts to Provide Seamless 
Transition of Care for OEF and OIF Servicemembers and Veterans, GAO-06-
794R (Washington, D.C.: June 30, 2006).
---------------------------------------------------------------------------
    Despite these coordination efforts, we found that DOD and VA were 
having problems sharing the medical records VA needed to determine 
whether servicemembers' medical conditions allowed participation in 
VA's vigorous rehabilitation activities. DOD and VA reported that as of 
December 2005 two of the four PRCs had real-time access to the 
electronic medical records maintained at Walter Reed Army Medical 
Center and only one of the two also had access to the records at the 
National Naval Medical Center. In cases where medical records could not 
be accessed electronically, the MTF faxed copies of some medical 
information, such as the patient's medical history and progress notes, 
to the PRC. Because this information did not always provide enough data 
for the PRC provider to determine if the servicemember was medically 
stable enough to be admitted to the PRC, VA developed a standardized 
list of the minimum types of health care information needed about each 
servicemember transferring to a PRC. Even with this information, PRC 
providers frequently needed additional information and had to ask for 
it specifically. For example, if the PRC provider notices that the 
servicemember is on a particular antibiotic therapy, the provider may 
request the results of the most recent blood and urine cultures to 
determine if the servicemember is medically stable enough to 
participate in strenuous rehabilitation activities. According to PRC 
officials, obtaining additional medical information in this way, rather 
than electronically, is very time consuming and often requires multiple 
phone calls and faxes. VA officials told us that the transfer could be 
more efficient if PRC medical personnel had real-time access to the 
servicemembers' complete DOD electronic medical records from the 
referring MTFs. However, problems existed even for the two PRCs that 
had been granted electronic access. During a visit to those PRCs in 
April 2006, we found that neither facility could access the records at 
Walter Reed Army Medical Center because of technical difficulties.
DOD and VA Collaboration Is Important for Early Intervention for 
        Rehabilitation
    As discussed in our January 2005 report, the importance of early 
intervention for returning individuals with disabilities to the work 
force is well documented in vocational rehabilitation literature.\9\ In 
1996, we reported that early intervention significantly facilitates the 
return to work but that challenges exist in providing services 
early.\10\ For example, determining the best time to approach recently 
injured servicemembers and gauge their personal receptivity to 
considering employment in the civilian sector is inherently difficult. 
The nature of the recovery process is highly individualized and 
requires professional judgment to determine the appropriate time to 
begin vocational rehabilitation. Our 2007 High-Risk Series: An Update 
designates Federal disability programs as ``high risk'' because they 
lack emphasis on the potential for vocational rehabilitation to return 
people to work.\11\
---------------------------------------------------------------------------
    \9\ GAO, Vocational Rehabilitation: More VA and DOD Collaboration 
Needed to Expedite Services for Seriously Injured Servicemembers, GAO-
05-167 (Washington, D.C.: Jan. 14, 2005).
    \10\ We also reported on early intervention in GAO, SSA Disability: 
Return-to-Work Strategies from Other Systems May Improve Federal 
Programs, GAO/HEHS-96-133 (Washington, D.C.: July 11, 1996).
    \11\ GAO, High-Risk Series: An Update, GAO-07-310 (Washington, 
D.C.: January 2007).
---------------------------------------------------------------------------
    In our January 2005 report, we found that servicemembers whose 
disabilities are definitely or likely to result in military separation 
may not be able to benefit from early intervention because DOD and VA 
could work at cross purposes. In particular, DOD was concerned about 
the timing of VA's outreach to servicemembers whose discharge from 
military service is not yet certain. DOD was concerned that VA's 
efforts may conflict with the military's retention goals. When 
servicemembers are treated as outpatients at a VA or military hospital, 
DOD generally begins to assess whether the servicemember will be able 
to remain in the military. This process can take months. For its part, 
VA took steps to make seriously injured servicemembers a high priority 
for all VA assistance. Noting the importance of early intervention, VA 
instructed its regional offices in 2003 to assign a case manager to 
each seriously injured servicemember who applies for disability 
compensation. VA had detailed staff to MTFs to provide information on 
all veterans' benefits, including vocational rehabilitation, and 
reminded staff that they can initiate evaluation and counseling, and, 
in some cases, authorize training before a servicemember is discharged. 
While VA tries to prepare servicemembers for a transition to civilian 
life, VA's outreach process may overlap with DOD's process for 
evaluating servicemembers for a possible return to duty.
    In our report, we concluded that instead of working at cross 
purposes to DOD goals, VA's early intervention efforts could facilitate 
servicemembers' return to the same or a different military occupation, 
or to a civilian occupation if the servicemembers were not able to 
remain in the military. In this regard, the prospect for early 
intervention with vocational rehabilitation presents both a challenge 
and an opportunity for DOD and VA to collaborate to provide better 
outcomes for seriously injured servicemembers.
DOD Screens Servicemembers for PTSD after Deployment, but DOD and VA 
        Face Challenges Ensuring Further PTSD Services
    In our May 2006 report, we described DOD's efforts to identify and 
facilitate care for OEF/OIF servicemembers who may be at risk for 
PTSD.\12\ To identify such servicemembers, DOD uses a questionnaire, 
the DD 2796, to screen OEF/OIF servicemembers after their deployment 
outside of the United States has ended. The DD 2796 is used to assess 
servicemembers' physical and mental health and includes four questions 
to identify those who may be at risk for developing PTSD. We reported 
that according to a clinical practice guideline jointly developed by 
DOD and VA, servicemembers who responded positively to at least three 
of the four PTSD screening questions may be at risk for developing 
PTSD. DOD health care providers review completed questionnaires, 
conduct face-to-face interviews with servicemembers, and use their 
clinical judgment in determining which servicemembers need referrals 
for further mental health evaluations.\13,\ \14\ OEF/OIF servicemembers 
can obtain the mental health evaluations, as well as any necessary 
treatment for PTSD, while they are servicemembers--that is, on active 
duty--or when they transition to veteran status if they are discharged 
or released from active duty.
---------------------------------------------------------------------------
    \12\ GAO, Post-Traumatic Stress Disorder: DOD Needs to Identify the 
Factors Its Providers Use to Make Mental Health Evaluation Referrals 
for Servicemembers, GAO-06-397 (Washington, D.C.: May 11, 2006).
    \13\ Health care providers that review the DD 2796 may include 
physicians, physician assistants, nurse practitioners, or independent 
duty medical technicians--enlisted personnel who receive advanced 
training to provide treatment and administer medications.
    \14\ DOD's referrals are used to document DOD's assessment that 
servicemembers are in need of further mental health evaluations.
---------------------------------------------------------------------------
    Despite DOD's efforts to identify OEF/OIF servicemembers who may 
need referrals for further mental health evaluations, we reported that 
DOD cannot provide reasonable assurance that OEF/OIF servicemembers who 
need the referrals receive them. Using data provided by DOD,\15\ we 
found that 22 percent, or 2,029, of the 9,145 OEF/OIF servicemembers in 
our review who may have been at risk for developing PTSD were referred 
by DOD health care providers for further mental health evaluations. 
Across the military service branches, DOD health care providers varied 
in the frequency with which they issued referrals to OEF/OIF 
servicemembers with three or more positive responses to the PTSD 
screening questions--the Army referred 23 percent, the Air Force about 
23 percent, the Navy 18 percent, and the Marines about 15 percent. 
According to DOD officials, not all of the OEF/OIF servicemembers with 
three or four positive responses on the screening questionnaire need 
referrals. As directed by DOD's guidance for using the DD 2796, DOD 
health care providers are to rely on their clinical judgment to decide 
which of these servicemembers need further mental health evaluations. 
However, at the time of our review DOD had not identified the factors 
its health care providers used to determine which OEF/OIF 
servicemembers needed referrals. Knowing these factors could explain 
the variation in referral rates and allow DOD to provide reasonable 
assurance that such judgments are being exercised appropriately.\16\ We 
recommended that DOD identify the factors that DOD health care 
providers used in issuing referrals for further mental health 
evaluations to explain provider variation in issuing referrals. DOD 
concurred with the recommendation.
---------------------------------------------------------------------------
    \15\ In our review we analyzed computerized data provided by DOD to 
identify 178,664 OEF/OIF servicemembers who were deployed in support of 
OEF/OIF from October 1, 2001, through September 30, 2004, and who have 
since been discharged or released from active duty. These 
servicemembers had answered the four PTSD screening questions on the DD 
2796 and had a record of their completed questionnaire available in a 
DOD computerized database. We found that DOD data indicated 9,145 of 
the 178,664 servicemembers in our review may have been at risk for 
developing PTSD.
    \16\ The John Warner National Defense Authorization Act for Fiscal 
Year 2007 required DOD to develop guidelines for mental health 
referrals, as well as mechanisms to ensure proper training and 
oversight, by April 2007. Pub. L. No. 109-364,  738, 120 Stat. 2083, 
2303	4.
---------------------------------------------------------------------------
    Although OEF/OIF servicemembers may obtain mental health 
evaluations or treatment for PTSD through VA when they transition to 
veteran status, VA may face a challenge in meeting the demand for PTSD 
services. In September 2004 we reported that VA had intensified its 
efforts to inform new veterans from the Iraq and Afghanistan conflicts 
about the health care services--including treatment for PTSD--VA offers 
to eligible veterans.\17\ We observed that these efforts, along with 
expanded availability of VA health care services for Reserve and 
National Guard Members, could result in an increased percentage of 
veterans from Iraq and Afghanistan seeking PTSD services through VA. 
However, at the time of our review officials at six of seven VA medical 
facilities we visited explained that while they were able to keep up 
with the current number of veterans seeking PTSD services, they may not 
be able to meet an increase in demand for these services. In addition, 
some of the officials expressed concern because facilities had been 
directed by VA to give veterans from the Iraq and Afghanistan conflicts 
priority appointments for health care services, including PTSD 
services. As a result, VA medical facility officials estimated that 
follow-up appointments for veterans receiving care for PTSD could be 
delayed. VA officials estimated the delays to be up to 90 days.
---------------------------------------------------------------------------
    \17\ GAO, VA and Defense Health Care: More Information Needed to 
Determine If VA Can Meet an Increase in Demand for Post-Traumatic 
Stress Disorder Services, GAO-04-1069 (Washington, D.C.: Sept. 20, 
2004).
---------------------------------------------------------------------------
Problems Related to Military Pay Have Resulted in Debt and Other 
        Hardships for Hundreds of Sick and Injured Servicemembers
    As discussed in our April 2006 testimony, problems related to 
military pay have resulted in overpayments and debt for hundreds of 
sick and injured servicemembers.\18\ These pay problems resulted in 
significant frustration for the servicemembers and their families. We 
found that hundreds of battle-injured servicemembers were pursued for 
repayment of military debts through no fault of their own, including at 
least 74 servicemembers whose debts had been reported to credit bureaus 
and private collections agencies. In response to our audit, DOD 
officials said collection actions on these servicemembers' debts had 
been suspended until a determination could be made as to whether these 
servicemembers' debts were eligible for relief.
---------------------------------------------------------------------------
    \18\ GAO, Military Pay: Military Debts Present Significant 
Hardships to Hundreds of Sick and Injured GWOT Soldiers, GAO-06-657T 
(Washington, D.C.: April 27, 2006).
---------------------------------------------------------------------------
    Debt collection actions created additional hardships on 
servicemembers by preventing them from getting loans to buy houses or 
automobiles or pay off other debt, and sending several servicemembers 
into financial crisis. Some battle-injured servicemembers forfeited 
their final separation pay to cover part of their military debt, and 
they left the service with no funds to cover immediate expenses while 
facing collection actions on their remaining debt.
    We also found that sick and injured servicemembers sometimes went 
months without paychecks because debts caused by overpayments of combat 
pay and other errors were offset against their military pay.\19\ 
Furthermore, the longer it took DOD to stop the overpayments, the 
greater the amount of debt that accumulated for the servicemember and 
the greater the financial impact, since more money would eventually be 
withheld from the servicemember's pay or sought through debt collection 
action after the servicemember had separated from the service.
---------------------------------------------------------------------------
    \19\ We found that after voluntary allotments and other required 
deductions, many times there was no net pay due the servicemember.
---------------------------------------------------------------------------
    In our 2005 testimony about Army National Guard and Reserve 
servicemembers, we found that poorly defined requirements and processes 
for extending injured and ill reserve component servicemembers on 
active duty have caused servicemembers to be inappropriately dropped 
from active duty.\20\ For some, this has led to significant gaps in pay 
and health insurance, which has created financial hardships for these 
servicemembers and their families.
---------------------------------------------------------------------------
    \20\ GAO, Military Pay: Gaps in Pay and Benefits Create Financial 
Hardships for Injured Army National Guard and Reserve Soldiers, GAO-05-
322T (Washington, D.C.: Feb. 17, 2005).
---------------------------------------------------------------------------
    Mr. Chairman, this completes my prepared remarks. I would be happy 
to respond to any questions you or other Members of the Subcommittee 
may have at this time.
Contacts and Acknowledgments
    For further information about this testimony, please contact 
Cynthia A. Bascetta at (202) 512-7101 or bascettac@gao.gov. Contact 
points for our Offices of Congressional Relations and Public Affairs 
may be found on the last page of this statement. Michael T. Blair, Jr., 
Assistant Director; Cynthia Forbes; Krister Friday; Roseanne Price; 
Cherie' Starck; and Timothy Walker made key contributions to this 
statement.
Related GAO Products
    High-Risk Series: An Update. GAO-07-310. Washington, D.C.: January 
2007.
    VA and DOD Health Care: Efforts to Provide Seamless Transition of 
Care for OEF and OIF Servicemembers and Veterans. GAO-06-794R. 
Washington, D.C.: June 30, 2006.
    Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors 
Its Providers Use to Make Mental Health Evaluation Referrals for 
Servicemembers. GAO-06-397. Washington, D.C.: May 11, 2006.
    Military Pay: Military Debts Present Significant Hardships to 
Hundreds of Sick and Injured GWOT Soldiers. GAO-06-657T. Washington, 
D.C.: April 27, 2006.
    Military Disability System: Improved Oversight Needed to Ensure 
Consistent and Timely Outcomes for Reserve and Active Duty Service 
Members. GAO-06-362. Washington, D.C.: March 31, 2006.
    Military Pay: Gaps in Pay and Benefits Create Financial Hardships 
for Injured Army National Guard and Reserve Soldiers. GAO-05-322T. 
Washington, D.C.: February 17, 2005.
    Vocational Rehabilitation: More VA and DOD Collaboration Needed to 
Expedite Services for Seriously Injured Servicemembers. GAO-05-167. 
Washington, D.C.: January 14, 2005.
    VA and Defense Health Care: More Information Needed to Determine If 
VA Can Meet an Increase in Demand for Post-Traumatic Stress Disorder 
Services. GAO-04-1069. Washington, D.C.: September 20, 2004.
    SSA Disability: Return-to-Work Strategies from Other Systems May 
Improve Federal Programs. GAO/HEHS-96-133. Washington, D.C.: July 11, 
1996.
    (290621)
                               __________
GAO HIGHLIGHTS
DOD AND VA HEALTH CARE
Challenges Encountered by Injured Servicemembers During Their Recovery 
        process
Why GAO Did This Study
    As of March 1, 2007, over 24,000 servicemembers have been wounded 
in action since the onset of Operation Enduring Freedom (OEF) and 
Operation Iraqi Freedom (OIF), according to the Department of Defense 
(DOD). GAO work has shown that servicemembers injured in combat face an 
array of significant medical and financial challenges as they begin 
their recovery process in the health care systems of DOD and the 
Department of Veterans Affairs (VA).
    GAO was asked to discuss concerns regarding DOD and VA efforts to 
provide medical care and rehabilitative services for servicemembers who 
have been injured during OEF and OIF. This testimony addresses (1) the 
transition of care for seriously injured servicemembers who are 
transferred between DOD and VA medical facilities, (2) DOD's and VA's 
efforts to provide early intervention for rehabilitation for seriously 
injured servicemembers, (3) DOD's efforts to screen servicemembers at 
risk for post-traumatic stress disorder (PTSD) and whether VA can meet 
the demand for PTSD services, and (4) the impact of problems related to 
military pay on injured servicemembers and their families.
    This testimony is based on GAO work issued from 2004 through 2006 
on the conditions facing OEF/OIF servicemembers at the time the audit 
work was completed.
What GAO Found
    Despite coordinated efforts, DOD and VA have had problems sharing 
medical records for servicemembers transferred from DOD to VA medical 
facilities. GAO reported in 2006 that two VA facilities lacked real-
time access to electronic medical records at DOD facilities. To obtain 
additional medical information, facilities exchanged information by 
means of a time-consuming process resulting in multiple faxes and phone 
calls.
    In 2005, GAO reported that VA and DOD collaboration is important 
for providing early intervention for rehabilitation. VA has taken steps 
to initiate early intervention efforts, which could facilitate 
servicemembers' return to duty or to a civilian occupation if the 
servicemembers were unable to remain in the military. However, 
according to DOD, VA's outreach process may overlap with DOD's process 
for evaluating servicemembers for a possible return to duty. DOD was 
also concerned that VA's efforts may conflict with the military's 
retention goals. In this regard, DOD and VA face both a challenge and 
an opportunity to collaborate to provide better outcomes for seriously 
injured servicemembers.
    DOD screens servicemembers for PTSD but, as GAO reported in 2006, 
it cannot ensure that further mental health evaluations occur. DOD 
health care providers review questionnaires, interview servicemembers, 
and use clinical judgment in determining the need for further mental 
health evaluations. However, GAO found that 22 percent of the OEF/OIF 
servicemembers in GAO's review who may have been at risk for developing 
PTSD were referred by DOD health care providers for further 
evaluations. According to DOD officials, not all of the servicemembers 
at risk will need referrals. However, at the time of GAO's review DOD 
had not identified the factors its health care providers used to 
determine which OEF/OIF servicemembers needed referrals. Although OEF/
OIF servicemembers may obtain mental health evaluations or treatment 
for PTSD through VA, VA may face a challenge in meeting the demand for 
PTSD services. VA officials estimated that follow-up appointments for 
veterans receiving care for PTSD may be delayed up to 
90 
days.
    GAO's 2006 testimony pointed out problems related to military pay 
have resulted in debt and other hardships for hundreds of sick and 
injured servicemembers. Some servicemembers were pursued for repayment 
of military debts through no fault of their own. As a result, 
servicemembers have been reported to credit bureaus and private 
collections agencies, been prevented from getting loans, g1 months 
without paychecks, and sent into financial crisis. In a 2005 testimony 
GAO reported that poorly defined requirements and processes for 
extending the active duty of injured and ill reserve component 
servicemembers have caused them to be inappropriately dropped from 
active duty, leading to significant gaps in pay and health insurance 
for some servicemembers and their families.

                                 

   Prepared Statement of Shane McNamee, MD, Director, Hunter Holmes 
 McGuire Richmond Veterans Affairs Medical Center, Richmond, VA, U.S. 
                     Department of Veterans Affairs
    Good afternoon, Mr. Chairman and Members of the Committee. Thank 
you for the opportunity to discuss the transition of our Wounded Heroes 
through the Veterans Health Administration. My name is Dr. Shane 
McNamee and I will be testifying from the perspective of a clinician as 
well as in my role as the Medical Director of the Richmond Polytrauma 
program. To frame the issue appropriately I will describe the typical 
transition process of severely Wounded Heroes and their families from 
the Military Treatment Facilities (MTF), through our programs and into 
communities. It is my firm belief that this highly coordinated, 
effective system is unparalleled in this Nation's medical system for 
those who have suffered a Traumatic Brain Injury (TBI).
    The key concepts of Seamless Transition I will be discussing are as 
follows:

    1.  The significance of medical record access across the continuum 
of care;
    2.  The importance of Relationship Based Medicine: and
    3.  The recognition of the Family as part the injury complex, and 
integration of family into the therapeutic plan of care.

    Our four Polytrauma Rehabilitation Centers (PRC) are consulted by 
the MTFs when a Wounded Hero screens positive for a TBI. The referrals 
that come to Richmond are processed by our Nursing Admissions 
Coordinator. Following collection and analysis of clinical and family 
information, we provide the MTF a decision on the referral within 
twenty 4 hours of DOD's request for referral. At the earliest possible 
time the family Members of the severely wounded are contacted by 
myself, the Nursing Admissions Coordinator and the Social Worker 
assigned to the case. This step has proved essential for several 
reasons. For the family, the transition of a Wounded Hero between 
medical facilities creates anxiety due to the unknown. Importantly, 
this contact provides an early opportunity to build a relationship with 
key family Members. This relationship with the patient and family 
Members forms the basis of successful rehabilitation. The family also 
serves as an invaluable resource in the recognition of personality and 
cognitive changes that are common after TBI.
    Numerous systems are used to develop an individualized plan of care 
prior to admission to our PRC. Medical records are obtained through our 
direct access of Walter Reed Army Medical (WRAMC) and Bethesda national 
Naval Medical Center. Up to date information about medications, 
laboratory studies, results of imaging studies and daily progress notes 
are reviewed to determine the individual case parameters. We access the 
web based Joint Patient Tracking Application (JPTA) to gain further 
understanding of the patient's clinical status. Specifically the field 
notes from Balad, Iraq and follow up at Landstuhl, Germany are 
indispensable in determining the severity of the TBI. Our Nursing 
Admissions Coordinator also obtains specific documentation through the 
VA/DOD liaison personnel stationed at both WRAMC and Bethesda. As 
Medical Director, I contact the referring physicians and discuss the 
particulars of the case. Our facilities have scheduled Video 
Teleconferences (VTC) to discuss the referral and to meet the Wounded 
Hero and family Members ``face to face''. These tools are essential in 
developing an intensive, individualized rehabilitation medicine plan 
for each Wounded Hero before admission. This also includes the 
coordination of resources necessary for the family; including housing, 
transportation, meals and psychosocial supports.
    Upon admission to our facility, each Member of our rehabilitation 
team individually evaluates the Wounded Hero within twenty 4 hours and 
pays particular attention to the functional needs. Our team consists of 
a Physiatrist (Rehabilitation Physician), Rehabilitation Nurses, 
Physical Therapists, Occupational Therapists, Speech and Language 
Pathologists, Recreation Therapists, Kinesiotherapists, 
Neuropsychologists, Psychologists, Dieticians, Social Work/Case 
Managers (SW/CM), Military Liaisons and Blind Rehabilitation 
Therapists. Our team meets three times weekly to discuss each patient 
and to continually adjust the therapeutic plan of care. Each patient 
undergoes three to 6 hours of therapy each day tailored specifically to 
their individual functional and cognitive needs. We actively work to 
reinstitute the roles that previously defined activities of our Wounded 
Heroes.
    As mentioned earlier, it is not just an individual who suffers a 
TBI. Rather, the entire family structure is affected and requires 
attention. The literature relating to TBI is very clear on the fact 
that those individuals with strong psychosocial support structures are 
more successful over time. Our support is multimodal and includes 
health information through site specific literature, informal education 
sessions, a formalized lecture series and intensive discharge planning. 
Traditionally we provide professional support, emotional support, 
logistical support, involvement in the care processes and the support 
of the Military Liaison Officer. To further support the families, we 
have instituted a pager and cell phone that are covered 24 hours a day 
by Members of our Social Work team. This allows yet another level of 
support of our families. Importantly, in a very real sense, the family 
Members become an integral part of our team. This programming serves to 
educate the family Members, decrease their anxiety of the unknown and 
prepare them to care for their loved one over time.
    In recognition of this need we have developed a model of care 
appropriately referred to as Relationship Based Medicine. We have found 
that it is the relationships with those involved in the continuum of 
care that drives the success. Initially, we intensively work with the 
families and patients to gain their trust and instill the recognition 
that we are on their side. Once this level of trust has been 
established, we can develop an effective treatment plan and approach. 
It is important to point out that this relationship does not end once 
discharged from our facility. Patients are followed at regular 
intervals by the SW/CM staff along with the Physiatrist.
    Intensive discharge planning is the cornerstone of any successful 
rehabilitation plan. Our discharge plans are initiated the moment a 
patient is admitted to the facility. On a weekly basis we discuss the 
discharge needs and timelines necessary for success. These are 
communicated with the families and aligned with their needs. Once a 
discharge disposition is provided by the family, we begin to contact 
necessary resources in their community. Based upon location, a consult 
is opened either with one of the Polytrauma Network Sites (PNS) or 
appropriate level of private care within the patient's community.
    The consultation process includes a VTC or teleconference between 
our team, the consulting team, the family and patient. These 
conferences allow for a smooth handoff of the plan of care and specific 
questions. Because many patients are still an Active Duty Service 
Member, the Military Case Managers (MCM) are responsible to obtain 
authorizations from the Military regarding orders and follow up care 
based upon our team's recommendations.
    Each family and patient is trained prior to discharge in medical 
and nursing care appropriate for the patient. At the time of discharge 
each of them are encouraged to evaluate our system. Their 
recommendations for improvement are always implemented if possible. 
After discharge our SW/CM follows each patient at prescribed intervals. 
As the Medical Director, I continue to follow their medical issues from 
afar and advocate for them when appropriate.
    The integrated transition plan of care from MTF to PRC and into the 
community is paramount in the success of our Wounded Heroes and 
families. The system set up throughout VA is world class and has no 
equal for those suffering from TBI. Across the system we continually 
monitor and incorporate improvements. I am proud to be a part of the 
exceptional rehabilitation staff who are fully dedicated in their 
mission to serve those who have sacrificed so much.
    Thank you Mr. Chairman and members of the Committee for your time.

                                 

 Prepared Statement of Steven G. Scott, M.D., Medical Director, Tampa 
 Polytrauma Rehabilitation Center, James A. Haley Veterans' Hospital, 
             Tampa, FL, U.S. Department of Veterans Affairs
    Mr. Chairman and Members of the Committee, thank you for the 
opportunity to discuss our experience as it relates to the ``Service 
Members Seamless Transition into Civilian Life--our Hero's Return.'' My 
name is Dr. Steven Scott and I have been a specialist in Physical 
Medicine and Rehabilitation since 1980. I have been employed at the 
James A. Haley Veterans Hospital in Tampa, Florida since 1990 and have 
directed both the spinal cord and traumatic brain injury (TBI) 
programs.
Polytrauma Rehabilitation Care
    I would like to provide you with a brief history of the development 
of polytrauma rehabilitation care. In the summer of 2003, we began to 
receive these unique patients who had been evacuated from the 
battlefield following Improvised Explosive Device (IED) blast injury. 
Due to tremendous advancements in military care, we now have the 
opportunity to rehabilitate young men and women who in years past would 
not have survived. These patients are medically complex and have 
sustained numerous injuries which are complicated by serious TBI. The 
primary focus of the polytrauma system of care has been to provide 
rehabilitation care to the most seriously injured. A typical patient 
has TBI, vision and/or hearing loss, pain, wounds, burns and orthopedic 
problems (including amputations). We deal with extended families in 
crisis, including spouses, children of all ages, parents, siblings as 
well as other care givers. The stress and sacrifice of the family 
frequently takes its toll, sometimes resulting in conflict and serious 
marital issues.
    The complexity of injuries to these combat veterans was unlike 
those seen previously. The unique needs of these patients required 
rapid realignment of our delivery of care to routinely include a 
multidisciplinary team of medical specialists. In addition to our team 
of physiatrists or physicians who specialize in physical medicine and 
rehabilitation, we also have specialists in surgery, neurosurgery, 
internal medicine, psychiatry, infectious disease, prosthetics, 
orthotics, and spinal cord injury as part of the day-to-day planning 
and patient care. Physiatrists also lead an interdisciplinary 
rehabilitation team consisting of physical therapists, occupational 
therapists, speech therapists, rehabilitation nurses, 
kinesiotherapists, vocational therapists, social workers, 
neurophysiologists, psychologists, advance nurse practitioners, wound 
care nurses, respiratory therapists, recreational therapists, 
rehabilitation counselors, military liaisons, chaplains, blind 
occupational therapy case managers, physical therapy amputee case 
managers, social worker case managers, education specialist and veteran 
benefit specialist. Each one of these medical specialties and health 
care disciplines has specialized expertise in caring for the polytrauma 
patient and family and are essential to be sure that their 
comprehensive care results in excellent outcomes.
Transition Between DOD and VA Polytrauma
    As we developed the program, it became essential to establish a 
mechanism to exchange medical information. Initially we established 
physician to physician phone conferences to National Naval Medical 
Center in Bethesda, Maryland, and at the Walter Reed Army Medical 
Center (WRAMC) in Washington, DC. Videoconferencing with patient and 
family Members in attendance was established with Brooke Army Medical 
Center in San Antonio, Texas, and the National Naval and WRAMC. A 
military treatment referral form is completed by the military and sent 
to the on-site case manager DOD-VA military liaison social worker. This 
form initiates the referral to the Polytrauma System of Care. Medical 
record exchanges occurred between the Tampa VA and the military 
treatment facilities (MTFs). This was a new practice for us, and we 
have progressively improved the process. We continue to work on 
improvements in the transfer of radiological images and microbiology 
lab results. The VA Polytrauma Rehabilitation Centers (PRCs) have been 
an active participant in the video-conference Trauma Continuum of Care 
with the DOD which established improved practices in the care and 
transportation of trauma patients. In addition, we were able to connect 
to the Patient Joint Tracking System allowing us to get more detailed 
medical information.
    Most polytrauma patients remain on active duty during their entire 
stay at the Tampa PRC. Therefore, ongoing information sharing between 
VA PRCs and DOD is necessary. The military liaison assigned to the PRC 
assists the patient and family with military issues and assists with 
the maintenance of non-medical attendant orders which pay for family 
Members to stay at the bedside. Patients are frequently referred back 
to the MTF for follow-up surgery or placement in medical hold.
Polytrauma Focus on Transition
    A military greeting team and case manager meets the patient and 
family on arrival in Tampa. Community volunteers arrange free housing 
and transportation to families through the Haley House Fund. Our 7-day-
week program for both patients and families always has community 
reentry as its primary goal. Our staff and volunteers provide family 
education classes, family support groups and planned family activities 
such as ``Spouses' Day Out'', trips to NASA, and so forth. Our Internet 
cafe provides activities outside structured therapy time. Recreational 
therapy provides community re-entry activities such as shopping and 
recreational activities. The patient and family advance in their 
rehabilitation to have day passes and eventually weekend overnight 
passes to practice their independence in community settings.
Transition to Home
    The first step for our more independent patients is the Polytrauma 
Transitional Day Program. The patient and family move into private 
housing in the Tampa Bay area and continue to participate in group and 
individual therapies for three to 6 months or more depending on their 
needs. A comprehensive work therapy program places individuals in 
community jobs to help develop vocational skills. If the patient 
transitions to veteran status, he or she can become a candidate for the 
Chapter 31 Independent Living Benefits.
    When the active duty individual is prepared to leave Tampa, our 
rehabilitation team and the patient and family meet to exchange 
information by video conferences with the Polytrauma Network site 
closest to the patient's home. Our case managers continue to follow the 
patient and family via phone and work closely with the MTF case manager 
on appropriate follow-up. The Network Site case manager and team 
provide progress reports to the Tampa VA on a monthly basis via video 
conferencing. Most patients are transitioned to home as active duty and 
may continue as such for up to one to 2 years. As active duty service 
Members, additional authorization numbers are required by Tri-Care for 
continued rehabilitation therapies and medical care. Patients are 
encouraged to return to the Tampa Polytrauma Outpatient Program at any 
time.
Conclusion
    I am honored to serve these courageous young men and women and 
their families. I look forward to working with DOD, Congress, our VA 
leaders, advocacy groups, and private citizens to continue to provide 
excellent care and to improve future care throughout the lifespan for 
America's wounded heroes.

                                 

   Prepared Statement of William F. Feeley, MSW, FACHE, Deputy Under 
  Secretary for Health for Operations and Management, Veterans Health 
          Administration, U.S. Department of Veterans Affairs
    Good afternoon Mr. Chairman and Members of the Committee.
    Thank you for this opportunity to discuss ongoing efforts in the 
Veterans Health Administration (VHA) to improve the quality of care we 
provide to veterans returning from Operation Iraqi Freedom and 
Operation Enduring Freedom. VHA is committed to providing 
comprehensive, quality primary and specialty care to all enrollees with 
an emphasis on meeting the specialized needs of OEF/OIF veterans. As 
Secretary Nicholson said on Wednesday, we must ensure that our heroes 
receive the best possible care and services. The VHA stands ready to do 
everything we can to provide top-quality health care to all returning 
OEF and OIF veterans. My comments will focus on the operational or 
facility based aspect of our efforts.
Access to Care
    Recent publications have acknowledged that VA provides veterans 
with the best health care anywhere. Ensuring veterans have timely 
access to that quality VA care is equally important.
    VHA monitors how long veterans must wait for appointments, 
including the time it takes for an OEF/OIF veteran to be seen. The 
waiting times are reported every 2 weeks and are a highly visible item 
for senior officials. Waiting times are a key performance element in 
Network and Facility Directors' performance plans.
    VHA has employed System Improvement Strategies in recent years to 
reduce clinic wait times and help us ensure that our clinic processes 
are as efficient as possible.
    Some examples of these innovations are as follows:

      Group Health Counseling in the dietetic area for diabetic 
and congestive heart failure;
      Extended hours in clinics, including Saturday clinics; 
and
      Normal Lab and x-ray reporting via phone rather than 
requiring the patient to make a return visit to the medical center.
Polytrauma Centers
    In order to meet the needs of our most severely injured veterans, 
VA has created a Polytrauma System of Care which involves a tiered 
approach to providing care for seriously injured veterans returning 
from operations in Iraq and Afghanistan.
    There are four tiers of acuity in the polytrauma system of care in 
VHA. Level I consists of four centers that provide acute comprehensive 
medical and rehabilitation care for complex and severe polytraumatic 
injuries. They maintain a full staff of dedicated rehabilitation 
professionals and consultants from other specialties related to 
polytrauma. The centers serve as resources for other VA facilities and 
are active in the development of educational programs and best practice 
models of care.
    These four level one centers are located in:

      Tampa, FL
      Richmond, VA
      Minneapolis, MN and
      Palo Alto, CA

    Each Level I center has social work case managers at a ratio of one 
for every six patients. These case managers assess the psychosocial 
needs of each patient and family, match treatment and support services 
to meet identified needs, coordinate services, and oversee the 
discharge planning process. The social work case managers associated 
with the center ensure that the combat wounded and their families 
receive intensive clinical and psychosocial case management and 
coordination of the veterans lifelong care needs.
    The Level I centers offer a therapeutic environment that reflects 
the preferences and needs of the combat injured. Resources have been 
assembled nationally and locally to meet the special needs of families 
who accompany the seriously injured service Members to the center. Such 
resources include lodging at Fisher Houses or hotel accommodations 
where a Fisher House is not yet available, transportation, telephone 
cards, and gift certificates for meals and entertainment.
    Patient improvement is assessed using a standardized instrument 
that measures functional improvement from admission to discharge.
    VHA also recognizes the severely injured may require extensive 
rehabilitative therapy to successfully integrate back into the 
community. To that end, the Department will develop four Residential 
Transitional Rehabilitation Programs co-located with the Level I 
Polytrauma Rehabilitation Centers. The activation date for these four 
new Residential Transitional Rehabilitation programs is July 2007. A 
transitional rehabilitation program is time limited and goal oriented 
to improve the patient's physical, cognitive, communicative, 
behavioral, psychological and social functioning under the necessary 
support and supervision. The goal of these programs is to return these 
patients to the least restrictive environment including, return to 
active duty, work and school or independent living in the community.
    Level II sites provide services for veterans who do not require the 
intensity of care provided in Level I centers. These sites are 
responsible for coordinating lifelong rehabilitation services for 
patients within their network. Level II sites provide a high level of 
expert care, a full range of clinical and ancillary services, and serve 
as resources for other facilities within their Network. They provide 
continued management of patients referred from the Level I Polytrauma 
sites and evaluate patients referred directly to the Level II sites. 
Services include proactive case management as well as patient family 
support and education. They also consult, whenever necessary, with the 
level I sites through the use of telerehabilitation technologies.
    Level III sites have teams of providers with rehabilitation 
expertise to deliver follow up services in consultation with regional 
and network specialists. Level III support teams treat patients with a 
stable treatment plan, provide regular follow-up visits, and respond to 
new problems that may emerge. They regularly consult with level I and 
II sites.
    Level IV sites have at least one person identified to serve as a 
central referral point for consultation, assessment and referral of 
polytrauma patients to a facility capable of providing the level of 
services required. They work closely with level I and level II centers.
    This extensive Polytrauma network was created to adapt VHA's 
existing health care system to provide care for the severely wounded 
and meet their complex rehabilitative needs. Each Network has a Level I 
or Level II center. VHA will continue to assess its Polytrauma services 
and adapt its approach to care for those brave men and women returning 
from combat.
    This concludes my statement. I will be happy to answer any 
questions you may have.

                                 

   Prepared Statement of Edward C. Huycke, MD, Chief, Department of 
  Defense Coordination Officer, Veterans Health Administration, U.S. 
                     Department of Veterans Affairs
    Mr. Chairman and distinguished Members of the committee, thank you 
for the opportunity to speak to you about the progress the Department 
of Veterans Affairs (VA) and the Department of Defense (DOD) have made 
in improving the delivery of health care and benefits to our Nation's 
veterans. Improving the transition from military to civilian life for 
veterans and their families is a high priority at VA and I am pleased 
to be here today to provide you with an overview of the programs and 
initiatives that VA and DOD have implemented to improve coordination 
between our two systems.
Seamless Transition of Care and Benefits
    Veterans Health Administration (VHA) staff coordinated the transfer 
of care for more than 6,800 injured or ill active duty members and 
veterans from DOD to VA--specifically those injured or ill as part of 
the Global War on Terrorism in Iraq and Afghanistan and in particular 
those transitioning directly from DOD Military Treatment Facilities 
(MTFs) to VA Medical Centers (VAMCs).
    And in partnership with DOD, VA has implemented a number of 
strategies and innovative programs to provide the timely, appropriate, 
and seamless services to the most seriously injured Operation Iraqi 
Freedom/Operation Enduring Freedom (OIF/OEF) active duty Members and 
veterans. One such program enables active duty Members to register for 
VA health care and initiate the process for benefits prior to 
separation from active service.
    The centerpiece program supporting the seamless transition of 
seriously injured service Members and veterans involves the placement 
of VA Social Work Liaisons, VA Benefit Counselors, and Outreach 
Coordinators at MTFs to educate service Members about VA services and 
benefits. These VA employees assist active duty service members during 
their transfer to VA medical facilities and ensure that returning 
service Members receive information about VA benefits and services. 
Currently, VA Social Work and Benefit liaisons are located at 10 MTFs 
including Walter Reed Army Medical Center (WRAMC), National Naval 
Medical Center Bethesda (NNMC), Naval Medical Center San Diego and 
Womack Army Medical Center at Ft. Bragg, North Carolina.
    In addition to the social work and benefits liaisons, a VA 
Certified Rehabilitation Registered Nurse (CCRN) was assigned to WRAMC 
in September 2006 to assess and provide regular updates to the VA 
Polytrauma Rehabilitation Centers (PRC) to which they may be 
transferred on the medical condition of the patient, educate families 
about VA benefits and services and prepare the active duty 
servicemember for transition to the rehabilitation phase of recovery.
    Once the MTF treatment team notifies VHA of its plan to transfer 
the patient, the VA Social Work Liaisons and the CCRN begin to 
coordinate the care and information prior to transfer to VA. The VHA 
Social Worker Liaison begins meeting with the patient and/or family to 
educate them about the patient's transition from DOD's health care 
system to VA's health care system. The VHA Social Work Liaison also 
registers the active duty service Member or enrolls the recently 
discharged veteran into the VA health care system, and begins the 
process of coordinating a transfer to the VA health care facility most 
appropriate for the services they need or for a location closest to 
home. In the case of a polytrauma patient transfer, both the CCRN and 
the Social Work Liaison remain an integral part of the treatment team 
at the MTF while providing input into the VHA care plan and 
collaborating with the patient and family throughout the remainder of 
the health care transition process.
    VA case management for these patients begins at the time of 
transition from the MTF and continues as their medical and 
psychological needs dictate. Once the patient is transferred to the 
receiving VAMC or reports to his/her home VAMC for care, the VHA Social 
Worker Liaison at the MTF follows up with the receiving VAMC to address 
any issues and to ensure the patient is attending appointments. 
Patients with severe injuries or those who have complex needs will 
receive ongoing case management at the VAMC where they receive most of 
their care.
    An important aspect of the coordination of care between DOD and VA 
prior to transfer is access to clinical information including the 
viewing of electronic medical information using remote access 
capabilities. Video teleconference calls are routinely conducted 
between the DOD MTF treatment team and the receiving VA PRC enabling a 
face-to-face discussion of a polytrauma patient's care prior to 
transfer. If feasible, the patient and family may attend a video 
teleconference in order to meet the team at the receiving VA PRC. 
Utilizing the Bidirectional Health Information Exchange (BHIE), VA and 
DOD clinicians are able to share text-based clinical data from WRAMC 
and NNMC, the two MTFs that refer the majority of the polytrauma 
patients. In addition, VA clinicians at the four Polytrauma 
Rehabilitation Centers (PRCs)have access to DOD's Joint Patient 
Tracking Application (JPTA) which tracks service Members from the 
battlefield through Landstuhl, Germany and to MTFs in the states. JPTA 
provides demographic and clinical information vital for the continued 
care and treatment of these severely injured service Members.
    In addition to the transition of health care, Veterans Benefits 
Administration (VBA) counselors assigned to MTFs provide VA benefits 
information and assistance in applying for these benefits. These 
counselors are often the first VA representatives to meet with the 
service member and his or her family to provide information about the 
full range of VA services including readjustment programs, and 
educational and housing benefits. Service Members and their families 
are assisted in completing their claims and in gathering supporting 
evidence.
    While service Members are hospitalized, they are routinely informed 
about the status of pending claims and given the VBA counselor's name 
and contact information should they have any questions or concerns. 
Compensation claims taken for the seriously disabled are expedited to 
the appropriate VA Regional Office (VARO) with a clear indication that 
they are for an OIF/OEF seriously disabled claimant. Although benefits 
are not payable prior to discharge from service, work may begin on the 
claim, and service Members may be informed about the status of their 
claim while they are hospitalized.
    Each VAMC and VARO has designated a point of contact (POC) to 
coordinate activities locally and to assure that the health care and 
benefits needs of returning service Members and veterans are met. A VBA 
OIF/OEF Coordinator is designated for all OIF/OEF outreach activities 
and acts as the primary VBA point of contact for seriously disabled 
servicemembers who first arrive in the RO's area of jurisdiction as 
medical patients. For each compensation claim received for a seriously 
disabled OIF/OEF servicemember, a VBA Case Manager is also assigned. 
The Case Manager then becomes the primary VBA point of contact for 
claims processing. The VBA Counselors at the MTF may continue to be 
involved if the servicemember is still a patient at the MTF.
    VA has distributed guidance to field staff to ensure that the roles 
and functions of the POCs and case managers are fully understood and 
that proper coordination of benefits and services takes place at the 
local level.
    VAMCs also host DOD representatives. In March 2005, the Army 
assigned full time active duty liaison officers to the four VA PRCs 
located at Tampa, FL; Richmond, VA; Minneapolis, MN; and Palo Alto, CA. 
The Army Liaison Officer supports service members and their families 
from all branches of the Service with a broad array of issues such as 
travel, housing, military pay, and movement of household goods. In 
addition, Marine Corps representatives from nearby local Marine 
commands visit and provide support to each of the four PRCs. In the VA 
Central Office, an active duty Marine Officer and an Army Wounded 
Warrior representative are assigned to and are part of the VA Office of 
Seamless Transition staff. All of the DOD liaisons have played a vital 
role in ensuring the provision of a bridge to services during the 
critical time of recovery and rehabilitation.
    Recognizing the need to provide assistance and support to families 
during the tumultuous time of transition, VA established a 
PolytraumaCall Center in February 2006 to assist our most seriously 
injured combat veterans and service Members. The Call Center is 
operational 24 hours a day, 7 days a week to answer clinical, 
administrative, and benefit inquiries from polytrauma patients and 
their families. The Call Center provides patients and families with a 
source of information, enhances coordination of care, and elevates 
system problems to VA for resolution.
Post Deployment Health Reassessment
    VA is also reaching out to returning veterans whose wounds may be 
less apparent. VA is participating in the DOD's Post Deployment Health 
Reassessment (PDHRA) program for returning deployed service Members. In 
addition to DOD's pre- and post-deployment assessments, DOD is now 
conducting an additional health reassessment 90 to 180 days after 
returning home from deployment to identify health issues that may 
surface weeks or months after service Members return home. VA is 
actively participating in the administration of PDHRA at Reserve and 
Guard locations by providing information on VA care and benefits, by 
enrolling these Reservists and Guardsmen in the VA healthcare system 
and by arranging appointments for referred service Members. As of 
December 2006, an estimated 68,800 service Members were screened 
resulting in more than 17,100 referrals to VA. Of the referrals, 32.8% 
were for mental health and readjustment issues with the remaining 67.2% 
for physical health issues.
Closing
    Meeting the comprehensive health care and benefit needs of our 
Nation's veterans is VA's highest priority. We are very proud of the 
progress we have made in the area of seamless transition as recognized 
by both the IG and GAO. Mr. Chairman, this concludes my statement. I 
thank you and Members of this Committee for your outstanding and 
continued support of our service members, veterans and their families.

                                 

 Prepared Statement of Ira R. Katz, MD, PhD, Deputy Chief Patient Care 
  Services Officer for Mental Health, Veterans Health Administration, 
                  U.S. Department of Veterans Affairs
    Mr. Chairman and Members of the Subcommittee, I am pleased to be 
here today to discuss the ongoing steps that the Department of Veterans 
Affairs (VA) is taking in order to meet the mental health care needs of 
our Nation's returning veterans.
    Care for Operation Iraqi Freedom and Operation Enduring Freedom 
(OIF/OEF) veterans is among the highest priorities in VA's mental 
health care system. For these veterans, VA has the opportunity to apply 
what has been learned through research and clinical experience about 
the diagnosis and treatment of mental health conditions; to intervene 
early; and to work to prevent the chronic or persistent courses of 
illnesses that have occurred in veterans of prior eras.
    Since the start of the Global War on Terror (GWOT) until the end of 
FY 2006, over 631,000 veterans have been discharged. Approximately 32.5 
percent have sought care from the Veterans Health Administration (VHA) 
medical facilities, and, of these, 35.7 percent have had diagnosis of a 
possible mental health condition or concern. This makes mental health 
second only to musculoskeletal conditions among the classes of 
conditions seen most frequently in these returning veterans.
    Somewhat less than half of the returning veterans with a mental 
health condition who are seen in our medical facilities have a possible 
diagnosis of post-traumatic stress disorder (PTSD), making it the most 
common of the mental health conditions. However, PTSD is not the whole 
story. Among the diagnosable conditions, mood disorders as a group, 
when added together, are more common. Moreover, many veterans 
experience non-specific stress-related symptoms that may be viewed more 
appropriately as normal reactions to abnormal situations in combat, 
rather than any disorder.
    In response to the growing numbers of veterans returning from 
combat in OIF/OEF, the Vet Centers initiated an aggressive outreach 
campaign to welcome home and educate returning service Members at 
military demobilization and National Guard and Reserve sites. Through 
its community outreach and coordination efforts, the Vet Center program 
also provides access to other VHA and Veterans Benefits Administration 
(VBA) programs. To augment this effort, the Vet Center program first 
recruited and hired 50 OEF/OIF veterans in February 2004 to provide 
outreach to their fellow veterans. An additional 50 were hired by March 
of 2005. When outreach leads to identification of mental health 
conditions, veterans have a choice. They may receive care in Vet 
Centers, medical facilities, or both. Last week Secretary Nicholson 
announced plans to hire an additional 100 OEF/OIF veterans to conduct 
outreach at both Vet Centers and VA medical facilities.
    VA's approach to PTSD is to promote early recognition of this 
condition for those who meet formal criteria for diagnosis and those 
with partial symptoms. The goal is to make evidence-based treatments 
(i.e., psychological, pharmacological, and rehabilitative) available 
early to prevent chronicity and lasting impairment.
    Throughout VHA, there is a sense of urgency about reaching out to 
OIF/OEF veterans, engaging them in care, screening them for mental 
health conditions, and making diagnoses, when appropriate. Screening 
veterans for PTSD and other stress related conditions is a necessary 
first step toward helping veterans recover from the psychological 
wounds of war. In cases where there is a positive screen, patients are 
further assessed and referred to mental health providers for further 
follow-up and treatment, as necessary.
    We recognize that even in America in 2007, there can still be some 
degree of stigma associated with mental health conditions and their 
treatment. That is why VA offers a number of options, for example for 
care in mental health specialty services, Vet centers, or, increasingly 
for mental health services provided in primary care settings. When 
veterans with severe symptoms are reluctant to enter care, we are 
prepared to educate them and their families, and to work with them to 
overcome resistances. When veterans with milder symptoms are reluctant, 
we watch them over time, and urge treatment if symptoms persist or 
worsen.
    VA has been a leader in research as well as clinical services for 
PTSD. Last week, the Journal of the American Medical Association (JAMA) 
included an article describing the benefits of a specific behavioral 
treatment for PTSD. Before the results were even published, VHA was 
establishing training programs to make this intervention available to 
our patients. The translation from research into clinical practice will 
not be instantaneous, but it can be accomplished more rapidly in VA 
than in any other clinical setting.
    Thank you, again, Mr. Chairman, for the opportunity to be here.

                                 

                                U.S. Department of Veterans Affairs
                                              Washington, DC, 20420
                                                      March 7, 2007
The Hon. Ginny L. Brown-Waite
U.S. House of Representatives
Washington, DC 20515

Dear Congresswoman Brown-Waite:

    In the past few weeks, questions have been raised about the ability 
of the Department of Defense (DOD) and the Department of Veterans 
Affairs (VA) to provide the world-class health care our service members 
and veterans earned through their service and sacrifices. Many of these 
questions are focused on conditions at Walter Reed Army Medical Center, 
a DOD facility. Concerns have also been raised about VA's ability to 
care for our returning Operation Iraqi Freedom and Operation Enduring 
Freedom (OIF/OEF) veterans. So, I am writing to tell you what VA did, 
is doing, and will do in the future to care for these heroes, who share 
the honored title of ``American veteran.''
    VA provides exceptional health care for veterans at more than 1,400 
locations throughout our Nation. This year, we estimate more than 5.8 
million patients will be cared for at our 154 hospitals, 135 nursing 
homes, 45 domiciliaries, and 881 outpatient clinics. Approximately 
209,000 of those veterans will have served in Iraq or Afghanistan. The 
VA health care system is rated by many as the best health care system 
in the country and a failure to provide our absolute best to even one 
veteran is inexcusable.
    I will not tolerate conditions within the facilities of the 
Department of Veterans Affairs that do not meet our high standards. I 
directed that all facilities for which I am responsible be inspected by 
management to assure that they are up to par. Moreover, I directed that 
VA focus all possible resources on providing priority service to our 
returning OIF/OEF veterans and streamlining their access to that 
service.
    I am concerned some service Members may not have experienced a 
seamless transition as they move from active military service to care 
administered by VA. Often that transition takes a severely injured 
service member from a military treatment facility (MTF) to a VA 
polytrauma center, which is equipped to deal with the multiple injuries 
we see in those patients, to include traumatic brain injury (TBI) and 
amputations. The transition also includes the service Member's move 
from the polytrauma center to his or her home, which may be distant 
from our facilities. If even one of these young men or women does not 
receive needed care, that is one too many, and we will do all within 
our power to ensure such a situation is rectified.
    Toward that end, I would like to tell you about a number of changes 
I directed to further improve the way VA provides health care to these 
heroes:

      We expanded our network of polytrauma centers from the 
original 4 to 1 in each of our 21 Veterans Integrated Service Networks. 
Enclosed is an information paper describing our Polytrauma System of 
Care.
      All VA health care professionals are being trained to 
recognize and care for patients with TBI.
      We will be screening all patients who served in the 
combat theater of operations for TBI and post-traumatic-stress disorder 
(PTSD).
      Every VA medical center now has specialty PTSD treatment 
capability.
      We are adding 23 new Vet Centers to our existing 209, 
each with the professional capacity to intervene on PTSD and other 
mental health issues.
      We will engage a panel of outside clinical experts to 
review and evaluate our Polytrauma System of Care.
      We will establish a VA Advisory Committee on OIF/OEF 
Veterans and Their Families. Membership will include severely wounded 
combat veterans who have experienced VA care, family Members and care 
givers of wounded veterans, and survivors. They are to help us identify 
where we can, and must, do better.

    Earlier this week, 1 directed that each of our polytrauma patients 
be provided an advocate who will Work with that patient and his or her 
family to ensure everything possible is done to minimize the strains on 
the family and to assist them in navigating the VA system of care and 
benefits. To expedite this, I directed the hiring of 100 additional 
people, most of whom will be veterans of the Global War on Terror, to 
be the personal advocates for these severely injured young men and 
women and their families. These advocates will be available to the 
veterans and their families around the clock, whether the patients are 
at polytrauma centers, other VA medical facilities or their homes.
    As service Members leave active duty, many will receive VA 
disability compensation for injuries received. Since the onset of 
combat operations in Iraq and Afghanistan, VA has expedited the claims 
of seriously injured OIF/OEF veterans and their families. I have now 
directed the Veterans Benefits Administration (VBA) to move the claims 
of all combat veterans who have served in Iraq or Afghanistan to the 
head of the line so processing their claims is a top priority. To 
support expedited processing of all OIF/OEF claims and reduce the 
claims backlog, I directed VBA to immediately begin an aggressive 
hiring program to increase our on-board staffing level in the regional 
offices by over 400 benefits employees between now and the end of June.
    The President announced the creation of a bipartisan Commission on 
Care for America's Returning Wounded Warriors to review the care of 
wounded service men and women from the time they leave the battlefield 
through their return to civilian life as veterans. The President has 
asked me to chair his new interagency Task Force on Returning Global 
War on Terror Heroes. We are charged to respond to the President in 45 
days with a report and recommendations to address the immediate needs 
of those making the transition from active military to veteran status.
    I invite you to visit our VA facilities in your district or 
elsewhere as soon as your schedule permits. When you do, I am confident 
that you will be impressed with the care and commitment of those 
serving our veterans. I would like to hear your reactions following 
such visits. Certainly, if you find there are any situations you 
consider unacceptable, I ask you to contact me. I can assure you I will 
take immediate corrective action.
    I have enclosed a separate fact sheet concerning the many VA 
initiatives under way to assist OIF/OEF veterans. Further, to ensure 
your concerns can be conveyed to me expeditiously, I have asked Tom 
Harvey, Acting Assistant Secretary for Congressional Affairs, to 
establish a separate phone number (202) 368-8895 for Members to call at 
any time. That line will be monitored by him or by one of his senior 
staff to assure your concerns about our Nation's veterans receive the 
prompt attention they deserve. Thank you for your support of our 
veterans.

            Sincerely yours,

                                                 R. James Nicholson
                                                          Secretary

Enclosures
                               __________

             Department of Veterans Affairs (VA) Fact Sheet

                       Poly trauma System of Care

      VA established a Poly trauma System of Care for veterans 
and active duty personnel with lasting disabilities due to poly trauma 
and traumatic brain injury (TBI).
      The mission of the Poly trauma System of Care is to 
provide the highest quality medical, rehabilitation, and support 
services to veterans and active duty service Members injured in service 
to our country.
      Development of the Poly trauma System of Care followed 
three fundamental principles:

          Geographic distribution of specialty rehabilitation 
        programs to facilitate transitioning veterans into their home 
        communities.
          Use an interdisciplinary model of care delivery where 
        specialists from several medical and rehabilitation disciplines 
        work together to develop an integrated treatment plan for each 
        veteran.
          Provide lifelong services for veterans with severe 
        impairments and functional disabilities resulting from poly 
        trauma and TBI.

      The Poly trauma System of Care is currently comprised of 
21 network sites, including 4 regional centers. Local polytrauma/TBI 
support teams are under development at all other VA facilities.
      VA is improving coordination of care for veterans with 
poly trauma and TBI by assigning a social work case manager to every 
patient treated at the poly trauma centers. The assigned case manager 
handles the continuum of care and care coordination, acts as the point-
of-contact for emerging medical, psychosocial, or rehabilitation 
problems, and provides psychosocial support and education.
      A Poly trauma Telehealth Network (PTN) links facilities 
in the Poly trauma System of Care and supports care coordination and 
case management. The PTN provides state-of-the-art multipoint 
videoconferencing capabilities. It ensures poly trauma and TBI 
expertise are available throughout the system of care and that care is 
provided at a location and time most accessible to the patient.
      From the experience of the Poly trauma Rehabilitation 
Centers, we have learned that inpatient rehabilitation is only the 
beginning of a long road toward recovery for many poly trauma patients. 
Efforts are under way to develop a full spectrum of rehabilitation 
services to include transitional rehabilitation and programs for 
patients who are slow to recover or have long-term care needs.

                                         Polytrauma System of Care Sites
-----------------------------------------------------------------------
              Polytrauma Rehabilitation Centers                 VISN            Polytrauma Network Sites
--------------------------------------------------
McGuire VAMC                                                       1         VA Boston HCS--West Roxbury Campus
                                                              --------------------------------------------------
  Richmond, VA
                                                                   2                 Syracuse VA Medical Center
                                                              --------------------------------------------------
                                                                   3                    Bronx VA Medical Center
                                                              --------------------------------------------------
                                                                   4             Philadelphia VA Medical Center
                                                              --------------------------------------------------
                                                                   5            Washington DC VA Medical Center
                                                              --------------------------------------------------
                                                                   6                 Richmond VA Medical Center
--------------------------------------------------
James A. Haley VAMC                                                7                  Augusta VA Medical Center
                                                              --------------------------------------------------
  Tampa, FL
                                                                   8                    Tampa VA Medical Center
                                                              --------------------------------------------------
                                                                   9                                           Lexington VA Medical Center
                                                              --------------------------------------------------
                                                                  16                  Houston VA Medical Center
                                                              --------------------------------------------------
VA North Texas Health Care System--
                                                                  17                   Dallas VA Medical Center
--------------------------------------------------
Minneapolis VAMC                                                  10                Cleveland VA Medical Center
                                                              --------------------------------------------------
  Minneapolis, MN
                                                                  11             Indianapolis VA Medical Center
                                                              --------------------------------------------------
                                                                  12                    Hines VA Medical Center
                                                              --------------------------------------------------
                                                                  15                                       St. Louis VA Medical Center
                                                              --------------------------------------------------
                                                                  23              Minneapolis VA Medical Center
--------------------------------------------------
Palo Also VAMC                                                                  VA Southern Arizona Health Care
  Palo Alto, CA                                                   18           System--Tucson VA Medical Center
                                                              --------------------------------------------------
                                                                                VA Eastern Colorado Health Care
                                                                  19           System--Denver VA Medical Center
                                                              --------------------------------------------------
                                                                                     VA Puget Sound Health Care
                                                                  20          System--Seattle VA Medical Center
                                                              --------------------------------------------------
                                                                                       VA Palo Alto Health Care
                                                                  21        System--Palo Alto VA Medical Center
                                                              --------------------------------------------------
                                                                                                    VA Greater Los Angeles Health Care
                                                                  22                              System--West LA VA Medical Center
----------------------------------------------------------------------

                               __________

             Department of Veterans Affairs (VA) Fact Sheet

Initiatives to Enhance Care and Service to Operation Iraqi Freedom and 
             Operation Enduring Freedom (OIF/OEF) Veterans

Summary
      VA is committed to its veterans. These courageous men and 
women serving in Iraq, Afghanistan and elsewhere in the Global War on 
Terror are Priority One.
      In a system that is rated by many as the ``best health 
care system in the country,'' not providing our absolute best to even 
one veteran is unacceptable.
      VA wants veterans, and all Americans, to know that it can 
and will do better.
      President Bush has made the administration's priority 
very clear: There should be no excuses, only action.
      On March 5, 2007, Secretary Nicholson directed the 
immediate hiring of 100 patient advocates. These new hires will serve 
as ``ombudsmen'' for seriously injured returning service Members and 
their families, helping them cut through red tape and navigate the 
system--24/7.
      Secretary Nicholson will also be working closely with 
President Bush's new Presidential Commission tasked to review the care 
provided to our wounded servicemen and women--from the time they leave 
the battlefield through their return to civilian life as veterans.
      Secretary Nicholson will head an interagency Task Force 
on Returning Global War on Terror Heroes, charged to respond to the 
President in 45 days, to address the immediate needs of those making 
the transition from active military to veteran status.
      Secretary Nicholson is establishing an advisory committee 
to focus on the concerns and needs of our returning OIF/OEF veterans 
and their families. Veterans and their families will be represented on 
the panel, and they will help us identify where we can do better.
Funding
      Earlier this month, VA announced the Administration is 
requesting a landmark budget of nearly $87 billion for VA in FY 08.
      This budget proposal represents a 77-percent increase in 
the overall budget since the President took office in FY 01, and more 
than 83 percent more for health care spending.
      With the continued support of Congress, the 
administration's FY 08 budget will provide VA with the resources it 
needs to continue its important mission.
Health Care
      Combat veterans have access to free health and dental 
care from VA for 2 years--bypassing the normal rules that require 
determinations of service-connected injuries or income levels.
      VA operates the largest integrated health care system in 
the country. VA treats patients at over 1,400 sites of care, including 
154 hospitals, more than 800 outpatient clinics and 135 nursing homes.
      To care for severely injured veterans, VA established 4 
regional Polytrauma Rehabilitation Centers (Palo Alto, CA; Minneapolis, 
MN; Richmond, VA; and Tampa, FL), staffed with the full range of 
specialists needed to treat these veterans. VA has expanded the 
polytrauma system of care to include 21 Polytrauma Network Sites (the 4 
regional Polytrauma Rehabilitation Centers serve as the Polytrauma 
Network Site for their respective Networks) and Polytrauma Support 
Clinic Teams across the country to care for these veterans as they 
return to their homes and communities.
      VA has mandated traumatic brain injury (TBI) training for 
all VA health care professionals.
      VA is implementing a program to screen all patients who 
served in the combat theaters of Iraq or Afghanistan for TBI.
      VA is also establishing a panel of outside experts to 
review its complete Polytrauma System of Care, including TBI programs. 
More than half of the physicians practicing in the United States 
received some of their professional education at VA medical centers.
      VA health care facilities help train students from 107 
medical schools, 55 dental schools and more than 1,200 schools of 
allied health.
Mental Health
      VA is the largest provider of mental health services in 
the country. VA employs more than 9,000 frontline mental health 
workers-- psychologists, psychiatrists and social workers-- up more 
than 15 percent since 2003.
      Last year, VA provided mental health care to about 1 
million patients.
      VA's FY 08 budget request calls for nearly $3 billion in 
mental health services, plus another $100 million for the operation of 
its Vet Centers.
      VA's health care system currently features more than 200 
specialized hospital-based Post-Traumatic Stress Disorder (PTSD) 
programs. Every VA medical center now has specialty PTSD capability.
      On February 7, 2007, Secretary Nicholson announced plans 
to open 23 new community-based ``Vet Centers,'' which are an important 
part of VA's mental health program, especially the treatment of PTSD. 
These will augment the more than 200 Vet Centers already operating.
      VA is the recognized leader in the study and treatment of 
PTSD. The National Center for PTSD operated by VA is an internationally 
recognized resource for research and clinical improvement in treatment 
of PTSD and other combat-related mental health problems.
Seamless Transition
      VA is reaching out to ensure our newest generation of 
combat veterans is aware of benefits available to them. Over the past 4 
years, VA has provided 29,000 briefings about VA benefits to over 1 
million active duty and reserve personnel.
      VA has hired 100 veterans to serve as ``outreach 
specialists'' in the Vet Center program to provide outreach and 
educational services to their fellow veterans returning from OIF/OEF. 
VA has been working aggressively to make contact with our newest 
generation of veterans at military demobilization and National Guard 
and Reserve sites.
      To date, VA has seen nearly 350 veterans at its 
polytrauma centers and has coordinated the transfer of 6,869 seriously 
injured and ill service Members directly from Department of Defense 
Military Treatment Facilities (MTFs) to VA hospitals throughout the 
Nation.
      On February 12,2007, Secretary Nicholson announced a 
collaborative effort between VA and the states. It will use VA staff to 
put the most severely injured veterans still in MTFs in contact with 
the veterans affairs departments in their home-states.
      Secretary Nicholson is establishing the position of 
Special Assistant to the Under Secretary for Health for OIF/OEF Health 
Issues to begin the process of offering polytrauma patients and their 
families ``second opinions'' from private rehabilitation facilities on 
their treatment plans and to continue the Secretary's policy of meeting 
regularly with small groups of GWOT veterans and their families to 
listen to concerns and resolve these issues quickly.

                                 

                                     U.S. General Accounting Office
                                              Washington, DC, 20548
                                                      June 30, 2006

The Hon. Michael Bilirakis
Chairman
Subcommittee on Oversight and Investigations
Committee on Veterans' Affairs
House of Representatives

    Subject: VA and DOD Health Care: Efforts to Provide Seamless 
Transition of Care for OEF and OIF Servicemembers and Veterans

Dear Mr. Chairman:

    As of the end of March 2006, over 1.3 million \1\ U.S. military 
servicemembers had served or were serving in Operation Enduring Freedom 
(OEF) or Operation Iraqi Freedom (OIF).\2\ These servicemembers, 
including Members of the reserves and National Guard, may be eligible 
to receive health care from the Department of Veterans Affairs (VA) 
while serving on active duty or upon separating from active duty. 
Although the Department of Defense (DOD) provides health care services 
to servicemembers under TRICARE,\3\ legislation passed by the Congress 
in May 1982 authorized VA to provide health care services to 
servicemembers in time of war or national emergency, when DOD may have 
insufficient resources to care for casualties.\4\ Through December 16, 
2005, DOD had arranged for 193 active duty servicemembers with serious 
injuries--traumatic brain injuries and other complex trauma, such as 
missing limbs--to receive medical and rehabilitative \5\ care at VA 
polytrauma rehabilitation centers (PRC).\6\ In addition, about 30 
percent (over 144,000) of the servicemembers who had separated from 
active duty following service in OEF or OIF have sought VA health care, 
including over 4,000 who received inpatient care at VA medical 
facilities.
---------------------------------------------------------------------------
    \1\ DOD's Contingency Tracking System Deployment File for 
Operations Enduring Freedom and Iraqi Freedom reported that as of March 
31, 2006, the total number of servicemembers ever deployed was 
1,312,221.
    \2\ OEF, which began in October 2001, supports combat operations in 
Afghanistan and other locations, and OIF, which began in March 2003, 
supports combat operations in Iraq and other locations.
    \3\ DOD provides health care through TRICARE--a regionally 
structured program that uses civilian contractors to maintain provider 
networks to complement health care services provided at military 
treatment facilities.
    \4\ The Veterans' Administration and Department of Defense Health 
Resources Sharing and Emergency Operations Act, Pub. L. No. 97-174,  
4(a), 96 Stat. 70, 74-75.
    \5\ Most servicemembers receive medical care from DOD providers. 
However, DOD does not typically provide long-term rehabilitative 
services and looks to VA to be a provider of these services.
    \6\ The Veterans Health Programs Improvement Act of 2004, Pub. L. 
No. 108-422,  302, 118 Stat. 2379, 2383-86, mandated that VA establish 
centers for research, education, and clinical activities related to 
complex multiple trauma associated with combat injuries. In response to 
that mandate, VA established PRCs at four VA medical facilities with 
expertise in traumatic amputation, spinal cord injury, traumatic brain 
injury, and blind rehabilitation. The PRCs address the rehabilitation 
needs of the combat injured in one setting and in a coordinated manner.
---------------------------------------------------------------------------
    In September 2005, we testified on VA's collaboration with DOD to 
provide seamless transition of care for servicemembers between DOD and 
VA health care systems--that is, no interruption of care as the person 
moves from being a DOD patient to being a VA patient.\7\ We reported 
that VA has developed policies and procedures that direct its medical 
facilities to provide OEF and OIF servicemembers with timely access to 
care but that the sharing of health information between DOD and VA was 
limited. You asked us to update the information we provided in our 
testimony by reviewing the efforts VA is making to inform 
servicemembers and veterans about VA health care services and to help 
ensure that there is a seamless transition of care for servicemembers 
from DOD's to VA's health care system. We addressed the following 
questions:
---------------------------------------------------------------------------
    \7\ GAO, VA and DOD Health Care: VA Has Policies and Outreach 
Efforts to Smooth Transition from DOD Health Care, but Sharing of 
Health Information Remains Limited, GAO-05-1052T (Washington, D.C.: 
Sept. 28, 2005). Also see Related GAO Products at the end of this 
report.

    1.  What outreach efforts has VA made to inform OEF and OIF 
servicemembers and veterans about the VA health care services that may 
be available to them?
    2.  What actions has VA taken to facilitate the seamless transition 
of medical and rehabilitation care for seriously injured OEF and OIF 
servicemembers who are transferred between DOD medical treatment 
facilities (MTF) and PRCs?
    3.  What special educational activities or clinical tools is VA 
using to help ensure its medical providers are aware of and recognize 
the needs of eligible OEF and OIF servicemembers and veterans?

    To determine outreach efforts VA has made to inform OEF and OIF 
servicemembers and veterans about the VA health care services that may 
be available to them, we interviewed, and collected supporting 
documentation from, VA officials on their efforts and programs that 
have been established to inform servicemembers and veterans about VA 
health care services. We also observed briefings given by VA 
representatives at two military installations \8\ to active duty and 
reserve servicemembers about VA health care services for which they may 
be eligible.
---------------------------------------------------------------------------
    \8\ VA provides briefings at hundreds of MTFs. We attended 
briefings at two judgmentally selected installations--the Naval Station 
Norfolk, Norfolk, Virginia, and Fort Benning Army Base, Columbus, 
Georgia.
---------------------------------------------------------------------------
    To identify actions VA has taken to facilitate the seamless 
transition of care between MTFs and PRCs for servicemembers seriously 
injured in OEF and OIF, we reviewed VA directives, policies, and 
handbooks governing access to VA health care by OEF and OIF 
servicemembers and veterans. We also visited the two MTFs that treat 
most of the seriously injured OEF and OIF servicemembers--Walter Reed 
Army Medical Center and the National Naval Medical Center, both located 
in the Washington, D.C., area--and the four PRCs that treat them. The 
PRCs are located at VA Medical Centers in Palo Alto, California; Tampa, 
Florida; Minneapolis, Minnesota; and Richmond, Virginia. During those 
visits, we interviewed medical providers and reviewed the VA electronic 
medical records of the 193 seriously injured servicemembers who were 
admitted to the PRCs from January 7, 2002,\9\ through December 16, 
2005. In addition, we attended a discharge planning conference for an 
OIF servicemember being discharged from a PRC to document the 
information provided to the servicemember about his follow-up health 
care from VA and DOD. We made subsequent visits to the Richmond and 
Tampa PRCs to observe the capability of PRC providers to access DOD 
electronic medical records.
---------------------------------------------------------------------------
    \9\ Although OEF began in October 2001, the earliest recorded date 
that a servicemember injured in OEF was admitted to a PRC for treatment 
was January 7, 2002.
---------------------------------------------------------------------------
    To identify the special educational activities or clinical tools 
that VA is using to help ensure its medical providers are aware of and 
recognize the needs of eligible OEF and OIF servicemembers and 
veterans, we interviewed, and collected supporting documentation from, 
VA officials. While we were at the Naval Station Norfolk conducting 
audit work, we also visited the VA Medical Center in Hampton, Virginia, 
to obtain information on the educational activities and clinical tools 
VA uses when treating OEF and OIF servicemembers and veterans. We also 
obtained this information from the four PRCs. Further, we determined 
the number of VA medical providers and other staff who completed online 
educational courses developed by VA.
    Our review was conducted from May 2005 through June 2006 in 
accordance with generally accepted government auditing standards.
Results in Brief
    VA has made a variety of outreach efforts to provide OEF and OIF 
servicemembers and veterans and their families with information on VA 
health care services. VA reported that from October 1, 2000, through 
May 31, 2006, it provided about 36,000 briefings to almost 1.4 million 
active duty, reserve, and National Guard servicemembers about VA health 
care services that may be available to them. In some cases, family 
Members also attended these briefings, which were provided at over 200 
sites, including 70 sites outside the United States. VA also maintains 
a Web site containing health information focused on OEF and OIF 
servicemembers and veterans, distributes brochures and pamphlets to 
provide information about topics of interest to OEF and OIF 
servicemembers and veterans and their families, and sends letters and 
newsletters to veterans about VA health care services and health issues 
specific to veterans.
    VA has taken several actions to facilitate the transition of 
medical and rehabilitative care for seriously injured servicemembers 
who are being transferred from MTFs to PRCs. In April 2003, the 
Secretary of VA authorized VA medical facilities to give priority to 
OEF and OIF servicemembers over veterans, except those with service-
connected disabilities. In April 2004, VA signed a memorandum of 
agreement (MOA) with DOD that established the referral procedures for 
transferring injured servicemembers from DOD to VA medical facilities. 
VA and DOD also established joint programs to ease the transfer of 
injured servicemembers to VA medical facilities, including a program 
that assigned VA social workers to selected MTFs to coordinate patient 
transfers to VA medical facilities. Nevertheless, problems remain in 
the process for electronically sharing the medical records VA needs to 
determine whether servicemembers are medically stable enough to 
participate in vigorous rehabilitation activities. According to VA 
officials, the transfer could be more efficient if PRC medical 
personnel had real-time access to the servicemembers' complete DOD 
electronic medical records from the referring MTFs. VA and DOD reported 
that as of December 2005 only two of the PRCs had requested and been 
granted real-time access to the electronic medical records maintained 
at Walter Reed Army Medical Center. One of these PRCs had also been 
granted access to the electronic medical records at the National Naval 
Medical Center. However, problems continue to exist with the PRCs' 
ability to access DOD electronic medical records. During a visit to the 
two PRCs in April 2006, we found that neither facility could access the 
DOD electronic medical records at Walter Reed Army Medical Center 
because of technical difficulties. Furthermore, while VA's electronic 
medical record system captures a wide range of patient information, we 
found that at the time we conducted our audit work it did not always 
contain a complete record of information related to the patient's 
discharge from the PRC, such as dates and times of follow-up medical 
appointments--information that could be useful for maintaining 
continuity of care or responding to a patient inquiry about future 
appointments. In response to our concerns about this problem, VA has 
taken corrective action. The department has developed a template that 
identifies the information given to servicemembers at discharge from 
PRCs. The template has been included in VA's electronic medical record 
for use systemwide.
    VA has developed a number of educational activities and online 
clinical tools to help ensure that VA medical providers and other staff 
are aware of and recognize the health care needs of OEF and OIF 
servicemembers and veterans. Examples of VA's educational efforts 
include developing online courses on infectious diseases of Southwest 
Asia; holding conferences on brain injuries; conducting conference 
calls, each of which provided more than 100 VA staff with information 
on transferring servicemembers from DOD to VA health care services; and 
developing publications on the long-term effects of using an 
antimalarial drug. VA has also provided educational activities at two 
East Coast centers targeting medical professionals (such as physicians, 
nurses, and social workers), including conferences on topics such as 
physical and mental health issues, infectious disease issues, and 
health care services provided by VA. Furthermore, VA has developed 
clinical tools to help its staff be aware of and responsive to the 
needs of OEF and OIF servicemembers and veterans. For example, it has 
added reminder screens to its electronic medical records that pop up 
when staff are accessing patients' records and prompt them to ask 
questions about OEF- and OIF-related medical and psychological 
conditions, such as infectious diseases and depression. VA and DOD have 
also developed guidelines to assist clinicians in providing medical 
care to OEF and OIF veterans.
    We provided a draft of this report to VA and DOD for comment. VA 
concurred with the information presented in our draft report. DOD 
commented that the report portrays the numerous efforts that have been 
made to improve the efficacy of programs designed to ensure a smooth 
transition and continuity of care as servicemembers transition back and 
forth between DOD and VA health care systems. DOD also stated that the 
report contained several inaccuracies; however, we maintain that the 
information contained in the report accurately presents the results of 
our audit work.
Background
    DOD has reported that as of June 26, 2006, over 19,000 
servicemembers have been wounded in action since the onset of OEF and 
OIF. Some of these servicemembers are surviving injuries that would 
have been fatal in past conflicts. In World War II, about 30 percent of 
American servicemembers wounded in combat died. Because of medical 
advances, this proportion has dropped to 3 percent for OEF and OIF 
servicemembers, but many of them are returning home with severe 
disabilities, including traumatic brain injuries and missing limbs. In 
2005, DOD reported that about 65 percent of the OEF and OIF 
servicemembers wounded in action were injured by blasts and fragments 
from improvised explosive devices, land mines, and other explosive 
devices. More recently, DOD estimated in 2006 that the percentage of 
those injured by blasts and fragments who have some degree of trauma to 
the brain ranged from less than 20 percent to 28 percent. These 
injuries may require comprehensive inpatient rehabilitation services to 
address complex cognitive, physical, and mental health impairments.\10\
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    \10\ Traumatic brain injuries may cause problems with cognition 
(concentration, memory, judgment, and mood), movement (strength, 
coordination, and balance), sensation (tactile sensation and vision), 
and emotion (instability and impulsivity).
---------------------------------------------------------------------------
    While servicemembers are on active duty, DOD manages where they 
receive their care--at an MTF, a TRICARE civilian provider, or a VA 
medical facility. Once discharged from the military or demobilized from 
the reserves or National Guard, veterans may be eligible to receive 
care from VA's health care system.
    From the OEF and OIF conflict areas, seriously injured 
servicemembers are usually brought to Landstuhl Regional Medical Center 
in Germany for treatment. From there, they are usually transported to 
MTFs located in the United States, with most of the seriously injured 
admitted to Walter Reed Army Medical Center or the National Naval 
Medical Center. Once seriously injured servicemembers are medically 
stabilized, DOD can elect to send those with traumatic brain injuries 
and other complex trauma, such as missing limbs, to one of the four 
PRCs for rehabilitative services.
    The transfer of injured servicemembers from MTFs to VA medical 
facilities for medical care requires the exchange of health information 
between DOD and VA. In August 1998, the President issued a directive 
requiring VA and DOD to develop a computer-based patient record system 
that would accurately and efficiently exchange information between the 
departments. The directive stated that VA and DOD should define, 
acquire, and implement a fully integrated computer-based patient record 
available across the entire spectrum of health care delivery over the 
lifetime of the patient.\11\
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    \11\ National Science and Technology Council, A National 
Obligation: Planning for Health Preparedness for and Readjustment of 
the Military, Veterans, and Their Families After Future Deployments, 
Presidential Review Directive 5 (Washington, D.C.: Executive Office of 
the President, Office of Science and Technology Policy, August 1998).
---------------------------------------------------------------------------
    Since receiving the President's directive, VA and DOD have been 
working to exchange patient health information electronically and 
ultimately to have interoperable electronic medical records. VA and DOD 
have begun to implement applications that exchange limited electronic 
medical information between the departments' existing health 
information systems. One of these applications--the Bidirectional 
Health Information Exchange--is a project to achieve the two-way 
exchange of health information on patients who receive care from both 
VA and DOD. The application has been implemented at all VA sites and at 
14 DOD sites to exchange information such as pharmacy and allergy data, 
but as we testified in September 2005, the goal of systemwide two-way 
electronic exchange of patient records remains far from being 
realized.\12\ As a separate effort, VA and DOD have undertaken an 
initiative to allow the four PRCs to electronically access medical 
records at Walter Reed Army Medical Center and the National Naval 
Medical Center to obtain information on seriously injured OEF and OIF 
servicemembers. The capability for electronic access was requested by 
the Richmond and Tampa PRCs in 2005 and by the Palo Alto and 
Minneapolis PRCs in 2006. This capability will be limited to a small 
number of providers at each of the PRCs.
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    \12\ GAO, Computer-Based Patient Records: VA and DOD Made Progress, 
but Much Work Remains to Fully Share Medical Information, GAO-05-1051T 
(Washington, D.C.: Sept. 28, 2005).
---------------------------------------------------------------------------
    Apart from joint efforts to share medical information, VA and DOD 
separately have developed electronic systems for recording and 
accessing patient health information. VA's electronic medical records 
are maintained in a system that captures a wide range of patient 
information, including doctors' progress notes, vital signs, laboratory 
results, medications dispensed, drug allergies, radiological images, 
and clinical reminders. VA's system also allows the patient's complete 
medical record to be accessed from any VA medical facility. While DOD's 
electronic medical record system also captures information such as 
doctors' progress notes, vital signs, medications dispensed, and 
laboratory results, it does not include radiological images, vision and 
hearing tests, or anesthesia notes. In addition, DOD does not have a 
systemwide approach to electronic medical record management since the 
information is maintained and stored at individual MTFs or, in some 
locations, in networks that service multiple MTFs within a small 
geographic area. Under DOD's approach, all medical information cannot 
be electronically accessed by providers throughout DOD's health care 
system. For example, providers at Walter Reed Army Medical Center and 
the National Naval Medical Center can access each other's electronic 
medical records but cannot access medical records from Landstuhl 
Regional Medical Center in Germany.
VA's Outreach Includes Briefings, Web Sites, and Newsletters
    VA has taken a number of actions to provide OEF and OIF 
servicemembers and their families with information about VA health care 
services, such as the cost of the services, how to register for VA 
health care, and where to obtain VA health care. VA reported that from 
October 1, 2000, through May 31, 2006, it held about 36,000 briefings 
for almost 1.4 million active duty, reserve, and National Guard 
servicemembers. These briefings were held at over 200 sites, including 
70 sites located outside the United States. VA reported that over 8,000 
family Members attended some of these briefings from October 1, 2005, 
through May 31, 2006. In addition, under a May 2005 MOA between VA and 
the National Guard, VA has trained staff hired by the National Guard to 
provide VA health and benefit information to National Guard units in 
each state.
    For both servicemembers and veterans, VA has also created a Web 
site \13\ that provides information for those who served in OEF and 
OIF, such as information on VA health and medical services, dependents' 
benefits and services, and transition assistance from military to 
civilian life. The Web site contains information about VA benefits 
available to active duty military personnel, including a page that 
briefly describes these benefits. VA has also developed a variety of 
informational materials, including a wallet-sized card with relevant 
toll-free telephone numbers and Web site addresses, fact sheets and 
pamphlets summarizing VA benefits, and a monthly video magazine called 
The American Veteran. VA reported that almost 1.4 million of the 
wallet-sized cards have been distributed during briefings. Fact sheets 
and pamphlets are sent to VA medical facilities for distribution to 
veterans and are also available on VA's Web site. The video magazine 
reports information about VA services on a VA Web site \14\ and on the 
Pentagon Channel, which is available online\15\ and on cable 
television.
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    \13\ See http://www.seamlesstransition.va.gov.
    \14\ See http://www1.va.gov/opa/feature/amervet/index.htm.
    \15\ See http://www.pentagonchannel.mil.
---------------------------------------------------------------------------
    VA also has outreach efforts designed specifically for active duty, 
reserve, and National Guard OEF and OIF veterans. The Secretary of VA 
sends new veterans a letter thanking them for their service to the 
country and informing them about VA health care services and assistance 
in their transition to civilian life. As of May 15, 2006, the Secretary 
had sent letters to over 530,000 OEF and OIF servicemembers who had 
left active duty. These letters include information about the VA health 
care services available to veterans and a toll-free number for 
obtaining additional health care information. In addition, from 
December 2003 through March 2006 VA sent four newsletters to OEF and 
OIF veterans with information on health issues of interest to these 
veterans.
VA Activities Facilitate the Transition of Care for Seriously Injured 
        OEF and OIF Servicemembers Transferred to PRCs
    VA has taken a number of actions to facilitate the transition of 
medical and rehabilitation care for servicemembers who have been 
seriously injured in OEF and OIF and are being transferred between DOD 
and VA medical facilities. These actions focus on establishing and 
expanding internal initiatives for providing care to this population as 
well as VA's efforts to electronically share medical records with DOD.
    In April 2003, when the President declared a national emergency 
with respect to the Iraq conflict, the Secretary of VA issued a 
memorandum authorizing VA medical facilities to give priority to 
servicemembers who sustained injuries in OEF and OIF over veterans and 
others eligible for VA health care, except those with service-connected 
disabilities. In October 2003, VA issued a directive requiring its 
medical facilities to designate a point of contact to receive and 
expedite transfers of servicemembers from DOD to VA medical facilities. 
In April 2004, VA signed an MOA with DOD to provide health care and 
rehabilitation services to servicemembers who sustain spinal cord 
injury, traumatic brain injury, or visual impairment. The MOA 
established the referral procedures for transferring active duty 
inpatient servicemembers from DOD to VA medical facilities.\16\ In June 
2005, VA issued a directive expanding the scope of care it would 
provide to include psychological treatment for family Members and 
intensive clinical and social work case management services \17\ at its 
four regional traumatic brain injury rehabilitation centers and renamed 
these facilities PRCs.
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    \16\ In addition to outlining DOD's and VA's responsibilities in 
the transfer process, the MOA also established the reimbursement rate 
between the two departments for inpatient care that VA would provide.
    \17\ Case management includes assessment of the individual's health 
care needs, care planning and implementation, referral coordination, 
monitoring, and periodic reassessment of the individual's health care 
needs.
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    VA has also established joint programs with DOD to ease the 
transfer of injured servicemembers to VA medical facilities. In August 
2003, VA and DOD established a program that assigned VA social workers 
to selected MTFs \18\ to coordinate patient transfers between DOD and 
VA medical facilities. The social workers make appointments for care, 
ensure continuity of therapy and medications, and follow up with 
patients after discharge. By late February 2006, VA reported that the 
social workers had received requests for transfer of care for over 
6,000 patients, and over three-fourths of them had been transferred to 
VA facilities; the rest of the requests were pending.\19\ Under another 
program, a uniformed servicemember was stationed at each PRC beginning 
in March 2005 to assist servicemembers being admitted to the PRC. The 
uniformed servicemembers serve as liaisons among injured servicemembers 
and their families, the MTFs, the PRCs, and the servicemembers' units. 
For example, they assist with reimbursement for travel and lodging 
costs for immediate family Members.
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    \18\ Five MTFs were originally selected because they received most 
of the OEF and OIF casualties. These facilities were Walter Reed Army 
Medical Center (Washington, D.C.), Brooke Army Medical Center (San 
Antonio, Texas), Dwight David Eisenhower Army Medical Center (Augusta, 
Georgia), Madigan Army Medical Center ( Tacoma, Washington), and the 
National Naval Medical Center (Bethesda, Maryland). In 2004 and 2005, 
three additional MTFs--Darnall Army Community Hospital (Fort Hood, 
Texas), Evans Army Community Hospital (Fort Carson, Colorado), and the 
Naval Hospital Camp Pendleton (Camp Pendleton, California)--were added 
to care for returning OEF and OIF servicemembers.
    \19\ According to VA, patients remain in pending status until DOD 
determines that the patient is ready for transfer to a VA facility and 
VA determines the patient's medical condition is stable.
---------------------------------------------------------------------------
    In January 2005, VA established the Seamless Transition Office to 
enhance servicemembers' transition back to civilian life by improving 
coordination within the Veterans Benefits Administration and the 
Veterans Health Administration,\20\ as well as between DOD and VA. The 
goals of the Seamless Transition Office related to health care include 
improving communication, coordination, and collaboration within VA and 
with DOD concerning health care, educating VA staff about OEF and OIF 
veterans' health care, and other needs. The office has been active in 
areas such as coordinating efforts of the VA social workers assigned to 
MTFs to help servicemembers transfer their health care from MTFs to VA 
health care facilities and issuing a handbook on the policy and 
procedures for PRCs, including recommended staffing levels for the 
different types of medical providers caring for patients.
---------------------------------------------------------------------------
    \20\ The Veterans Benefits Administration provides benefits and 
services, such as disability compensation, to veterans. The Veterans 
Health Administration's primary responsibility is the delivery of 
health care to veterans.
---------------------------------------------------------------------------
    There are also a number of routinely scheduled teleconferences and 
videoconferences within VA and between VA and the military medical 
facilities to coordinate medical care for injured servicemembers and to 
discuss and resolve medical issues. Topics include issues that are 
general in nature and would apply to a number of servicemembers or that 
are specific to individual servicemembers. For example, monthly, and as 
needed, VA's Seamless Transition Office and PRC staff hold 
teleconferences to discuss such issues as obtaining DOD medical records 
and how to provide follow-up medical care once the servicemember is 
discharged from the PRC. Further, on a bimonthly basis, PRCs hold 
teleconferences or videoconferences with Walter Reed Army Medical 
Center and the National Naval Medical Center to discuss issues arising 
during the transfer of injured servicemembers from their facilities to 
the PRCs, such as obtaining military medical records. Servicemembers 
and their families sometimes participate in the videoconference to meet 
PRC staff prior to transfer. Also on a monthly basis, VA and DOD hold 
videoconferences to discuss medical and logistical issues that arise 
with injured servicemembers. These videoconferences include DOD medical 
providers from Landstuhl Regional Medical Center in Germany and combat 
medical units located in Iraq. For example, during one videoconference, 
VA and DOD staff discussed the blood filters \21\ that were being 
surgically implanted in injured servicemembers in Iraq.\22\ Medical 
providers in Baghdad asked if there was a different type of blood 
filter that they could use that would make removal easier at the 
stateside MTF or PRC.
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    \21\ Blood filters are filters that screen blood to remove clots 
that could result in death.
    \22\ VA officials in attendance included staff from the PRCs and 
the Seamless Transition Office. DOD officials in attendance included 
staff from Walter Reed Army Medical Center; the National Naval Medical 
Center; Brooke Army Medical Center; Wilford Hall Medical Center; Army 
Institute for Surgical Research; Landstuhl Regional Medical Center in 
Germany; and combat medical units located in Balad and Baghdad, Iraq.
---------------------------------------------------------------------------
    Despite coordination, we found that the departments are having 
problems exchanging health care information electronically between the 
four PRCs and the two MTFs--Walter Reed Army Medical Center and the 
National Naval Medical Center. While our current review focused on the 
electronic transfer of information among these six facilities, over 5 
years ago we recommended that VA and DOD create comprehensive and 
coordinated plans to ensure that the departments can share 
comprehensive, meaningful, accurate, and secure patient health 
data.\23\ Both VA and DOD concurred with this recommendation and are in 
the process of implementing it. From a systemwide perspective, we 
testified over 2 years ago and again last September on the need for VA 
and DOD to intensify their efforts to implement the capability to share 
health care information electronically. In those testimonies, we 
recognized the actions VA and DOD had taken to electronically exchange 
health information but also acknowledged that much work remains to 
attain this goal.\24\
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    \23\ GAO, Computer-Based Patient Records: Better Planning and 
Oversight by VA, DOD, and IHS Would Enhance Health Data Sharing, GAO-
01-459 (Washington, D.C.: Apr. 30, 2001).
    \24\ GAO, Computer-Based Patient Records: Sound Planning and 
Project Management Are Needed to Achieve a Two-Way Exchange of VA and 
DOD Health Data, GAO-04-402T (Washington, D.C.: Mar. 17, 2004); 
Computer-Based Patient Records: Short-Term Progress Made, but Much Work 
Remains to Achieve a Two-Way Data Exchange Between VA and DOD Health 
Systems, GAO-04-271T (Washington, D.C.: Nov. 19, 2003); and GAO-05-
1051T.
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    During our visits to the PRCs from October through December 2005, 
we observed that none of the PRCs had real-time access to the injured 
servicemembers' DOD electronic medical records from the transferring 
MTFs. Instead, the MTF faxed copies of some of the medical information, 
such as the servicemember's medical history and physical and doctor's 
progress notes from these records, to the PRC. Because this information 
did not always provide enough data for the PRC provider to determine if 
the servicemember was medically stable enough to be admitted to the PRC 
and to engage in vigorous rehabilitation activities and because the PRC 
did not have access to the complete medical records (paper or 
electronic), VA developed a standardized list of the minimum types of 
health care information needed about each servicemember transferring 
from an MTF. However, after they reviewed this basic medical 
information PRC providers stated that they frequently needed additional 
information and had to ask the PRC social worker to obtain it from the 
VA social worker at the MTF. For example, if the PRC provider noticed 
that the servicemember was on a particular antibiotic therapy, the 
provider might request the results of the most recent blood and urine 
cultures to determine if the servicemember was medically stable enough 
to participate in strenuous rehabilitation activities.
    According to PRC officials, obtaining additional medical 
information in this way rather than electronically was very time 
consuming and often required multiple phone calls and faxes between the 
facilities.
    According to VA officials, the main barrier to PRC medical 
providers' getting real-time access to medical records was DOD's 
interpretation of the Health Insurance Portability and Accountability 
Act 1996 (HIPAA) \25\ and the HIPAA Privacy Rule.\26\ The HIPAA Privacy 
Rule permits VA and DOD to share servicemembers' health information 
under certain circumstances, such as for purposes of treatment or if 
the individual signs a proper authorization. However, DOD officials 
told us they initially were reluctant to provide this access to VA 
because they were concerned that VA would have access to health 
information of all servicemembers, not only the information of those 
being transferred to the PRC for treatment.
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    \25\ Pub. L. No. 104-191, 110 Stat. 1936 (1996).
    \26\ The Privacy Rule, which became effective on April 14, 2001, 
specifies how individually identifiable health information may be used 
and disclosed by covered entities, which include health plans, health 
care clearinghouses, and certain health care providers. See 45 C.F.R. 
 164.500(a), 164.502 (2005). Both TRICARE and the VA health care 
system are health plans. See 45 C.F.R.  160.103 (2005).
---------------------------------------------------------------------------
    Since we initiated our review, the four PRCs and Walter Reed Army 
Medical Center and the National Naval Medical Center have reached 
separate agreements on the records VA would be able to access and have 
begun to take action to share medical records.\27\ During our initial 
visits, two PRCs--Richmond and Tampa--were in the process of separately 
negotiating with Walter Reed Army Medical Center to obtain real-time 
access to injured servicemembers' electronic medical records. VA 
reported that as of December 27, 2005, PRC providers in Richmond and 
Tampa have real-time access to these records. The Tampa PRC also gained 
access to the National Naval Medical Center's electronic medical 
records on February 21, 2006. VA and DOD officials have not established 
a date when all PRCs would have real-time access to electronic records 
at Walter Reed Army Medical Center and the National Naval Medical 
Center.
---------------------------------------------------------------------------
    \27\ This initiative is a unique undertaking by the four PRCs, 
Walter Reed Army Medical Center, and the National Naval Medical Center. 
It is distinct from VA's and DOD's Bidirectional Health Information 
Exchange.
---------------------------------------------------------------------------
    In April 2006, we revisited the Tampa and Richmond PRCs and found 
that problems continued with access to DOD electronic medical records. 
Providers at both PRCs that had been granted electronic access by DOD 
to obtain medical information stated that they could not always access 
the DOD electronic records. For example, during our visits neither 
facility could access the DOD electronic medical records at Walter Reed 
Army Medical Center because of a technical problem. Furthermore, while 
a nurse practitioner at the Tampa PRC was able to access the electronic 
medical records at the National Naval Medical Center, the admitting PRC 
provider for rehabilitative services could not.
    While VA's electronic medical records offer ready access to VA 
medical information for its medical providers, we found that during our 
site visits some information related to servicemembers' and veterans' 
discharge from PRCs was not always entered into the records. When 
servicemembers and veterans are discharged from PRCs, many still 
require follow-up medical care at VA, DOD, or private-sector 
facilities. The social worker at the PRC is responsible for arranging 
follow-up appointments prior to the patient's discharge from the PRC. 
Information on follow-up appointments and points of contact is provided 
to the servicemember or veteran during the discharge planning 
conference, along with a large amount of other medical information and 
discharge instructions. Our review 193 servicemembers' VA electronic 
medical records showed that 126 patients required follow-up medical 
appointments after discharge from the PRC.\28\ An examination of the 
126 records indicated that appointments were made for 122 of the 
patients, with the remaining 4 patients instructed to call their local 
VA medical centers for appointments. However, while the date and time 
for the appointment was in the electronic medical record, it was not 
clearly summarized in 96 of 122 of these records, nor was there 
evidence that it was given to the patient. In addition, 75 of the 122 
records did not clearly indicate the points of contact, nor was there 
evidence that this information was given to the patient. If this 
information were clearly documented in patients' electronic medical 
records, it would be available to VA providers who may need it to 
manage future care.
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    \28\ The remaining 67 patients did not need follow-up outpatient 
appointments because they were still patients in the PRC; had been 
transferred to another inpatient facility, such as an MTF or VA long-
term care facility; or did not need follow-up medical care.
---------------------------------------------------------------------------
    In February 2006, in response to questions we raised during our 
review, VA developed a template for PRC social workers to complete when 
a patient is discharged. The social worker includes on the template 
information on follow-up medical appointments, contact names and 
telephone numbers for the medical facilities where the servicemember is 
going to obtain follow-up medical care, military contacts, and PRC 
contacts. This template is entered into the electronic medical record. 
During our visit to the Tampa and Richmond PRCs in April 2006, we found 
that the social workers had been using the templates for patients 
discharged since mid-March 2006.
VA Is Using Courses, Conferences, and Online Clinical Tools to Help 
        Ensure Medical Providers Are Aware of and Recognize Needs of 
        Eligible OEF and OIF Servicemembers and Veterans
    VA has developed activities to educate its medical providers and 
other staff on the health care needs of those who are or have been 
deployed in OEF and OIF. As part of its Veterans Health Initiatives, VA 
produced 14 educational courses that address OEF- and OIF-related 
topics, such as traumatic brain injuries and infectious diseases of 
Southwest Asia. These courses are available on VA's intranet, over the 
Internet, and on compact discs. As of December 31, 2005, VA reported 
that nearly 2,000 courses had been completed by VA staff, including 
nearly 1,200 courses that were completed by physicians. Also over 
12,000 courses were completed by non-VA staff, such as veterans, family 
Members, and staff from veterans service organizations.
    VA medical centers have also used conferences and in-house 
presentations to train staff on the needs of OEF and OIF servicemembers 
and veterans. For example, the Tampa PRC sponsored blast injury 
conferences in 2004 and 2005 that were attended by physicians, nurses, 
psychologists, and social workers. In addition, from April 2005 through 
April 2006, VA held five 1-hour conference calls for VA social workers 
that focused on the transfer of care for servicemembers from DOD to VA 
medical facilities, including information such as ways to be proactive 
in working with military families as they transition from active duty 
to veteran status and recognizing the signs and symptoms of stress and 
post-traumatic stress disorder in returning OEF and OIF veterans. VA 
reported that attendance for the conference calls ranged from 105 to 
360 social workers.
    VA's educational efforts have also included publications. VA's 
Under Secretary for Health has issued five informational letters to 
VA's medical providers offering guidance on OEF- and OIF-related 
topics. The topics of these letters include the long-term effects of 
heat-related illnesses and the long-term effects of using an 
antimalarial drug. In addition, VA's War-Related Illness and Injury 
Study Centers have produced publications providing information for 
combat veterans and providers on topics such as management of chronic 
pain and the effects of exposure to depleted uranium.\29\
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    \29\ In May 2001, VA established the two War-Related Illness and 
Injury Study Centers, one in Washington, D.C., and one in East Orange, 
New Jersey. The mission of these centers includes providing health-
related educational services to veterans and health care professionals.
---------------------------------------------------------------------------
    VA's War-Related Illness and Injury Study Centers have also 
provided educational activities and clinical tools to help medical 
professionals treat OEF and OIF servicemembers and veterans. In 2004 
and 2005 the centers reported that they held three conferences, with a 
total attendance of more that 450 health care providers, including 
physicians, nurses, and social workers, that addressed such topics as 
physical and mental health issues, infectious disease issues, and 
health care services provided by VA. They also held six workshops from 
2003 through 2005 on topics such as patient-provider communication and 
the recognition and treatment of undiagnosed illnesses, and established 
Web sites that provide links to their publications and to other sources 
of education for medical providers.
    VA has also developed various clinical tools to enhance the ability 
of its providers and other staff to be aware of and responsive to the 
needs of OEF and OIF servicemembers and veterans. For example, VA has 
added reminder screens to its electronic medical records that pop up 
when a patient's record is opened if the veteran served in the military 
after September 11, 2001. These screens prompt providers to ask 
questions about medical and psychological issues related to OEF and OIF 
veterans, such as infectious diseases and depression. The screens 
continue to pop up each time the patient's medical record is opened 
until the information requested is entered into that record. The pop-up 
reminder screens were the subject of one of the informational letters 
issued to VA staff. Further, VA and DOD developed 25 guidelines for 
clinical practice,\30\ which can be viewed on a VA Web site.\31\ VA 
officials stated that any of the guidelines may be used for OEF and OIF 
servicemembers and veterans depending on their needs. Finally, VA's 
National Center for Post-Traumatic Stress Disorder and DOD developed 
the Iraq War Clinician Guide. It addresses the needs of veterans of the 
Iraq war and is available on a VA Web site.\32\
---------------------------------------------------------------------------
    \30\ Clinical practice guidelines are recommendations for treating 
specific diseases or conditions.
    \31\ See http://www.oqp.med.va.gov/cpg/cpg.htm.
    \32\ See http://www.ncptsd.va.gov/war/guide/index.html.
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Agency Comments and Our Evaluation
    VA and DOD reviewed a draft of this report and provided written 
comments, which appear in enclosures I and II respectively. VA 
concurred with the information presented in our draft report. It also 
stated that PRCs' access to DOD's electronic medical records has been a 
significant challenge for VA in accomplishing its mission. VA further 
commented that it is justifiably proud of the accomplishments of its 
dedicated staff in successfully responding to the often overwhelming 
transitional needs of these young servicemembers and their families. 
DOD commented that the report portrays the numerous efforts that have 
been made to improve the efficacy of programs designed to ensure a 
smooth transition and continuity of care as servicemembers transition 
back and forth between DOD and VA health care systems.
    DOD commented that the statements in the draft report concerning 
its lack of a systemwide approach to electronic medical record 
management and the inability of providers throughout DOD's health care 
system to access medical records is completely inaccurate. Our 
statements are not inaccurate. While our draft report recognizes DOD's 
longstanding ongoing efforts to achieve the capability to 
electronically share the complete medical record, we did not find that 
this capability exists yet at DOD. For example, in March 2006 the Chief 
Information Officer at the National Naval Medical Center explained to 
us that MTFs did not have access to electronic medical records at other 
MTFs across the United States. He told us that while information could 
be shared among providers linked by a local area network, those 
providers could not electronically access medical records from other 
local area networks. Specifically, he noted that providers at Walter 
Reed Army Medical Center and the National Naval Medical Center can 
access each other's medical records electronically, but they cannot 
access medical records from Landstuhl Regional Medical Center in 
Germany or from MTFs in San Antonio, Texas. He acknowledged that DOD's 
Armed Forces Health Longitudinal Technology Application (AHLTA)--a 
comprehensive electronic health record--will allow providers to access 
medical information. In its comments, DOD also cited the access that 
AHLTA will provide. However, DOD documentation that describes the 
system states that it is for outpatient care--only one part of the 
complete medical record. VA providers treating OEF and OIF 
servicemembers are in need of information concerning the inpatient 
care--not just the outpatient care--that servicemembers received at 
DOD. Furthermore, AHLTA cannot be accessed by all of DOD's providers. 
In its comments on our draft report DOD stated that AHLTA is not 
operational at 19 percent of DOD's MTFs and that full deployment is not 
expected until December 2006. In comparison, VA's system allows the 
patient's complete medical record to be accessed from any VA medical 
facility.
    In its comments, DOD also mentioned that a section of our draft 
report that described the actions VA has taken to facilitate the 
transition of care from DOD to VA is misleading. However, the section 
is an accurate presentation of VA initiatives as presented to us by VA 
and as observed during our audit work. Furthermore, DOD stated that it 
transmits certain medical information to VA on a monthly basis, 
although VA providers told us they need ready electronic access to 
current medical record information for the seriously injured OEF and 
OIF servicemembers. We believe that in order to plan and begin 
appropriate treatment immediately upon a servicemember's arrival at a 
PRC, medical record information is best provided through direct 
electronic access, not through monthly transmissions. Our draft report 
recognized the technical advances that VA has made in that it has the 
capability to electronically share the complete medical record of each 
of its beneficiaries among all its providers at all its medical 
facilities. This means that all medical services provided by VA to its 
beneficiaries--including information such as outpatient or inpatient 
procedures, pharmacy, or radiology notes--are included in VA's 
electronic record.
    VA and DOD provided technical comments that we incorporated where 
appropriate.
                                 ______
                                 
    As agreed with your office, unless you publicly announced its 
contents earlier, we plan no further distribution of this report until 
30 days after its report date. We will then send copies of this report 
to the Secretaries of Veterans Affairs and Defense and appropriate 
congressional committees. We will also make copies available to others 
on request. In addition, the report will be available at no charge on 
GAO's Web site at http://www.gao.gov.
    If you or your staff have any questions, please contact me at (202) 
512-7101 or bascettac@gao.gov. Contact points for our Offices of 
Congressional Relations and Public Affairs may be found on the last 
page of this report. GAO staff who made major contributions to this 
report are Michael T. Blair, Jr., Assistant Director; Cynthia Forbes; 
Roseanne Price; Shannon Slawter; and Cherie Starck.

            Sincerely yours,

                                                Cynthia A. Bascetta
                                              Director, Health Care

    Enclosures--2

Comments from the Department of Veterans Affairs

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Comments from the Department of Defense

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Related GAO Products
    Information Technology: VA and DOD Face Challenges in Completing 
Key Efforts. GAO-06-905T. Washington, D.C.: June 22, 2006.
    VA and DOD Health Care: VA Has Policies and Outreach Efforts to 
Smooth Transition from DOD Health Care, but Sharing of Health 
Information Remains Limited. GAO-05-1052T. Washington, D.C.: September 
28, 2005.
    Computer-Based Patient Records: VA and DOD Made Progress, but Much 
Work Remains to Fully Share Medical Information. GAO-05-1051T. 
Washington, D.C.: September 28, 2005.
    1Military and Veterans' Benefits: Improvements Needed in Transition 
Assistance Services for Reserves and National Guard. GAO-05-844T. 
Washington, D.C.: June 29, 2005.
    Military and Veterans' Benefits: Enhanced Services Could Improve 
Transition Assistance for Reserves and National Guard. GAO-05-544. 
Washington, D.C.: May 20, 2005.
    DOD and VA: Systematic Data Sharing Would Help Expedite 
Servicemembers' Transition to VA Services. GAO-05-722T. Washington, 
D.C.: May 19, 2005.
    Vocational Rehabilitation: VA Has Opportunities to Improve 
Services, but Faces Significant Challenges. GAO-05-572T. Washington, 
D.C.: April 20, 2005.
    VA Disability Benefits and Health Care: Providing Certain Services 
to the Seriously Injured Poses Challenges. GAO-05-444T. Washington, 
D.C.: March 17, 2005.
    Vocational Rehabilitation: More VA and DOD Collaboration Needed to 
Expedite Services for Seriously Injured Servicemembers. GAO-05-167. 
Washington, D.C.: January 14, 2005.
    Computer-Based Patient Records: Sound Planning and Project 
Management Are Needed to Achieve a Two-Way Exchange of VA and DOD 
Health Data. GAO-04-402T. Washington, D.C.: March 17, 2004.
    Computer-Based Patient Records: Short-Term Progress Made, but Much 
Work Remains to Achieve a Two-Way Data Exchange Between VA and DOD 
Health Systems. GAO-04-271T. Washington, D.C.: November 19, 2003.
    Computer-Based Patient Records: Better Planning and Oversight by 
VA, DOD, and IHS Would Enhance Health Data Sharing. GAO-01-459. 
Washington, D.C.: April 30, 2001.
                               __________
UNITED STATES GOVERNMENT ACCOUNTABILITY OFFICE
Report to the Ranking Democratic Member, Committee on Veterans' 
Affairs, House of Representatives

  VOCATIONAL REHABILITATION--More VA and DOD Collaboration Needed to 
         Expedite Services for Seriously Injured Servicemembers

                                 ______
                                 

                                Contents

Letter

Results in Brief

Background

VA Has Taken Steps to Expedite Vocational Rehabilitation and Employment 
Services for Seriously Injured Servicemembers

VA Faces Significant Challenges in Expediting Services to Seriously 
Injured Servicemembers

Conclusions

Recommendations

Agency Comments

Appendix I--Comments from the Department of Veterans Affairs

Appendix II--Comments from the Department of Defense

Related GAO Products

Figures

Figure 1: Seriously Injured Army Servicemembers Receive Treatment at 
Five Major Army Medical Facilities and Relocate to One of 57 VA Regions 
after Medical Stabilization

Figure 2:VA's Early Intervention Could Work at Cross Purposes to DOD's 
Retention Evaluation Process

Abbreviations

DOD  Department of Defense

MTF  Military Treatment Facility

VR&E  Vocational Rehabilitation and Employment

VA  Department of Veterans Affairs

                                     U.S. General Accounting Office
                                              Washington, DC, 20548
                                                   January 14, 2005
Hon. Lane Evans
Ranking Democratic Member
Committee on Veterans' Affairs
House of Representatives

Dear Mr. Evans:

    Since the onset of U.S. operations in Afghanistan in October 2001 
and Iraq in March 2003, the Department of Defense (DOD) has reported 
that more than 10,000 service men and women have been injured in 
combat. While many return to active duty after they are treated, others 
who are more seriously injured are likely to be discharged from their 
military obligations and return to civilian life with disabilities. In 
addition to cash compensation, the Department of Veterans Affairs (VA) 
offers vocational rehabilitation and employment (VR&E) services to help 
veterans with disabilities restore their lives and participate in the 
civilian work force. We have reported that intervening early after a 
disabling injury increases the likelihood that an individual will 
successfully return to work.\1\ Moreover, there is growing awareness 
that people with disabilities can and want to work and that changes in 
the nature of work and advances in assistive technologies help them to 
do so. Further, as the U.S. work force is projected to shrink, the U.S. 
economy will need all who are able to participate in the paid labor 
force. Because federal disability programs, including VA's, lack 
emphasis on the potential for vocational rehabilitation to return 
people to work and also rely on outmoded assumptions about the 
relationship between impairment and work, we have designated these as 
``high-risk'' programs.\2\
---------------------------------------------------------------------------
    \1\ GAO, SSA Disability: Return-to-Work Strategies From Other 
Systems May Improve Federal Programs, GAO-96-133 (Washington, D.C.: 
July 11, 1996).
    \2\ GAO, High-Risk Series: An Update, GAO-03-119 (Washington, D.C.: 
Jan. 2003).
---------------------------------------------------------------------------
    In view of the importance of early intervention in returning people 
who have been disabled to work, you asked that we review how quickly VA 
is able to provide VR&E services to seriously injured servicemembers 
from Afghanistan and Iraq who are likely to become veterans with 
disabilities. We assessed (1) how VA expedites VR&E services to these 
seriously injured servicemembers and (2) the challenges VA faces in its 
efforts to do so.
    To address these objectives, we reviewed VA's formal and informal 
procedures for expediting VR&E services to seriously injured 
servicemembers returning from Afghanistan and Iraq. We reviewed 
applicable laws and regulations. We interviewed officials at VA's 
central office and at 12 of VA's 57 regional offices. Five of these 
offices are located near the five major Army medical treatment 
facilities treating the majority of the seriously injured Army 
servicemembers: Brooke Army Medical Center at Fort Sam Houston, Texas; 
Darnall Army Community Hospital at Fort Hood, Texas; Eisenhower Army 
Medical Center at Fort Gordon, Georgia; Madigan Army Medical Center at 
Fort Lewis, Washington; and Walter Reed Army Medical Center in 
Washington, D.C. The corresponding VA regional offices are Houston and 
Waco, Texas; Atlanta, Georgia; Seattle, Washington; and Washington, 
D.C. We selected the other seven regional offices based on Army data 
indicating that servicemembers injured in Afghanistan and Iraq are 
being treated at military treatment facilities in their regions. They 
are Buffalo, New York; Denver, Colorado; Muskogee, Oklahoma; Nashville, 
Tennessee; New Orleans, Louisiana; Wichita, Kansas; and Winston-Salem, 
North Carolina. Our findings for these regional offices cannot be 
generalized to all of VA's regional offices. We focused on Army 
servicemembers, including activated National Guard and Reserve, because 
they constituted the majority of servicemembers wounded in Afghanistan 
and Iraq. In addition, we visited Walter Reed Army Medical Center in 
Washington, D.C., where most seriously injured Army servicemembers are 
initially treated. We also interviewed DOD officials about their 
efforts to work with VA on the transition of injured servicemembers 
being discharged from active duty. We conducted our work between April 
2004 and November 2004 in accordance with generally accepted government 
auditing standards.
Results in Brief
    We found that VA has taken steps to expedite VR&E services for 
seriously injured servicemembers returning from Iraq and Afghanistan. 
VA has instructed its regional offices to make seriously injured 
servicemembers a high priority for all VA assistance and asked DOD to 
share data that would help VA identify and monitor them. Because most 
seriously injured servicemembers are initially treated at major 
military treatment facilities, VA deployed staff to these sites to 
provide information on VA benefits programs, including VR&E services, 
to servicemembers injured in the conflicts in Afghanistan and Iraq. To 
ensure the identification and monitoring of all seriously injured 
servicemembers, VA initiated a memorandum of agreement proposing that 
DOD systematically provide information on them, including their names, 
location, and medical condition. Pending an agreement with DOD, VA 
instructed its regional offices to establish local liaison with 
military medical treatment facilities in their areas to learn who the 
seriously injured are, where they are located, and the severity of 
their injuries. Reliance on local relationships, however, has resulted 
in varying completeness and reliability of information developed by the 
12 regional offices in our review. We also found that VA has no policy 
for VR&E staff to maintain contact with seriously injured 
servicemembers who do not apply for VR&E services. Nevertheless, some 
offices reported efforts to maintain contact with these servicemembers, 
noting that some who are not initially ready to consider employment 
when contacted about VR&E services may be receptive at a future time.
    We found significant challenges to VA's efforts to expedite VR&E 
services. An inherent challenge is that individual differences and 
uncertainties in the recovery process make it difficult to determine 
when a seriously injured service Member will be ready to consider VR&E 
services. Additionally, given that VA is conducting outreach to 
servicemembers whose discharge from military service is not yet 
certain, VA is challenged by DOD's concerns that VA's outreach about 
benefits, including early intervention with VR&E services, could work 
at cross purposes to the military's retention goals. Finally, VA is 
currently challenged by a lack of access to DOD data that would, at a 
minimum, allow the agency to readily identify and locate all seriously 
injured servicemembers. VA officials we interviewed both in the 
regional offices and at the central office reported that this 
information would provide them with a more reliable way to identify and 
monitor the progress of those servicemembers with serious injuries. 
However, DOD officials reported that they have privacy concerns about 
the type of information that VA had requested and the time that VA 
wants it to be provided.
    To improve VA's efforts to expedite VR&E services, we recommend 
that VA and DOD collaborate to reach agreement about information that 
VA needs to promote the recovery and return to work of seriously 
injured servicemembers and that VA develop a policy and procedures for 
maintaining contact with those who do not initially apply for VR&E 
services. VA and DOD provided written comments on a draft of this 
report. Both VA and DOD generally concurred with our findings and 
recommendations.
Background
    VA's VR&E program is designed to ensure that veterans with 
disabilities find meaningful work and achieve maximum independence in 
daily living. In 2004, VA estimates that it spent more than $670 
million on its VR&E program to serve about 73,000 participants. This 
represents about 2 percent of VA's $37 billion budget for nonmedical 
benefits, most of which involves cash compensation for veterans with 
disabilities.
    VR&E services include vocational counseling, evaluation, and 
training that can include payment for tuition and other expenses for 
education, as well as job placement assistance. Interested veterans 
generally apply for VR&E services after they have applied and qualified 
for disability compensation based on a rating of their service-
connected disability. This disability rating--ranging from 0 to 100 
percent in 10 percent increments--entitles veterans to monthly cash 
payments based on their average loss in earning capacity resulting from 
a service-connected injury or combination of injuries. To be entitled 
to VR&E services, veterans with disabilities generally must have at 
least a 20 percent disability rating and an employment handicap as 
determined by a vocational rehabilitation counselor. Although cash 
compensation is not available to servicemembers until after they 
separate from the military, they can receive VR&E services prior to 
separation under certain circumstances.\3\ To make these services 
available prior to discharge, VA expedites the determination of 
eligibility for VR&E by granting a preliminary rating, known as a 
memorandum rating.
---------------------------------------------------------------------------
    \3\ Hospitalized military personnel pending discharge may receive 
all vocational rehabilitation and employment benefits--such as 
counseling, evaluation, and training--except for the monthly 
subsistence allowance. 38 U.S.C.  3102, 3104, and 3113.
---------------------------------------------------------------------------
    VA's outreach to servicemembers who plan to apply for veterans' 
disability compensation has been part of its transition assistance 
program, which was established in 1990.\4\ Either in group sessions or 
in one-on-one encounters, VA provides servicemembers with information 
about disability benefits and services, which includes the VR&E 
program, and offers assistance in applying for them. In addition, VA 
administers a pre-discharge program that expedites the disability 
compensation claims processing for servicemembers who are pending 
discharge. This program also helps VR&E staff identify those who could 
benefit from vocational rehabilitation and employment services. VA has 
recently included activated National Guard and Reserve Members in its 
outreach efforts.
---------------------------------------------------------------------------
    \4\ GAO, Military and Veterans' Benefits: Observations on the 
Transition Assistance Program, GAO-02-914T (Washington, D.C.: July 18, 
2002).
---------------------------------------------------------------------------
    Servicemembers injured in Iraq and Afghanistan are surviving 
injuries that would have been fatal in past conflicts, due, in part, to 
advanced protective equipment and medical treatment. However, the 
severity of their injuries can result in a lengthy transition from 
injured servicemember to veteran. Initially, most seriously injured 
servicemembers, including activated National Guard and Reserve Members, 
are brought to Landstuhl Regional Medical Center in Germany for 
treatment. From there, they are transported to the appropriate U.S. 
medical facilities, which are usually major military treatment 
facilities (MTFs) but may also be VA medical centers. According to DOD 
officials, once stabilized and discharged from the hospital, 
servicemembers usually relocate to be closer to their homes or military 
bases and are treated as outpatients by the closest VA or military 
hospital. (See fig. 1.) At this point, the military generally begins to 
assess whether the servicemember will be able to remain in the 
military, a process that could take months to complete. The process can 
take even longer if the servicemember appeals the military's initial 
disability decision.
Figure 1: Seriously Injured Army Servicemembers Receive Treatment at 
        Five Major Army Medical Facilities and Relocate to One of 57 VA 
        Regions after Medical Stabilization

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
        
    In response to recommendations made by the VA Vocational 
Rehabilitation and Employment Task Force, VA is beginning to change its 
approach to VR&E to better reflect contemporary views of disability. 
The Secretary of Veterans Affairs established this external task force 
in 2003 to conduct a comprehensive review of VA's VR&E program.\5\ In 
addition, faced with the immediate need to provide benefits and 
services to a new generation of veterans with disabilities, VA in 
August 2003 formed an internal task force to develop and implement 
policies to improve the transition of injured servicemembers back to 
civilian life. Known as the Seamless Transition Task Force, it included 
ad hoc participation from DOD.\6\ Although this task force's initial 
priority was to ensure the continuity of medical care for injured 
servicemembers as they transition from military to VA health care, it 
has also coordinated efforts to ensure access to all other VA benefits, 
including VR&E services.
---------------------------------------------------------------------------
    \5\ VA Vocational Rehabilitation and Employment Task Force. Report 
to the Secretary of Veterans Affairs: The Vocational Rehabilitation and 
Employment Program for the 21st century Veteran (Washington, D.C.: 
March 2004).
    \6\ DOD has supported transition assistance in various ways. For 
example, the VA/DOD Joint Executive Committee was established in 
February 2002 to further promote collaboration between the two 
agencies, including resolving obstacles to information sharing. The 
Committee is chaired by the Deputy Secretary of Veterans Affairs and 
the Under Secretary of Defense for Personnel and Readiness. In 
addition, the Army--in cooperation with VA--established the Disabled 
Soldier Support System (DS3) in April 2004 as an advocacy group and 
information clearinghouse to clarify the services available to disabled 
soldiers as they transition to civilian life.
---------------------------------------------------------------------------
    We have previously reported on the importance of early intervention 
to maximize the work potential of individuals with disabilities. We 
have also reported, however, that current Federal disability programs 
offer little opportunity for early intervention with individuals who 
apply for compensation. These programs require lengthy assessments in 
which applicants must focus on demonstrating their work limitations 
rather than their abilities and potential to work.\7\ Consequently, 
vocational rehabilitation is typically introduced late in the process. 
Furthermore, we have designated Federal disability programs, including 
VA's, as high-risk programs because they lack emphasis on the potential 
for vocational rehabilitation to return people to work and also rely on 
outmoded assumptions about the relationship between impairment and 
work.
---------------------------------------------------------------------------
    \7\ GAO, SSA Disability: Program Redesign Necessary to Encourage 
Return to Work, GAO/HEHS-96-62 (Washington, D.C.: Apr. 24, 1996).
---------------------------------------------------------------------------
VA Has Taken Steps to Expedite Vocational Rehabilitation and Employment 
        Services for Seriously Injured Servicemembers
    VA has instructed its regional offices to make seriously injured 
servicemembers a high priority for all VA assistance and asked DOD to 
provide data that would ensure VA's ability to identify and monitor 
this population. Because many seriously injured servicemembers are 
initially treated at major military treatment facilities, VA has 
deployed staff to these sites to provide information on all veterans' 
benefits, including VR&E services. To ensure the identification and 
monitoring of all seriously injured servicemembers, VA initiated a 
memorandum of agreement proposing that DOD share a range of 
information, including the names of those with serious injuries, their 
medical condition, and their military status. As of December 2004, a 
formal agreement with DOD had not been reached. In the meantime, VA has 
instructed its regional offices to develop local liaison with DOD in 
order to identify and assist seriously injured servicemembers. The 12 
regional offices we reviewed have developed information of varying 
completeness and reliability. However, once regional offices have 
identified and contacted seriously injured servicemembers, VA has no 
policy for VR&E staff to maintain contact with those individuals who do 
not apply for VR&E services while in the hospital or after they return 
home. Nevertheless, some regional offices reported maintaining contact 
with these servicemembers while others did not.
VA Has Instructed Its Regional Offices to Make Seriously Injured 
        Servicemembers a High Priority and Asked DOD for Data to Help 
        Identify Them
    In a September 2003 letter, VA instructed its regional offices to 
provide priority consideration and assistance to seriously injured 
servicemembers returning from Afghanistan and Iraq. VA specifically 
instructed regional offices to focus on servicemembers whose 
disabilities are definitely or likely to result in military separation. 
Minimally, this includes servicemembers with injuries DOD has 
classified as ``very serious,'' ``serious,'' or in a ``special 
category.'' \8\ In this letter, VA instructed its regional offices to 
assign a case manager to each seriously injured servicemember who 
applies for disability compensation. In addition, VA noted the 
particular importance of early intervention for those who are seriously 
injured and emphasized that seriously injured servicemembers applying 
for VR&E should receive the fastest possible service. Moreover, VA 
reminded VR&E staff that they can initiate evaluation and counseling 
and, in some cases, authorize training before a servicemember is 
discharged.
---------------------------------------------------------------------------
    \8\ Army regulations classify illness and injuries as ``very 
serious'' when life is imminently endangered; as ``serious'' when there 
is a cause for immediate concern but there is no imminent danger to 
life; and as ``special category'' when the patient has a particular 
condition, such as loss of limb or sight, a psychiatric condition, 
paralysis, or a permanent disfigurement.
---------------------------------------------------------------------------
    Since most seriously injured servicemembers are initially treated 
at major MTFs, VA has detailed staff to these facilities.\9\ These 
staff have included VA social workers and disability compensation 
benefits counselors. In addition to these staff, at Walter Reed, where 
the largest number of seriously injured servicemembers has been 
treated, VA's Washington D.C. regional office has since 2001 provided a 
vocational rehabilitation counselor to work with hospitalized patients.
---------------------------------------------------------------------------
    \9\ These six facilities are Brooke Army Medical Center in Texas; 
Walter Reed Army Medical Center in Washington, D.C.; Madigan Army 
Medical Center in Washington; Darnall Army Community Hospital in Texas; 
Eisenhower Army Medical Center in Georgia; and the Bethesda Naval 
Medical Center in Maryland. We focused on the five Army medical 
treatment facilities.
---------------------------------------------------------------------------
    To identify and monitor those whose injuries may result in a need 
for VA services, including vocational rehabilitation, VA has asked DOD 
to share data about injured servicemembers. VA has been working to 
develop a formal agreement with DOD on what specific information to 
share. In the spring of 2004, VA submitted a draft memorandum of 
agreement to DOD's Office of the Assistant Secretary of Defense for 
Health Affairs proposing that DOD provide lists of all injured 
servicemembers admitted to MTFs. In addition, VA requested personal 
identifying information, medical information, and DOD's injury 
classification for each listed servicemember. VA also requested monthly 
lists of servicemembers being evaluated for medical separation from 
military service. Several VA officials and regional office staff we 
interviewed said that systematic information from DOD would provide 
them with a way to more reliably identify and monitor seriously injured 
servicemembers. As of December 2004, a formal agreement with DOD was 
still pending.
VA Regional Offices Have Relied on Local Liaisons with MTFs In Order to 
        Identify Seriously Injured Servicemembers Who May Need 
        Assistance
    In the absence of a formal arrangement to ensure that DOD provides 
data on seriously injured servicemembers, VA has relied on its regional 
offices to obtain information about them. In its September 2003 letter, 
the agency asked the regional offices to coordinate with staff at MTFs 
and VA medical centers in their areas to ascertain the identities, 
medical conditions, and military status of the seriously injured. While 
VA officials reported to us that they had provided veterans' benefits 
information to injured servicemembers, they did not have complete and 
reliable data as to how many of these were seriously injured.
    In response to guidance by VA's central office, every regional 
office has designated a coordinator to serve as a point of contact with 
MTFs and VA medical centers, as well as other VA regional offices, in 
order to monitor injured servicemembers as they relocate across the 
country. When servicemembers are discharged from an MTF, VA officials 
told us that the affiliated VA regional office coordinator notifies the 
coordinator in the region to which the person relocates. The new 
coordinator contacts the seriously injured servicemember to discuss any 
claims that have been filed and to provide those who have not already 
done so an opportunity to apply for other benefits, including VR&E 
services. Regional officials we interviewed reported that they have 
followed VA's instructions to keep updated logs of all contacts they 
have with seriously injured servicemembers. Regional offices are 
required to send these logs to VA's central office, which uses them to 
monitor outreach.
    In our review of 12 regional offices, we found that they have 
developed different information sources resulting in varying levels of 
information on seriously injured servicemembers. The nature of the 
local relationships between VA staff and military staff at MTFs was a 
key factor in the completeness and reliability of the information that 
the military provided. For example, the military MTF staff at one 
regional office provided VA staff with only the names of new patients 
with no indication of the severity of their condition or the theater 
from which they were returning. Another regional office reported 
receiving lists of servicemembers for whom the Army has initiated a 
medical separation in addition to lists of patients with information on 
the severity of their injuries. Some regional offices were able to 
capitalize on longstanding informal relationships. For example, the VA 
coordinator responsible for identifying and monitoring the seriously 
injured at one regional office had served as an Army nurse at the local 
MTF and was provided all pertinent information. In contrast, staff at 
another regional office reported that local military staff did not 
until recently provide them with information on seriously injured 
servicemembers admitted to the MTF.
    Once they have identified the seriously injured servicemembers, 
regional office staff reported that they are largely following 
outreach, coordination, and case management procedures outlined in VA's 
September 2003 guidance. Under these procedures, disability 
compensation benefit counselors usually conduct VA's initial outreach 
by contacting hospitalized servicemembers to provide information on all 
veterans' benefits, including VR&E. Traditionally responsible for 
taking applications and processing disability compensation claims, 
these staff Members are neither vocational rehabilitation experts nor 
are they generally trained to work with persons who have serious 
injuries. Accordingly, VA reported that it has begun requiring all 
staff Members who provide in-person or telephone outreach to receive 
training on how to interact with seriously injured servicemembers. VR&E 
staff reported that they generally rely on the benefits counselors to 
notify them of injured servicemembers at MTFs who are interested in or 
who apply for VR&E. Only then would a vocational rehabilitation 
counselor or counseling psychologist usually contact the hospitalized 
servicemember to begin counseling and evaluation. In one regional 
office, VR&E staff said that they do not contact injured servicemembers 
until they apply for services and obtain a memorandum rating 
establishing their eligibility.
    The Washington, D.C., regional office has assigned a vocational 
rehabilitation counselor to be available on site at Walter Reed Army 
Medical Center, where a large number of seriously injured 
servicemembers are treated. Although VA also deployed benefits 
counselors to Walter Reed who are responsible for outreach activities 
and the provision of information on all VA benefits, the VR&E counselor 
works with hospitalized patients specifically to offer and provide 
vocational counseling and evaluation. She reported attempting to 
contact all patients within 48 hours of their arrival and visiting them 
routinely thereafter to establish rapport. Her primary mission is to 
work with servicemembers who will need to prepare for civilian 
employment, although she told us that her early intervention efforts 
could also help servicemembers who are able to remain in the military.
    According to VA staff, many seriously injured servicemembers are 
not ready or able to consider VR&E services when they are first 
contacted. Yet, we found that VA has no policy for maintaining contact 
with those servicemembers who do not apply for VR&E services when they 
were in the hospital or when they returned to a home base or to their 
residence. Several regional offices reported that they do not stay in 
contact with these individuals while others attempt to do so in various 
ways. One office said it is considering contacting them after 1 year. 
Another regional VR&E officer reported that staff ask the 
servicemembers to specify when they would like to be contacted for 
further information or to BEGIN Program participation. Staff at this 
regional office noted that they are strong advocates of early 
intervention. They said that they try to contact servicemembers as soon 
as possible to establish rapport and provide VR&E program information 
even before the servicemembers are physically ready to begin developing 
a vocational rehabilitation plan. At the same time, they noted that 
readiness to participate in VR&E varies by individual and that 
professional judgment is required to balance effective outreach with an 
approach that could be viewed as intrusive.
    VR&E program officials noted the potential value of maintaining 
contact with seriously injured servicemembers who may not initially be 
ready to participate when initially contacted by VA, but they also 
recognized the need to focus resources on those who do participate. 
Nevertheless, officials from a veterans service organization told us 
that it is critical to maintain contact with seriously injured veterans 
who do not initially apply for VR&E because they may need months or 
even years before they are ready. In our prior work, we have also noted 
that maintaining contact with individuals who have disabilities may 
help encourage their return to work.\10\
---------------------------------------------------------------------------
    \10\ GAO, SSA Disability: Return-to-Work Strategies From Other 
Systems May Improve Federal Programs, GAO/HEHS-96-133 (Washington, D.C: 
July 11, 1996).
---------------------------------------------------------------------------
VA Faces Significant Challenges in Expediting Services to Seriously 
        Injured Servicemembers
    While experts and advocates for individuals with disabilities 
attest to the value of early intervention for returning people to work, 
VA is challenged to reach injured servicemembers early for several 
reasons. First, determining the best time to approach recently injured 
servicemembers and gauge their personal receptivity to consider 
employment in the civilian sector is inherently difficult. The nature 
of the recovery process is highly individualized and requires 
professional judgment to determine the appropriate time to begin 
vocational rehabilitation. Further, because VA is trying to prepare 
servicemembers who are still on active duty for a transition to 
civilian life, DOD is concerned that VA's efforts may be working at 
cross purposes to the military's retention goals. Finally, because VA 
lacks systematic information from DOD on seriously injured 
servicemembers, VA cannot ensure that all servicemembers and veterans 
who could benefit from the VR&E program have the opportunity to receive 
services at the appropriate time.
Individual Differences in the Recovery Process Complicate the Timing of 
        Early Intervention
    Individual differences and uncertainties in the recovery process 
make it inherently difficult to determine when a seriously injured 
servicemember will be ready to consider vocational rehabilitation. 
Since the appropriate time to intervene depends to a large extent on 
the individual's medical condition and personal readiness, the time to 
broach the subject of a return to work, whether in the military or the 
civilian labor force, will vary. Regional office staff reported that 
many servicemembers are eager to return to military duty and do not 
intend to consider a career outside military service. They also 
reported that many injured servicemembers need time to recover and 
adjust to the likelihood that they may have to leave the military and 
prepare for civilian employment.
    Because of the individual differences in receptivity to VR&E, VA 
staff reported needing to monitor the condition of seriously injured 
servicemembers and to engage them more than once during their recovery 
to be able to gauge their readiness for VR&E. One regional VR&E 
official told us that VA could benefit from more collaboration with DOD 
medical staff in order to make decisions on the appropriate timing of 
VR&E intervention. The vocational rehabilitation counselor at Walter 
Reed reported visiting servicemembers routinely, including evenings and 
weekends, so that she would be available when they were ready to 
discuss their need for vocational rehabilitation. For one patient, she 
reported visiting him 12 times before he expressed interest in VR&E. In 
some locations, VA staff reported participating in pre-discharge 
planning meetings with military and medical staff, which they said 
helped them stay informed about the servicemember's condition and 
likely discharge and provided an opportunity to include VR&E in their 
discharge planning.
VA Is Challenged by DOD's Concern that Early Intervention Could Work at 
        Cross Purposes to Military Retention
    VA is also challenged by DOD's concern that outreach about VA 
benefits, including disability compensation and VR&E services, could 
work at cross purposes to military retention goals. In particular, DOD 
expressed concern about the timing of VA's outreach to servicemembers 
whose discharge from military service is not yet certain. To expedite 
VR&E services, VA's outreach process may overlap with the military's 
process for evaluating servicemembers for a possible return to duty. 
According to DOD officials, it may be premature for VA to begin working 
with injured servicemembers who may eventually return to active duty. 
(See fig. 2.) With advances in medicine and prosthetic devices, many 
serious injuries no longer result in work-related impairments. Army 
officials who track injured servicemembers told us that many seriously 
injured servicemembers overcome their injuries and return to active 
duty. Recognizing this potential, both Congress \11\ and the President 
have recently expressed interest in seeing the military provide the 
retraining needed to support the return of injured servicemembers to 
their military occupations or other occupations within the military if 
possible. In an attempt to enable more amputees to return to active 
duty, Walter Reed Army Medical Center plans to open a new 
rehabilitation center in 2005.
---------------------------------------------------------------------------
    \11\ Congress expressed its sense that the Secretary of Defense 
should develop protocols that include options for injured 
servicemembers who are highly motivated to return to active duty 
service and for them to be retrained to perform military missions fo 
which they are fully capable. Ronald W. Reagan National Defense 
Authorization Act for Fiscal Year 2005, Pub. L. No. 108-375,  588, 
Oct. 28, 2004, the ``Sense of Congress Regarding Return of Members to 
Active Duty Service upon Rehabilitation from Service-Related 
Injuries.''
---------------------------------------------------------------------------
    Both VA and DOD officials suggested that the earliest appropriate 
time for VA to intervene for regular active duty servicemembers would 
be when it is clear that the servicemember will not be retained by the 
military. Currently, VA can only provide VR&E services to active duty 
servicemembers who are pending discharge due to a disability. VR&E 
services could begin earlier for injured Members of the National Guard 
and Reserve since these individuals usually expect to return to their 
previous civilian employment. They may need VR&E services to return to 
their prior employment or to prepare for a different occupation in the 
civilian economy.
Figure 2: VA's Early Intervention Could Work at Cross Purposes to DOD's 
        Retention Evaluation Process

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
        
VA Is Also Challenged by the Lack of Access to Systematic Data 
        Regarding Seriously Injured Servicemembers
    In the absence of a formal information sharing agreement with DOD, 
VA does not have systematic access to DOD data about the population who 
may need its services. Specifically, VA cannot reliably identify all 
seriously injured servicemembers or know with certainty when they are 
medically stabilized, when they are undergoing evaluation for a medical 
discharge, or when they are actually medically discharged from the 
military. VA has instead had to rely on ad hoc regional office 
arrangements at the local level to identify and obtain specific data 
about seriously injured servicemembers. While regional office staff 
generally expressed confidence that the information sources they 
developed enabled them to identify most seriously injured 
servicemembers, they have no official data source from DOD with which 
to confirm the completeness and reliability of their data nor can they 
provide reasonable assurance that some seriously injured servicemembers 
have not been overlooked. In addition, informal data sharing 
relationships could break down with changes in personnel at either the 
MTF or the regional office.
    DOD officials expressed their concerns about the type of 
information to be shared and when the information would be shared. DOD 
noted that it needed to comply with legal privacy rules on sharing 
individual patient information.\12\ DOD officials told us that 
information could be made available to VA ``upon separation'' from 
military service, that is, when a servicemember enters the separation 
process. At this time, servicemembers would undergo assessment by a 
physical evaluation board, which DOD officials said typically takes 
between 30 to 90 days and usually results in a medical discharge from 
the military. However, prior to separation, information can only be 
provided under certain circumstances, such as when a patient's 
authorization is obtained.\13\
---------------------------------------------------------------------------
    \12\ Health Insurance Portability and Accountability Act (HIPAA) 
Privacy Rule, 45 C.F.R. Parts 160 and 164.
    \13\ 45 C.F.R.  164.508(a).
---------------------------------------------------------------------------
Conclusions
    VA has taken steps to help the nation's newest generation of 
veterans move forward with their lives, particularly those who return 
from combat with disabling injuries. VA has made seriously injured 
servicemembers a priority and, among other measures, deployed staff to 
major MTFs to conduct outreach to them prior to separation. However, VA 
benefits counselors are usually the first VA representatives to contact 
injured servicemembers. While they may provide an overview of all VA 
benefits, they may not emphasize vocational rehabilitation and 
employment services.
    The importance of early intervention for returning individuals with 
disabilities to the work force is well documented in the vocational 
rehabilitation literature. However, the lack of an agreement with DOD 
for systematic data sharing impedes VA's attempt to identify all 
seriously injured servicemembers who might benefit from such 
intervention. It also poses the risk that some who are discharged with 
disabilities may be overlooked and not afforded the opportunity for 
VR&E. As VA recognizes, the current ad hoc approach of their regional 
offices for obtaining information is not the most efficient way to 
proceed. Furthermore, because individuals with disabilities vary in 
their readiness and need for VR&E services, maintaining contact with 
them would better ensure that VR&E staff know when the person is ready 
to participate. Because VA has no policy for maintaining contact with 
those who do not apply for VR&E, opportunities to rehabilitate veterans 
who have sustained serious injuries in Afghanistan and Iraq may be 
lost.
    At a time when the U.S. labor force is projected to shrink, it is 
imperative that those who can work, whether in military or civilian 
jobs, are well supported in their efforts to do so. VA's early VR&E 
efforts, rather than working at cross purposes to DOD goals, could 
facilitate servicemembers' return to the same or different military 
occupation, or to a civilian occupation, if they were not able to 
remain in the military. In this regard, the prospect for early 
intervention with VR&E services presents both a challenge and an 
opportunity for VA and DOD to collaborate to provide better outcomes 
for this new generation of seriously injured servicemembers.
Recommendations
    To improve VA's efforts to expedite VR&E services to seriously 
injured servicemembers, we recommend that VA and DOD collaborate to 
reach an agreement for VA to have access to information that both 
agencies agree is needed to promote servicemembers' recovery and return 
to work.
    We also recommend that the Secretary of Veterans Affairs direct the 
Under Secretary for Benefits to develop a policy and procedures for 
regional offices to maintain contact with seriously injured 
servicemembers who do not initially apply for VR&E services, in order 
to ensure that they have the opportunity to participate in the program 
when they are ready.
Agency Comments
    In commenting on a draft of this report, VA concurred with our 
findings and recommendations. VA emphasized that access to DOD 
information is crucial to promoting servicemembers' recovery and return 
to work and, to that end, is currently negotiating an agreement to 
allow VA to obtain protected medical information on servicemembers 
prior to their discharge for VA benefits purposes. In addition, VA 
noted that its follow-up policies and procedures include sending 
veterans information on VR&E benefits upon notification of a disability 
compensation award and 60 days later. However, we believe a more 
individualized approach, such as maintaining personal contact, could 
better ensure the opportunity for veterans to participate in the 
program when they are ready. VA noted that it is currently reviewing 
its outreach and follow-up procedures for injured servicemembers and 
will make any appropriate revisions. VA's written comments are 
reprinted in appendix I.
    DOD also concurred with our findings and recommendations. DOD 
stated its commitment to retaining seriously injured servicemembers who 
are able and willing to return to duty. DOD also noted that a draft 
memorandum of agreement for information sharing between VA and DOD is 
under consideration by the two departments and the military services. 
DOD's written comments are reprinted in appendix II.
    As agreed with your office, unless you publicly announce the 
contents of this report earlier, we plan no further distribution of 
this report until 30 days after the date of this letter. We will then 
send copies of this report to the Secretary of Veterans Affairs, the 
Secretary of Defense, appropriate congressional Committees, and other 
interested parties. The report will also be available on GAO's Web site 
at http://www.gao.gov.
    If you or your staff have any questions regarding this report, 
please call me at (202) 512-7215 or Irene Chu, Assistant Director, at 
(202) 512-7102.
    Susan Bernstein, Connie Peebles Barrow, Margaret Boeckmann, William 
R. Chatlos, Clarette Kim, Joseph J. Natalicchio, and Roger Thomas also 
made key contributions to this report.

            Sincerely yours,

                                                Cynthia A. Bascetta
                                   Director, Education, Work force,
                                         and Income Security Issues
                               __________
Appendix I: Comments from the Department of Veterans Affairs

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Appendix II: Comments from the Department of Defense

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Related GAO Products
    VA and Defense Health Care: More Information Needed to Determine if 
VA Can Meet an Increase in Demand for Post-Traumatic Stress Disorder 
Services. GAO-04-1069. Washington, D.C.: September 20, 2004.
    VA Vocational Rehabilitation and Employment Program: GAO Comments 
on Key Task Force Findings and Recommendations. GAO-04-853. Washington, 
D.C.: June 15, 2004.
    VA Benefits: Fundamental Changes to VA's Disability Criteria Need 
Careful Consideration. GAO-03-1172T. Washington, D.C.: September 23, 
2003.
    High-Risk Series: An Update. GAO-03-119. Washington, D.C.: January 
2003.
    Major Management Challenges and Program Risks: Department of 
Veterans Affairs. GAO-03-110. Washington, D.C.: January 2003.
    SSA and VA Disability Programs: Re-Examination of Disability 
Criteria Needed to Help Ensure Program Integrity. GAO-02-597. 
Washington, D.C.: August 9, 2002.
    Military and Veterans' Benefits: Observations on the Transition 
Assistance Program. GAO-02-914T. Washington, D.C.: July 18, 2002.
    SSA Disability: Other Programs May Provide Lessons from Improving 
Return-to-Work Efforts. GAO-01-153. Washington, D.C.: January 12, 2001.
    Vocational Rehabilitation: Opportunities to Improve Program 
Effectiveness. GAO/T-HEHS-98-87. Washington, D.C.: February 4, 1998.
    Veterans Benefits Administration: Focusing on Results in Vocational 
Rehabilitation and Education Programs. GAO/T-HEHS-97-148. Washington, 
D.C.: June 5, 1997.
    Vocational Rehabilitation: VA Continues to Place Few Disabled 
Veterans in Jobs. GAO/HEHS-96-155. Washington, D.C.: September 3, 1996.
    SSA Disability: Return-to-Work Strategies From Other Systems May 
Improve Federal Programs. GAO/HEHS-96-133. Washington, D.C: July 11, 
1996.
    SSA Disability: Program Redesign Necessary to Encourage Return to 
Work. GAO/HEHS-96-62. Washington, D.C.: April 24, 1996.

                                 

                                                     Cedar Park, TX
                                                     March 27, 2007
Hon. Harry E. Mitchell
Hon. Virginia Brown-Waite
Subcommittee on Oversight and Investigations
Committee on Veterans' Affairs
U.S. House of Representatives

Dear Chairman Mitchell and Ranking Member Brown-Waite:

    Please find my enclosed answers to your follow-up questions from 
your March 8, 2007, hearing regarding seamless transition of new Iraq 
and Afghanistan war veterans from the military to the Department of 
Veterans Affairs (VA).
    From July 2000 through March 2006, I worked as a lead program 
analyst (GS-14) in the Office of Performance Analysis and Integrity 
(OPA&I), which reported directly to the office of the Under Secretary 
for Benefits. The team I led as a project manager was identifying, 
monitoring, and providing analysis on the VA disability claims activity 
of veterans who had been deployed to the Iraq and Afghanistan wars, 
often referred to as the Global War on Terror (GWOT), and Operation 
Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF).
    In addition to regular briefings to OPA&I's Assistant Director and 
Director, on several occasions I briefed the Deputy Under Secretary for 
Benefits and the Chief of Staff at the Veterans Benefits 
Administration. During 2004, I regularly attended then-VA Secretary 
Anthony Principi's Task Force on Seamless Transition and prepared the 
year end report in 2004, which is also attached.
    Question One: In your testimony, you referenced data sent to your 
supervisors relating to possible surges in disability compensation 
claims among the Iraq and Afghanistan war veterans. Please submit this 
material to the Committee.
    In early 2005, the Department of Defense (DOD) began providing VA 
with consistent and nearly complete data on service Members deployed to 
the war zones who had separated from active duty. Shortly thereafter, 
VA began matching the DOD data with VA systems in order to count the 
number of veterans filing VA disability claims and monitor trends. Here 
are three e-mails containing statistics and/or analysis.

      July 8, 2005, e-mail from Susan Perez, Assistant 
Director, Office of Performance Analysis and Integrity to Jack McCoy, 
Associate Deputy Under Secretary for Benefits, citing ``concerns'' 
about GWOT claims. There were 13 attachments with this e-mail.
      August 26, 2005, e-mail from Paul Sullivan to Susan 
Perez, with a ``strong warning'' about claims activity among GWOT 
veterans. There were six attachments with this e-mail.
      October 5, 2005, e-mail from Paul Sullivan to Doris 
Morgan containing a power point briefing describing increasing claims 
among GWOT veterans for the Performance Analysis (PA) staff within 
OPA&I. The PA staff also briefs senior VA management each month. There 
is one attachment for this e-mail.

    Question Two: Please also provide the Committee with a copy of the 
report by Harvard professor, Linda Bilmes, estimating the number of 
patients and the cost of the war.
    Attached for your review is Professor Bilmes' report about the 
impact of the Iraq and Afghanistan wars on veterans and VA along with 
two columns she wrote about her report.

      ``Battle of Iraq's Wounded,'' Los Angeles Times, January 
5, 2007
      ``Soldiers Returning from Iraq and Afghanistan: The Long-
term Costs of Providing Veterans Medical Care and Disability 
Benefits,'' Harvard University, January 8, 2007
      ``Soldiers Trapped in Limbo,'' Boston Globe, March 21, 
2007

    I thank you for the opportunity to testify on March 8. If the 
Subcommittee has any additional question, please contact me.
            Sincerely,
                                                      Paul Sullivan

    [The Attachments reference above letter are being retained in 
Committee files.]