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



 
                       CARE OF SERIOUSLY WOUNDED

                          AFTER INPATIENT CARE

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


                                HEARING

                               before the

                     SUBCOMMITTEE ON OVERSIGHT AND
                             INVESTIGATIONS

                                 of the

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

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 13, 2008

                               __________

                           Serial No. 110-76

                               __________

       Printed for the use of the Committee on Veterans' Affairs



                   U.S. GOVERNMENT PRINTING OFFICE
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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            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     HENRY E. BROWN, Jr., South 
Dakota                               Carolina
HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
PHIL HARE, Illinois                  GINNY BROWN-WAITE, Florida
MICHAEL F. DOYLE, Pennsylvania       MICHAEL R. TURNER, Ohio
SHELLEY BERKLEY, Nevada              BRIAN P. BILBRAY, California
JOHN T. SALAZAR, Colorado            DOUG LAMBORN, Colorado
CIRO D. RODRIGUEZ, Texas             GUS M. BILIRAKIS, Florida
JOE DONNELLY, Indiana                VERN BUCHANAN, Florida
JERRY McNERNEY, California           VACANT
ZACHARY T. SPACE, Ohio
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 
further refined.


                            C O N T E N T S

                               __________

                             March 13, 2008

                                                                   Page
Care of Seriously Wounded After Inpatient Care...................     1

                           OPENING STATEMENTS

Chairman Harry E. Mitchell.......................................     1
    Prepared statement of Chairman Mitchell......................    49
Hon. Ginny Brown-Waite, Ranking Republican Member................     2
Hon. Cliff Stearns...............................................     3
Hon. Nick Lampson................................................     5
    Prepared statement of Congressman Lampson....................    50

                               WITNESSES

U.S. Department of Veterans Affairs, Mahdulika Agarwal, M.D., 
  MPH, Chief Officer, Patient Care Services, Veterans Health 
  Administration.................................................    40
    Prepared statement of Dr. Agarwal............................    57

                                 ______

Iraq and Afghanistan Veterans of America, Todd Bowers, Director 
  of Government Affairs..........................................    33
    Prepared statement of Mr. Bowers.............................    55
Owens, Corporal Casey A., USMC (Ret.), Houston, TX...............     6
    Prepared statement of Corporal Owens.........................    51
Wade, Sarah, Chapel Hill, NC, on behalf of Sergeant Edward Wade, 
  USA (Ret.).....................................................     9
    Prepared statement of Ms. Wade...............................    52
Wounded Warrior Project, Meredith Beck, National Policy Director.    30
    Prepared statement of Ms. Beck...............................    54

                   MATERIAL SUBMITTED FOR THE RECORD

Memorandum entitled, ``Acceptance Requirements for VA 
  Volunteers'' from the William F. Feeley, MSW, FACHE, Deputy 
  Under Secretary for Operations and Management (10N), dated 
  February 22, 2007..............................................    63

Post Hearing Questions and Responses for the Record:

Hon. Harry E. Mitchell, Chairman, and Hon. Ginny Brown-Waite, 
  Ranking Republican Member, Subcommittee on Oversight and 
  Investigations, Committee on Veterans' Affairs, to Hon. James 
  B. Peake, Secretary, U.S. Department of Veterans Affairs, 
  letter dated April 17, 2008, and VA responses..................    65


                       CARE OF SERIOUSLY WOUNDED



                          AFTER INPATIENT CARE

                              ----------                              


                        THURSDAY, MARCH 13, 2008

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

    The Subcommittee met, pursuant to notice, at 10:00 a.m., in 
Room 340, Cannon House Office Building, Hon. Harry E. Mitchell 
[Chairman of the Subcommittee] presiding.

    Present: Representatives Mitchell, Space, Walz, Brown-
Waite, Stearns, Bilbray.

             OPENING STATEMENT OF CHAIRMAN MITCHELL

    Mr. Mitchell. Good morning. This hearing will come to 
order. This is the Subcommittee on Oversight and Investigations 
and the hearing today is on the care of seriously wounded after 
inpatient care.
    We are here today to hear from veterans, their families, 
and the U.S. Department of Veterans Affairs (VA) about the 
long-term care of our most severely wounded Afghanistan and 
Iraqi veterans.
    We do know that the U.S. Department of Defense (DoD) and VA 
provide excellent inpatient healthcare for these warriors, but 
many of the most seriously injured require extensive outpatient 
care, some for the rest of their life. Their families need care 
and assistance as well.
    Unfortunately, once these veterans leave the hospital, the 
care they receive does not seem to be on par with what they 
receive directly following their injury. And I think we can do 
better.
    Planning for veterans health care was not planned very well 
at the outset of this war. The need to provide care and 
assistance to wounded servicemembers and their families in 
significant number and for the long term has been largely 
ignored.
    We will hear today what it has been like for some of them. 
Their stories are inspiring, but also discouraging. They are 
inspiring because even after they suffered terrible injuries, 
they carry no bitterness, only pride from their service, 
discouraging because they have been left to fend for themselves 
for too long.
    The DoD and the VA are large organizations with an 
overwhelming bureaucracy. Their care and services often overlap 
in messy, unpredictable ways. At a time of enormous stress, 
this bureaucracy only hurts the injured warrior and his family.
    When our troops return from theater with serious injuries, 
they are met with a dozen seemingly unrelated people with 
different services. We addressed much of these problems last 
year with the passage of the Wounded Warrior provisions in the 
Defense bill, but there is obviously still more to be done.
    We need to realize that families are an integral part of 
treatment and recovery and have their own needs. Unfortunately, 
the VA is restricted from providing the many services families 
need and deserve when their sons and daughters, siblings, and 
parents return with service-connected injuries.
    We have been playing catch-up since the beginning of this 
war. It is irresponsible that the only support structure 
available to a 19-year-old wife of an injured soldier is the 
wife of a similarly injured soldier. We are going to hear from 
people that have been dealing with the difficulties of the 
system for a long time.
    On February 14, 2004, Sergeant Ted Wade lost his right arm 
and suffered severe traumatic brain injury (TBI), along with 
many other injuries in an improvised explosive device (IED) 
explosion in Iraq. Sergeant Wade is here today with his wife, 
Sarah.
    Marine Corporal Casey Owens of Houston, Texas, lost both 
his legs when his unarmored Humvee struck a landmine in Iraq on 
September 20, 2004.
    Corporal Owens and Ms. Wade will tell us about the 
frustrations and difficulties they have faced and we look 
forward to their testimony.
    Sarah and Ted Wade have devoted themselves to helping 
hundreds of other injured servicemembers and their families.
    Just 2 weeks after he was injured, Casey Owens told his 
family that he wanted a camcorder so he could document his 
progress from start to finish. He could only communicate by 
writing at the time of his request. He wanted to show his 
future children how far he had come and how good he had it. 
Today you can find Casey gliding down the slopes at Aspen.
    We owe Corporal Owens and Sergeant Wade a great debt. We 
cannot repay that debt, but we can make sure that Corporal 
Owens and Sergeant Wade, their families, and everyone like them 
get long-term care and services that are also world class.
    [The prepared statement of Chairman Mitchell appears on p. 
49.]
    Mr. Mitchell. Before I recognize Ranking Republican Member 
for her remarks, I would like to swear in our witnesses. And I 
would ask all witnesses if they would please stand, and raise 
their right hand.
    [Witnesses sworn.]
    Mr. Mitchell. Thank you.
    Next I would like to ask unanimous consent that Mr. Lampson 
be invited to sit at the dais for the Subcommittee hearing 
today. Hearing no objection, so ordered.
    Mr. Lampson, please join us at the dais.
    I would now like to recognize Ms. Brown-Waite for opening 
remarks.
    [Microphone technical difficulties.]

          OPENING STATEMENT OF HON. GINNY BROWN-WAITE

    Ms. Brown-Waite. Let us hope this works a little bit 
better. I am sorry.
    Good morning. Mr. Chairman, I thank you for holding this 
hearing and also for yielding. I am going to keep my comments 
short because I am looking forward to hearing from our 
witnesses on how we can make the system better.
    Over the past several years, this Committee has watched 
over the development of the Polytrauma Rehabilitation Care 
(PRC) units throughout the VA system. It has seen good work 
including one in my own neighborhood in Tampa, Florida.
    We are happy that we are doing better on inpatient care for 
our severely wounded servicemembers. What we have observed 
during our oversight visits is a dedicated staff and resources 
that are necessary to make sure that the care given to our 
veterans is second to none.
    However, this Subcommittee is concentrating its focus on 
what happens after the servicemember or veteran is discharged 
from the VA. How are these severely injured veterans and their 
families actually integrating back into their communities and 
back with their families? What kind of post hospitalization 
care and support services are they receiving? What avenues do 
they find opened or closed to them? Basically, what are the 
challenges that the veterans are facing?
    We are all looking forward to hearing from our first panel 
as to what they have encountered since their discharges. 
Hearing their stories is not only important to the Committee 
but also to the VA as they develop their Federal Care 
Coordinator Program to reach out to our severely injured 
veterans and assist them whenever and however they need it.
    Those who are serving on the front lines of battle do not 
consider where their actions will take them in the future. Our 
Nation's heroes have sacrificed their time, energy, and often 
physical health to secure freedom and democracy throughout the 
world.
    And I think every American believes that they deserve the 
best possible care that we can give. Our obligation to care for 
severely injured servicemembers does not end when they leave 
the PRC but continues long after the discharge care process.
    Again, Mr. Chairman, thank you for holding this hearing and 
I yield back my time. And I apologize for the problematic 
microphone here and it is not my Blackberry because I handed it 
over.
    Mr. Mitchell. Thank you.
    Congressman Walz.
    Mr. Walz. I will reserve my time.
    Mr. Mitchell. Congressman Stearns.

            OPENING STATEMENT OF HON. CLIFF STEARNS

    Mr. Stearns. Yeah. Let us see if this works. Thank you, Mr. 
Chairman, for holding this hearing.
    Obviously today we are addressing a very critical issue 
facing our heroic wounded warriors and their families and, of 
course, their transition back into civilian life.
    A recent article in which former U.S. Department of Health 
and Human Services (HHS) Secretary Shalala commented, she 
indicated if we are asking people to risk their lives and their 
future, then we ought to be willing to make this investment. 
And that is what we are trying to do here.
    Families are the most important factor in the successful 
transition back to civilian life for our warriors. Obviously 
they deserve all the support we can provide for them.
    I am very glad that on our first panel of witnesses, we 
will hear the personal testimonies from two individuals who 
have experienced these issues firsthand, Corporal Casey Owens, 
and Ms. Sarah Wade will be speaking on behalf of herself and on 
behalf of her heroic husband, Sergeant Edward Wade.
    And I want to thank both of them for traveling the distance 
to come here and take the time to testify before us.
    My colleagues, since 2003, I have been pleased at some of 
the initiatives that the VA has established to serve wounded 
warriors and their families.
    In June of 2005, the VA issued a directive expanding the 
scope of care it would provide to include psychological 
treatment for family members. This is very important. In 
addition, the VA has expanded their team of caseworkers, but we 
do need more.
    Intensive clinical and social work case management services 
have been created for the four regional traumatic brain injury 
rehabilitation centers now named the polytrauma rehabilitation 
centers. VA also established joint programs with the Department 
of Defense to ease the transfer of injured servicemembers to 
the VA medical facilities.
    In August of 2003, VA and DoD established a program 
assigning VA social workers to select military treatment 
facilities to coordinate patient transfers between DoD and the 
VA medical facilities. The social workers make appointments for 
care, ensure continuity of therapy and medications, and 
followup with the patients after their discharge.
    But I am concerned, first of all, that caseworkers seem to 
have too large a caseload which may inhibit the amount of time 
and focus they are able to spend with each and every family. 
Particularly when servicemembers are discharged from the VA 
polytrauma rehabilitation centers, most, if not all, still 
require followup care at the VA, at DoD, or private-sector 
facilities.
    I want to know if this transition system functions 
smoothly, whether the patient is going back to the military or 
is the patient going back to the private sector.
    In addition, most of the most severely wounded patients 
require long-term care and will become veterans eligible for VA 
care when discharged from active duty.
    So I look forward to this hearing, Mr. Chairman.
    I have had the opportunity, as I am sure many members have, 
to participate in the VA winter sports clinic out at Snow Mass, 
Colorado, and seeing the enormous energy disabled veterans put 
into that skiing clinic and to see how successful they are and 
it is inspiration for all of us. And so I welcome our witnesses 
today and I look forward to their testimony, Mr. Chairman.
    Mr. Mitchell. Thank you.
    Mr. Space.
    [No response.]
    Mr. Mitchell. Thank you.
    I ask unanimous consent that all Members have five 
legislative days to submit a statement for the record. Hearing 
no objection, so ordered.
    At this time, I would like to recognize Congressman Nick 
Lampson of Texas who is here to introduce his constituent, 
Corporal Casey Owens.
    Congressman Lampson.

             OPENING STATEMENT OF HON. NICK LAMPSON

    Mr. Lampson. Thank you, Mr. Chairman. Hopefully this one 
works.
    I want to thank Chairman Mitchell and Ranking Member Brown-
Waite and Members for allowing me to come and sit in on this 
hearing with you today. I am honored to join you on this 
distinguished Subcommittee and very proud to introduce Corporal 
Casey Owens of Missouri City, Texas.
    Casey is an extremely exemplary young man and I commend him 
for his willingness to continue to serve his country and his 
fellow veterans. We are proud of his service to this Nation in 
many, many ways.
    I was impressed when we met yesterday for the first time by 
all of his accomplishments. A graduate of May Creek High 
School, he went to the University of Texas. But following the 
attacks on September 11, he decided to join the Marines.
    He was deployed twice, the first time from February 2003 to 
October of 2003 and the second time from August of 2004 until 
September 20, 2004, when he sustained his injuries. During this 
time in the Marine Corps, he received several medals in 
recognition of his distinguished service.
    Less than a year after sustaining his injuries, Casey 
successfully completed the Marine Corps marathon in 2005 using 
a hand-cranked wheelchair with a time of approximately 2\1/2\ 
hours, probably better than any of us here could do. I know 
better than I could do.
    He is currently training as a member of the competitive ski 
team in Colorado that has been recognized by the Paralympics 
and the VA as an official training center.
    Even more impressive than the three accomplishments, than 
all of these accomplishments in my opinion, is Casey's advocacy 
for veterans' care. He has worked with Mayor Bill White, 
Houston Mayor Bill White's Veterans Task Force which was 
established last year to address the needs of Houston's 
veterans, both young and old, when it comes to housing, health 
and mental care, job training, and other issues.
    And he has come here today to testify before Congress about 
the challenges new veterans in this country continue to face as 
they transition from DoD to the VA system and try to navigate 
it.
    The most impressive, though, is the concern for his fellow 
veterans and those that will come after him. He is here today 
to ensure that our Nation's future wounded warriors will not go 
through the same frustrations and feelings of neglect that he 
and his friends have experienced at the DoD and the VA and have 
struggled to adapt to a new breed of patients as they have 
struggled to adapt. So they deserve much more in return for 
their service. And I commend Casey for his advocacy on their 
behalf.
    And, again, I thank the Subcommittee for allowing me to sit 
in and I yield back my time, Mr. Chairman.
    [The prepared statement of Congressman Lampson appears on 
p. 50.]
    Mr. Mitchell. Thank you.
    At this time, I would like to recognize our first panel, 
Corporal Owens, Ms. Wade, and Sergeant Wade.
    And I just want to say that last evening, I met with all 
three in my office and we had a great visit. And I hope that 
you convey in a very matter-of-fact way what you told me 
yesterday because I think it is a very compelling story and 
everyone should hear it.
    So thank you very much. And we will start with Corporal 
Owens.

STATEMENTS OF CORPORAL CASEY A. OWENS, USMC (RET.), HOUSTON, TX 
  (U.S. MARINE CORPS COMBAT VETERAN); AND SARAH WADE, CHAPEL 
 HILL, NC, ON BEHALF OF SERGEANT EDWARD WADE, USA (RET.) (U.S. 
                      ARMY COMBAT VETERAN)

       STATEMENT OF CORPORAL CASEY A. OWENS, USMC (RET.)

    Corporal Owens. Good morning. Thank you, Chairman Mitchell 
and Members of the Subcommittee, for coming.
    I was injured September 20, 2004. I was serving with the 
1st Battalion, 7th Regiment Weapons 
Company. I was in Al Anbar Province out west on the Syrian 
border. We were on a reconnaissance mission, dropped off a 
reconnaissance team. Minutes later, we got a call to pick them 
back up for a medivac mission. A Sergeant from reconnaissance 
had been shot in the throat who later succumbed to his 
injuries.
    On the way back to base, we were engaged again and ran over 
two anti-tank mines, which resulted in the loss of both my 
legs. I was flown to a field hospital in Iraq, stabilized, 
treated there, and to Landstuhl, Germany. I was there for 3 to 
4 days and then flown to the Bethesda, Maryland Naval Hospital.
    I woke up about a month later from a coma to find my legs 
were missing. I had suffered two collapsed lungs, a pulmonary 
embolism, serious head trauma, broken my clavicle and my jaw, 
which now has a metal plate, and my teeth were knocked out, 
several shrapnel wounds to my neck and torso.
    From there, I had several surgeries over the next 2 to 3 
months to stabilize me and was transferred to Walter Reed to 
join the amputee program there and to walk again.
    Over this time, I was a patient at Walter Reed and Brooke 
Army Medical Center and was discharged and retired February 26 
of 2006. And I did not have my right leg completed yet. I was 
still experiencing problems.
    Upon retiring in February, I needed another surgery, about 
March, early April. My right leg, which is my myodesis, which 
is kind of the muscle flap that goes over the end of your 
femur, kind of gives you a padding, it had previously, once 
about a year earlier, had torn completely off my femur and I 
had my leg amputated again about an inch, and my sciatic nerve 
cut. They reattached it. It looked good.
    Over the next year, I still had more surgeries. I had 
problems with heterotrophic ossification, which is a bone 
growth which kind of held me back with my prosthetic care, my 
prosthetic progress.
    So when I was retired, I had a 60-day window that you are 
still under the Department of Defense care. So I was able to 
return to Brooke Army Medical Center to have it repaired. That 
is where it had been done the first time. I went back there. 
They repaired it.
    Within a month, it had failed again for the third time. And 
when I say third time, the myodesis was performed on the 
initial injury. Failed the first time, second time, now third, 
so this would be the fourth time to fix it.
    I was now enrolled in the VA as of April 1, 2006. I went to 
the VA, said, you know, I think it is failing again. I know it 
is failing again. I can feel the bone coming through the muscle 
this time and you could see it.
    They instructed me to work with prosthetics, and that is 
use their standard procedure is prosthetics, you know, 
adjusting your prosthetics before, you know, surgery. I told 
them that, you know, this is the third time. I have been down 
this road. I know what I need.
    They did not agree with me. The first day, they did not 
agree with me. I said, I will be back in about 4 to 5 weeks. 
The condition is going to be worse. Sure enough, about 5 weeks 
later, over the weekend, the muscle started retracting, pulling 
back, leg, you know, was very painful.
    It was the weekend, so my choices were to go to the 
emergency room, which I knew would be come back Monday, see an 
orthopedic doctor. So I drove to Brooke Army Medical Center 
about 3 hours away, found one of my orthopedic surgeons that 
had performed the surgery the first two times. He looked at it 
right away and said, yes, failed myodesis. And I said, well, 
what are you going to do and what procedure. And he said, we 
will do what is called a Goshock procedure named after the 
doctor who invented it.
    He said, well, this has failed four times now or failed 
three times. This will be the fourth time to do the procedure. 
I said, you know, I do not have any more of my leg to give, so 
he pretty much said, well, that is what we can do.
    So I went home disappointed. I spoke to a prosthetist who 
told me about a new procedure, the Ertle procedure. Because he 
was prosthetics, he said, you know, this advice did not come 
from me and because in the past, he had been reprimanded for 
giving advice from an orthopedic because for some reason, that 
is not his field, even though prosthetics, orthopedics go hand 
in hand.
    So I found it. On the Internet, I found Dr. Ertle. I went 
to my doctors at the VA and said I would like to get this Ertle 
procedure done. They did not agree with me.
    So over the next 6 months, I debated with the VA until I 
finally got my surgery done, which the previous two times had 
taken me less than 72 hours to get it done.
    So during this time, I cannot move forward. I cannot go to 
work, school. I am in pain. I got back on my pain meds which I 
had already gotten off of. And also my insurance, my TRICARE 
insurance supposedly through a clerical error, was canceled. So 
that was another deal to deal with.
    I did not have a social worker for the first 3 months, so I 
sought the advocacy of a friend with Marine for Life who kind 
of took over my case and Marine for Life, Wounded Warrior 
Project and other people who just stepped up to the plate and 
helped me out that were not even government agencies or people 
from the VA.
    I had the surgery done in Oklahoma. The doctor, well, he 
has VA benefits, so, you know, I was not really going outside 
the box. So, you know, I cannot understand what took so long 
for the approval. I never really got an answer other than 
sorry, we made a mistake.
    And I have had the surgery done. It has performed. It is 
doing well. But they had to amputate two more inches of my leg 
and cut another 3 inches of my sciatic nerve which now I suffer 
from chronic phantom pain.
    And I returned home. I went out to Aspen. I had to recover. 
I had several months before I could work with prosthetics, so I 
went out to Aspen. And I was invited out there to train for the 
Paralympics skiing, mono skiing.
    I returned home early summer. I went to the VA and said I 
am home. I am here to work solely on my prosthetics. This is my 
number one goal. I am not working. I am not in school. I had 
appointments about once a week, you know, for an hour which was 
not sufficient to me, so I said, you know, I need to get this 
done, you know. I am technically retired from the military, 
but, you know, I am ready to go back to school and move on, you 
know, with a job and career. And I cannot do it until I have 
this done because it is going to take several months of rehab.
    So they outsourced me because they said they had too many 
patients and not enough staff to meet my needs. So they 
outsourced me to a prosthetist in Houston, which there is only 
one prosthetist there. And he did not have a technician at the 
time either, which even slowed the process more.
    I spent the following summer, the next 8 months up until 
about December. And I had prior engagements with my race team 
starting early November and, you know, prior commitments to my 
sponsors for my racing.
    I put it off for 2 months until January, still trying to 
work on my prosthetics which finally resulted in him telling me 
I cannot fit you. You should look elsewhere.
    So I returned back to Colorado and finished my skiing. And 
next week I go to Oklahoma to a company, some specialists that 
other guys I know go to. But I am going there on the bill of 
the Wounded Warrior Project because it is too much of a hassle 
to deal with the VA and which it should be their 
responsibility. They are the ones who have failed to fit me.
    But, like I say, at times, it gets, you know, it is not 
even worth dealing with the VA because it so much of a hassle 
and that is how it has been.
    You know, I suffer from post traumatic stress disorder 
(PTSD) and the VA and all the problems I have dealt with have, 
you know, furthered it even more. And in that 6 months that I 
dealt with, you know, wondering why no one is helping me, why 
the government is not stepping up to the plate, and it just 
feels like I was abandoned.
    And, you know, I did my duty and those that are in place 
are not doing theirs. And it is a very frustrating feeling to 
go through. And for me, it has been a harder battle coming back 
to the States and dealing with everything I have dealt with 
than it was going to the war both times. That was a cake walk 
compared to this.
    And so here I am now and my struggles, I have gone through 
and done on my own or a lot of my own through the help of, you 
know, advocates, but I do not want others to go through it 
either. So here I am.
    [The prepared statement of Corporal Owens appears on p. 
51.]
    Mr. Mitchell. Thank you. Thank you very much.
    Sarah, are you or Ted going to talk?

          STATEMENTS OF SERGEANT EDWARD AND SARAH WADE

    Sergeant Wade. Chairman Mitchell, Members of the 
Subcommittee, thank you for the opportunity to speak to you 
today regarding our experiences following my injury in Iraq.
    My name is Edward Wade, or Ted, as I prefer to be called. 
And this my wife, Sarah Wade.
    Ms. Wade. Hello. I am not as brave as Casey. I am going to 
actually read my comments because I am worried I will get off 
course.
    Ted sustained a very severe traumatic brain injury or TBI 
and his right arm was completely severed above the elbow. He 
suffered a fractured leg, broken right foot, shrapnel injuries, 
visual impairment, complications due to acute anemia, 
hyperglycemia, infections, and was later diagnosed with post 
traumatic stress disorder.
    Ted remained in a coma for over 2\1/2\ months and 
withdrawal of life support was considered. But thankfully he 
pulled through.
    As an above-elbow amputee with severe TBI, Ted was one of 
the first major explosive blast polytrauma cases from Operation 
Iraqi Freedom that Walter Reed or the Department of Veterans 
Affairs had to rehabilitate.
    Much of his treatment was by trial and error and there was 
no model system of care for a patient like Ted. And there still 
does not appear to be a long-term model today.
    His situation was an enormous challenge as Walter Reed was 
only able to rehabilitate an amputee, not a TBI. The VA was 
able to nominally treat a TBI but not an above-elbow amputee 
and neither were staffed to provide appropriate behavioral 
healthcare for a patient with a severe TBI.
    Because Ted could not access the necessary services where 
and when he needed them, he suffered a significant setback in 
2005 that put him in the hospital for 2 weeks and would later 
take him probably a year to rebound from.
    Ted has made a remarkable recovery, by any standards, 
because we strayed from standardized treatment and developed 
our own patient-centered path. I had to educate myself about 
and coordinate additional outside care. Often access to the 
necessary services required intervention from the highest 
levels of government or pressed to personally finance them 
ourselves.
    But despite our best efforts, Ted is still unable to easily 
receive comprehensive care for all of his major healthcare 
issues due to shortcomings in the current system. And because 
of the time his needs demand of me, I have been unable to 
return to regular work or school.
    We have been blessed to have family with the means to see 
us through these difficult times and to help with the expenses. 
I was fortunate to have the education of growing up in 
Washington, DC, and learning about the workings of the various 
Federal agencies, but our situation is not typical.
    We do have a few ideas to provide better long-term care for 
people like Ted that we would respectfully like to share.
    The first one is about special monthly compensation, 
particularly for reasons of integration, quality of life, 
dependent's educational assistance, and respite care.
    Individuals like Ted who required someone to be available 
for assistance at all times are not compensated appropriately. 
These veterans would require residential care otherwise, but 
are not granted the higher level of aid and attendance because 
they do not require daily healthcare services provided in the 
home by a person licensed to perform these services or someone 
under regular supervision of a licensed healthcare 
professional.
    I would be more than willing to be supervised if that is 
what it took. But we feel the criteria should be clearly 
outlined so appropriate compensation may be granted in the case 
of an individual whose needs of assistance are managing their 
care and personal affairs or they require support outside of 
the home to rehabilitate and integrate into their community or 
to achieve a better quality of life.
    Both in the past and at present, we have paid someone to 
assist Ted outside of the home. This allows him the flexibility 
to hire a peer of his choice to provide community support and 
accompany him on sightseeing outings he has researched and 
planned with his therapist as part of his community 
reintegration, to provide transportation to the store to 
purchase books for homework assignments, go to the community 
center to swim laps, or help him balance his checkbook at the 
end of a day.
    Not only has this enabled Ted to come closer to achieving 
independence, but it has greatly improved symptoms of 
depression by restoring hope and self-confidence, allowed him 
to attain fitness goals and control his blood sugar without 
insulin injections, all while providing much needed respite 
care for me.
    Unfortunately, the current VA respite programs are not 
appropriate for a veteran like Ted. My option for that is to 
put him in an extended care facility for 30 days a year or, as 
my husband says, I could kennel him and the dogs and go on 
vacation. And that is not really something that I am interested 
in doing. I would rather go on vacation with him, or I could 
also have someone come provide care in the home, but they 
cannot take him to the places he needs to go and do the things 
he needs to do.
    And with better resources, I might be able to access the 
dependent's educational assistance for which I qualify, but 
under the circumstances, I cannot use. And I think one of my 
great concerns is that these benefits do expire and I am, you 
know, already probably 4 years into the expiration time.
    I would like to see a change maybe in that, but also 
someone provide the assistance we need for me to go to school 
because not only would it give me the education that I have 
available to me, but I think it would also help increase the 
standard of living for Ted by increasing my earning capacity.
    Another suggestion we have is about the Compensated Work 
Therapy Program in the VA system. Largely due to the success of 
the program we have created for Ted, the next phase of his 
recovery will probably include some sort of vocational 
rehabilitation. He has already had the opportunity to 
participate in volunteer work through counseling and job 
coaching provided by a private practice near our home where he 
attends a day treatment program for behavioral health and TBI.
    But now he is ready for the next stepping stone to 
employment. The current Department of Veterans Affairs' 
vocational rehabilitation and employment service is more of a 
challenge than is healthy for someone like Ted, with 
significant cognitive deficits and significant emotional needs.
    VA work therapy programs, while developing work tolerances 
and promoting effective social skills for more seriously 
impaired patients, are set in insulated environments. A work 
therapy program expanded to other community settings to 
accommodate patients like Ted who are better served outside of 
a sheltered atmosphere would be more effective.
    Volunteer internship positions or later a part-time job 
that sparks his interest would be more therapeutic. Not only 
would this help him acquire the confidence and independence he 
needs to someday become gainfully employed, but it would also 
aid in his reintegration by providing constructive, meaningful 
activities for him to participate in outside of the home.
    I think my last comment will be about counseling and life 
skills for patients like Ted with TBI and really patient-
specific case management.
    Although many basic therapies are offered, rarely do they 
include teaching socially appropriate behaviors which are 
commonly an issue after TBI. This task often falls on the 
veteran's family member or spouse, increasing the 
responsibility of the caregiver, and causing conflict with the 
veteran who feels like they are being treated like a child.
    Ted has had the advantage of a community support peer, but 
also a counselor at the private practice I previously mentioned 
to help him redevelop age-appropriate social skills and allow 
me to be his spouse while maintaining his dignity.
    She has also worked with Ted to develop healthy coping 
skills, to manage cognitive deficits, improve mental health, 
and develop patient-centered treatment plans, which focus 
specifically on his unique challenges.
    Again, our situation is not typical, though. This is 
something difficult to provide in an institutional care 
environment like the Veterans Health Administration without 
greater flexibility and more resources to provide increased 
face time with the patients and better injury-specific 
expertise.
    The challenges we have faced are the same as countless 
other veterans, many of whom have not had the resources Ted has 
had available to him or an advocate capable of negotiating the 
system.
    A veteran I often think about who had a young wife with a 
newborn baby and nothing more than a high school education 
should have received the same world-class care as my husband 
but sadly did not nor will not. Despite my best efforts to be a 
support to his spouse, who is overwhelmed by motherhood while 
trying to negotiate a seemingly impossible system, she 
eventually left him because it was more than she could handle. 
I think it is a lot to ask any mother to neglect their child.
    A veteran's care should not depend on what family they were 
born into, who they married, or whether or not family 
obligations allow their loved one to advocate for them, but 
sadly it does.
    Though we will never be able to fully compensate seriously 
wounded veterans for the sacrifice they have made on our 
behalf, we can certainly do a better job of managing their 
care, rehabilitating them to the fullest potential in a timely 
manner, and providing the necessary resources to maximize their 
quality of life.
    I am very pleased to see that the Subcommittee is taking a 
look back to explore ways to learn from the past and address 
the needs of the veterans injured yesterday. I think this will 
make a tremendous change for the people who are being injured 
today.
    And I want to thank you all again for having us here and 
look forward to answering any questions.
    [The prepared statement of Ms. Wade appears on p. 52.]
    Mr. Mitchell. Thank you very much.
    And let me just ask a question of all of you very quickly 
because we know that Congressman Walz has to leave. But 
yesterday in talking to all of you, you all have some 
individual needs. You are saying that the VA, in a way, has a 
number of things set up, but nothing to deal individually.
    And I would just like, Corporal Owens, for you to tell the 
story that you told us yesterday about when you went to the 
methadone clinic, when they sent you out there because they did 
not know what else to do with you or something like that. But 
would you tell that story?
    Corporal Owens. During the time, I was, you know, that 6 
months, waiting for my surgery, got too much to deal with 
anymore, so I started taking my pain meds again, still 
suffering from phantom pains and just the muscle tearing and 
just grinding against the bone and whatnot.
    So I was back on them. I had my surgery done, so I was 
still recovering. About 2, 3 months later, went to the VA, went 
to my doctor, primary care doctor, said I think it is time I 
want to get off these, but they are very, very strong narcotic 
medications. So, you know, your blood pressure elevates, you 
know, your body goes through a lot, you know, lack of sleep, 
sweating, shakes.
    So I said I would just like to be monitored, you know, I am 
ready to get off it. He said okay. So gives me an appointment. 
So a couple days later, I go up to see a doctor, to the floor, 
to the substance abuse program. First, they say, well, what are 
you here for. I said I do not know. I said I just want to get 
off my meds. I thought I was coming to see a doctor to monitor 
me.
    So he says, no, you must have been flagged. Do you have a 
problem? I said no. I said call my doctor, put him on speaker 
phone. He calls him, asks my doctor. My doctor is saying, no, 
he does not have a problem, I just do not have the time, you 
know, big patient load. He said he just wants to be monitored 
and, you know, helped and, you know, blood pressure medicine, 
whatnot.
    So he gets off the phone. The guy says, well, we want to 
put you in the methadone clinic where you will come in every 6 
days and you will get 6 days worth of methadone. I said I do 
not want any more drugs. I want to get off of them.
    So I left there and, again, went to an outside nonprofit 
veteran group and they sent me to a doctor and to a detox 
center and I got off of them, have not been on them since.
    But, you know, it amazed me that just a simple week-long 
monitoring could have taken care of it, but instead just led to 
more problems, more frustration, and giving me more of an 
attitude to not deal with the VA which I really do not do. And 
most of all my care since I have gotten retired has been from 
outside doctors and outside sources. I rarely use the VA.
    Mr. Mitchell. Thank you.
    I just wanted you to kind of finish that and then we will 
get into our regular questions.
    Mr. Walz.
    Mr. Walz. I thank the Chairman. I thank the Ranking Member 
for her courtesy.
    I do have another appointment, but I can tell you with 
absolute certainty there is no place more important in this 
country right now than being right in this room. And I am 
humbled to hear your testimony. I am also ashamed that this 
would happen to our warriors.
    We have talked about it time and time again that dealing 
with our wounded warriors is a zero sum proposition, that if 
one is not treated with all the care and all the dignity and 
their issues are addressed with the utmost concern, then we 
have failed. And that has been obvious in these cases, 
especially with Corporal Owens. I am not even sure what to say.
    And to make matters worse even, coming to this hearing 
today, we just came from over in the Rotunda where we had an 
Iraq and Afghanistan war remembrance where a lot of people 
spoke and talked about a lot of nice things and you are sitting 
over here telling us this story.
    And I think Senator Dole summed it up best when he came in 
and testified. He said you spent billions putting them in 
harm's way, do whatever is necessary to get them out of harm's 
way. And obviously we failed you.
    And Sergeant Wade, Ms. Wade, you brought up some very good 
points. I just have a couple of quick questions on this.
    Corporal Owens, you talked about how your TRICARE was 
canceled. And what is so troubling to me about this whole thing 
is that you have come to expect that we are going to fail you. 
I mean, that is obvious that your experience has showed that we 
are going to fail you. That means we failed. Our job is to 
provide that oversight. It does not matter.
    Last year, we talked about how much we were able to do in 
the VA. It obviously did not help you and that is a concern, 
this Committee's primary concern.
    So what happened with that, with TRICARE?
    Corporal Owens. Supposedly it was when I got my medical ID, 
it was supposed to be if you are discharged with a hundred 
percent from the military, you only get care at--this is how it 
was explained to me--that you can only get care at the VA. So 
they discharged me with 90 percent and the VA found me a 
hundred percent disabled. And that way, with TRICARE, I can go 
to outside the VA.
    And when I got my ID, they gave me a hundred, the military, 
or I do not know who it was, gave me a hundred percent and so 
it canceled it. But it took several, I do not know how long, 
month, 2 months or longer to reestablish it.
    Mr. Walz. What happened during that time, I mean, as far as 
your care and bills and things like that?
    Corporal Owens. I was going to the VA, so I was not billed 
anything, but it was just one more hassle, setting up 
appointments, calling people, and having to deal with it.
    Mr. Walz. You mentioned a couple of times, too, about this 
resource issue and people are telling you we are just 
overburdened, we just cannot do it.
    Would it surprise you that members of the VA have sat in 
front of us and we have asked them if they needed more 
resources and they said no?
    Corporal Owens. That is a good point. You know, I hear all 
the time about reports that 100, 200 new people have been added 
to the system to Operation Iraqi Freedom/Operation Enduring 
Freedom (OIF/OEF) patients. It looks good on paper, but in 
reality, that is just an extra nurse or something to the 
hospital, you know, a new doctor, delegate of the hospital that 
can treat OIF patients, not to OIF patients, you know.
    I mean, it is for us, but, you know, it is good for reports 
and good for Committees because it sounds like you are making 
progress. But the reality is, I do not see any results. I do 
not see any changes. You know, there are now OIF/OEF 
coordinators at all the VAs and whatnot, but the problem is, 
and this is a solution that I find, they need to have an OIF/
OEF center.
    You know, they have psychologists, this and that set aside 
for us, but they are in all different parts, different wings of 
the building. There is no correlation or communication among 
each other.
    And, like I wrote in my testimony, a good example would be 
Johnny is not going to, say, his prosthetic appointments or 
other appointments and so he gets reprimanded, written up. They 
are like why are you not going, you are not doing anything to 
further your care. And the reality is he may be suffering from 
severe PTSD or his own emotional problems and so he just sits 
in his room.
    And what they need is they need to come together like they 
do at Walter Reed and Brooke where all, social worker, 
prosthetist, orthopedic, vocational worker, they all meet every 
week and discuss their cases and the patients. And it helps 
give insight into some of the people's problems and the avenues 
of care they could give them.
    Mr. Walz. Thank you.
    And then a final question as my time expires here. Ms. 
Wade, I think you have given a really powerful testimony and a 
really strong insight into an area that I think we are not 
addressing. And it is the issue of respite care and what 
happens with the family and the caregivers, what happens to 
their career, what happens to their well-being. And there has 
been talk about that.
    And this country means well and all of my constituents want 
to do whatever they can to help, but I know what happens to you 
as you see people and they will say, oh, it is good to see you, 
you are looking good. It looks like Ted is doing well and all 
that. And then they see you another 4 or 5 months later and 
they say, gee, how are you doing, are things going well. They 
do not realize every hour of every day of the intensity that 
goes into that and this is all part of the care. It is all part 
of taking care of that veteran.
    So I appreciate your testimony. And I can tell you there 
are Members up here that definitely share this concern and 
believe this is the area, maybe the next big area where we 
should be focusing as quickly as possible to address that.
    So I thank the Chairman and Ranking Member. I do thank you 
again for your kindness to let me speak.
    And, of course, I am not sure what to say to you. Sorry is 
not good enough in this case. And everybody is going to stand 
in front of you and tell you that. You said you have heard it 
many a time.
    The only thing we can say to you is that we are going to 
give every ounce of effort that we can to address this and make 
sure that you do not go through this. And I know we may never 
gain your trust back in that system, but we owe it to those 
that follow you to do that.
    So thank you for being here.
    Mr. Mitchell. Thank you.
    Ms. Brown-Waite.
    Ms. Brown-Waite. I will try this one again.
    [Microphone technical difficulties.]
    I guess I will not.
    All three of you, your statements certainly were riveting 
and sad, very sad. I visit the various hospitals as many other 
Members do and I have to ask a basic question.
    When you were going through this, did you ever contact your 
Member of Congress' office for help? Because I know that many 
Members of Congress take the care of the veteran to be very, 
very personal.
    As a matter of fact, I have the VA hopping in giving me a 
report every 2 weeks on a veteran in my district that I know 
kind of slipped through the cracks. And I think it is very 
important that we know about it because I do not think there is 
a Member of Congress who, if he or she knew that this was going 
on would have not immediately jumped into action.
    So did any of you contact your Member of Congress about the 
problems you were having with care?
    Corporal Owens. Well, for me, did I contact my Member of 
Congress, no. I do not know if other people on my behalf did. I 
know one incident, I had written the President and wrote a 
letter and gave it to Colin Powell to give to him, but it was 
returned the following week. But, no, I cannot say I did.
    Ms. Brown-Waite. Sergeant or Ms. Wade.
    Ms. Wade. I guess I have worked some with Senator Byrd's 
office, one of our Senators from North Carolina. He came to me 
and offered to help. I had tried to contact Senator Dole's 
office and there was just too many hoops to jump through and 
too much red tape.
    And honestly I think this is one of the problems with 
people with severe brain injuries or someone that requires a 
lot of intensive long-term care. I do not have time. There is a 
lot of people that I need to ask for help in a lot of different 
areas. And I just gave up.
    I had contacted Senator Dole's office about a military-
related issue since she is on the Armed Services Committee and 
I was sent a VA waiver. And I just did not have time to explain 
that it was not a VA issue.
    And so I mean, honestly, the people that have helped me 
also, Senator Hagel, I had met by accident. It is an 
interesting story. I was quarantined with him during an anthrax 
scare, but, you know, there is a couple of Senators that I met 
that offered me help. And those are the people that I have gone 
to because there are just people that are trying mightily to 
get by every day and we do not have the time to get these 
things done.
    Ms. Brown-Waite. The reason I ask that is because every 
Member of Congress has staff that work on these kinds of issues 
and get the elected Member involved to make sure that things 
happen.
    I am sorry that you did not have a positive reaction and 
that you did not have action by the Congressional staff and the 
Members of Congress, the Senators that you mention.
    You know, maybe the House Members are so much closer and 
our districts are so much smaller that maybe we have the luxury 
that the Senators do not. I honestly do not know. But I know 
that every Member of Congress, every Member in this House on 
both sides of the aisle deeply care about veterans and followup 
on veterans' care.
    Absolutely. Mr. Bilbray, Representative Bilbray from 
California just said, ``that is what we are here for.''
    Let me ask each of you if you had any outreach from either 
the Department of Defense or the Department of Veterans Affairs 
after your discharge from inpatient care and what kind of 
support or care was offered to you or your family.
    Corporal, would you like to go first?
    Corporal Owens. Nothing really stands out. I cannot say 
that they did not. But nothing stands out because when I was 
discharged, you know, this all happened within a month. You 
know, with my leg tearing, the muscle failing again all 
happened within a month and 6 months it took to get this done.
    So I cannot really think if they had, you know, I do not 
see what it would have taken this long. I went to them, to the 
VA, and told them, so they were aware of everything. It was 
obvious what was wrong with me. No, not that I can think of.
    Ms. Brown-Waite. Sergeant or Ms. Wade.
    Sergeant Wade. I do not----
    Ms. Wade. Do you want me to start from the beginning since 
you were asleep? Okay.
    For Ted, he had a social worker initially at Walter Reed 
and Ted was retired from the military before he regained 
consciousness. So he quickly was not their responsibility. We 
did have a social worker at Walter Reed, who even though he was 
not her jurisdiction, she still kept in touch with me and tried 
to help me out.
    I will say the person, the group that has been in touch 
with us from start until now is the amputee service at Walter 
Reed. That is the only group of people that have been with us 
through the whole ride. The amputee case manager there, I am 
convinced knows everything in the world. But Steve Springer, 
the amputee case manager, and the physician who ran the amputee 
program at Walter Reed who is now the Chief of Rehabilitation, 
Colonel Paul Paswena, they are the ones that have been with us 
throughout this whole ride.
    Ted's care was very fragmented. We had a social worker when 
he was in Richmond where one of the level one polytrauma sites 
is now. But, you know, once we left there, there was not any 
contact with them anymore.
    When we got home, there is an OEF/OIF case manager at our 
VA hospital. She is there when I go to her for issues, but she 
is not really there for any kind of really injury-specific case 
management. It is out of her realm of expertise. So she was 
there when we were at Durham the first time and she was there 
when we were at Durham the second time. We have been through 
seven facilities.
    And really, I guess the last 3 years, our continuity has 
been the civilian place where Ted goes, the civilian practice 
he goes to. They have a brain injury case manager who from the 
first day we went there until just Monday was the last time I 
talked to her.
    Even when Ted is at a different facility for treatment, 
like right now he is at Walter Reed getting a new prosthesis 
and doing prosthetic training and rehabbing from some surgery, 
she still talks to Ted for an hour once a week regardless of 
where he is in the United States.
    So the amputee case manager at Walter Reed and the case 
manager at our civilian facility for TBI have been our most 
continuity.
    And what we are very hopeful about is the Federal Recovery 
Coordinator Program. Ted was recently assigned someone in the 
Federal Recovery Coordinator Program. And that has been maybe 
2, 2\1/2\ weeks. She has already passed her first couple of 
tests which is a big thing with me.
    But we are hopeful that that will maybe create some better 
continuity. My concern, though, with that, is there are good 
reasons why they are starting off slowly with this program, 
because it is hard to get a hundred people out there, training 
them when you do not even know what you need to train them for 
yet and what kind of services people need.
    But one of my concerns is in starting off slowly and where 
a lot of the case management focus has been after the Walter 
Reed articles in the Washington Post, a lot of the focus has 
been on the military treatment facilities and the polytrauma 
sites. Polytrauma network sites, only a small handful, a few 
hundred people have been through those. It is a relatively 
small number compared to the large group of people being 
wounded.
    And needless to say, the military treatment facilities are 
short lived.
    My concern with the changes in case management, I know that 
I hear patients at Walter Reed are currently complaining that 
they have to check in with five different case managers in 1 
day and doctors complaining that the case managers are getting 
underfoot and they do not have time.
    Ms. Brown-Waite. Excuse me. Is that currently----
    Ms. Wade. Yes, ma'am.
    Ms. Brown-Waite [continuing]. They are complaining about 
that?
    Ms. Wade. And so what I feel like is that it would be smart 
to have some sort of visibility of all the case managers that 
exist from all these different programs. I mean, Ted 
theoretically has five or six, because there are a lot of 
people who left the military treatment facilities like my 
husband who just dropped off a cliff.
    I really think that if some of these groups of case 
managers could be restructured and reassigned that someone 
needs to have the job of reaching back and finding the people 
that have been lost for the last few years and finding out if 
they ever got the treatment they needed. And if they did not, 
make it happen now.
    Ms. Brown-Waite. Thank you very much.
    Did you get a copy of the case plan for your husband when 
he was leaving the hospital, a case management plan, what they 
were going to do?
    Ms. Wade. No, ma'am. I do not think they were doing that.
    Ms. Brown-Waite. So there was no case management plan with 
followup care?
    Ms. Wade. I will say our Federal Recovery Coordinator, the 
first day I met with her, that was our first conversation was 
what were our immediate goals for the next 6 months and what 
were our goals for the next 5 years. And one of the big 
improvements, but it was about my goals too. It was the first 
time anyone has ever asked about me and, you know, what was 
going to happen to me in all of this.
    Ms. Brown-Waite. Thank you very much.
    I have exceeded my time and I thank the Chairman for being 
understanding. And I yield back.
    Mr. Mitchell. Thank you.
    Congressman Space.
    Mr. Space. Thank you, Mr. Chairman.
    Corporal Owens, Sergeant Wade, Ms. Wade, I am really struck 
by your testimony. By the way, you did a wonderful job. I know 
this was not easy for you. I am struck by your sacrifice and 
your courage and your heroism.
    I think that Tim Walz, what he said is right. There is 
really no more important place in America than right here, 
especially for a Member of Congress.
    What you have done, what you have given up, and what you 
have gone through are quite remarkable. It is really important 
for you to be here. It is really important for me and my 
colleagues to hear your stories, again because it is important 
for us to know the kind of sacrifice that you are all making 
and you have made.
    Certainly it is important for us to understand what we have 
to do better to live up to our obligation to you that 
tragically we have not been as good as we should have been on. 
And perhaps most importantly, it is important for us, for the 
Members of Congress, to see firsthand the price that is being 
paid for this war.
    And I thank you for being here.
    Corporal, I had one question I wanted to ask you about in 
response to your testimony. You had indicated that time and 
again, you differed in your own assessment of your own injuries 
and your own need for treatment from what VA hospital doctors 
were advising you on and that I think you had three or four 
different amputative procedures on the same leg and that as a 
result of what appear to be flawed procedures or diagnoses or 
opinions, you have endured a lot of pain and a lot of suffering 
that might not have otherwise occurred.
    And my question is this: You know, was there an avenue? Did 
you feel that there was an appropriate avenue for you to obtain 
a second opinion? I mean, it is something that many of us who 
are not within the veterans' system take for granted.
    Did you feel that you had that kind of recourse that you 
could have seen a doctor efficiently, quickly, just to get a 
different assessment or did you feel that your options were 
limited in that respect?
    Corporal Owens. It was kind of limited. And there is a team 
at an amputee clinic, you know, an orthopedic and kind of a 
primary doctor, so that is my point of reference or contact. 
And that is who did not approve of, you know, our--you know, 
who referred me back to Brooke who wanted to do the same 
procedure. And I said, well that is not what I want. So, I was 
really there and then come back to the VA and say, well, this 
is what they are going to do. It is not what I want.
    And so from there, I was just kind of on my own, you know. 
I did not really know where else to turn to find someone to 
back me up and say this is the procedure, you know, that I 
found and want. And the way I feel, it is my right to choose 
what care and what procedure I want.
    I mean, it is not like it was going to be something harmful 
or something that was just blatantly just going to be wrong. I 
mean, it is my preference and I researched it and read up on 
it. It is a medically proven procedure. It is not like some 
quack procedure or anything. It is done by qualified 
professionals.
    So, no, I did not really feel I had a lot of places to turn 
for a second opinion.
    Mr. Space. Okay. Thank you.
    And I just want to close. Corporal, are you the one from 
Congressman Lampson's district? You know, I heard your 
testimony that you had not reached out to his office. I can 
tell you that you have one of the most compassionate and 
concerned Members in this body and I know that he would have 
been there for you had you reached out to him.
    But I think the point is that you should not have to reach 
out to your Member of Congress to get adequate just 
satisfactory base-level care within the administration. And we 
want to make sure that we do everything we can to allow you to 
get that care without having to take those extraordinary steps.
    Thank you. I yield back.
    Mr. Mitchell. Thank you.
    Mr. Stearns.
    Mr. Stearns. Thank you, Mr. Chairman.
    I had my staff here, so I had to go to another hearing, but 
I am very glad to be back. And I had some notes that she took 
and particularly with Corporal Owens. In your testimony, you 
talked about dealing with the VA and it is a bit of a hassle. I 
think those are your words. You also said that sometimes you 
feel like you are on your own and almost there is no support 
system.
    I notice in some of the notes here that the VA is trying to 
improve that and one of the things they have talked about is 
developing several Web-based applications, including a Federal 
Individual Recovery Plan and National Resource Directory.
    They are going to team with military healthcare personnel 
to use the recovery plan to create in one set of documents on 
the Web a so-called map for recovery for wounded veterans ill 
or perhaps obviously ones that are injured and their families.
    And I guess my question for you, I guess for both of you, 
Ms. Wade and Corporal Owens, would this Web portal that would 
provide all these benefits in one area be helpful for you?
    I have a bill, H.R. 3646, where you could go to the VA and 
find every job in the country that is giving affirmative action 
for veterans. So if you are in my hometown of Ocala and you 
have a disability and you want to find work in the government 
or in the private sector that is giving special preference to 
veterans, this Web site, this bill was established so that you 
could go and find this work. And it might be in Colorado, it 
might be in New Hampshire, it might be in Florida, but you 
could go to one area and find it.
    And so I think the Department of Veterans Affairs is trying 
to develop all this in one Web site and I guess it is sort of a 
clearinghouse.
    And so my question to you is, this Web-based application 
for individual recovery plans and National Resource Directory, 
health records, and creating one set of documents, sort of a 
recovery map for you, perhaps each of you might talk a little 
bit about that if that would be helpful.
    Corporal Owens. It cannot hurt, but that is not where the 
effort and money and time needs to be spent. It is nice, but it 
is something to try to glitz and glamour, you know, just making 
a Web site. No one is going to go look at it. There are tons of 
Web sites out there. I can tell you that. I get papers all the 
time, go to this Web site, go to that.
    With the VA and stuff, there are vocational rehab jobs and, 
you know, several other places. That is not a problem finding a 
job or places that will take you. The problem lies on the 
ground. They need more foot soldiers. They need more people 
that are experienced and know the system and know how to work 
it and advocate for you when you need something, not turning to 
a computer or calling a hotline.
    You need someone. You call up and say here is my problem. 
You tell them that day and then you go carry on with your job 
and what you have else and leave it to them because with a Web 
site, that is just leaving stuff to you. And that is not our 
job to do this. Our job was to recover and move on with our 
life, which all of us wanted to do and put this behind us.
    And the problem is not all these programs. The problem is 
the accessibility to the healthcare and the bureaucracy and red 
tape is what needs to be fixed. And I see all the time they are 
setting up this program, they are setting up that. I think that 
is just a way to get more funding to make it look like 
attention has been going places.
    And I think probably what you hear at all these hearings 
is, because I know at least from my experience and all my 
friends, they do not have problems finding a job or training or 
education. They have a problem getting their benefits, getting 
their ratings.
    I know she is still dealing with it, you know, still trying 
to get his proper rating and what he is entitled to. And that 
was a problem for me. It took me a year and a half to finally, 
through the VA, to get my claims and everything processed.
    You know, I went through several months to do my med board. 
It took 3 to 5 months of meetings, addendums, talk to the 
psychologist, rehashing everything, getting ready only----
    Mr. Stearns. So you are just saying it is a multitude of 
bureaucracy and you have to jump through all these hoops, 
families do, to eventually get service which at some point is a 
breaking point for families because they are so frustrated.
    Ms. Wade.
    Ms. Wade. I have some concerns with this. I do think it 
would have helped me narrow down where to look for things, but 
you also have to keep in mind that I am someone who loves to 
research things and there are other people that are not very 
good at that.
    I think also a very important point to make and I think 
that the culture of the VA has to change. The culture of DoD 
has to change in expecting people to come to them. Someone like 
my husband is not capable of using a Web site like that. It is 
part of the impairment from his brain injury.
    And so for him, it would not be useful. And, again, it 
means then that it is falling on somebody else to do it for 
him. And there are also a lot of people with TBI who just are 
not able to initiate things. And so that is one of the 
difficulties with something like that.
    I do think it would be useful for someone like myself who 
likes to hunt down information.
    But part of the problem with it also is that so often, I 
just had this happen a couple of weeks ago when I was talking 
to some VA people in the polytrauma system, that, you know, it 
is we have X, Y, and Z. And I will say, well, I was actually 
looking for A, B, and C.
    I think that part of the problem with consolidating how to 
get to these programs is you have to know what program you 
need. You also have to have someone who knows the patient well 
enough to know when one of those programs is not available, you 
know, when there is something else they need that is not there.
    There just has to be more. You need a case manager who 
really, really knows the individual. I do not think it should 
be up to the individual to identify what their needs are. They 
may not know better.
    Mr. Stearns. What happened if the VA provided a proactive 
person to help you with the portal, that that person would come 
over, go through the Web, show you everything, go through all 
the programs, and on a regular basis in one spot sit down with 
you and do it for you?
    Ms. Wade. Three hours later, my husband would not remember 
how to do it. He has memory issues. So for him, that would not 
help.
    Mr. Stearns. But the family would benefit by seeing it and 
seeing the networking that they could go through.
    Ms. Wade. If they do not have a full-time job and children 
to take care of and they have the time to. I mean, I do think 
that it is a useful resource. I am just concerned that it is 
going to become some sort of catch-all.
    Mr. Stearns. Both of you seem to be advocating that the VA 
should have more personnel to come into the home, help the 
families in a way to go through the bureaucracy without them 
having to funnel the attack against the bureaucracy.
    Ms. Wade. And to know the patient better. I mean, just 
recently, Ted had some issues with medication. Anybody who 
would have encountered him at the VA hospital would have just 
assumed that he was being agitated, getting easily agitated 
because that happens with TBI.
    His amputee case manager at Walter Reed who has known him 
for years encountered my husband and knows what his individual 
baseline is and knew that that was not how he usually is and 
asked me. Well, he actually looked up that there were some 
medication changes and he called me about it.
    But it is not just having anyone there to show me. Someone 
has to really know my husband.
    Mr. Stearns. Someone that knows the history. Yeah, knows 
your husband.
    Ms. Wade. And really know him.
    Mr. Stearns. Yeah.
    Thank you, Mr. Chairman.
    Mr. Mitchell. Thank you.
    Mr. Bilbray.
    Mr. Bilbray. Thank you, Mr. Chairman.
    First, I want to say to the panel, I want to thank you very 
much. And I do not think you realize what a service you are 
providing this Nation by being here today and by doing what you 
have been doing over the last how many months. It is a very 
measured, very effective message.
    I also have got to say that as somebody who grew up in the 
Navy and still hear my mother to this day as an 88-year-old 
lady talking about having to sit in the emergency room from six 
in the morning until six at night waiting for somebody to see 
you that bureaucracies, especially Federal bureaucracies, and 
even the military can be very frustrating sometimes.
    It is inherent that in a system where people neither get 
fired for doing the wrong thing nor get more pay for doing the 
right thing, the system inherently tends to be very insensitive 
to outcome and service.
    But I think that, you know, Ms. Wade, you have given us 
some good insight into two things. First, the concept of having 
a clearinghouse is something that some people could use and 
could help to improve it.
    But I think when it comes down to it is while we may have a 
triage team to talk about the multi facets, we need to have a 
designated caseworker who is delegated the responsibility of 
being basically an ombudsman of making sure that when there is 
a glitch, you have somebody that you can contact. When there is 
a frustration with a certain bureaucrat, there is always that 
person you can come back to as your team or your advocate to 
help you in the system.
    And I guess the frustration always with working with 
government, any kind of bureaucracy is to have somebody to be 
your advocate who knows your case and your situation and knows 
the bureaucracy and how to navigate through it.
    And when we get too many people playing the games where you 
have five or six or ten people, you do not know who to go to to 
specifically address those issues. So you need to have that go-
to person. And I hope that we can talk about that.
    And I have got to apologize to you, Ms. Wade, because you 
have really been very measured at the fact of starting this 
small process with a few trainees and working out. And the 
reason why they have to do that is that if we do train, we do 
have a big program and it does not work out, nobody wants to go 
back and correct those problems.
    You know, the biggest problem in Washington is not that we 
try new things and it is not that we make mistakes. The problem 
is when we try new things and make mistakes, we never want to 
be brave enough to go back and correct it and say we have had a 
problem.
    I really do not have any specific question except for the 
fact that, you know, am I right to assume that we really do 
need to give the returning heroes the ability to have one 
person and somebody that they can kind of rely on in this 
situation, because sadly, as the Congresswoman pointed out, we 
do not teach our kids in school which government agency to go 
to when you take care?
    I know Richard very well. The Senator is a good friend of 
mine and we sat together for 6 years in the House. But it is 
your representative in the House of Representatives who has a 
small enough district to be more responsive than a Senator.
    And sadly the people will call us about traffic lights and 
potholes in Congress and I say I do not do that anymore. I used 
to be a Mayor and now I am not.
    But then do not call when it is a specific issue and do not 
understand that Congressman are not up here. They are here to 
serve and that is why we are here to be your ombudsman until we 
can get you one in the system.
    So the question is, am I right to assume that the 
clearinghouse is a good thing, but what we really do need to do 
is simplify the oversight part and try to give a designee, one 
designee for you to go to?
    Corporal Owens. Yeah. What you have to understand is that 
our needs are newer needs than past veterans. You know, we are 
a whole new breed of patients. Our survival rate is a lot 
higher. The type of injuries are different. And so it is going 
to require a new game plan and different mode of thinking than 
what has been implemented in the past. And that is what, I 
think, a lot of people do not understand because they are not 
opening themselves up to a newer--that we need newer programs, 
a newer way of doing things.
    Mr. Bilbray. Maybe our thing is we need to make sure their 
job reflects more on doing the right thing and less on worrying 
about making mistakes if they make mistakes. You know, that is 
the biggest problem we have is the bureaucracy tends to say the 
less I do, the less exposure I have of making a mistake and 
they only judge me by mistakes, not by successes.
    Ms. Wade. My only----
    Mr. Mitchell. Go ahead. We have got to go. And I want Mr. 
Lampson very quickly. Go ahead.
    Ms. Wade. My only comment with the one person is I do not 
want that to be misunderstood. I do need more than one person. 
I need a single point of contact. My husband's amputee case 
manager is a very important thing for him.
    You know, like, for instance, the issue that Casey was 
having with his leg, an amputee case manager who has worked a 
lot with amputees that are recently injured would have known 
what to do in that situation.
    For me, I need a TBI case manager for Ted's TBI 
rehabilitation plan. So what I have told many people is I need 
a case manager for my case managers.
    Mr. Mitchell. Thank you.
    Ms. Wade. So I just do not need it to be one person.
    Mr. Bilbray. That is good.
    Mr. Mitchell. Thank you.
    We have to go vote and we will be back. And I want those 
people here to stay here.
    But, Mr. Lampson, before we go, would you like to make a 
comment?
    Mr. Lampson. I would like to make a comment, actually two 
very short comments and one question. And it follows up really 
on what Congressman Bilbray was just talking about.
    But, first, you know, it is as if the care they do receive 
has been by trial and error. And I think that is their point. 
It is something new. Corporal Owens just made the comment that 
it is a new set of problems. They are polytrauma patients today 
that we have not known how to take care of in the past.
    I am very impressed by your concern about those who you are 
trying to be a representative for and coming here to Congress 
in the hopes that someone else will not have to come here later 
on.
    My other point is the comment that both Congressmen 
Bilbray, Stearns, and Zach Space made about how we really do 
want to know about what is going on and try our best to be 
responsive to what is happening.
    I carry a card in my pocket, and have for more than a year 
now, with the names of the 19 men who have died from my 
district. I walk the halls of the veterans' hospital in 
Houston, Texas, and at Walter Reed visiting with folks like 
this recovering from their injuries. Yet, it took being 
contacted by this Committee to find out that I had a person in 
my district who was having this kind of problem.
    So there is something that is even further broken. How do 
we get information? Here is my question of you all. How do we 
get information out to other members of the service to know 
that they should be able to turn to any level of this 
government, whether it is their Representative, their Senator, 
their President, or whoever else, to be able to say something 
is wrong and I need special attention? Do you have any further 
comment that you can make about that?
    Corporal Owens. It just never really crossed my mind 
because there is the hospital, the VA. That is what it is, for 
medical needs. So I do not think of my Senator or Congressman 
to turn to for medical needs, you know. And I have no doubt 
that you or any other person want to serve me. It is just I----
    Mr. Lampson. My point is that we need to find a way that we 
can make sure that other folks in your situation know to 
contact us. We want to reach out to you.
    Ms. Wade. I guess part of the difficulty with that is 
patient confidentiality and overcoming those barriers. But I do 
know that somehow or other, one of our Senators does--I do not 
know if they scour newspapers to find out who has been wounded 
or what, but, I mean, we got a letter offering assistance if we 
needed it in the mail.
    Mr. Lampson. Well, we do both as well. And I have a retired 
Marine who returned from Iraq and went to work on my staff as 
the outreach person. And we even meet with on a bimonthly basis 
about 15 organizations of veterans, their leaders in my offices 
every other month. Still there are things that are falling 
through the cracks.
    I have a physician at home who has actually volunteered to 
repair the face, he is a plastic surgeon, of anybody who needs 
that special attention. Getting that information out is 
something that I think that we need to pay attention to.
    I think you are magnificent people for being willing to 
give your lives to our country. You should not have to be going 
through the difficulties that you are facing today. If there is 
ever anything that any Member of Congress can do, ask your 
friends to ask us to respond. I think we will do so.
    Thank you, Mr. Chairman and Ranking Member, for allowing me 
to come today.
    Mr. Mitchell. Hopefully you will all be able to stay here. 
We are going to finish this up and we have got some other 
questions. And we will be back right after the vote. Thank you.
    [Recess.]
    Mr. Mitchell. We are going to go ahead and get started. 
Others are on their way.
    One of the things that I wanted to ask both the groups here 
are, first of all, Corporal Owens, you mentioned last night 
that you have been trying to get your medical records and you 
have never received your records; is that correct?
    Corporal Owens. Right. I have not. I have been trying to 
get my med board which is about four inches thick. I have not 
gotten it yet.
    Mr. Mitchell. And I would hope that those of you who are 
here that have some responsibility of that make sure that 
Corporal Owens gets his medical records. He has never had them. 
About four inches thick. He has asked for them and asked for 
them.
    And when were you injured?
    Corporal Owens. September 2004.
    Mr. Mitchell. September of 2004 and he does not have them. 
That is one of the things we have been trying to deal with, to 
get some kind of a seamless transition with DoD records and the 
VA records. There is no way he can get the right and proper 
care without all the records and he does not have them.
    The other thing that is interesting you told me last night 
is that you found in your records that you were not even 
awarded the Purple Heart; is that correct?
    Corporal Owens. When I got to the VA, this was about a year 
ago or so or I do not know how long ago, several months ago, I 
was looking through my case manager's computer and scrolled 
down. It said I did not have the Purple Heart. It said I did 
not have dental injuries. It did not have any of my claims. All 
it had was I lost both legs and that is it.
    Mr. Mitchell. That is amazing that they have on there you 
lost both legs, but not a Purple Heart. And they rebuilt your 
jaw and your mouth and it had nothing about your dental.
    Corporal Owens. No PTSD, no dental, no scars, nothing.
    Mr. Mitchell. And I will tell you it is the lack of records 
and the continuity of them that has caused--you can imagine 
what it does to people who have PTSD and traumatic brain 
injury. It does not help.
    And, Ms. Wade, I think you suggested a similar situation 
with you.
    Ms. Wade. And I think what is hard for us, too, is that I 
have had so much on my plate trying to manage all Ted's medical 
affairs that there are things that have just simply slipped my 
mind.
    I am trying to get a hold of some records. I want to get 
his PEV, his physical evaluation word file as well. There are 
some records from Germany I have never been able to get a hold 
of. Particularly I wanted his MRIs of his brain after his brain 
surgery.
    But, I mean one of the things that is difficult with this, 
I guess, lack of continuity in the records is I had a therapist 
recently comment that it seems like my husband was tracking 
strangely with his eyesight when they were working on a 
crossword puzzle. And it triggered a memory. And I went back 
and read an article that his speech therapist from the 
polytrauma center had written about him. And I had completely 
forgotten that my husband was having vision issues back in 
Richmond. Well, there was no followthrough. He had never been 
seen by an ophthalmologist.
    And come to find out Walter Reed referred Ted to a neuro-
ophthalmologist and he has visual impairment. He has a blind 
spot in his vision and he also has some other visual 
impairment.
    But, you know, in this jumping from hospital to hospital 
and the lack of case management, the lack of records, you know, 
a nice, concise record and maybe a list of just his major 
injuries, it would have been nice.
    But we are also dealing with having his VA rating fixed. He 
just had his new one updated. I guess it was a 3-year update. 
And it was simply done on his VA medical records. Well, really 
the only thing he goes to the VA for anymore is speech therapy. 
And so they did not have access to any of his other records. So 
I am going to have to file an appeal to have other things added 
in.
    And like Casey, there were new things that came up. There 
is not a complete record and there is not a complete diagnosis 
of all his issues.
    Corporal Owens. But the problem with that is, and in my 
case, and it has got to be for her, since they do not have 
those records, you have to then be reevaluated by the VA. So 
since they did not have anything other than my legs, I had to 
go to the dentist, you know, or to, you know, dental. I had to 
set up an appointment, wait like a month for it.
    I had to have MRIs for different things. I had to see the 
dermatologist. I had to see all these different doctors, 
psychologists for my PTSD, another stranger I have never met, 
have to tell my story again, rehash old memories, and it just 
gets old time and time again doing it over and over when you 
have done it once for your med board by qualified, competent 
people. It is just like why can it not pass on to other people? 
And, you know, that is----
    Ms. Wade. And Medicare included, I think, because we--I 
mean, I do not know if you had to do this, but we had to go 
through the whole welcome to Medicare exam also. There is a lot 
of repetition.
    Mr. Mitchell. Right. And, you know, this hearing is not 
only to hear your story here, but it is also to send a message 
to those that can do something about it. And they are sitting 
behind you and they will be testifying later. And I hope that 
they look at this, that both of you are unique and that you 
have worked through the system. In spite of the system, you 
have gotten things done. A lot of them, as you said, do not 
have the time. They do not have the resources. They just cannot 
do it.
    And this is you serving as a model, that if this has 
happened to you and you are people who know how to work the 
system, think of how many others that it is happening to. And 
it should not.
    Okay. If there is anything else that either one of you 
would like to say? Okay. Yes, Ms. Brown-Waite?
    Ms. Brown-Waite. Thank you, Mr. Chairman.
    Ms. Wade, what disability rating did Ted receive?
    Ms. Wade. He was given both a hundred percent by the 
military and the VA. I had a couple people look at his rating 
that actually told me, and I am going to have to have this 
fixed, but based on the way his rating is written, I had a 
couple former raters read it and a couple----
    Mr. Walz. It is all in the wording.
    Ms. Wade. Yeah. It is all in the wording. They said that 
Ted actually may qualify for a next level of special monthly 
compensation if his injuries are worded differently.
    But part of the problem is and one of the reasons I brought 
up about the special monthly compensation is that those things 
are written based on physical residuals, not cognitive 
residuals. They have not been updated for the current injuries.
    I mean, again, even in some of the vocational rehab 
aspects, the Independent Living Program for vocational rehab is 
really designed for physical needs, not cognitive needs. And I 
think all of these things need to be updated to fit the current 
injuries.
    And I think part of that with the special monthly 
compensation and needing more assistance is one of the 
important things to keep in mind is that not everyone has 
family to help them out and they might need to hire someone to 
lend them a hand.
    Ms. Brown-Waite. Another question. Having served as 
basically a patient advocate for family members, I know it is 
all in the questions that you ask. Certainly when I was taking 
care of my mom and now my husband and I know you have to be 
specific and you have to press for the right answers.
    Along the line, did you find anybody purposely gave you 
incorrect information, Corporal?
    Corporal Owens. No.
    Ms. Brown-Waite. Sergeant or Ms. Wade.
    Ms. Wade. I have been given incorrect information. Whether 
or not it was done on purpose, I do not know. I have been given 
incorrect information quite a few times, though, and I do not 
know if it is the people do not know the rules or if someone 
has interpreted them differently than I have when I have read 
them. But I have been given a lot of incorrect information.
    Ms. Brown-Waite. And I would like to ask both of you, on a 
scale of one to five, five being the highest, how would you 
rate the orthotic and prosthetic department of the facilities 
that you were treated in?
    Corporal Owens. Well, I was treated at Walter Reed or 
Brooke. Five.
    Sergeant Wade. Five as well.
    Ms. Wade. We do not use the VA orthotics and prosthetics. I 
mean, like Casey's situation, it was just too much of a hassle. 
And part of that is because of the nature of Ted's injury, that 
the closest VA contractor to work on his arm is maybe about a 
6-hour drive from us. It is easier for us to come to Walter 
Reed than to wait a few weeks to have someone work on his 
prosthesis.
    And there also is not a therapist with the expertise that 
they need for his prosthetic training at our VA hospital. So we 
just do not even bother. It is just easier to go back to the 
military because there are no hassles and we can just walk 
right in the door.
    Corporal Owens. The problem for me is, and other people 
like us, is we are a different patient than what they usually 
deal with because they are usually dealing with diabetics, 
people that are older in age, that are retired. And so, you 
know, I want my stuff. I want to see them 4 or 5 days a week 
for an hour or two and get done, whereas some people are just, 
you know, they can come in, get fitted once, twice a week, and, 
you know, they are not as active and not as, I will not say 
motivated, but are not requiring them as much and needing them 
expedited, you know, not needing them as quick and as fast 
because I need it done so I can get back to school and go back 
to work. So it is accessibility, I guess.
    Ms. Brown-Waite. One of my concerns about the orthotic and 
prosthetic service providers is in many States, they have to be 
licensed. I know Florida when I was in the State legislature, 
we were like the second State to license them, but we had no 
effect on licensing for the Federal Government.
    And the Federal Government still does not require in States 
where a license is required that the VA providers or even the 
DoD providers have to be licensed and meet all of the State 
qualifications. That is why I asked about how you would rank 
the level of service.
    Thank you very much. I have no further questions, Mr. 
Chairman.
    Mr. Mitchell. Thank you.
    Just one last thing. I think it is something you are going 
through, but also for some of our next panelists. And that is 
how do inaccurate records, your medical records affect the 
ability to get VA benefits?
    Corporal Owens. Well, you know, like I said, since they 
only had me under, you know, just missing my legs, I was a 
hundred percent, but if you do not have those other records and 
those claims, you can only go to a hundred percent, but having 
those claims, you get extra compensation. If you have all your 
claims, but you cannot get treatment for them unless it is 
claims because then it is not service connected.
    Ms. Wade. I think it is also, like my husband, I was 
looking at his records because I need to appeal his final 
medical board and we are looking at about 3,500 pages, and so 
it seems like there needs to be a better way to really 
highlight the major issues.
    But part of what is difficult with that, again, is the 
physicians have to know what exactly it is they need to 
document. They are not raters. And the raters have their set 
guidelines they are using and if the doctor does not know those 
guidelines, then they do not know how they are supposed to be 
documenting things.
    I mean, one of the things with my husband is, yes, he got a 
hundred percent for the traumatic brain injury, but he also 
has, one of the things we were discussing last night, he has 
very bad muscle spasticity. And at times, he loses voluntary 
control of his limbs.
    Well, his records say muscle spasticity. A friend of ours, 
it says loss of voluntary control of two limbs. His friend is 
rated as hemiplegic which gives him the next level of special 
monthly compensation. Ted just has muscle spasticity and, 
therefore, is not given anything for that residual.
    It means that he cannot use his prosthesis when he is 
having trouble. It gives him loss of use of his limb he has 
already lost. It is harder for him to compensate for the loss 
of his arm because of this medical condition. But if the person 
documenting this does not know how they are supposed to be 
wording it to meet what a rater is looking for, then it becomes 
an issue.
    Ms. Brown-Waite. Just one other thing. I would strongly 
suggest in getting your husband's records that you do engage 
your Member of Congress. As many of us have said, that is what 
we are here for. And the congressional staff and the 
Congressperson do get involved in this.
    And I always apologize to my veterans that they have to 
come to me to get the records that they should be able to get. 
But getting records from DoD is not easy. And that is something 
that every Member of Congress on both sides of the aisle that 
their offices do regularly.
    Now, you will have to fill out a privacy form that 
authorizes your Member of Congress to help you, but it sure 
will speed things up if you have had a problem. And please pass 
that word on to other families that you are in touch with. 
Please use us. We are here and we are grateful to help those 
who sacrificed so much for our country while in the military 
and the families. And with all you have been through, I am 
surprised you do not have gray hair.
    And I yield back.
    Mr. Mitchell. Thank you.
    And I want to thank you not only for the sacrifice for the 
country, but what you are doing for other veterans. You are 
speaking for a lot of people, a lot of people. And I appreciate 
that.
    And I also in my opening statement, I pointed out that, you 
know, you may be disappointed, but you are not bitter. You are 
very proud to have served your country and that is admirable. 
And I appreciate everything that you are doing.
    And with that, we will conclude this panel. Thank you very 
much.
    And the second panel, Meredith Beck and Todd Bowers. And, 
Meredith, would you care to go first?
    Ms. Beck. Yes, sir.

STATEMENTS OF MEREDITH BECK, NATIONAL POLICY DIRECTOR, WOUNDED 
   WARRIOR PROJECT; AND TODD BOWERS, DIRECTOR OF GOVERNMENT 
       AFFAIRS, IRAQ AND AFGHANISTAN VETERANS OF AMERICA

                   STATEMENT OF MEREDITH BECK

    Ms. Beck. Mr. Chairman, distinguished Members of the 
Subcommittee, thank you for the opportunity to testify before 
you regarding post-acute care for seriously injured 
servicemembers.
    My name is Meredith Beck and I am the National Policy 
Director for the Wounded Warrior Project (WWP), a nonprofit, 
nonpartisan organization dedicated to assisting the men and 
women of the United States Armed Forces who have been injured 
in the recent conflicts around the world.
    During those conflicts in Iraq and Afghanistan, there have 
been approximately 30,000 soldiers, sailors, airmen, and 
Marines wounded in action. Fortunately, due to the advances in 
medical technology, the number of those killed in action are 
far fewer.
    However, in many cases, the wounded have suffered 
devastating injuries and require long-term outpatient care and 
rehabilitation. As they have suffered these injuries, WWP is 
pleased that the Subcommittee has chosen to focus on this 
aspect.
    As a result of our direct daily contact with these wounded 
warriors, we have a unique perspective on their needs and 
obstacles they face as they attempt to transition, reintegrate, 
and live in the communities where they have served.
    I also want to note that my job as the Policy Director is 
to speak directly to these families across the board. What I 
then do is create policy themes and proposals based on the 
themes that they have demonstrated.
    Unfortunately, my job is easy these days because the themes 
that the families are presenting are almost uniform in what 
they are presenting. The Wades, Casey, they are prime examples 
of that.
    However, as Sarah noted, it is very important for you all 
to understand that these two, the Wades and Casey, are not 
typical of your daily average wounded veteran and their 
families.
    Sarah is very well-spoken. Casey is incredible at what he 
does. And the families that we deal with, and they represent 
them well, but the families they deal with do not in many cases 
have the capacity to be able to navigate these systems as well 
as they have.
    Because of our contact with these servicemembers, we have 
identified a number of areas, and you will probably hear some 
repetition from the two of them because they have come directly 
from people like them, and the following areas are common 
themes among these families.
    The options for care specifically with respect to those 
with traumatic brain injury, those suffering from TBI require 
individualized comprehensive care. And while the VA has made 
progress in this area, the Agency is still in the process of 
establishing extensive, consistent, long-term continuum of care 
available throughout the Nation.
    As such and due to the need for long ongoing therapy and 
rehabilitation, many seriously injured veterans and families 
have indicated that their number one request is increased 
access to options for care, including access to private 
facilities previously available to them while on active duty.
    The next topic is discrepancies in benefits. Many veterans 
and families of the seriously injured have indicated confusion, 
frustration, and disappointment upon learning that they are not 
eligible for the same benefits and care as veterans as they 
were on active duty and vice versa.
    For example, consider that an active-duty patient can be 
seen at a VA polytrauma center to treat his traumatic brain 
injury. However, while at the VA facility, the servicemember, 
due to his duty status, cannot enjoy VA benefits such as 
vocational rehabilitation or independent living services. They 
can be assessed for those benefits, but they cannot have them 
until they are actually retired.
    Alternatively, as mentioned previously, and unbeknownst to 
most families, a medically retired servicemember cannot use his 
or her TRICARE benefits to access private care as TRICARE does 
not cover cognitive therapy once retired.
    While there is an obvious need for and advantage to an 
active-duty service, those who are severely injured as a result 
of their service in an all-volunteer force deserve special 
consideration.
    The recently passed NDAA contained a provision intended to 
address those discrepancies. Specifically section 1631 
authorizes for a limited period of time the Secretary of 
Defense to provide any veteran with a serious injury or illness 
the same medical care and benefits as a member on active duty 
and entitles the severely injured still on active duty to 
receive those veterans' benefits, excluding compensation, to 
facilitate their long-term recovery and rehabilitation.
    While the provision recognizes the strengths of each 
Agency, and they do both have strengths, and the necessity of 
basing an individual's care and benefits on his or her medical 
condition rather than on their status as active duty or 
retired, it is subject to significant regulation and will 
require oversight to ensure its success.
    The next topic is respite care. I will say personally my 
brother is currently a Marine major serving in Fallujah. He has 
four children under the age of seven. If something happens to 
him, I want to know, and this is why I do this and why I talk 
to these families, I want to know that he is going to be taken 
care of and that his wife will have the ability to take care of 
their children and take care of him.
    For those who have suffered and who are seriously injured, 
one cannot discuss their care without discussing their 
caregiver. While the VA currently offers some respite care, the 
available options are often not entirely appropriate given the 
average age and types of injuries of those serving in Iraq and 
Afghanistan.
    For example, similar to the Wades, retired Army Sergeant 
Eric Edmondson from North Carolina suffered a severe brain 
injury in Iraq several years ago, but he is aware and 
responsive. In fact, he enjoys spending time with his family 
and recently went fishing with his 3-year-old daughter, Gracie.
    Eric's family is unwilling to place him in a respite 
facility for fear it could cause a regression in his 
rehabilitation and cause Eric distress, which ultimately means 
his family does not get any form of respite.
    However, WWP has noted that similar to others, Eric's 
family has used their personal funds to pay for an innovative 
type of individualized therapy that also provides a unique form 
of respite to the caregiver.
    In Eric's case, rather than staying indoors all day, his 
family pays an individual out of their own funds to take him to 
the park and watch his daughter play. Eric thrives each time 
and his progress and enjoyment are noticeable.
    As a result of Eric's success as well as others in similar 
situations, WWP proposes that the Department of Veterans 
Affairs initiate a pilot program partnering with local 
universities that the VA already has partnerships with to 
provide such a care and respite initiative for those with brain 
injury.
    As part of the veteran's ongoing therapy, the program would 
draw graduate students from the appropriate fields, i.e., 
social work, nursing, psychology, train them to interact with 
the veterans and match them with the eligible veterans in their 
local area so that an individualized program can be developed.
    In return for making the requisite reports to the veteran's 
physician on his or her status, the graduate student would 
receive course credit for doing such work.
    The creation of a program would have several positive 
effects. In recognition of the individual nature of brain 
injury, the program would encourage an innovative means of 
providing age-appropriate maintenance therapy to those 
suffering from TBI, which for the long term is absolutely 
necessary. Their rehab is never finished.
    While the veteran is benefiting from the therapy aspects of 
the program, the family caregiver would be offered much needed 
respite.
    And, three, interaction with the graduate students would 
increase general community awareness of the sacrifices of our 
Nation's veterans and the needs of those suffering from TBI.
    Mr. Mitchell. Could you wrap it up?
    Ms. Beck. Yes, sir.
    Last, the oversight aspect of this. Finally, consistent 
with the recommendations of the Veterans' Disability Benefits 
Commission and to ensure the best care and benefits for those 
who have sacrificed for our Nation, it is imperative that a 
joint permanent structure be in place to evaluate the changes, 
monitor the systems, and make further recommendations for 
process improvement.
    It should not require Casey and the Wades to be the ones 
who find the problems. They should be able to rely on the 
people who are providing their care to provide that oversight 
and the ability to give those recommendations for change.
    With the passage of time, as veterans' issues fade from the 
national spotlight, it is necessary to have that structure so 
that we can all make sure that we are coordinating future 
intra- and interagency coordination.
    Thank you, and I look forward to your questions.
    [The prepared statement of Ms. Beck appears on p. 54.]
    Mr. Mitchell. Thank you.
    Mr. Bowers, you have 5 minutes.

                    STATEMENT OF TODD BOWERS

    Mr. Bowers. Mr. Chairman, Ranking Member, and distinguished 
members of the Subcommittee, on behalf of the Iraq and 
Afghanistan Veterans of America (IAVA) and our tens of 
thousands of members nationwide, I thank you for the 
opportunity to testify today regarding this important subject.
    I would also like to point out that my testimony today is 
as Director of Government Affairs for the Iraq and Afghanistan 
Veterans of America and does not reflect the views and opinions 
of the United States Marine Corps of which I currently serve as 
a Sergeant in the Reserves.
    The tremendous advancements in frontline medical care have 
made many combat injuries more survivable. In Vietnam, the 
mortality rate of combat injuries was one in four while the 
mortality rate in Iraq is one in ten. That means today's 
battlefield medicine has saved approximately 6,000 American 
lives that would have been lost if they were still using 
Vietnam era medical techniques. This is a tremendous success 
story for the DoD medical system.
    But the corollary of improved survival rate is an increase 
in the number of severely wounded troops returning home. As the 
Independent Budget states, and I quote, ``We are seeing 
extraordinarily disabled veterans coming home from Iraq and 
Afghanistan with levels of disability unheard of in past 
wars.''
    Many of these young wounded veterans will require long-term 
care, not just at Walter Reed and Bethesda, but in their 
communities across this country.
    At the VA, these veterans with traumatic brain injury and 
blast injuries are confronting a system designed to treat 
diabetes and Alzheimer's.
    The DoD and the VA have already taken some crucial steps to 
improve inpatient care for these young, severely wounded 
patients. There are four major polytrauma rehabilitation 
centers in Florida, Virginia, Minneapolis, Minnesota, and Palo 
Alto, California, which use teams of physicians and specialists 
that administer individually tailored rehabilitation plans, 
including full spectrum care, for traumatic brain injuries.
    These centers are also part of the defense and veterans 
brain injury center network. These key centers offer cutting-
edge treatment for severely wounded troops who are receiving 
inpatient care. But what is available to troops near their 
homes?
    As of 2003, according to the U.S. Government Accountability 
Office, more than 25 percent of veterans enrolled in VA 
healthcare, over 1.7 million, live over 60 minutes driving from 
a VA hospital. This number is likely higher today because the 
mission in Iraq has relied heavily on recruits from rural areas 
and under-served by VA hospitals and clinics.
    This places a tremendous burden on the families and also 
the veteran. With the current gasoline prices, for example, and 
many treatment centers hours away, treatment is often 
impossible to facilitate.
    Imagine, if you will, that your loved one has returned from 
combat wounded and it is your responsibility to make sure they 
are receiving the proper treatment. This is too much to ask of 
our servicemembers and their veteran families.
    In response, the VA has created regional network sites that 
work with major polytrauma centers to cater to patients closer 
to their homes. The VA is also planning to add new polytrauma 
support clinics to provide followup services for those who no 
longer require inpatient care but still need rehabilitation.
    The 75 polytrauma support clinic teams help veterans get 
access to specialized rehabilitation services closer to their 
homes and communities and also are responsible for ensuring 
these patients do not fall through the cracks after leaving 
full-time care.
    For hospitals without a polytrauma support clinic, a single 
person has been designated as the point of contact to 
coordinate care for local veterans with polytraumas. These are 
good first steps, but much more has to be done to get these 
wounded veterans the care they need. A single point of contact 
that can offer referrals to distant hospitals and clinics is 
simply not an adequate response to a wounded veteran's 
healthcare needs.
    IAVA joins the other Independent Budget of veterans service 
organizations in calling for an increase in funding for home 
and community-based care and a detailed plan from the VA 
regarding their long-term response to the need of today's 
veterans.
    I would be happy to answer any questions at this time.
    [The prepared statement of Mr. Bowers appears on p. 55.]
    Mr. Mitchell. Thank you very much.
    I have a question of both of you. Both of your 
organizations came about as a result of the wars in Afghanistan 
and Iraq. How many other organizations like that have spurred 
up as a result of this war?
    Ms. Beck. Probably countless numbers of organizations. I am 
not sure that the number, though, who have--there are countless 
organizations that provide care support services benefits for 
servicemembers. Of the organizations that actually do policy 
work related to this area, I would say that we are probably the 
only two.
    Mr. Bowers. Uh-huh. And we are good friends.
    Ms. Beck. And we are friends.
    Mr. Mitchell. The reason I ask that is that with this war, 
which is relying solely on volunteers and the growth in the 
number of organizations like yours to serve this war, it really 
seems that it is kind of market driven. The government is not 
doing its job and as a result, volunteers from the private 
sector are stepping forward. And that is really not a very good 
story.
    And I listened to Corporal Casey Owens, many times saying 
that he has completely given up on the government services and 
has gone completely to the private services and all those 
services are organizations like you.
    That is a sad commentary. And just a comment on that.
    Ms. Beck. If I could, sir, one thing about that, and, yes, 
the government certainly needs to be providing a lot of these 
benefits in a more organized, better fashion, and quality of 
care obviously in the past two situations we have seen.
    There is one aspect for the organizations, though, to make 
sure that the communities are aware. I know that Todd has a 
large campaign to make sure that the communities are aware of 
the needs of these servicemembers and to provide a means 
through which individuals can contribute and understand.
    So there is hopefully a need for them. But at the same 
time, I certainly agree that the government should be providing 
a better, more structured form of quality benefits for the 
individuals.
    Mr. Mitchell. Well, and to comment along with that, most 
people are not personally affected----
    Ms. Beck. No, sir.
    Mr. Mitchell [continuing]. By this war. And very few are. 
And we see how affected those that are involved in this area. 
And I applaud you for doing that because we need to make people 
aware. It is just not a typical war.
    It has been said before by the first panel that it looks 
like they are dealing with a government organization or the VA 
that is not aware. Times have changed. It is a different war, 
different wounds, different conditions, and that we need to 
catch up.
    And I applaud your organizations because at least I gather 
that you are trying to do that very thing, to really turn 
things around and come up to speed with today's war and today's 
needs.
    Mr. Bowers. Just to add on that, Meredith mentioned 
something that we are doing actually with IAVA is communication 
is key to let individuals know what resources are available not 
only through the VA or DoD but also what other veterans service 
organizations are there to help.
    And we have partnered with the Ad Council on a 3-year 
campaign that is going to communicate to the American public to 
let them know what services are available and also to 
destigmatize, and I emphasize this, to destigmatize the stigma 
related to servicemembers seeking mental health treatment.
    Mr. Mitchell. Absolutely.
    Mr. Bowers. Until that is broken, we are really going to 
have a hard time getting people to step into the doors to 
receive the treatment they need. And we are hoping that this 
campaign will be a good way to do that.
    Mr. Mitchell. Absolutely. And you all are doing a very 
admirable job. And it is unfortunate. I have heard from hearing 
after hearing where the veterans do not know what is available. 
Unless they know the right questions to ask, they do not know 
what is available.
    And I understand that is what you all are doing is 
reminding people what is available and how to ask the questions 
and how to access what it is that they should have because the 
government is not doing that. They are not telling everyone 
what they should get.
    Ms. Beck. The government tends to be in its own stovepipe 
essentially. So it is not only DoD and VA. DoD and VA, you 
know, for the most part recognize that there is a problem here 
and they are working on fixing it and they have got a ways to 
go, but they are working on it.
    These guys, they do not just have to deal with the DoD and 
VA, especially as the most severely injured. You have Medicare, 
Social Security Disability Insurance, the Department of Labor, 
the Department of Education, all of those agencies right in a 
row, and any one of them is difficult to navigate much less 
seven or eight of them as a severely injured servicemember or a 
19-year-old spouse.
    Mr. Mitchell. And I appreciate the fact that you are saying 
the VA recognizes they need to change. But, you know, that is 
in the long run. In the short run, you know, there are the 
Wades, the Owens. There are 19-year-old mothers. They have to 
live every day. And it is great that they see that they need to 
turn the ship around, but we have got people who are living 
right now. And that is who we need to take care of.
    Ms. Beck. Which is why it is so important, sir, that when 
we are creating--there is a common misperception out there that 
people like the Wades and Casey who were injured a little while 
ago that all of their problems are fixed now because they were 
injured a while ago. But it is so important that as we put 
these new policies and programs into place that we are reaching 
back to those families who came before and making sure that 
they are taken care of because they are the reason those 
programs were created in the first place. So that is of the 
utmost importance to the Wounded Warrior Project is to find 
those families who came before.
    Mr. Mitchell. And just one last comment before I turn it 
over. Mr. Bowers talked about the need for bringing services 
out to the rural areas. It is a different kind of war. As you 
mentioned, it is not a draft. So most of the recruits are 
coming from rural areas and this is where the need is going to 
be.
    So instead of maybe in past wars where you can locate in 
large urban areas, the recruits, the needs are coming from 
different areas. And I think that is something that the VA 
needs to recognize.
    Mr. Bowers. It is. And I would also add to that that it is 
very important to know that rural veterans do not necessarily 
have access to the Internet. So as we often hear that, well, we 
can put together a Web site and an outreach element, that is 
very effective for most, but only 8 percent of this country's 
rural areas have access to broadband.
    You also have issues with individuals who have traumatic 
brain injury or post traumatic stress disorder. It is going to 
be extremely difficult for them to try and rely on a Web site 
to find answers. You know, that is something that we have 
always said there needs to be that direct contact.
    And specifically at my Reserve center last weekend, we 
actually had the VA there. They were there to register every 
single Marine there. We also met with folks from the Vet 
Centers. There were six individuals there and we also completed 
an electronic version of our post-deployment health 
reassessment form. It was textbook. It was exactly what we 
needed to start doing the second these conflicts began and when 
troops started returning home.
    But there has been a long period of time since then and a 
lot of people have fallen through that gap. And the biggest 
takeaway was that it was not mandated. It was just my unit 
being proactive and saying we need to make sure our Marines get 
this. It is not a mandate by any way, shape, or form.
    Ms. Beck. Sir, Sarah will come after me if I do not point 
out that, yes, the rural veterans are certainly in need of the 
aspects. But what Sarah would point out and I will speak for 
her is that they were from Chapel Hill, North Carolina. They 
were in the heart of the research triangle and because of the 
way benefits were configured, they did not have access to the 
places they need to be. So that is also a concern.
    Mr. Mitchell. Thank you.
    Ms. Brown-Waite.
    Ms. Brown-Waite. Thank you. Thank you, Mr. Chairman.
    Mr. Bowers, when I read your biography, it was one of those 
moments when you say ``wow.'' Thank you so much for your 
service as a Marine and for your two voluntary tours in Iraq.
    Mr. Bowers. Another one coming up in January, too, so I 
will miss you guys.
    Ms. Brown-Waite. Please stay in touch by the Internet. You 
heard me before say about the importance of staying in touch 
with your Member of Congress.
    I congratulate you on your award for the Purple Heart. You 
know, it is amazing that the sniper round hit your rifle scope. 
You know, we can only hope that you, too, had him in the scope 
of your rifle.
    You had indicated that your organization has about 80,000 
active members.
    Mr. Bowers. Yes, ma'am.
    Ms. Brown-Waite. Could you tell us how many of the 
approximately 80,000 active members would fall in the category 
of today's hearing, just a percentage, and can you give us any 
specific complaints, shortfalls, or perhaps unaddressed issues 
that we have not touched on today? In other words, people and 
issues that kind of fall through the cracks.
    Mr. Bowers. I would say that of our membership, we have 
relatively low numbers of individuals who deal with polytrauma 
centers and who have been injured. With that said, I spend a 
lot of time up at Walter Reed and Bethesda just hearing from 
the servicemembers and finding out what their difficulties are.
    The biggest thing that I have come across is the lack of 
support for families. I would say that is the number one thing 
that we have heard from folks at a lot of different levels. 
Many times with families, and Ms. Wade was right on with this, 
you know, she is, you know, bearing the brunt of a lot of the 
lack of support networks and things for these wounded 
servicemembers. And that is probably the biggest thing I have 
heard across the board there.
    Ms. Brown-Waite. Have you heard of any of the other 
polytrauma units actually hiring the spouse to work in the VA 
hospital? I know that down in Tampa in Haley Hospital, they 
actually do that. Is that happening around the country in the 
other polytrauma units?
    Mr. Bowers. I have not heard of any cases. I have heard of 
one case where someone was offered a job, but the polytrauma 
center was 4 hours away, so they could not facilitate the move.
    Ms. Brown-Waite. This actually was a family that moved to 
Tampa to be close to the servicemember while he was being 
treated there. And I thought that is wonderful. We should 
encourage that. You know, if they want to work or if they need 
to work, that is a great way to provide families support and 
have that person right there in the hospital.
    Ms. Beck. Ma'am, if I could, one of the primary objectives 
of the Wounded Warrior Project, we do not have members, but 
that is our sole base is attempting to have caregivers 
compensated for the work that they are doing.
    The VA actually already has this program for spinal cord 
injury patients. And they train, certify, and make eligible for 
compensation those family caregivers.
    In many cases, I know that it may not be the most ideal 
situation for the family member to be providing that care, but 
they are doing it anyway.
    So what we would ask is that through those programs, 
looking at that San Diego VA where they provide that service, 
looking at replicating that especially for the most severely 
injured, brain injured servicemembers where their families are 
often leaving their jobs and providing that care really and 
suffering from extreme financial distress from doing so.
    Ms. Brown-Waite. Do you have an estimate of how much the 
proposed respite care pilot program would cost the VA?
    Ms. Beck. I do not have an overall estimate. I would say 
that since it would be done with the universities and the 
students would be not paid, they would be getting course credit 
for doing that, it would really be a cost of organizing and 
coordinating, not necessarily the payment process for providing 
that service.
    Ms. Brown-Waite. We are having the Blackberries going off 
and it is not to be rude, but we have to have them on so we 
know when once again we will be called to the floor.
    Do you have any additional suggestions that you did not 
include in your testimony?
    Ms. Beck. Gosh, I could go on forever, but I will not.
    Really I think Todd hit the nail on the head with the 
family aspect of this, including the families in the care 
aspect of it, and also understanding that without the families, 
the VA would be in a lot of trouble, and that we rely on them 
tremendously. And for that aspect, the issue of coordination 
among the agencies which I know is something that we have 
talked about before, but it is of utmost importance.
    I had someone from the Department of Defense, from TRICARE 
tell me, we were trying to resolve a very complex issue that 
faces these servicemembers about their eligibility for Medicare 
and TRICARE, and her response was what do you want me to do, 
hand walk these guys through the process. That was my answer. 
So, yes, yes, actually. Then we solved the problem.
    Ms. Brown-Waite. That is that person's job?
    Ms. Beck. The awareness factor here is tremendous and 
promoting that awareness of what these servicemembers do and 
how the families are suffering should not be borne by only 
those people who happen to be either interested in or happen to 
be suffering from it. So the increased awareness from Members 
of Congress, their staff, down to every citizen in the United 
States is absolutely imperative.
    Mr. Bowers. One portion that I did not include in my 
testimony, but I would point the Subcommittee toward, the 
Independent Budget makes a lot of comments in regards to 
nursing home care. A tremendous amount of veterans are coming 
home and having to rely on nursing home care because of the 
increased amount of traumatic brain injuries that we have seen 
in the wars in Iraq and Afghanistan.
    What we have heard from our membership and from personal 
stories from individuals is that it is hard to be a 22- and 25-
year-old in a nursing home, in a VA nursing home. There is not 
a lot going on for these younger veterans and they are still 
young, vibrant individuals who still have their entire lives to 
look forward to. And the resources are not necessarily made 
available to them to be able to continue to better themselves.
    And whether it be educational resources, social activities, 
things along those lines, there is a gap for a lot of those 
folks that are at the nursing homes. And there has also been 
some discrepancies that the Independent Budget also identifies 
that there has been a shortage of beds within these nursing 
homes also.
    Ms. Brown-Waite. I know that there is a program of assisted 
living where the person truly just needs some assistance. Do we 
need to focus more resources on that? And I happen to 
personally agree with you. I come from Florida. I know that the 
majority of people in nursing homes in Florida are elderly. And 
there is a great divide there and a lack of common interest 
even. And so is the answer more assisted living facilities and 
specific nursing homes for OIF/OEF returning warriors?
    Ms. Beck. I think we need to be careful, however, because 
we do have an opportunity here because this is a smaller 
population. But if we build these large facilities just for 
OEF/OIF servicemembers, then their families will have to travel 
to those facilities because there just are not enough of them, 
of a need there.
    So building a facility is maybe one option, but I think 
that looking at the options of, you know, thinking outside the 
box here. We have individuals with individual needs. We should 
take this as an opportunity that we have of such a small 
population and perhaps leverage community resources and 
leverage those things that are already there to be able to 
provide the best care and nursing home care near these people's 
homes.
    Ms. Brown-Waite. Do you think that the veteran population 
would resist perhaps, especially in rural areas, a contract 
with a service provider of respite care, of physical therapy? I 
mean, we want to make sure the services come to the veteran who 
needs them.
    Mr. Bowers. I would definitely stand by that individuals 
when given the choice whether they need to stay at a nursing 
home or be at home with assisted living will much rather be at 
home with assisted living. It allows them to be out involved 
more with the community. So I would say yes to that.
    If they do require a nursing home, if they do not have the 
family support and, therefore, they do have to live in a 
nursing home, those steps to make it easier for these 
individuals would be much more effective.
    But I would agree with Meredith that by going out and 
developing centers specifically for OIF/OEF veterans may be a 
bit much. We need to think long term.
    And, you know, just speaking with my Marines, we know the 
Global War on Terrorism is never going to end. So we have got a 
lot of work to do.
    Ms. Brown-Waite. Please thank your Marines for us and thank 
you for again going back and thank you for your service.
    And, Ms. Beck, thank you for all that you do.
    I yield back.
    Mr. Mitchell. Thank you.
    And thank you very much.
    I would like at this time to welcome panel three and I am 
probably going to mess your name up. I am sorry. Dr. Madhulika.
    Dr. Agarwal. Madhulika Agarwal.
    Mr. Mitchell. Agarwal. Thank you. Is the Chief Patient Care 
Services Officer for the Veterans Health Administration (VHA). 
We look forward to hearing from her and her team.
    Let me just say before you start, and I appreciate you 
being here and I know that you are also a messenger, and 
hopefully what you heard today, what we all heard today brings 
some results and some fruits because it is just frustrating 
when we hear these things and we write it down and it is just 
another report somewhere.
    You have heard today real needs and real concerns. And I 
suspect that you are in a position to do something about it, at 
least we hope so. Thank you.

   STATEMENT OF MAHDULIKA AGARWAL, M.D., MPH, CHIEF OFFICER, 
  PATIENT CARE SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. 
  DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY KRISTIN DAY, 
    LCSW, CHIEF CONSULTANT, CARE MANAGEMENT AND SOCIAL WORK 
   SERVICE, OFFICE OF PATIENT CARE SERVICES, VETERANS HEALTH 
  ADMINISTRATION; AND LUCILLE BECK, PH.D., CHIEF CONSULTANT, 
REHABILITATION SERVICES AND, PROGRAM DIRECTOR FOR AUDIOLOGY AND 
  SPEECH PATHOLOGY PROGRAM, OFFICE OF PATIENT CARE SERVICES, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
                            AFFAIRS

    Dr. Agarwal. Thank you.
    Good afternoon, Mr. Chairman and distinguished Members of 
the Subcommittee. Thank you for the opportunity to testify 
before you on the Department of Veterans Affairs care for 
seriously wounded veterans after they complete their inpatient 
care.
    I am accompanied by Dr. Lucille Beck on my right, who is 
the Chief Consultant for Rehabilitation Services, and Ms. 
Kristen Day on my left, who is the Chief Consultant, Care 
Management and Social Work Services.
    I would like to request that my written statement be 
submitted for the record.
    Mr. Mitchell. Yes, it will.
    Dr. Agarwal. Thank you.
    With your permission, sir, before I begin my oral 
testimony, I would like to thank Corporal Owens, Sergeant Wade, 
and Ms. Wade. As you said earlier, they have tremendous courage 
and enormous resilience. I want to thank them for their 
sacrifice and for their service to our country.
    We have heard your story and with your input and your 
support, we will continue to work every day to enhance and 
improve our healthcare system.
    VA is committed to providing the scope of services that 
ensure a continuum of world-class care, which extends from 
acute rehabilitation to vocational and community reentry 
programs for all veterans at locations closer to their home and 
communities.
    In May 2007, VA expanded the case management program for 
OEF/OIF veterans in response to the President's Commission on 
Care for America's Returning Wounded Warriors.
    VHA and the Veterans Benefits Administration (VBA) 
established new procedures for the transition of care, 
coordination of services, and case management of the OEF/OIF 
veterans.
    This program represents an integrated team approach located 
in VA medical centers. Now the OEF/OIF veterans are screened 
for case management needs and those with severe injuries are 
automatically provided a case manager. Additionally, any 
veteran who requests a case manager is also provided one.
    VA provides clinical rehabilitative services in several 
specialized areas that employ the latest technology and 
procedures to provide our veterans with the best available care 
and access to rehabilitation for polytrauma and traumatic brain 
injury, spinal cord injury, visual impairment, mental health, 
and other areas.
    In October 2007, as recommended by the Dole-Shalala 
Commission, we have partnered with DoD to establish the Joint 
VA/DoD Federal Recovery Coordination Program. The Federal 
Recovery Coordinator, or the FRC, is intended to serve all 
seriously injured servicemembers and veterans regardless of 
where they receive their care and has the unique authority to 
navigate within and between the VA, DoD, and the private 
sector.
    These newly established FRCs will collaborate with VA 
medical centers, military treatment facilities, and private-
sector treatment teams during recovery and rehabilitation phase 
to ensure that veterans receive the right services at the right 
time.
    VA is committed to providing key services to assist 
caregivers with case management service coordination and 
support for the veteran, as well as education on how to obtain 
community resources such as legal assistance, financial 
support, and housing assistance.
    Eight caregiver assistance pilot programs were awarded 
grants in October 2007 to explore options, providing support 
services for caregivers in areas across the country, especially 
in areas where few such options are available.
    In February 2008, VA's Under Secretary for Health approved 
funding to enhance programs that provide specialized support 
and care in home and communities that facilitate the transition 
and support of seriously injured veterans.
    These programs include the Volunteer Respite Program which 
will create access to the needed home respite services for 
family caregivers, and the Medical Foster Home Program which 
provides an in-home alternative to nursing home care, merging 
personal care in a private home with medical and rehabilitation 
support from specialized VA home care programs.
    These programs will aid seriously injured veterans living 
in their own homes and those who are no longer able to live 
independently, but prefer an in home alternative within their 
community.
    Moreover, in compliance with the 2008 ``National Defense 
Authorization Act,'' VA is collaborating with the Defense and 
Veterans Brain Injury Center to design and execute a 5-year 
pilot program to assess the effectiveness of providing assisted 
living services to eligible veterans to enhance their 
rehabilitation, quality of life, and community reintegration.
    VA is providing outreach both locally and nationally to 
veterans and servicemembers. This begins with a letter from the 
Secretary of Veterans Affairs providing information about 
healthcare and other benefits while thanking them for their 
services and welcoming them home.
    VA works with the DoD in implementing the post-deployment 
health reassessment and among National Guard and Reserve 
component.
    Additionally, VA established a national polytrauma Web site 
and a polytrauma call center. The call center is available 24 
hours a day, 7 days a week for families and patients for 
questions about care as well a polytrauma system of care. This 
center is staffed by healthcare professionals.
    We are honored to provide care and service to America's 
veterans. VA has the unique privilege of having a lifelong 
commitment to those who have borne the battle in service to our 
country.
    For those who return from combat with serious injuries or 
illness, we work closely with DoD to ensure a continuum of 
care, but we also work with those who do not need immediate 
care to make it as accessible as possible.
    Thank you again for the opportunity to testify before you 
and for your input. I will be happy to address your questions 
at this time.
    [The prepared statement of Dr. Agarwal appears on p. 57.]
    Mr. Mitchell. Thank you very much.
    There is a couple of things that I heard about the programs 
you had and I think you heard some response by the first panel 
about some of the programs.
    And Web sites may be good, but what are we doing about 
individualizing, people who do not access the Web sites, people 
who cannot access the Web sites, people who cannot because they 
do not know how, or they are not connected with the internet?
    You know, one of the things that I think, and I want to say 
this in general, because as we listen to these individuals, and 
this is a different war with different injuries, you are going 
to have a much different clientele than the VA is used to 
having.
    We heard even from the last panel about young veterans 
being in care centers, 24-year-olds, 25-year-olds. There is a 
difference. And I think that someone needs to recognize the 
difference and also the fact that it is great for the long term 
that we are changing the VA.
    But, again, these people are living right now and these 
people need services now. They need respite care now. They need 
people to guide them through now. And it is great to have long-
term vision and do this, but I am concerned about what is 
happening right now.
    One of the things that I have been concerned about since 
the very beginning is the records and tracking the records. And 
I hope that you will be able to get the records that were asked 
for in the very first panel.
    And I am going to ask you again to get those records and we 
are going to check back that all the complete records that 
these people deserve and should have, are received. And if you 
would afterward find out how to contact them so they can get 
their records.
    Dr. Agarwal. Yes, sir.
    Mr. Mitchell. The other thing that is important, and I 
think you recognize this by listening to these people, that 
total care is a family thing and that if families do not get 
the help, and we heard earlier and in the very first panel 
where a 19-year-old mother finally just gave up and left. This 
is what we are dealing with. It is not just the soldiers.
    In fact, when I went to Iraq, we heard from the military 
people at that time that because this is an all-volunteer Army 
and all-volunteer service now, they are recruiting families. It 
is not just the soldier. So the families are a very important 
part of the total service and, therefore, the families should 
be treated in the same way that the individual servicemember is 
treated.
    One of the things that is important, and I knew this from 
being a government teacher and involved with all levels of 
government, you know, it is important to have a trust in 
government. And sometimes the only government agency, wherever 
it is, whatever level, that a person goes to gives them an 
attitude about the whole government in general. And I am not 
talking local or State. All of them.
    And it sounds to me from the very first panel that Corporal 
Owens just gave up. He did not trust the VA anymore. He went to 
private providers. This is horrible. And how do we get people 
to continue to volunteer not only for the military, but in 
government service in general if they lose trust because it is 
too much trouble, it is too big, they do not take care of their 
needs?
    And you are an important part of helping build trust in 
government because I do not know of anyone, and you have heard 
this up here, who does not believe that these soldiers, deserve 
the very best. They are giving up more than the general public 
because this is a volunteer Army.
    The other thing I want to mention that there was an office, 
the Office of Seamless Transition that was created and it was 
supposed to be a point of contact between the veterans and the 
DoD. And this office was disbanded almost immediately after it 
was implemented.
    And we continually talk about a seamless transition from 
the DoD to VA. I want to ask if you know why this office was 
disbanded and why we have not been working toward a seamless 
transition?
    Dr. Agarwal. I am sorry if I may answer the last question. 
We do have seamless transition processes currently in the 
Central Office. And, in fact, Kristen Day's office in the 
Office of Patient Care Services has assumed a large part of 
that responsibility of working with the DoD as well as working 
within our own system in the VA.
    Mr. Mitchell. So you are saying that the Office of Seamless 
Transition is in effect, it is there, or is it just individual 
departments within the VA that are trying to bring about a 
seamless transition?
    Dr. Agarwal. I----
    Mr. Mitchell. If you do not know, that is okay. But I would 
like if you would check into it and get back to us.
    Dr. Agarwal. I will check into it and get back to you.
    Mr. Mitchell. What happened to this office? What has 
happened to making sure----
    Dr. Agarwal. Sure. I will do that.
    Mr. Mitchell [continuing]. That there is a seamless 
transition?
    Dr. Agarwal. Yes.
    [The following information from VA was subsequently 
received:]

          Question: Why was the Office of Seamless Transition 
        dissolved? Who has taken on their responsibilities?

          Answer: The Office of Seamless Transition is not dissolved; 
        rather, it is reorganized to best allow for the operation and 
        management of the component parts. The component parts evolved 
        as the mission expanded, and the logical placement of the work 
        became evident. The Office of Seamless Transition has 
        transitioned into the following three categories: clinical, 
        outreach and policy.
          Care Management and Social Work Services (Care Management) is 
        responsible for the clinical component. Care Management works 
        closely with Polytrauma, Rehabilitation, Social Work, and 
        Mental Health Services. These program offices are all under the 
        single VHA organizational structure of Patient Care Services. 
        Military liaisons, VBA and our internal social work and nursing 
        staff members are responsible for patient issues.
          This new office's missions are to coordinate patients' health 
        care and to partner with VBA in meeting their benefits needs. 
        OEF/OIF coordinators at each VA medical center and benefits 
        office coordinate with DoD discharge staff to facilitate a 
        continuum of care and services at locations nearest the 
        veteran's residence after their military discharge. This 
        coordination allows enhanced identification of these veterans 
        at their local VA facilities for processing of benefits claims 
        and continuity of medical care.
          VA/DoD Coordination is responsible for the VHA OEF/OIF 
        outreach component. This component works with the Reserve and 
        National Guard and closely with DoD. For example, starting in 
        May 2008, VA/DoD Coordination began making phone calls to 
        17,000 veterans who may have a need for care management, and to 
        550,000 separating Guard/Reserve veterans who may not be aware 
        of the VA health care system. VA/DoD Coordination also 
        coordinates efforts with Reserve and National Guard Units on 
        DoD's Post-Deployment Health Reassessment (PDHRA) Initiative. 
        During the period November 2005 thru May 2008, Vet Centers 
        staff have supported over 1,400 PDHRA On-Site and Call Center 
        Unit level events along with DoD's 24/7 PDHRA Call Center. 
        These Reserve and National Guard PDHRA activities have 
        generated over 60,000 referrals to VA Medical Centers and Vet 
        Centers.
          The OEF/OIF Policy Coordination Office is responsible for the 
        policy component. The Executive Director and staff serve the 
        Under Secretary for Health in a special assistant role created 
        to address the numerous Commission, Task Force and report 
        recommendations that have come out in the past year. The Policy 
        Coordination Office works with several offices, departments and 
        agencies within and outside of VHA to facilitate changes. The 
        office also serves as the Under Secretary for Health's daily 
        contact point for Senior Oversight Committee (SOC) activities.

    Mr. Mitchell. And one last question before I turn it over. 
The Federal Recovery Coordinators, what kind of benefits will 
they provide? Are they going to be able to provide not only 
medical benefits and information but also the general benefits 
that every veteran is entitled to?
    Dr. Agarwal. Sir, they are the overarching coordinators and 
so, therefore, they will have the ability and the authority to 
oversee all benefits.
    Mr. Mitchell. Not only medical----
    Dr. Agarwal. Not just healthcare----
    Mr. Mitchell [continuing]. But all the benefits.
    Dr. Agarwal [continuing]. But all, yes, sir.
    Mr. Mitchell. We are talking about GI Bill, everything.
    Dr. Agarwal. Yes, sir.
    Mr. Mitchell. Thank you.
    Ms. Brown-Waite.
    Ms. Brown-Waite. Thank you.
    And as you can tell, we have votes that have started.
    Doctor, why are the VHA and VBA just now jointly developing 
a comprehensive list of severely injured OEF/OIF veterans? Is 
this not something that should have been done all along, that 
the Department should have been tracking?
    Dr. Agarwal. Thank you for that question, ma'am.
    Yes, they have been tracking. But I think they are working 
on the proper requirements and the definitions in that list. 
There is such a list that exists at this point in time between 
the two departments and we are further refining it.
    Ms. Brown-Waite. When did the list start to be created?
    Dr. Agarwal. In fact, very soon, we have an initiative in 
place which is going to work toward outreaching for all those 
that were mentioned earlier who may not have come into our 
system, to have the telephone contact so that we can then 
connect them to our OEF/OIF case management programs as well as 
to the right kinds of individuals in our own healthcare system.
    Ms. Brown-Waite. Let me make sure I understand what you 
said because I do not think you answered my question. How long 
ago did you start this list?
    Dr. Agarwal. Ma'am, I will have to take that for the record 
and get back to you. I do not know when we started this list.
    [The following information from VA was subsequently 
received:]

          Question: Why are VHA and VBA only now tracking seriously 
        injured (SI) veterans? When did this process start?

          Answer: The Department of Veterans Affairs (VA) began 
        tracking seriously injured veterans in 2003 by placing VA 
        Liaisons for Health Care and benefits counselors at those 
        military treatment facilities serving as key medical centers 
        for seriously wounded returning troops. VA experimented with 
        organizing this data several different ways, but found earlier 
        versions were not sufficiently responsive to clinical and care 
        management needs. VA is now working with the Department of 
        Defense to consolidate data into a single, comprehensive list.
          VHA's Care Management and Social Work Service, in 
        collaboration with VBA, is overseeing the development of a VA 
        national list of severely injured patients from Operation 
        Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) 
        treated in VA's health care system. This national VA list 
        integrates information across programs and includes patients 
        receiving VA care management within the following programs: (1) 
        Spinal Cord Injury, (2) Polytrauma, (3) Visual Impairment, and 
        (4) Amputation. Each list also identifies Care Managers in 
        these program areas, the VBA regional office of jurisdiction, 
        and the OEF/OIF Coordinator responsible for case managing the 
        servicemember or veteran's claims.
          VA also developed a Web-based system that will identify care 
        managers, by name, across the VA system for patients whose care 
        falls into the four categories mentioned above. Additional 
        features were built into this online system to identify care 
        management follow-up timeframes and issues identified in the 
        care management process. VA implemented the application on 
        April 29, 2008.
          VA staff gathers critical information about servicemembers 
        medically evacuated from the war zones in and around Iraq and 
        Afghanistan shortly after their arrival at military treatment 
        facilities in the United States. Additionally, VA medical 
        centers and Regional Offices established local teams to provide 
        benefits, services, and track care management locally 
        throughout their program areas. In April 2007, VA implemented 
        the Veterans Tracking Application (VTA), a modified version of 
        the DoD Joint Patient Tracking Application (JPTA) that tracks 
        the movement of medically evacuated servicemembers, and their 
        medical information, from the theater of operations to MTFs. 
        VTA merged information from existing spreadsheets and other 
        programs to form one Web-based system that allows users from 
        different locations to access real-time information about the 
        servicemembers and veterans we serve.
          Not all servicemembers or veterans transition from an MTF to 
        a VA medical center. The newly created Federal Recovery 
        Coordination Program identifies these individuals and assists 
        in coordinating their care as required.

    Ms. Brown-Waite. A ballpark. Last year, last 2 years, 
last----
    Dr. Agarwal. I am going to ask Kristen Day.
    Ms. Day. The original Office of Seamless Transition began 
consolidating information and the list, I believe, in 
approximately 2005. The clinical care of those individuals are 
consolidated in the new Office of Care Management and Social 
Work.
    And the coordination, we have VBA representatives in our 
office. We have DoD representatives in our office. And we are 
refining and building a list that is more comprehensive and has 
more data elements attached to it. So the list has been in 
existence for several years, but we are implementing a strategy 
that will go beyond a list and identify the single point of 
contact case manager, the current needs, and the current 
status.
    Ms. Brown-Waite. Okay. So it is a refined list is what I 
think I am hearing you say?
    Ms. Day. Yes, ma'am.
    Ms. Brown-Waite. Okay. Doctor, in your testimony, you 
mentioned medical foster homes and volunteer respite services. 
We unfortunately have found that many times when you have 
volunteers that their intentions are not always what we would 
hope that they would be.
    What kind of screening procedure do you have or plan on 
having? What kind of background checks are you going to be 
doing for these volunteers to protect the obvious wounded 
military person?
    Dr. Agarwal. Yes, ma'am. Thank you for that question.
    May I just address the issue of the medical foster homes? 
This program has been in effect for several years at this point 
in time. It actually started in Arkansas and has been scaled to 
some other areas and has also been used in a pilot program 
setting with the spinal cord injury and disease programs. It 
has proven to be remarkably successful with seemingly high 
satisfaction rates much to the surprise of our own staff as 
well as, of course, the families and the veterans.
    So there is fairly intense screening that goes on before 
the veterans are placed in these settings, which includes home 
inspections, which includes regular visits, which includes all 
kinds of background checks, as well as constant vigilance. This 
is a medical foster home, so the individuals who are placed in 
these settings are also followed by our home-based primary care 
teams or the spinal cord injury and home care teams.
    And that is what is envisioned for the traumatic brain 
injury program at this moment.
    Ms. Brown-Waite. So I want to make sure that I fully 
understand what your plans are. You are going to have extensive 
background checks done on the volunteer respite program?
    Dr. Agarwal. Ma'am, let me confirm the extensive piece of 
it, but I know that for----
    Ms. Brown-Waite. Doctor, I am sorry. I did not mean to be 
disrespectful. If you do not do criminal checks, that is 
criminal.
    Dr. Agarwal. I agree with you.
    [The following information from VA was subsequently 
received:]

          Question: Please describe the background checks VA performs 
        on volunteers in the Medical Foster Home and Volunteer Respite 
        programs, as well as any other programs where volunteers 
        provide in-home assistance to veterans.

          Answer: Volunteers who have home respite assignments require 
        a Special Agreement Check (SAC) for fingerprints, which serves 
        as a criminal background check. Volunteers are also checked 
        against the List of Excluded Individuals & Entities (LEIE) 
        database and the Healthcare Integrity and Protection Data Bank 
        (HIPDB), both of which are administered by the Department of 
        Health and Human Services (HHS).
          VA's Medical Foster Home Program follows Federal Regulations 
        for Community Residential Care (38 CFR 17.61 to 17.72). The 
        home caregivers or sponsors are not volunteers, as they are 
        paid by the veteran. VA is revising Community Residential Care 
        regulations to clarify that Federal or State criminal 
        background checks are required to participate in VA's Community 
        Residential Care programs. Currently, VA follows State 
        regulations regarding mandated background checks.
          All VISNs and VA facilities accept and process volunteers 
        according to the same standardized procedures outlined in the 
        VHA Handbook 1620.01, ``Voluntary Service Procedures,'' and the 
        memorandum titled ``Acceptance Requirements for VA Volunteers'' 
        from the Deputy Under Secretary for Operations and Management 
        (10N), dated February 22, 2007. This handbook and the 
        memorandum are attached.

        [The VHA Handbook 1620.01, ``Voluntary Service Procedures'' 
        will be retained in the Committee files.]

        [The Memorandum entitled, ``Acceptance Requirements for VA 
        Volunteers'' from the Deputy Under Secretary for Operations and 
        Management (10N), dated February 22, 2007, appears on p. 63.]

    Ms. Brown-Waite. Mr. Chairman, I yield back.
    Mr. Mitchell. Thank you.
    Again, we are going to wrap up because we have had all the 
panels, but I just want to emphasize that I hope that you get 
the records for Corporal Owens and for Sergeant Wade, the 
medical records that they have been asking for since their 
injuries and get them to them.
    [The following information from VA was subsequently 
received:]

          The FRC provided hard copies of the results to Mr. and Mrs. 
        Wade during their face-to-face meeting on March 6, 2008. 
        Corporal Owens confirmed the receipt of his records on April 
        25. Additional information was provided to the Subcommittee, 
        which will be retained in the Committee files.

    Mr. Mitchell. Thank you very much----
    Dr. Agarwal. Thank you.
    Mr. Mitchell [continuing]. For being here. And I want to 
thank all our witnesses and thank you all again for something 
that is very important to all of us.
    Thank you. This Committee is adjourned.
    [Whereupon, at 1:00 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
    We are here today to hear from veterans, their families, and the 
Department of Veterans Affairs about the long-term care of our most 
severely wounded Afghanistan and Iraq veterans. We know that DoD and VA 
provide the excellent inpatient healthcare for these warriors. But many 
of the most seriously injured require extensive outpatient care, some 
of them for life. Their families need care and assistance as well. 
Unfortunately, once these veterans leave the hospital, the care they 
receive does not seem to be on par with what they received directly 
following their injury. I think we can do better.
    Planning for veterans' healthcare was not planned very well at the 
outset of this war. The need to provide care and assistance to wounded 
servicemembers, and their families, in significant number and for the 
long term has been largely ignored. We will hear today what it has been 
like for some of them. Their stories are inspiring but also 
discouraging. They are inspiring because--even after they have suffered 
terrible injuries--they carry no bitterness, only pride from their 
service. Discouraging because they have been left to fend for 
themselves for too long.
    The Department of Defense and the VA are large organizations with 
an overwhelming bureaucracy. Their care and services often overlap in 
messy and unpredictable ways. At a time of enormous stress, this 
bureaucracy only hurts the injured warrior and his family
    When our troops return from theater with serious injuries, they are 
met with a dozen seemingly unrelated people with different services. We 
addressed much of these problems last year with the passage of the 
Dignity for Wounded Warriors bill. But there is obviously still more to 
be done.
    We need to realize that families are an integral part of treatment 
and recovery, and have their own needs. Unfortunately, the VA is 
restricted from providing the many services families need and deserve 
when their sons, daughters, siblings, and parents return with service-
connected injuries.
    We have been playing catch-up since the beginning of this war. It 
is irresponsible that the only support structure available to the 19 
year old wife of an injured soldier is the wife of a similarly injured 
soldier.
    We are going to hear from people that have been dealing with the 
difficulties of the system for a long time. On February 14, 2004 Army 
Sergeant Ted Wade lost his right arm and suffered severed traumatic 
brain injury, along with many other injuries, in an IED explosion in 
Iraq. Sgt. Wade is here today with his wife, Sarah.
    Marine Corporal Casey Owens of Houston, Texas lost both his legs 
when his unarmored Humveee struck a landmine in Iraq on September 20, 
2004. Corporal Owens and Mrs. Wade will tell us about the frustrations 
and difficulties they have faced, and we look forward to their 
testimony.
    Sarah and Ted Wade have devoted themselves to helping hundreds of 
other injured servicemembers and their families. And just 2 weeks after 
he was injured, Casey Owens told his family that he wanted a camcorder 
so he could document his progress from start to finish. He could only 
communicate by writing at the time of his request. He wanted to show 
his future children how far he had come and how good he'd had it.
    Today, you can find Casey gliding down the slopes at Aspen. We owe 
Corporal Owens and Sergeant Wade a great debt. We cannot repay that 
debt, but we can make sure that Corporal Owens and Sergeant Wade, their 
families, and everyone like them, get long-term care and services that 
are also world class.

                                 
                Prepared Statement of Hon. Nick Lampson
          a Representative in Congress from the State of Texas
    Thank you, Chairman Mitchell and Ranking Member Brown-Waite for 
inviting me to today's hearing. I am honored to join you on this 
distinguished Subcommittee and am proud to introduce Corporal Casey 
Owens of Missouri City, Texas. Casey is an exemplary young man, and I 
commend him for his willingness to continue to serve his country and 
his fellow veterans.
    I was impressed when we met yesterday for the first time by all of 
his accomplishments. A graduate of Mayde Creek High School, he went on 
to the University of Texas. But following the attacks on September 11, 
he decided to join the Marines. He was deployed twice--the first time 
from February 2003 to October 2003 and the second time from August 2004 
until September 20, 2004 when he sustained his injuries. During his 
time in the Marine Corps he received several medals in recognition of 
his distinguished service.
    Less than a year after sustaining his injuries, Casey successfully 
completed the Marine Corps Marathon in 2005 using a hand-cranked wheel 
chair with a time of approximately 2\1/2\ hours--probably better than 
any of us here. He is currently training as a member of a competitive 
ski team in Colorado that has been recognized by the Paralympics and 
the VA as an official training center.
    Even more impressive than these accomplishments, in my opinion, is 
Casey's advocacy for veterans' care. He has worked with Mayor Bill 
White's Veterans Task Force, which was established last year to address 
the needs of Houston's veterans, both young and old, when it comes to 
housing, health and mental care, job training, and other issues. And he 
has come here today, to testify before Congress about the challenges 
new veterans in this country continue to face as they transition from 
DoD to the VA system and try to navigate it.
    Most impressive, though is the concern for his fellow veterans and 
those that will come after him. He is here today to ensure that our 
Nation's future wounded warriors will not go through the same 
frustrations and feelings of neglect that he and his friends have 
experienced as the DoD and VA have struggled to adapt to a new breed of 
patients. They deserve much more in return for their service, and I 
commend Casey for his advocacy on their behalf.

                               __________

    Thank you again, Chairman Mitchell and Ranking Member Brown-Waite 
for allowing me to join the Subcommittee today for this hearing. As a 
Representative from a State with of one of the Nation's largest 
veterans' populations, I sincerely appreciate your invitation, and 
would like to commend your leadership and the entire Committee for your 
commitment to all of our Nation's veterans. I am especially pleased to 
be here to listen to the testimony of my constituent, Casey Owens, as 
well as the other witnesses.
    Care for veterans such as Edward Wade and Casey Owens was by trial 
and error, as there was no system of care in place for these new types 
of injuries--both external and internal. Casey expressed to me his 
worry that there are still issues with care for polytrauma patients 
today. And I was most impressed with his concern for those who will 
come after them and his hope that they will not come to Congress with 
the same exact issues, complications, and frustrations as we are 
hearing today. I am proud that this Congress has taken steps to address 
the issues--through record funding levels and new initiatives to 
address the injuries of these conflicts--multiple amputations, TBI, 
PTSD. The DoD and VA have initiated new, and innovative ways to help 
OEF and OIF veterans, but the system is still daunting and adapting to 
a new model for care has proven difficult. Casey pointed out however, 
that as he has traveled across the country, meeting and competing with 
fellow veterans, he has realized and encountered the disparity in care 
at VA centers across the country. He also brought up an important point 
to me--what are the new caseworkers and nurses doing? How is the new 
funding being put to use exactly? What are the results? As we are knee-
deep in the budget season and approach the appropriations process, I 
believe these are critical questions that MUST be answered--so that 
veterans 2 to 3 years down the line do not come to us with the same 
problems. These wounded warriors deserve no less--they truly have made 
the ultimate sacrifice for our country and they do not deserve to be 
feel that they must jump through hoops--or worse, that they have been 
neglected, when they need our help the most.
    Over the past couple of years I have heard about the same issues 
from veterans across my district--as well as from the testimony we will 
hear today: increase options for care, increase coordination between 
DoD and VA regarding records and evaluations, increase coordination 
between departments of the VA, and the need for more help for families 
and caregivers. Last year this Congress approved record funding levels 
and other legislation to address these issues--and I am eager to hear 
about the progress. As we are continuing to hear about these issues, I 
fear we still have a long way to go. The hurdles our soldiers and their 
families face should not be so difficult.

                                 
Prepared Statement of Corporal Casey A. Owens, USMC (Ret.), Houston, TX
                   (U.S. Marine Corps Combat Veteran)
    I was seriously injured on September 20, 2004 while serving under 
1st Battalion 7th Regiment. I was assisting in a 
medivac (medical evacuation) to rescue Sgt. Foster Harrington when I 
ran over two anti-tank mines, which resulted in the loss of both legs. 
Consequently, I also suffered two collapsed lungs, numerous shrapnel 
wounds, pulmonary embolism, broken clavicle and jaw, perforated 
eardrums, trauma to my head. I was flown to Landstuhl, Germany from a 
field hospital in Iraq, and awoke from a coma 3 weeks later in Bethesda 
Maryland Naval Hospital. After numerous surgeries to stabilize me, I 
was transferred to Walter Reed Army Medical Center and Brooke Medical 
Center for my recovery phase. Over the next year and a half, I received 
more than sufficient care from these centers.
    I was retired February 26, 2006. Shortly thereafter, I had to 
return to Brooke Army Medical Center to have my right myodesis repaired 
for a second time. I enrolled into the VA on April 1, 2006. I had 
transitioned to care under the VA system and was no longer in the 
Department of Defense's system. By this time, my right myodesis failed 
for a third time. After bringing it to the attention of the VA doctors, 
I was instructed to return to Brooke Army Medical Center for treatment. 
The doctor had suggested that I undergo the same procedure that I had 
the first two times again. I did not approve of their recommendation, 
and my objections had fallen on his deaf ear. I returned to the Houston 
VA letting them know I was not satisfied.
    It was not until 6 months later that the procedure I had requested 
and wanted was performed. The two previous surgeries took less than 72 
hours to be approved. I decided to call on non-profit organizations for 
assistance. Organizations such as Semper Fi Fund, Marine for Life, 
Wounded Warriors and other non-government personnel helped me and their 
help was colossal. In my opinion, this reflects poorly upon the culture 
and decisions of the VA system currently in place. While some of the 
problems I have encountered have been resolved, many have not. The 
learning curve of VA's system is steep and its bureaucratic maze is 
hard to understand. It has been 30 years since the last major war and 
what lessons has the VA learned since then? Did no one expect another 
war or learn anything from Viet Nam? What have the educated and highly 
paid personnel who have been appointed to correct the system been 
focusing their attention on? While the system continues to be broken, 
where is all the government funding going that is supposed to be fixing 
the system and what are they doing with it?
    A tremendous problem that I have encountered is the double standard 
of the VA and the Department of Defense's claims and rating for 
veterans. It took me 3 to 5 months of agonizing appointments and 
addendums to finalize my medical board, which were performed by 
competent and qualified military and civilian personnel. After I had 
completed my medical boards, I thought I was finished with that 
process, only to find out I was not. When I enrolled in the VA, it took 
almost another year and a half to finalize those claims. It is actions 
like this that make veterans avoid the VA. My qualms are not that the 
VA does not have enough programs in place to benefit veterans or the 
adequacy of it rather, it is the bureaucracy and red tape that are the 
problems. While many problems have been addressed, it is time for 
SOLUTIONS.
    A key solution to solving many problems is establishing an OIF/OEF 
Center. Though this idea has been explored by setting up OIF/OEF 
coordinators at every VA, it is not enough. There needs to be a 
centralized building or group of personnel specifically for them. A 
great example for the VA to emulate is something I experienced at 
Walter Reed and Brooke Army Medical Centers. There, key staff met 
weekly to discuss all aspects of patient care and kept an open line of 
communication between departments. For example, Joe Marine does not 
show up for physical therapy or his prosthetic appointments. With all 
of the departments communicating with one another, a psychologist may 
intervene and have some insight as to why he may be avoiding these 
appointments. It may be because he is suffering from severe PTSD and 
does not want to leave his room. From there, the department heads can 
agree on the best course of treatment and can initiate it in a holistic 
approach. Another matter I take great issue with, and have experienced 
it and continue to do so, is the sharing of medial records between the 
Department of Defense and the VA. One solution may be the 
implementation of an ID card, similar to that which is in place for 
Active duty personnel. Each ID card has a microchip, which could 
contain all of their military and medical records accessible by a 
computer.
    The impression that I get from the VA is that some within the 
organization think it is the duty of the veteran to endure and resolve 
these problems on their own. Those, like me, who were paid as a Marine 
Corp Grunt to do their job to the best of their ability never 
questioned whether if we got injured my government would be there for 
me. We all knew it would. It is now time for those who are responsible 
for the VA to care for those who did their duty.
    This is my sworn testimony and I stand by it just as I stand by my 
Marine Corp and the job we did in Iraq.

            Semper Fi
                                           Cpl. Casey Owens, 1-7 US

                                 
           Prepared Statement of Sarah Wade, Chapel Hill, NC
             on behalf of Sergeant Edward Wade, USA (Ret.)
                       (U.S. Army Combat Veteran)
    Chairman Mitchell, Members of the Subcommittee, thank you for the 
opportunity to speak to you today regarding our experiences following 
my husband's injuries in Iraq. My name is Sarah Wade. I am the wife of 
SGT Edward Wade, or Ted as he prefers to be called.
    My husband joined the Army's 82nd Airborne Division 
during the summer of 2000, and following the attacks of September 11, 
he was called on to serve first in Afghanistan and later Iraq. On 
February 14, 2004, his humvee was hit by an Improvised Explosive Device 
on a mission in Mahmudiyah. He sustained a very severe traumatic brain 
injury, or TBI, his right arm was completely severed above the elbow, 
suffered a fractured leg, broken right foot, shrapnel injuries, visual 
impairment, complications due to acute anemia, hyperglycemia, 
infections, and would later be diagnosed with Post Traumatic Stress 
Disorder. He remained in a coma for over 2\1/2\ months, and withdrawal 
of life support was considered, but thankfully he pulled through.
    As an above elbow amputee with a severe TBI, Ted was one of the 
first major explosive blast ``polytrauma'' cases from Operation Iraqi 
Freedom, Walter Reed Army Medical Center or the Department of Veterans 
Affairs (VA) had to rehabilitate. Much of his treatment was by trial 
and error, as there was no model system of care for a patient like Ted, 
and there still is no long-term model today. His situation was an 
enormous challenge, as Walter Reed was only able to rehabilitate an 
amputee, not a TBI, the VA was able to nominally treat a TBI, but not 
an above elbow amputee, and neither were staffed to provide appropriate 
behavioral health care for a patient with a severe TBI. Because Ted 
could not access the necessary services, where and when he needed them, 
he suffered a significant setback in 2005, that put him in the hospital 
for 2 weeks, and would take a year to rebound from.
    Ted has made a remarkable recovery by any standard, because we have 
strayed from standardized treatment, and developed a patient-centered 
path. I had to educate myself about, and coordinate, additional outside 
care. Often, access to the necessary services required intervention 
from the highest levels of government, or for us to personally finance 
them ourselves. But despite our best efforts, Ted is still unable to 
easily receive comprehensive care for all of his major health issues, 
due to shortcomings in the current system, and because of the time his 
needs demand of me, I have been unable to return to regular work or 
school. We have been blessed to have family, with the means to see us 
through these difficult times, and help with the expenses. I was 
fortunate to have the education, of growing up in Washington, D.C. and 
learning about the workings of the various Federal agencies. Our 
situation is not typical though.
    We have a few ideas, to provide better long-term care, we 
respectfully wish to share:
Special Monthly Compensation for Integration, Quality of Life, 
        Dependents' Educational Assistance, and Respite Care
    Individuals like SGT Wade, who require someone to be available for 
assistance at all times, are not compensated appropriately. These 
Veterans would require residential care otherwise, but are not granted 
the higher level of Aid and Attendance, because they do not require 
daily healthcare services provided in the home by a person licensed to 
perform these services, or someone under regular supervision of a 
licensed healthcare professional. We feel the criteria should be 
clearly outlined, so appropriate compensation may be granted in the 
case of an individual who needs assistance managing care, personal 
affairs, or requires support outside of the home, to rehabilitate and 
integrate into their community, or to achieve a better quality of life.
    Both in the past and at present, we have paid someone to assist Ted 
outside of the home. This allows him the flexibility to hire a peer of 
his choice, to provide community support, and accompany him on 
sightseeing outings he has researched and planned with his therapist as 
part of his community integration, to provide transportation to the 
store to purchase books for homework assignments, go to the community 
center to swim laps, or help him balance his checkbook at the end of 
the day. Not only has this enabled Ted to come closer to achieving 
independence, but it has greatly improved symptoms of depression by 
restoring hope and self confidence, allowed him to attain fitness goals 
and control his blood sugar without insulin injections, all while 
providing much needed respite care for me. Unfortunately, the current 
VA respite programs are not appropriate for a veteran like Ted. With 
better resources, I might be able to access the Dependents' Educational 
Assistance for which I qualify, but our circumstances do not allow me 
to take advantage of, before the benefits expire. This would not only 
help me get back to having a life of my own, but raise Ted's standard 
of living as well, by increasing my earning capacity.
Compensated Work Therapy (CWT) for TBI
    Largely due to the success of the program we have created for Ted, 
the next phase of his recovery will probably include some sort of 
vocational rehabilitation. He has already had the opportunity to 
participate in volunteer work, through counseling and job coaching 
provided by a private practice near our home, where he attends a day 
treatment program for behavioral health and TBI. Now he is ready for 
the next stepping stone to employment. The current Department of 
Veterans Affairs Vocational Rehabilitation and Employment Service is 
more of a challenge than is healthy for someone with the significant 
cognitive deficits and the emotional needs Ted has. VA work therapy 
programs, while developing work tolerances and promoting effective 
social skills for the more seriously impaired, are set in an insulated 
environment. A work therapy program, expanded to other community 
settings, to accommodate patients like Ted, who are better served 
outside of a sheltered atmosphere, would be more effective. Volunteer 
or internship positions, or later, a part-time job that sparks his 
interest, would be more therapeutic. Not only would this help him 
acquire the confidence and independence he needs to someday become 
gainfully employed, but aid in his integration, by providing 
constructive, meaningful activities for him to participate in outside 
of the home.
Counseling, Life Skills and Patient-Specific Case Management
    Although many basic therapies are offered, rarely do they include 
teaching socially appropriate behaviors, which are commonly an issue 
after a TBI. This task often falls on the veteran's family member or 
spouse, increasing the responsibility of the caregiver, and causing 
conflict with the veteran, who feels he is being treated like a child. 
Ted has had the advantage of community peer support, but also a 
counselor at the private practice I have previously mentioned, to help 
him redevelop age appropriate social skills, allow me to be his spouse, 
and him to maintain his dignity. She has also worked with Ted to 
develop healthy coping skills, to manage cognitive deficits, improve 
mental health, and develop patient-centered treatment plans, which 
focus specifically on his unique challenges. Again, our situation is 
not typical though. This is something difficult to provide in an 
institutional care environment, like the Veterans Health 
Administration, without greater flexibility, and more resources to 
provide increased face time with the patient, and better injury-
specific expertise.
Conclusion
    The challenges we have faced are the same as countless other 
veterans, many of whom have not had the resources Ted has had available 
to him, or an advocate capable of negotiating the system. A veteran I 
often think about, who had a young wife with a newborn baby, and 
nothing more than a high school education, should have received the 
same world-class care as my husband, but sadly will not. Despite my 
best efforts to be a support to his spouse, who was overwhelmed by 
motherhood, while trying to negotiate a seemingly impossible system, 
she eventually left him, because it was more than she could handle. A 
veteran's care should not depend on what family they were born into, 
who they married, or whether or not family obligations allow for their 
loved one to advocate for them, but sadly it does. Though we will never 
be able to fully compensate seriously wounded veterans for the 
sacrifice they have made on our behalf, we can certainly do a better 
job of managing their care, rehabilitating them to their fullest 
potential in a timely manner, and providing the necessary resources to 
maximize their quality of life. I am pleased to see the Subcommittee is 
taking a look back to explore ways to learn from the past, and address 
the needs of the veteran injured yesterday. This will ultimately 
improve the care of the servicemember injured today, as well. Mr. 
Chairman, thank you again for the opportunity to share our story with 
you today. I look forward to answering any questions you may have for 
us.

                                 
                  Prepared Statement of Meredith Beck
           National Policy Director, Wounded Warrior Project
    Mr. Chairman, Ranking Member Brown-Waite, distinguished Members of 
the Subcommittee, thank you for the opportunity to testify before you 
regarding post-acute care for the seriously injured. My name is 
Meredith Beck, and I am the National Policy Director for the Wounded 
Warrior Project (WWP), a non-profit, non-partisan organization 
dedicated to assisting the men and women of the United States Armed 
Forces who have been injured during the current conflicts around the 
world.
    During the recent conflicts in Iraq and Afghanistan, there have 
been approximately 30,000 soldiers, sailors, airmen, and Marines 
wounded in action. Fortunately, due to advances in medical technology, 
the number of those killed in action is far lower. However, in many 
cases, as the wounded have suffered devastating injuries and require 
long-term outpatient care and rehabilitation, WWP is pleased that the 
Subcommittee has chosen to focus on this aspect.
    As a result of our direct, daily contact with these wounded 
warriors, we have a unique perspective on their needs and the obstacles 
they face as they attempt to transition, reintegrate, and live in their 
communities. As such, WWP has identified the following areas of 
concern:
    Options for Care: Specifically with respect to Traumatic Brain 
Injury, those suffering from TBI require individualized, comprehensive 
care, and while the VA has made progress in this area, the agency is 
still in the process of establishing an extensive, consistent, long-
term continuum of care available throughout the Nation. As such, and 
due to the need for ongoing therapy and rehabilitation, many seriously 
injured veterans and families have indicated that their number one 
request is increased access to options for care, including access to 
private facilities previously available to them while on active duty.
    Discrepancies in Benefits: On a related topic, many veterans and 
families of the seriously injured have indicated confusion, 
frustration, and disappointment upon learning that they are not 
eligible for the same benefits and care as veterans as they were on 
active duty and vice versa. For example, consider that an active duty 
patient can be seen at a VA Polytrauma Center to treat his Traumatic 
Brain Injury. However, while at the VA facility, the servicemember, due 
to his duty status, cannot enjoy VA benefits such as Vocational 
Rehabilitation or Independent Living Services that can be helpful in 
his recovery. Alternately, as mentioned previously and unbeknownst to 
most families, a medically retired servicemember cannot use his/her 
TRICARE benefits to access private care as TRICARE does not cover 
cognitive therapy once retired. While there is an obvious need for an 
advantage to active duty service, those who are severely injured as a 
result of their service in an all-volunteer force deserve special 
consideration.
    The recently passed National Defense Authorization Act for FY2008 
contained a provision intended to address these discrepancies. 
Specifically, section 1631 authorizes for a limited period of time the 
Secretary of Defense to provide any veteran with a serious injury or 
illness the same medical care and benefits as a member on active duty 
and entitles the severely injured still on active duty to receive 
veterans' benefits, excluding compensation, to facilitate their long-
term recovery and rehabilitation. While this provision recognizes the 
strengths of each agency and the necessity of basing an individual's 
care and benefits on his/her medical condition rather than on military 
status, it is subject to regulation and will require significant 
oversight to ensure its success.
    Respite Care: For those who are seriously injured, one cannot 
discuss their care without discussing their caregiver. While the VA 
currently offers some respite care, the available options are often not 
entirely appropriate given the average age and types of injuries of 
those serving in Iraq and Afghanistan. For example, retired Army 
Sergeant Eric Edmundson suffered a severe brain injury in Iraq several 
years ago, but he is aware and responsive. In fact, he enjoys spending 
time with his family and recently went fishing with his 3-year-old 
daughter Gracie. Eric's family is unwilling to place him in a respite 
facility for fear that it could cause a regression in his 
rehabilitation and cause Eric distress.
    However, WWP has noted that similar to others, Eric's family has 
used their personal funds to pay for an innovative type of 
individualized therapy that also provides a unique form of respite for 
the caregiver. In Eric's case, rather than staying indoors all day, his 
family pays an individual to take him to the park to watch his daughter 
play. Eric thrives each time, and his progress and enjoyment are 
noticeable.
    As a result of Eric's success as well as others in similar 
situations, WWP proposes that the Department of Veterans Affairs (VA) 
initiate a pilot program partnering with local universities to provide 
such a care/respite initiative for those with brain injury. As part of 
the veteran's ongoing therapy, the program would draw graduate students 
from appropriate fields (i.e. social work, nursing, psychology, etc.), 
train them to interact with the veterans, and match them with eligible 
veterans in their local area so that an individualized program can be 
developed. In return for making the requisite reports to the veteran's 
physician on his/her status, the graduate student would receive course 
credit.
    The creation of such a program would have several positive effects 
including:

    1.  In recognition of the individual nature of Traumatic Brain 
Injury (TBI), the program would encourage an innovative means of 
providing age-appropriate maintenance therapy to those suffering from 
TBI.
    2.  While the veteran is benefiting from the therapy aspects of the 
program, the family caregiver would be offered much needed respite.
    3.  Interaction with the graduate students would increase general 
community awareness of the sacrifices of our Nation's veterans and the 
needs of those suffering from TBI.

    Caregiver Compensation: Traumatic Brain Injury (TBI) has been 
widely identified as the ``signature wound'' of the Global War on 
Terror. While many organizations appropriately focus on the needs of 
the affected servicemember, the Wounded Warrior Project (WWP) has also 
identified the family caregiver as an individual in need of assistance. 
For example, in many circumstances, the spouse or parent is forced to 
leave his/her job to provide the necessary care for their loved one, 
leaving the entire family to suffer from an adverse economic situation. 
In these cases, the VA relies on the family member to assist in the 
servicemember's care, but has been denied financial compensation for 
such labor.
    In recognition of this reality, WWP developed and endorsed 
legislation introduced by Representatives Salazar and Pascrell 
requiring the VA to train, certify, and make eligible for compensation 
the personal care attendants of severely injured TBI patients. This 
program would expand on one already in existence at the San Diego VA 
Medical Center for Spinal Cord Injury patients and would help alleviate 
some of the financial burden incurred by these families. WWP encourages 
the Subcommittee to review the program and help to ensure its 
implementation.
    Oversight: Finally, consistent with the recommendation of the 
Veterans Disability Benefits Commission and to ensure the best care and 
benefits for those who have sacrificed so much for our Nation, it is 
imperative that a joint, permanent structure be in place to evaluate 
changes, monitor systems, and make further recommendations for process 
improvement. This office must be structured to minimize bureaucracy and 
must have a clearly defined mission with the appropriate authority to 
make necessary changes or recommendations as warranted. With the 
passage of time, as veterans issues fade from the national spotlight, 
it will be necessary to have such a joint structure in place to ensure 
future inter- and intra-agency coordination.
    Mr. Chairman, thank you again for the opportunity to testify today, 
and I look forward to answering any questions you may have.

                                 
                   Prepared Statement of Todd Bowers
   Director of Government Affairs, Iraq and Afghanistan Veterans of 
                                America
    Mr. Chairman, Ranking Member and distinguished Members of the 
Committee, on behalf of Iraq and Afghanistan Veterans of America, and 
our tens of thousands of members nationwide, I thank you for the 
opportunity to testify today regarding this important subject. I would 
also like to point out that my testimony today is as the Director of 
Government Affairs for the Iraq and Afghanistan Veterans of America and 
does not reflect the views and opinions of the United States Marine 
Corps.
    The tremendous advancements in frontline medical care have made 
many combat injuries more survivable. In Vietnam, the mortality rate 
for combat injuries was 1 in 4, while the mortality rate in Iraq is 1 
in 10. That means today's battlefield medicine has saved approximately 
6,000 American lives that would have been lost if we were still using 
Vietnam-era medical techniques. This is a tremendous success story for 
the DoD medical system.
    But the corollary of the improved survival rate is an increase in 
the number of severely wounded troops returning home. As the 
Independent Budget states, ``We are seeing extraordinarily disabled 
veterans coming home from Iraq and Afghanistan with levels of 
disability unheard of in past wars.'' Many of these young, wounded 
veterans will require long-term care, not just at Walter Reed and 
Bethesda, but in their communities across this country. At the VA, 
these veterans with Traumatic Brain Injury and blast injuries are 
confronting a system designed to treat diabetes and Alzheimer's.
    The DoD and the VA have already taken some crucial steps to improve 
inpatient care for these young, severely wounded patients. There are 
four major Polytrauma Rehabilitation Centers, in Tampa, FL, Richmond, 
VA, Minneapolis, MN, and Palo Alto, CA, which use teams of physicians 
and specialists that administer individually tailored rehabilitation 
plans, including full-spectrum care for Traumatic Brain Injuries. These 
centers are also part of the Defense and Veterans Brain Injury Center 
network.

[GRAPHIC] [TIFF OMITTED] 41376A.001


    These key centers offer cutting-edge treatment for the severely 
wounded troops who are receiving inpatient care. But what is available 
to troops near their homes? As of 2003, according to the GAO, ``more 
than 25 percent of veterans enrolled in VA health care--over 1.7 
million--live over 60 minutes driving time from a VA hospital.'' This 
number is likely higher today, because the mission in Iraq has relied 
heavily on recruits from rural areas often underserved by VA hospitals 
and clinics. This places a tremendous burden on the families and also 
the veteran. With the current gasoline prices and many treatment 
centers hours away, treatment is often impossible to facilitate. 
Imagine if you will that your loved one has returned from combat 
wounded and it is your responsibility to make sure they are receiving 
the proper treatment. This is too much to ask of our servicemembers and 
veterans' families.
    In response, the VA has created regional network sites that work 
with the major polytrauma centers to cater to patients closer to their 
homes. The VA is also planning to add new Polytrauma Support Clinics to 
provide followup services for those who no longer require inpatient 
care but still need rehabilitation. The 75 Polytrauma Support Clinic 
Teams help veterans get access to specialized rehabilitation services 
closer to their home communities, and also are responsible for ensuring 
that these patients don't ``fall through the cracks'' after leaving 
full-time care. For hospitals without a Polytrauma Support Clinic, a 
single person has been designated as the ``point of contact'' to 
coordinate care for local veterans with polytraumas.
    These are good first steps, but much more must be done to get these 
wounded veterans the care they need. A ``point of contact'' that can 
offer referrals to distant hospitals and clinics is simply not an 
adequate response to a wounded veteran's health care needs. IAVA joins 
the other IB-VSOs in calling for increased funding for home and 
community-based care, and a detailed plan from the VA regarding their 
long-term response to the needs of today's veterans.
    Respectfully submitted.

                                 
           Prepared Statement of Mahdulika Agarwal, M.D., MPH
  Chief Officer, Patient Care Services, Veterans Health Administration
                  U.S. Department of Veterans Affairs
    Good morning, Mr. Chairman and Members of the Subcommittee. Thank 
you for the opportunity to discuss the Department of Veterans Affairs' 
(VA's) care for seriously wounded veterans after they complete their 
inpatient care. I am accompanied by Dr. Lucille Beck, Chief Consultant 
for Rehabilitation Services and Ms. Kristin Day, Chief Consultant Care 
Management & Social Work Service, Veterans Health Administration (VHA).
    VHA has long emphasized the importance of a personalized continuum 
of care for servicemembers. Our commitment extends beyond the initial 
transition across systems of care to ensure services continue to be 
provided to these individuals as veterans, and to their family members, 
who are essential to the recovery and rehabilitation of these injured 
warriors.
    It is important to emphasize, however, that neither the transfer 
between health care systems, nor the transfer to veterans' status is a 
linear path. To ensure every veteran or servicemember receives the care 
and benefits they deserve, VA has created a Case Management Program for 
Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans. 
The VA/DoD Federal Recovery Coordination Program (FRCP) further 
provides needed assistance and support for veterans and servicemembers 
with serious injuries or illnesses. VA's provision of both inpatient 
and outpatient rehabilitation services in locations across the country 
is designed to meet the short- and long-term needs of veterans with 
serious injuries, including Polytrauma, Traumatic Brain Injury (TBI), 
Spinal Cord Injury (SCI), and mental health needs. These overlapping 
strategies of case management and coordination of rehabilitative care 
allow me to state with confidence that VA is adapting to the needs of 
our returning veterans and operating a system capable of providing 
lifelong care to them. These programs provide little net value if 
veterans are unaware of the services available to them; consequently, 
VA has pursued outreach on multiple levels to see that our veterans, 
particularly those with severe injuries or illnesses, can access our 
system and receive the care they have so bravely earned.
OEF/OIF Case Management Program and Federal Recovery Coordination 
        Program
    We deeply appreciate the recommendations of The President's 
Commission on Care for America's Returning Wounded Warriors, chaired by 
Senator Dole and Former Secretary Shalala. Specifically, we echo their 
description of the importance of integrated care management, which they 
describe as providing, ``. . . patients with the right care and 
benefits at the right time in the right place by leveraging all 
resources appropriate to their needs. For injured servicemembers--
particularly the severely injured--integrated care management would 
build bridges across health care services in a single facility and 
across health care services and benefits provided by DoD and VA.'' \1\
---------------------------------------------------------------------------
    \1\ President's Commission on Care for America's Returning Wounded 
Warriors. ``Serve, Support, and Simplify: Subcommittee Reports and 
Findings.'' p. 20-21. Available online: http://www.pccww.gov/docs/
TOC%20Subcommittee%20Reports.pdf.
---------------------------------------------------------------------------
    VHA and VBA published a joint handbook (VHA Handbook 1010.01) in 
May 2007 establishing procedures for the transition of care, 
coordination of services and case management of OEF/OIF veterans. This 
joint Case Management Program represents a fully integrated team 
approach, and includes a Program Manager, Clinical Case Managers, a VBA 
Veterans Service Representative, and a Transition Patient Advocate. 
These teams are active at every VA Medical Center (VAMC). The Program 
Manager, who is either a nurse or social worker, has overall 
administrative and clinical responsibility for the team, and must 
ensure all OEF/OIF veterans are screened for case management needs. 
OEF/OIF veterans with severe injuries are automatically provided a case 
manager; all other OEF/OIF veterans are assigned a case manager upon 
request. Clinical Case managers, who are either nurses or social 
workers, coordinate patient care activities and ensure all VHA 
clinicians are providing care to the patient in a cohesive, integrated 
manner. VBA team members assist veterans by educating them on VA 
benefits and assisting them with the benefit application process.
    The Transition Patient Advocates (TPAs) serve as liaisons between 
the VAMC, the Veterans Integrated Service Network (VISN), VBA, and the 
patient. The TPA acts as a communicator, facilitator and problem 
solver. The team documents their activities in the Veterans Tracking 
Application (VTA), a Web-based tool designed to track injured and ill 
servicemembers and veterans as they transition to VA. VHA is also using 
the Primary Care Management Module (PCMM), an application within VHA's 
VistA Health Information system, to track patients assigned to an OEF/
OIF Case Management team.
    VA has developed a rigorous training schedule for this new program 
to ensure it is operating fully and effectively for all veterans 
requesting assistance. TPAs and VISN Points of Contact attended a 
training conference in Washington, D.C. in June 2007, and Program 
Managers received training in September 2007. VA held a week-long 
training conference in San Diego in January 2008 for Case Managers, and 
two regional training conferences for the entire OEF/OIF Case 
Management Team are planned for May and June 2008.
    As a part of this effort, VHA and VBA are jointly developing a 
comprehensive list of severely injured OEF/OIF veterans. The two 
administrations are defining the requirements and definitions for this 
list, and will establish a single record to track VHA or VBA contact 
each month with severely injured veterans and servicemembers.
    VA and DoD are working on jointly developing and implementing a 
comprehensive policy on improvements to the care, management, and 
transition of recovering servicemembers, pursuant to the National 
Defense Authorization Act of 2008.
    In October 2007, VA partnered with DoD to establish the Joint VA/
DoD Federal Recovery Coordination Program (FRCP). The FRCP will 
identify and integrate care and services for the seriously wounded, 
ill, and injured servicemember, veteran, and their families through 
recovery, rehabilitation, and community reintegration. VA hired an FRCP 
Director, an FRCP Supervisor, and eight Federal Recovery Coordinators 
(FRCs) in December 2007. The FRCs are currently deployed to Walter Reed 
and Brooke Army Medical Centers, as well as National Naval Medical 
Center at Bethesda. Two additional FRCs are currently being recruited 
and will be stationed at Brooke Army Medical Center and Balboa Naval 
Medical Center in San Diego. The FRCP is intended to serve all 
seriously injured servicemembers and veterans, regardless of where they 
receive their care. The central tenet of this program is close 
coordination of clinical and non-clinical care management for severely 
injured servicemembers, veterans, and their families across the 
lifetime continuum of care.
Caregiver Assistance
    The Caregiver Pilot Task Force was formed in response to a 
provision of the ``Veterans Benefits, Health Care, and Information 
Technology Act of 2006''. Eight Caregiver Assistance Pilot Programs 
were awarded grants beginning in October 2007, at a total cost of 
approximately $5 million. The goal is to explore options for providing 
support services for caregivers in areas across the country where such 
services are needed for families of disabled or aging veterans, and 
where there are few other options available. These programs will also 
increase the caregiver support services available to OEF/OIF veterans 
in the immediate future and the long term. Examples of these pilots 
include:

       Home Based Primary Care programs, in Memphis and Palo 
Alto, are implementing interventions from the evidence-based REACH II 
National Institutes of Health Initiative to train and support 
caregivers in managing patient behaviors and their own stress.
       Caregivers in Gainesville, Florida will participate in a 
Transition Assistance Program using videophone technology to provide 
skills training, education and supportive problem solving.
       In Ohio, Caregiver Advocates will be available via 
telephone 24 hours a day to coordinate between VA and community 
services.
       VA will work with a community coalition to provide 
education, skills, training, and support for caregivers of veterans 
with TBI in California, using telehealth technology.
       The VA Pacific Islands Healthcare System will develop a 
Medical Foster Home program to provide overnight respite care for 
veterans.
       In Miami and Tampa, funding will be used to expand 
respite care, train home companions, and develop an emergency response 
system.
       Atlanta will use a model telehealth program to provide 
instrumental help and emotions support to caregivers who live in remote 
areas.

    VA is committed to providing key services to assist caregivers with 
case management, service coordination, and support for the veteran, as 
well as education on how to obtain community resources such as legal 
assistance, financial support, housing assistance, and spiritual 
support.

Medical Foster Homes and Volunteer Respite Services
    In February 2008, VA's Under Secretary for Health approved funding 
for programs to facilitate the transition and support of seriously 
injured veterans with Polytrauma, TBI, and/or SCI by providing 
specialized support and care in their homes and communities. This 
program will aid both veterans living in their homes and those who are 
no longer able to live independently but prefer an in-home alternative 
within their community. The Volunteer Respite program will create 
access to needed home respite services for family caregivers, while 
giving members of the community an opportunity to volunteer with VA 
closer to home, regardless of distance from a VA facility. VA Voluntary 
Service would recruit, train, and coordinate community volunteers to 
provide respite care in the homes of OEF/OIF veterans. The Medical 
Foster Home component provides an in-home alternative to nursing home 
care, merging personal care in a private home with medical and 
rehabilitation support from specialized VA home care programs.
    Through these programs and others, VA will expand the availability 
of Medical Foster Homes (MFH) to seriously injured OEF/OIF veterans 
near specialized facilities within the communities in which they live. 
We will also expand the number of MFH sites and modify them to meet the 
needs of younger, seriously injured veterans with Polytrauma, TBI, and/
or SCI, and strengthen the rehabilitation expertise of the VA home care 
teams who will serve them. Veterans with disabling injuries or 
conditions may need the support of a non-familial caregiver as they 
work toward independent living in the community, or may have long term 
care needs that initially, or eventually, exceed the capabilities their 
family can sustain. MFH may be a favorable alternative to nursing homes 
for these veterans as we facilitate their return to homes and 
communities.
Rehabilitative Services
    VA provides clinical rehabilitative services in several specialized 
areas that employ the latest technology and procedures to provide our 
veterans with the best available care and access to rehabilitation for 
polytrauma and traumatic brain injury, spinal cord injury, visual 
impairment, and other areas. VA's Under Secretary for Health directed 
our facilities to seek a second opinion from civilian physicians upon 
request. Whenever an OEF/OIF veteran requires specialized 
rehabilitative services, the assigned OEF/OIF case manager engages with 
the clinical case manager that is appropriate for that area of 
rehabilitation; e.g., polytrauma, spinal cord injury, blindness. 
Throughout the rehabilitative process, the OEF/OIF case manager 
coordinates with the appropriate clinical case manager regarding the 
veteran's progress and rehabilitation.
Polytrauma System of Care
    Over the past 2 years, VA has implemented an integrated system of 
specialized care for veterans sustaining traumatic brain injury (TBI) 
and other polytraumatic injuries. The Polytrauma System of Care 
consists of four regional TBI/Polytrauma Rehabilitation Centers (PRC) 
located in Richmond, VA; Tampa, FL; Minneapolis, MN; and Palo Alto, CA. 
A fifth PRC is currently under design for construction in San Antonio, 
TX, and is expected to open in 2011. The four regional PRCs provide the 
most intensive specialized care and comprehensive rehabilitation for 
combat injured patients transferred from military treatment facilities. 
As veterans recover and transition closer to their homes, the 
Polytrauma System of Care provides a continuum of integrated care 
through 21 Polytrauma Network Sites, 76 Polytrauma Support Clinic Teams 
and 54 Polytrauma Points of Contact, located at VAMCs across the 
country. Throughout the Polytrauma System of Care, we have established 
a comprehensive process for coordinating support efforts and providing 
information for each patient and family member. On February 27, 2006, 
VA established a national Polytrauma Call Center available 24 hours a 
day, 7 days a week, for families and patients with questions. This 
Center is staffed by health care professionals trained specifically in 
Polytrauma care and case management issues and can be reached by 
calling 1-888-827-4824.
    The care coordination process between the referring DoD military 
treatment facility and the PRC begins weeks before the active duty 
servicemember is transferred to VA for health care. The PRC physician 
monitors the medical course of recovery and is in contact with the MTF 
treating physician to ensure a smooth transition of clinical care. The 
admissions nurse case manager maintains close communication with the 
referring facility, obtaining current and updated medical records. A 
social work case manager is in contact with the family to address their 
needs for psychosocial and logistical support. Prior to transfer, the 
PRC interdisciplinary team meets with the DoD treatment team and family 
by teleconference as another measure to ensure a smooth transition. The 
PRCs provide a continuum of rehabilitative care including a program for 
emerging consciousness, comprehensive acute rehabilitation, and 
transitional rehabilitation. Each of the PRCs is accredited by the 
Commission on Accreditation of Rehabilitation Facilities (CARF). 
Intensive case management is provided by the PRCs at a ratio of 1 case 
manager per 6 patients, and families have access to assistance 24 hours 
a day, 7 days a week. The interdisciplinary rehabilitation treatment 
plan of care reflects the goals and objectives of the patient and/or 
family.
    From March 2003 through December 2007, the PRCs provided inpatient 
rehabilitation to 507 military servicemembers injured in combat 
theaters. The transition plan from the PRCs to the next care setting 
evolves as the active duty servicemember progresses in the 
rehabilitation program. Families are integral to the team and are 
active participants in therapies, learning about any residual 
impairments and ongoing care needs. The team collaborates with the 
family to identify the next care setting, and determine what will be 
needed to accommodate the transition of rehabilitative care. The 
consultation process includes a teleconference between the PRC team, 
the consulting team, the family, and the patient. These conferences 
allow for a coordinated transfer of the plan of care, and an 
opportunity to address specific questions.
    Prior to discharge, each family and patient is trained in medical 
and nursing care appropriate for the patient. Once a discharge plan is 
coordinated with the family, VA initiates contact with necessary 
resources near the veteran's home community. Based upon location, an 
agreement is reached with one of the 21 VA Polytrauma Network Sites or 
an appropriate local provider within the patient's community. As 
veterans and servicemembers transition to their home communities, 
ongoing clinical and psychosocial case management is provided by a 
rehabilitation nurse and social worker from one of 76 Polytrauma 
Support Clinic Teams. VA social work case managers follow each patient 
within the Polytrauma System of Care at prescribed intervals contingent 
upon need. For example, there are four levels of case management: 
intensive case management, where contact is made daily or weekly; 
progressive case management, where VA contacts the patient monthly; 
supportive case management, quarterly; and lifetime case management, 
annually. For the many patients who are still active duty 
servicemembers, the military case managers are responsible for 
obtaining authorizations from DoD regarding orders and followup care 
based upon VA medical team recommendations.
    VA is committed to ongoing review and improvement of our provision 
of care for these wounded or injured warriors. In this spirit, VA 
assembled a national research task force last summer to review and 
evaluate the long term care needs of our most seriously wounded or 
injured returning OEF/OIF veterans. This taskforce recently completed 
its work and identified several recommendations, which are being 
submitted to the Secretary for his review. Moreover, in compliance with 
the 2008 National Defense Authorization Act, VA is collaborating with 
the Defense and Veterans Brain Injury Center to design and execute a 5-
year pilot program to assess the effectiveness of providing assisted 
living services to eligible veterans to enhance their rehabilitation, 
quality of life, and community integration.
Spinal Cord Injury and Disorders
    For Spinal Cord Injury and Disorders (SCI/D), VA has the largest 
single network of care in the Nation. VA facilities nationwide provided 
a full range of services to 26,191 veterans with SCI/D in 2007; 12,789 
of these veterans received specialized care within the Spinal Cord 
Injury Centers and Spinal Cord Injury Support Clinics. For veterans 
with SCI/D, VA provides health care, maintains their medical equipment, 
and provides supplies, education and preventive health services. Since 
2003, 364 active duty servicemembers have been treated in VA SCI units; 
of these, 116 acquired spinal cord injury in an OEF/OIF theater of 
operations. Each of these patients received care from a VA facility 
accredited by CARF. A national, multi-site vocational improvement 
research project identifies evidence-based vocational rehabilitation 
programs for veterans with SCI/D.
    VA is improving and expanding our SCI/D nationally, with plans for 
a ribbon-cutting ceremony for a new facility in Minneapolis in February 
2009. Our Denver, CO facility's design was funded in 2004 and land was 
acquired in 2006, while our Jackson, MS facility's funding is still 
being determined. Tampa's LTC facility (30 beds) is under construction 
and planning is underway for the VISN 3 SCI LTC facility. Each VA 
Spinal Cord Injury Center will be provided with state-of-the-art 
technology and equipment to better support home-based therapies, 
provide closer management and monitoring of function and complications 
in the home, and offer closer attention to health promotion and 
prevention.
Blind Rehabilitation
    For veterans and active duty personnel with visual impairment, VA 
provides comprehensive Blind Rehabilitation services that have 
demonstrated significantly greater success in increasing independent 
functioning than any other blind rehabilitation program. Currently, 164 
Visual Impairment Service Team (VIST) Coordinators provide lifetime 
case management for all legally blind veterans, and all OEF/OIF 
patients with visual impairments. Additionally, 38 Blind Rehabilitation 
Outpatient Specialists (BROS) provide blind rehabilitation training to 
patients who are unable to travel to a blind center.
    The VA Blind Rehabilitation Continuum of Care, announced January 
2007, further extends a comprehensive, national rehabilitation system 
for all veterans and active duty personnel with visual impairments. 
Program expansion during 2008 will add 55 outpatient vision 
rehabilitation clinics, 35 additional BROS at VAMCs currently lacking 
those services, and 11 new VIST positions. The continuum of care will 
provide the full scope of vision services--from basic, low vision 
services to blind rehabilitation training--across all Veteran 
Integrated Service Networks (VISNs).
Outreach
    VA has always been committed to outreach, and all the more so 
during periods of armed conflict. Given the importance of outreach to 
servicemembers and veterans of OEF/OIF, VA promotes and conducts 
activities at both national and local levels. VA has developed an array 
of training materials, directives, publications, and established points 
of contact at each VA facility. VA also partners with Federal agencies, 
Veterans Service Organization (VSOs), and State, county, and local 
agencies and governments. Our outreach to OEF/OIF participants begins 
when the servicemember returns home and continues through the 
transition period from servicemember to veteran and beyond.
    Outreach to active duty personnel is a major part of VA's Outreach 
program and is generally accomplished through the Transition Assistance 
Program (TAP) sponsored in cooperation with the Departments of Defense 
and Labor. All VA benefits and services are included in TAP briefings. 
All returning OEF/OIF servicemembers are given a copy of VA Pamphlet 
80-06-01, Federal Benefits for Veterans and Dependents.
    Special outreach to Reserve/Guard members is an integral part of 
VA's outreach efforts. VA provides briefings on benefits and health 
care services at townhall meetings, family readiness groups, and during 
unit drills near the homes of returning Reserve/Guard members.
    Since 2003, VA's outreach to those severely injured in OEF/OIF 
includes placing VA/DoD Social Work and Registered Nurse Liaisons and 
Benefits Counselors at Walter Reed Army Medical Center, the National 
Naval Medical Center and nine other military treatment facilities 
across the country.
    In November 2005, VA began partnering with DoD in implementing the 
Post-Deployment Health Reassessment (PDHRA) among National Guard and 
Reserve Component (RC). The PDHRA is a DoD global health-screening tool 
that includes specific questions covering PTSD, alcohol misuse and 
Traumatic Brain Injury (TBI). VA's role in this partnership is 
fourfold: provide information on VA benefits among Reserve and Guard 
personnel; enroll eligible veteran in VA health care; provide 
assistance in scheduling followup appointments at VAMCs and Vet 
Centers; and develop ongoing referral and training relationships with 
Reserve and Guard Commanders. As of January 31, 2008, VA has supported 
PDHRA referrals from DoD's 24/7 Call Center, 283 Unit Call Center PDHRA 
events and 888 Unit On-Site PDHRA events. The RC PDHRA initiative has 
generated over 75,000 referrals, including 36,199 referrals to VAMCs 
and 17,214 referrals to Vet Centers representing 71% of total 
referrals.
    Vet Center staff regularly participates in DoD-sponsored PDHRA 
events. Vet Centers provide information on VA benefits and care to 
servicemembers as they transition from military to civilian life at 
National Guard and Reserve demobilization sites, active duty transition 
briefings, and community events involving returning combat veterans 
such as homecoming events. Outreach is also performed with local VSOs 
and community agencies. Vet Center outreach is designed to provide 
information, minimize stigma, and help veterans obtain needed services 
as early as possible. More than 200,000 servicemembers have been 
provided outreach services, primarily at military demobilization sites, 
including National Guard and Reserve units. Vet Centers initiate 
outreach efforts to area military installations and closely coordinate 
their efforts with military family support services at various military 
bases.
    In October 2005, DoD Health Affairs began providing VA with a list 
of servicemembers entering the Physical Evaluation Board (PEB) process. 
These servicemembers sustained an injury or developed an illness that 
may preclude them from continuing on active duty and result in medical 
separation or retirement. This list will enable VHA to send outreach 
letters encouraging them to contact the nearest VA medical facility for 
future assistance in enrolling in VA health care and addressing their 
health care needs as they transition from active duty to veteran 
status. As of January 31, 2008, the VA has mailed 16,905 PEB outreach 
letters to servicemembers.
    The Veterans Assistance at Discharge System process mails a 
``Welcome Home Package,'' including a letter from the Secretary, ``A 
Summary of VA Benefits'' (VA Pamphlet 21-00-1), and ``Veterans Benefits 
Timetable'' (VA Form 21-0501), to veterans recently separated or 
retired from active duty (including Guard/Reserve members). We re-send 
this information 6 months later to these veterans.
    The Secretary of Veterans Affairs sends a letter to newly separated 
OEF/OIF veterans. The letters thank veterans for their service, welcome 
them home, and provide basic information about health care and other 
benefits provided by VA. To date, VA has mailed over 766,000 initial 
letters and 150,000 followup letters to veterans.
    VA Regional Offices assist and support seriously injured OEF/OlF 
servicemembers and veterans by conducting case management activities, 
including outreach, coordinating services, and streamlining claims 
processing procedures.
    In collaboration with DoD, VA published and distributed one million 
copies of a new brochure called, ``A Summary of VA Benefits for 
National Guard and Reservists Personnel.'' The new brochure summarizes 
health care and other benefits available to this special population of 
combat veterans upon their return to civilian life.
    As part of VA's ``Coming Home to Work'' program, participants work 
with a Vocational Rehabilitation and Employment Counselor (VRC) to 
obtain unpaid work experiences at government facilities. This 
represents an early outreach effort with special emphasis on OEF/OlF 
servicemembers pending medical separation from active duty at military 
treatment facilities.
    VA also continues its Benefits Delivery at Discharge program, where 
servicemembers can apply for service-connected compensation, vocational 
rehabilitation, and employment services before discharge. Normally, 
prior to discharge, required physical examinations are conducted, 
service medical records are reviewed, and rating decisions are made.
Access to Care
    VA has identified access to outpatient care as a priority in our 
effort to provide care for seriously wounded veterans after inpatient 
care is complete. VHA's strategic direction is to enhance non-
institutional care with less dependence on large institutions. Our 
comprehensive care management plans offer guidance for providing care 
to veterans in their homes and communities. For those veterans who 
prefer to visit in person, VA issued a directive last June instructing 
our medical centers to explore offering extended hours for veterans 
unable to schedule appointments during the day. Similarly, our Vet 
Centers are available to veterans on nights and weekends for 
readjustment counseling needs.
    Community Based Outpatient Clinics (CBOCs) have been the anchor for 
VA's efforts to expand access for veterans. CBOCs are complemented 
through partnerships, such as contracts in the community for physician 
specialty services or referrals to local VA medical centers, depending 
on the location of the CBOC and the availability of specialists in the 
area. In addition, we provide rural outreach clinics that are operated 
by a parent CBOC to meet the needs of rural veterans.
    Telehealth provides veterans with access to care in their homes and 
local communities where possible and appropriate. It is a new modality 
of care requiring robust clinical practices, technology infrastructure 
and business processes to maintain and sustain the modality. Telehealth 
capabilities in VA have expanded in all clinical areas since FY 2004. 
There are telehealth programs within all VISNs and many programs have 
grown from point-to-point connections to inter-hospital and VISN-based 
networks. VA continues to evaluate the effectiveness of telehealth and 
to work with clinical leadership in the VISNs and VA facilities to 
introduce new clinical processes based on information technologies to 
assist clinicians in meeting the health care needs of older veterans. 
This reduces the barriers of distance and time that may restrict the 
availability of care. Currently, VA is piloting applications to create 
national tele-consultation networks to expand the provision of 
specialty care to rural and remote areas.
Conclusion
    We are honored to provide care and service to America's veterans. 
For those who return from combat with serious injuries or illness, we 
work closely with DoD to ensure a swift and seamless transition to VA, 
but we also work with those who do not need immediate care to make it 
as accessible as possible. Thank you again for you the opportunity to 
meet with you today. I would be happy to address any questions that you 
have at this time.

                               __________
Memorandum

Department of Veterans Affairs

    Date:
            February 22, 2007

    From:
            Deputy USH for Operations and Management (10N)

    Subj:
            Acceptance Requirements for VA Volunteers

    To:
            All VISN Directors (10N1-23)
            All Medical Center Directors (00)

    1.  Effective immediately, all VISNs and VA facilities will accept 
and process volunteers according to the standardized process outlined 
in this memorandum and attachment.
    2.  This process is necessary to reduce barriers to volunteering at 
VA facilities, while complying with current laws and VA regulations. It 
enables VA to establish reasonable expectations for managing our 
ability to accept new volunteers while enhancing our volunteer 
recruitment activities.
    3.  For the purpose of accepting new volunteers, and determining 
the level of cyber security and privacy training they will require, 
four specific groups of volunteers have been established. Each group 
has specific requirements that correlate with the level of cyber 
security risk involved in their volunteer assignment. Every volunteer 
assignment will be categorized in one or more of the groups listed 
below.

Group A
    VA employees who have volunteer assignments will require:

           A completed and signed application
           A general orientation
           An assignment-specific orientation
           A physical examination if driving is their volunteer 
        assignment

    Type of 10 Badge Required: Standard employee 10 badge

Group B

    Volunteers with recreation, cemetery, book cart, or similar 
assignments will require:

           A completed and signed application
           A general orientation
           An assignment-specific orientation
           Privacy Policy Training
           A PPD Inoculation
           A photo 10 badge
           A physical examination if driving is their volunteer 
        assignment
           A List of Excluded Individuals & Entities (LEIE) 
        Health and Human Services (HHS) database check. The LEIE 
        database check is performed automatically between databases.
           A Healthcare Integrity and Protection Data Bank 
        (HIPDB) HHS database check. The HIPDB database check is 
        completed by facility personnel.

Type of 10 Badge Required: FLASH

Group C

    Volunteers who have assignments in any of the seven categories 
outlined in VHA Directives 0710 and VHA Handbook 1620.1 will require:

           All Group B requirements plus:
           A Special Agreement Check (SAC) for Fingerprint Only

    Type of 10 Badge Required: NON-PIV

    The seven categories for Group C are volunteers who have:

           Assignments associated with home health care;
           Assignments involving the provision of patient care 
        or working alone with patients;
           Assignments involving contact with pharmaceuticals 
        or other biological agents;
           Assignments that provide access to patient records;
           Assignments involving clinical research;
           Assignments that provide access to any VA computer 
        system; or
           Access to any sensitive information not identified 
        above (e.g., Privacy Act Protected Information)

Group D

    Volunteers who have computer access or access to the LAN will 
require:

           All Group B & C requirements plus:
           A National Agreement Check Inquiry (NACl) 
        Investigation
           Cyber Security Training
           A signature that the volunteer has read the VA's 
        Rules of Behavior

    Type of 10 Badge Required: PIV

    4.  These volunteer categories will standardize the acceptance 
process for all VA volunteers, regardless of the facility where they 
volunteer their time. This process will enable members of the community 
to serve those who have served, while safeguarding veteran private 
information.
    5.  The process outlined in this memorandum will be included as 
policy in VHA Handbook 1620.1, 'Voluntary Service Procedures''. All 
VISN Directors and Medical Center Directors will ensure the 
implementation of this standardized process for acceptance of 
volunteers.

                                      William F. Feeley, MSW, FACHE

                              ----------                              



                                 Attachment:  Volunteer Acceptance Requirements
----------------------------------------------------------------------------------------------------------------
                                                 Volunteers with No Access  Volunteers with    Volunteers with
   VA Employees as Volunteers (already have      to Veterans Records or VA     Access to       Access to VA IT
        necessary training and checks)                  IT Systems              Veterans           Systems
----------------------------------------------------------------------------------------------------------------
 Completed                                  Completed and      All Group B      All Group B & C
                                                                   signed
  and signed                                                  application     requirements   requirements plus:
  application                                             General            plus:
                                                              orientation
 General                                 Assignment-specif                         NACI
                                                                       ic
  Orientation                                                 orientation    Specia       Investigation
                                                                                         l
 Assignment-                               Privacy Policy        Agreement      Complete
                                                                 Training                                     d
  specific                                        PPD Inoculation           Checks      Returned
  orientation                                            Photo ID        (SAC) for        Cyber
                                                                                                       Security
 Physical                                        Physical      Fingerprint             Training
                                                               exmination
  exmination                                      (for volunteer drivers)             Only    Sign VA's
                                                                                                          Rules
  (if driving                                                    LEIE database              of Behavior
                                                                    check
  is their                                                              (List of Excluded
  volunteer                                          Individual/Entities,
  assignment)                                            Health and Human
                                                   Services database, not
                                                         completed by the
                                                               volunteer)
                                                 Health Integrity
                                                 and Protection Data Bank
                                                                    Check
----------------------------------------------------------------------------------------------------------------
Ongoing Requirement--Annual Supervisor Evaluation.


                                 

                                     Committee on Veterans' Affairs
                       Subcommittee on Oversight and Investigations
                                                    Washington, DC.
                                                     April 17, 2008
Hon. James B. Peake
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

    Dear Secretary Peake:

    On Thursday, March 13, 2008, the Subcommittee on Oversight and 
Investigations of the House Committee on Veterans' Affairs held a 
hearing on Care of Seriously Wounded After Inpatient Care.
    During the hearing, the Subcommittee heard testimony from Dr. 
Madhulika Agarwal, Chief Patient Care Services Officer for the Veterans 
Health Administration. Dr. Agarwal was accompanied by Dr. Lucille Beck, 
Chief Consultant for Rehabilitation Services in the Veterans Health 
Administration; and Kristin Day, Chief Consultant for Care Management 
and Social Work. As a followup to that hearing, the Subcommittee is 
requesting that the following questions be answered for the record:

     1.  Please provide the Committee with a timeline for full 
implementation of the Federal Individual Recovery Plan (FIRP), and 
include in the timeline dates for each stage of implementation.
     2.  When will VA go back through the medical records and other 
sources of information for those seriously wounded veterans who have 
already been discharged into the civilian community (like Corporal 
Owens and Sergeant Wade) and bring these veterans into the FIRP with 
their own assigned Federal Recovery Coordinator (FRC), or otherwise 
provide those veterans with effective case management services?
     3.  Does the VA currently have sufficient staffing to handle the 
number of servicemembers and veterans who will need to rely on a 
Federal Recovery Coordinator (FRC) to assist them with their FIRP?
     4.  Are the FRCs in the current pilot assigned to newly injured 
servicemembers, to previously injured servicemembers (i.e., 
servicemembers who were injured prior to the creation of the FRC 
pilot), or a combination thereof? If a combination, please provide the 
relative percentages of the two groups. If the pilot FRCs are being 
assigned primarily to newly injured servicemembers, please explain why 
this scare resource--FRCs--is being assigned to newly injured 
inpatients who have multiple case managers instead of previously 
injured servicemembers who may not have adequate case management?
     5.  Many of the most seriously injured OEF and OIF vets are 
treated in the VA's four Polytrauma Rehabilitation Centers (PRC). Has 
the VA tracked PRC patients after they leave the PRCs? If not, why not? 
How is VA ensuring that they receive everything they need?
     6.  Apart from PRC patients, what steps has VA taken to identify 
severely injured separated servicemembers who need ongoing care 
coordination?
     7.  What are VA's criteria to decide when a servicemember who has 
been treated at a PRC is no longer the responsibility of PRC case 
managers? In other words, what are the criteria for deciding to 
transition a servicemember from PRC case management to OIF/OEF care 
coordinator case management or something else?
     8.  What is the average caseload of a OIF/OEF care coordinator? Is 
this considered manageable? Is there a health care standard for this 
issue?
     9.  Have the special needs of severely injured rural vets been 
identified?
    10.  Please explain how VETSNET is being used to support the FRC 
pilot and the OIF/OEF care coordination program.
    11.  The testimony of Dr. Agarwal on page 3 states:

            As a part of this effort, VHA and VBA are jointly 
developing a comprehensive list of severely injured OEF/OIF veterans. 
The two administrations are defining the requirements and definitions 
for this list, and will establish a single record to track VHA or VBA 
contact each month with severely injured veterans and servicemembers.

        Describe in detail how this list is being constructed and what 
the timeline is for completion of a comprehensive list.

    We request you provide responses to the Subcommittee no later than 
close of business on June 11, 2008. If you have any questions 
concerning these questions, please contact Subcommittee on Oversight 
and Investigations Staff Director, Geoffrey Bestor, Esq., at (202) 225-
3569 or the Subcommittee Republican Staff Director, Arthur Wu, at (202) 
225-3527.
            Sincerely,
                                                  HARRY E. MITCHELL
                                                           Chairman

                                                  GINNY BROWN-WAITE
                                          Ranking Republican Member

                               __________

                        Questions for the Record
               The Honorable Harry E. Mitchell, Chairman
       The Honorable Ginny Brown-Waite, Ranking Republican Member
               Oversight and Investigations Subcommittee
                   House Veterans' Affairs Committee
                             March 13, 2008
             Care of Seriously Wounded After Inpatient Care

    Question 1: Please provide the Committee with a timeline for full 
implementation of the Federal Individual Recovery Plan (FIRP), and 
include in the timeline dates for each stage of implementation.

    Response: A memorandum of understanding (MOU) between the 
Department of Veterans Affairs (VA) and the Department of Defense (DoD) 
was signed on October 30, 2007, for the joint oversight of the Federal 
recovery coordination program (FRCP). In December 2007, VA hired the 
program's director and supervisor. In January 2008, VA hired Federal 
recovery coordinators (FRCs) who were placed at the following military 
treatment facilities (MTF):


----------------------------------------------------------------------------------------------------------------
              Number of FRCs
----------------------------------------------------------------------------------------------------------------
     3                                      Walter Reed Army Medical Center,    All on site and serving
                                                              Washington DC                            patients
----------------------------------------------------------------------------------------------------------------
     2                                       National Naval Medical Center,    (1) On site and serving patients
                                                               Bethesda, MD                  (1) Starts 5/19/08
----------------------------------------------------------------------------------------------------------------
     3                                      Brooke Army Medical Center, San    (2) On site and serving patients
                                                                Antonio, TX             (1) In boarding process
----------------------------------------------------------------------------------------------------------------
     2                                      Naval Medical Center, San Diego,       (1) In final selection stage
                                                                         CA             (1) In boarding process
----------------------------------------------------------------------------------------------------------------


    The FRCs started working with patients January 28, 2008. FRCs 
developed Federal individualized recovery plans (FIRP) for severely 
wounded, ill and injured servicemembers or veterans who meet the FRCP 
criteria. Phase One of the FRC program targeted those catastrophically 
wounded, ill or injured arriving from theatre to the MTF and is 
scheduled to be completed in May 2008. Phase Two, which will begin 
immediately after Phase One is complete, will expand the program's 
scope to include those servicemembers and veterans who were discharged 
from an MTF prior to January 2008.

    Question 2: When will VA go back through the medical records and 
other sources of information for those seriously wounded veterans who 
have already been discharged into the civilian community (like Corporal 
Owens and Sergeant Wade) and bring these veterans into the FRCP with 
their own assigned Federal Recovery Coordinator (FRC), or otherwise 
provide those veterans with effective case management services?

    Response: At this time, FRCs are accepting servicemembers/veterans 
injured prior to January 2008 into the FRCP on a referral basis. As 
mentioned above, Phase Two will start in June 2008, and will expand the 
program's scope to include those servicemembers and veterans who were 
discharged from a MTF prior to January 2008. Identification of this 
population will be conducted through a review of VA rehabilitation 
databases, to include spinal cord and blind rehabilitation, along with 
the polytrauma centers. In tandem, DoD will work through TRICARE in an 
effort to identify the same population for potential inclusion into the 
FRCP. Recruitment of staff to support this expansion effort has begun. 
An additional registered nurse is being recruited to champion this 
effort along with additional FRCs whose geographic placement will be 
based on identified patient needs.

    Question 3: Does the VA currently have sufficient staffing to 
handle the number of servicemembers and veterans who will need to rely 
on the Federal Recovery Coordination Program to assist them with their 
FIRP?

    Response: VA and DoD continue to closely monitor workload and 
geographic distribution of cases as the program matures. As of now the 
number of FRCs is adequate, but we expect that number to increase as we 
continue to identify servicemembers in need of their services.

    Question 4: Are the FRCs in the current pilot assigned to newly 
injured servicemembers, to previously injured servicemembers, (i.e. 
servicemembers who were injured prior to the creation of the FRCP), or 
a combination thereof? If a combination, please provide the relative 
percentages of the two groups. If the pilot FRCs are being assigned 
primarily to newly injured servicemembers, please explain why this 
scarce resource--FRCs--is being assigned to newly inured inpatients who 
have multiple case managers instead of previously injured 
servicemembers who may not have adequate case management?

    Response: Almost 25 percent of the patients in the FRCP were 
admitted to a MTF prior to the implementation of the program January 
21, 2008. Phase One of the program is targeting catastrophically 
wounded, ill or injured arriving from theatre to a MTF. Phase Two will 
expand the program's scope to include those servicemembers and veterans 
who were discharged from a MTF prior to January 2008. The rationale 
behind this decision was that it allowed the FRCs to establish working 
relationships with the multidisciplinary teams, the MTF leadership, and 
those programs that support the severely ill/injured servicemembers.

    Question 5: Many of the most seriously injured OEF and OIF vets are 
treated in the VA's four Polytrauma Rehabilitation Centers (PRC). Has 
the VA tracked PRC patients after they leave the PRCs? If not, why not? 
How is VA ensuring that they receive everything they need?

    Response: Follow-up case management is provided by the PRCs in 
accordance with Veterans Health Administration (VHA) Handbook 1172.1. 
The assigned case manager is involved in developing the discharge plan 
of care with the treatment team, patient and family. This includes, 
arranging and coordinating ongoing services, and communicating with DoD 
and/or the local VA case manager.
    While a patient is on active duty, DoD has authority over the 
servicemember's medical care. The PRC case manager partners with the 
military case manager, and documents post-discharge recommendations in 
the medical record to provide to DoD for active duty patients.
    For patients who are veterans when they leave the PRC, the PRC case 
manager provides regular contact and followup with the patient, family, 
VA and any other service providers. The PRC case manager also tracks 
and monitors implementation of the care plan by the local VA by 
reviewing the electronic medical record. Video teleconferencing is 
often used to facilitate a smooth transition of care to the receiving 
VA care team and the polytrauma network site (PNS) responsible for 
monitoring the care plan and consulting with the local VA team.

    Question 6: Apart from PRC patients, what steps has VA taken to 
identify severely injured separated servicemembers who need ongoing 
care coordination?

    Response: VHA liaisons for health care and Veterans Benefit 
Administration (VBA) benefits counselors are stationed at 11 of the 
major MTFs receiving casualties from Afghanistan and Iraq. VHA 
liaisons, are either social workers or nurses. They facilitate the 
transfer of servicemembers and veterans from the MTF to a VA PRC or 
medical center closest to their home or most appropriate for the 
specialized services their medical condition requires. The benefits 
counselors brief servicemembers about VA benefits and assist them in 
applying for VA benefits and services.
    These teams ensure that a VA facility has a process in place for 
the care of all Operation Enduring Freedom/Operation Iraqi Freedom 
(OEF/OIF) veterans and servicemembers. The care is coordinated. Each VA 
medical center has an OEF/OIF team which includes a nurse or social 
worker program manager, and nurse or social worker case manager. 
Transition patient advocates also support severely injured or ill OEF/
OIF veterans by acting as an advocate for the patient and family as 
they move through the VA system of care. Additionally, each VA medical 
center has a process in place to ensure that the care of all OEF/OIF 
veterans and servicemembers is well-coordinated and that those who are 
severely ill or injured receive case management services from a nurse 
or social worker case manager.
    The polytrauma system of care integrates services at regional 
centers, network sites, and at local VA medical centers to optimize 
resources and create points of access along a continuum of care. 
Specialized polytrauma care is provided at the VA facility closest to 
the veteran's home with the expertise necessary to manage 
rehabilitation, medical or mental health needs, and facilitate the 
veteran's re-integration into the home community.
    The polytrauma system of care is designed to provide smooth 
transition from one level of care to the next. The PRC case manager 
maintains contact and/or monitors the care of patients discharged from 
the PRC for the patient's lifetime. The level of oversight, monitoring, 
or direct involvement of the PRC depends on the patient's access to 
care and services that are being provided at the local level.

    Question 7: What are VA's criteria to decide when a servicemember 
who has been treated at a PRC is no longer the responsibility of PRC 
case managers? In other words, what are the criteria for deciding to 
transition a servicemember from PRC case management to OIF/OEF care 
coordinator case management or something else?

    Response: The transition process may range from weekly or monthly 
contact for some, while monitoring on a quarterly or annual basis for 
others is appropriate. When direct PRC case management is no longer 
required, the PRC case manager will monitor the patient through the 
polytrauma case manager at a PNS, polytrauma support clinic team, or 
the OEF/OIF case manager. The PRC case manager continues to have 
ongoing responsibility to review the medical record and continue to 
followup with the primary case manager. The local VA continually has 
access to its PNS or PRC for consultation if new problems arise, or if 
the patient needs to be referred to a higher level for evaluation and 
treatment.

    Question 8: What is the average caseload of an OEF/OIF care 
coordinator? Is this considered manageable? Is there a health care 
standard for this issue?

    Response: Each OEF/OIF care manager follows approximately 24 
patients as a national average. VHA Handbook 1010.01 states the 
caseload for nurse and social worker case managers will typically be no 
more than 25 to 30 patients per care manager. This ratio is consistent 
with DoD caseload as published in its medical management guide, DoD/
TRICARE management activity, dated January 2006, which suggests a 
caseload of 25-35 acute and chronic cases per care manager.
    Recognizing the crucial role nurses and social workers provide in 
case management and the need for a more consistent approach to 
determining caseloads, two national organizations are currently 
studying caseload calculations for nurses and social workers. The Case 
Management Society of America and the National Association of Social 
Workers are developing a caseload matrix.

    Question 9: Have the special needs of severely injured rural vets 
been identified?

    Response: Severely injured veterans living in rural areas are 
provided the case management services and oversight available to each 
veteran seen throughout the VA polytrauma system of care as well as the 
OEF/OIF care management program located at each VA medical facility 
(e.g., a nurse or social worker clinical case manager, transition 
patient advocates, OEF/OIF case manager, VBA counselors). An 
interdisciplinary team of rehabilitation specialists assesses the needs 
of seriously injured patients to match the treatment plan and 
coordinate support services needed. If local VA care is not available 
to a patient due to their geographic location, fee-based rehabilitation 
services are provided through the local community. The Office of Rural 
Health is working closely with the veterans integrated service networks 
to address access for all rural veterans, and has recently implemented 
initiatives to increase access to care to primary care.

    Question 10: Please explain how VETSNET is being used to support 
the FRC pilot and the OEF/OIF care coordination program.

    Response: Veterans services network (VETSNET) provides benefits 
counselors, OEF/OIF managers and coordinators with improved access to 
veteran and claims data, on-time updates, and immediate status on pay. 
VETSNET is not directly available to the FRCs or the OEF/OIF team at 
the VA medical centers.
    VETSNET is primarily used at this time by benefits counselors at 
MTFs. The benefits counselors meet with servicemembers and their 
families to provide benefits information and assistance to 
servicemembers applying for VBA benefits and services. Counselors 
assist servicemembers in completing claims and in gathering supporting 
evidence. While servicemembers are hospitalized, they are routinely 
informed of the status of their pending claims and given their 
counselor's name and contact information should they have followon 
questions or concerns.
    The OEF/OIF team at the VA medical centers collaborates with the 
benefits counselors at the closest VA regional office.

    Question 11: Dr. Agarwal's testimony on page 3 states that VHA and 
VBA are jointly developing a comprehensive list of severely injured 
OEF/OIF veterans. Describe in detail how this list is being constructed 
and what the timeline is for completion of a comprehensive list.

    Response: VHA recently developed a new tool to track the care 
management of severely ill and injured OEF/OIF veterans. The new 
application is known as the care management tracking and reporting 
application (CMTRA). This robust tracking system allows OEF/OIF care 
managers to specify a care management schedule for each individual 
veteran and to identify specialty care managers such as polytrauma case 
managers and spinal cord injury case managers. The new application was 
implemented at VA medical centers on April 29, 2008. VHA mandated that 
all severely ill and injured OEF/OIF patients being case-managed need 
to be added to CMTRA. VBA is identifying a similar list of severely 
ill/injured patients. VA information technology staff will consolidate 
VHA and VBA information into a single, comprehensive database.