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Hearing Transcript on Polytrauma Center Care and the Traumatic Brain Injury (TBI) Patient: How Seamless is the Transition Between the U.S. Department of Veterans Affairs and the Department of Defense and Are Needs Being Met?

 

 

POLYTRAUMA CENTER CARE AND THE TRAUMATIC BRAIN INJURY PATIENT:  HOW SEAMLESS IS THE TRANSITION BETWEEN THE U.S. DEPARTMENTS OF VETERANS AFFAIRS AND DEFENSE AND ARE NEEDS BEING MET?

 


HEARING

BEFORE  THE

SUBCOMMITTEE ON HEALTH

OF THE

COMMITTEE ON VETERANS' AFFAIRS

U.S. HOUSE OF REPRESENTATIVES

ONE HUNDRED TENTH CONGRESS

FIRST SESSION


MARCH 15, 2007


SERIAL No. 110-9


Printed for the use of the Committee on Veterans' Affairs

 

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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman

 

CORRINE BROWN, Florida
VIC SNYDER, Arkansas
MICHAEL H. MICHAUD, Maine
STEPHANIE HERSETH, South Dakota
HARRY E. MITCHELL, Arizona
JOHN J. HALL, New York
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
SHELLEY BERKLEY, Nevada
JOHN T. SALAZAR, Colorado
CIRO D. RODRIGUEZ, Texas
JOE DONNELLY, Indiana
JERRY MCNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota

STEVE BUYER,  Indiana, Ranking
CLIFF STEARNS, Florida
JERRY MORAN, Kansas
RICHARD H. BAKER, Louisiana
HENRY E. BROWN, JR., South Carolina
JEFF MILLER, Florida
JOHN BOOZMAN, Arkansas
GINNY BROWN-WAITE, Florida
MICHAEL R. TURNER, Ohio
BRIAN P. BILBRAY, California
DOUG LAMBORN, Colorado
GUS M. BILIRAKIS, Florida
VERN BUCHANAN, Florida

 

 

 

Malcom A. Shorter, Staff Director


SUBCOMMITTEE ON HEALTH
MICHAEL H. MICHAUD, Maine, Chairman

CORRINE BROWN, Florida
VIC SNYDER, Arkansas
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
SHELLEY BERKLEY, Nevada
JOHN T. SALAZAR, Colorado
JEFF MILLER, Florida, Ranking
CLIFF STEARNS, Florida
JERRY MORAN, Kansas
RICHARD H. BAKER, Louisiana
HENRY E. BROWN, JR., South Carolina

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 15, 2007


Polytrauma Center Care and the Traumatic Brain Injury (TBI) Patient:  How Seamless is the Transition between the U.S. Departments of Veterans Affairs (VA) and Defense (DoD) and Are Needs Being Met?

OPENING STATEMENTS

Chairman Michael H. Michaud
  Prepared  statement of Chairman Michaud,
Hon. Jeff Miller, Ranking Republican Member, prepared statement of
Hon. John Kline
   Prepared statement of Congressman Kline


WITNESSES

U.S. Department of Veterans Affairs, Barbara Sigford, M.D., Ph.D., National Program Director, Physical Medicine and Rehabilitation, Veterans Health Administration
     Prepared statement of Dr. Sigford
U.S. Department of Defense, Department of the Army, Colonel Mark Bagg, Chief, Department of Orthopaedics and Rehabilitation, Brooke Army Medical Center, Fort Sam Houston, TX, and Director, Center for the Intrepid, 
       Prepared statement of Colonel Bagg


Blinded Veterans Association, Thomas Zampieri, Ph.D., Director of Government Relations
       Prepared statement of Dr. Zampieri
Disabled American Veterans, Adrian M. Atizado, Assistant National Legislative Director
       Prepared statement of Mr. Atizado
George, Karyn, MS, CRC, Service Delivery Manager, Military One Source/Severely Injured Services,
       Prepared statement of Ms. George
Lakeview Healthcare Systems, Inc., Effingham Falls, NH, Tina M. Trudel, Ph.D., President and Chief Operating Officer, and Principal Investigator, Defense and Veterans Brain Injury Center at Virginia NeuroCare
       Prepared statement of Dr. Trudel
Paralyzed Veterans of America, Carl Blake, National Legislative Director
       Prepared statement of Mr. Blake


SUBMISSIONS FOR THE RECORD

Acquired Brain Injury Diversification, MENTOR Network, Debra Braunling-McMorrow, Vice President, statement
American Veterans (AMVETS), Kimo S. Hollingsworth, National Legislative Director, statement
Brown, Hon. Corrine, a Representative in Congress from the State of Florida, statement
Gagnier, John and Cindy, Valparaiso, IN, statement


MATERIAL SUBMITTED FOR THE RECORD

Post-Hearing Questions and Responses for the Record:

Hon. Michael H. Michaud, Chairman, Subcommittee on Health, to Barbara Sigford, M.D, Ph.D., National Program Director, Physical Medicine and Rehabilitation, Veterans Health Administration, U.S. Department of Veterans Affairs, letter dated April 10, 2007
Hon. Michael H. Michaud, Chairman, Subcommittee on Health, to Colonel Mark Bagg, Director, Center for the Intrepid, and Chief, Orthopedics and Rehabilitation, Brooke Army Medical Center, Fort Sam Houston, TX, letter dated April 10, 2007


POLYTRAUMA CENTER CARE AND THE TRAUMATIC BRAIN INJURY (TBI) PATIENT:  HOW SEAMLESS IS THE TRANSITION BETWEEN THE U.S. DEPARTMENTS OF VETERANS AFFAIRS (VA) AND DEFENSE (DoD) AND ARE NEEDS BEING MET?


Thursday, March 15, 2007
U. S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.

The Subcommittee met, pursuant to notice, at 2:20 p.m., in Room 334, Cannon House Office Building, Hon. Michael Michaud [Chairman of the Subcommittee] presiding.

Present: Representatives Michaud, Hare, Salazar, Miller
Also Present: Boyda, Kline, Herseth.

OPENING STATEMENT OF CHAIRMAN MICHAUD

Mr. MICHAUD. I call this hearing to order. I apologize for the lateness. We were over voting. We had to wait for the appropriators to get there before we could close the vote, so I apologize.

The Subcommittee on Health will be hearing from distinguished individuals this afternoon. I would like to welcome Ranking Member Congressman Miller of Florida of this Subcommittee. I look forward to working with him on this very important issue, as well as Congressman Phil Hare.

In order to expedite the process, since we are running behind, I would ask unanimous consent to have my opening remarks submitted for the record. Hearing no objection, so ordered.

I would now like to recognize Mr. Miller, the Ranking Member of the Subcommittee on Health, for an opening statement.

[The prepared statement of Chairman Michaud appears in the Appendix.]

Mr. MILLER. Thank you very much, Mr. Chairman. In lieu of time, I have an opening statement that I would like to submit for the record, and I ask unanimous consent to add it directly.

[The prepared statement of Congressman Miller appears in the Appendix.]

Mr. MICHAUD. Without objection, so ordered. Without objection, any member who wishes to submit an opening statement for the record may do so.

I also ask unanimous consent that all written statements be made part of the record. Without objection, so ordered. And I ask unanimous consent that all members will be allowed five legislative days to revise and extend their remarks. Without objection, so ordered.

The first panel we have here today I would like to welcome Dr. Barbara Sigford of the Department of Veterans Affairs and accompanying her is Dr. Lucille Beck. We look forward to hearing your testimony and to having a frank discussion about meeting the needs of our veterans.

So without further ado, Doctor.

 STATEMENT OF BARBARA SIGFORD, M.D., PH.D., NATIONAL PROGRAM DIRECTOR, PHYSICAL MEDICINE AND REHABILITATION, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY LUCILLE BECK, M.D., CHIEF CONSULTANT FOR REHABILITATION, AND DIRECTOR, AUDIOLOGY/SPEECH PATHOLOGY, VA MEDICAL CENTER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

Dr. SIGFORD.  Thank you.  Good afternoon, Mr. Chairman and members of the Committee.  I am Dr. Barbara Sigford.  And I serve as—

Mr. MICHAUD. Could you turn your microphone. on, please?

Dr. SIGFORD.  It is on.  Oh, is that—

Mr. MICHAUD. Pull it closer.

Dr. SIGFORD. Okay. I feel like I am yelling. But clearly you are having trouble hearing. Is that better?

Mr. MICHAUD. Yes.

Dr. SIGFORD. Okay. I am the VA's National Program Director for Physical Medicine and Rehabilitation. And joining me this afternoon is Dr. Lucille Beck, the VA's Chief Consultant for Rehabilitation.

I really want to thank you for this opportunity to talk about the Veterans Health Administration seamless transition process from the perspective of the polytrauma system of care.

The mission of the polytrauma system of care is to provide the highest quality of medical, rehabilitation, and support services for veterans and active duty servicemembers injured in the service to our country.

This is a system consisting of four Polytrauma Rehabilitation Centers at Tampa, Richmond, Minneapolis, and Palo Alto. And they provide the most acute intensive medical and rehabilitation care for the complex and severely polytraumatic injuries, including brain injury.

We also have 21 Polytrauma Rehabilitation Network Sites, which manage the post-acute sequelae of polytrauma, and 76 Polytrauma Support Clinic Teams located at local medical centers throughout the 21 networks and across the country that provide care closer to home for the stable sequelae of traumatic brain injury and polytrauma.

Our system of care has been designed to balance the need of our combat injured for highly-specialized care and their needs for local access to lifelong rehabilitation care.

Facilities in the Polytrauma System of Care are linked through a telehealth network that provides state-of-the-art multipoint videoconferencing capabilities. We are able to use this to extend our access into our local communities, and to provide more specialized care closer to home for our combat injured.

Case management is also a critical function in our Polytrauma System of Care, and it is designed to ensure the lifelong coordination of services for patients with polytrauma and traumatic brain injury. Every patient seen in one of our polytrauma rehabilitation programs is assigned a case manager who maintains the contact with the patient and the family in a proactive manner to assess their ongoing needs and emerging problems, and provide any necessary supports and arrange for any necessary continued or new treatment.

We transition people through our system from the most intensive regional facilities to the more local facilities through warm hand offs from case manager to case manager. Each case manager remains actively involved until the new team is well versed in the care of that patient.

A critical area is the transition from DoD to VA, and our severely injured veterans and servicemembers and their families make transitions that are really unknown in the civilian sector. They must transition across space, time, and systems, and we have put many processes in place to make sure that patients moving from DoD to VA receive their care at the appropriate time and under optimal circumstances for their safety and convenience.

In looking at their needs, I have identified three key elements in providing this transition: the continuity of medical care, psychosocial support for the patients and families, and logistical supports such as transportation and housing. And we have addressed all of these needs.

In terms of medical care, the PRC's receive their advanced notice of potential admissions. After notification, they initiate a pre-transfer review and follow the clinical progress of the patient until transfer. Our PRC clinicians are able to complete a pre-transfer review of the electronic medical records at the medical treatment facilities by a remote access capability and up-to-date information about the patent in the progress notes, about medications, laboratory studies, results of imaging are all available.

We also identify or access additional clinical information through the Joint Patient Tracking Application, which allows us to see the care these individuals received in Iraq and Landstuhl, Germany.

And in addition to the medical record review, it is very important that we have clinician-to-clinician conversation about medical issues. And this is also in place. So we talk physician to physician, nurse to nurse.

We have stationed a certified rehabilitation registered nurse at Walter Reed who follows the ongoing clinical progress and reports to our teams at our Polytrauma Rehabilitation Centers. And she is available for up-to-date information. We also have VA social workers at ten of the military treatment facilities (MTFs) who are able to assist with medical records.

In terms of psychosocial support for transition, the needs for psychosocial support include the psychological support, education about rehabilitation and the next setting of care, and information about benefits and military processes and procedures.

The VA social workers at the ten MTFs are able to do this. Our Certified Rehabilitation Registered Nurse (CRRN) provides a lot of in-depth counseling and education to our families and patients while they remain at Walter Reed. We also have admission case managers at our Polytrauma Rehabilitation Centers who make initial contacts with the patients and families so they can meet the team. And we assess what they will need when they reach our PRCs, so we can have those arrangements in place.

We also have veterans benefits liaisons in the MTFs to provide early briefings on the benefits for patients and families.

Upon admission to the Psychosocial Resource Center (PRC), our senior leadership meets with the families to assure that their needs are being met, and we have support services in place to help meet those needs. We have an Army liaison officer, a uniformed officer, at each one of our PRCs who can address ongoing military issues and concerns such as housing, military pay, and the non-medical attendant orders.

In terms of logistical support, when we transition individuals, we coordinate with our social workers to provide the necessary transportation and housing. We have Fisher Houses at two of our PRCs. And they will be planned and under construction at the other two PRCs.

Overarching all of these efforts is the addition of a new OIF/OEF program manager at our sites who will oversee the coordination of care and services provides to all of our veterans and families, and really assure that all of them receive the case management and support that they need.

We can't neglect then the transition from the Polytrauma Rehabilitation Center to the community. This is also very important, and the needs of the patient at this transition remain the same. Records for our medical care are readily available through remote access across the VA system. In addition, our transferring practitioners have personal communication to support the electronic record. Follow-up appointments are made prior to discharge. Again, our proactive case management system assists with on-going support and problem solving in the home community while continually assessing for new and emerging problems.

In terms of logistical support, each of our Polytrauma Rehabilitation Centers team members carefully assesses the expected needs at discharge for transportation, equipment, home modifications, and makes arrangements for those needs.

Finally, I would like to again recognize that the VA is committed to providing the highest quality of services to the men and women who have served in our country. It is important to note that last week the President created an Interagency Task Force on Returning Global War on Terror Heroes, which is chaired by the Secretary of Veterans Affairs, and this Committee will respond to the immediate needs of returning Global War on Terror servicemembers. The Heroes Task Force will work to identify and resolve any gaps in service for servicemembers.

And as Secretary Nicholson has said, "No task is more important to VA than ensuring our heroes receive the best possible care and services."

The VHA's work is to provide a seamless transition for high-quality medical, rehabilitation, and support services for veterans and active-duty servicemembers injured in the service of our Nation. We are helping to ensure that our heroes do receive the best possible care.

This concludes my statement. And at this time, I would be pleased to answer any questions that you may have.

[The prepared statement of Dr. Sigford appears in the Appendix.]

Mr. MICHAUD. Thank you very much, Doctor. We really appreciate it. At this time I would ask unanimous consent that Ms. Herseth of South Dakota, Mr. Kline of Minnesota, and Ms. Boyda of Kansas be invited to sit at the dais for the Subcommittee hearing today.

Hearing no objections, so ordered.

Doctor, I have a couple of questions.  There are concerns that the VA may not have sufficient programs in place to monitor the mental health care needs of veterans with TBI, especially in rural areas. What steps is the VA taking to monitor the mental health of veterans with TBI? And what mechanisms are there to monitor the mental health status of a TBI veteran after the veteran returns home, especially in rural and under served areas?

Dr. SIGFORD. That is an important question. And we have put in place what we are calling our Polytrauma Support Clinic Teams, which will be—which is the third step that I mentioned in the Polytrauma System of Care. These teams have—it is an interdisciplinary team of clinicians who are trained to assess and monitor all the needs of the polytrauma patient, which include mental health needs in addition to perhaps their physical or cognitive needs.

As necessary these teams will be seeing these patients in regular follow up. That is our expectation that they will see them on a regular and routine basis to meet their needs, identify any mental health needs. And if they are unable to manage the needs, then identify the appropriate resources, which they would need.

Mr. MICHAUD. I saw a list of the new polytrauma centers that are going to be established. Is that where the teams are going to work out of, or are they going into the rural areas to help as far as addressing the access issue for veterans in rural areas?

Dr. SIGFORD. Well, they will operate out of—out of the medical centers to which they are assigned. They will have at their disposal certainly the option to go out to other rural areas if that meets the needs or if the need is identified in those rural areas.

They also have, as I mentioned, telehealth at their disposal, which I think is going to be an incredibly useful tool to meet those needs in the rural communities.

We also have all of our primary care professionals trained to screen and identify problems due to TBI and ensure that an individual is referred to the appropriate resources.

One of the areas I would like to stress is that this is an area that requires specialized care, and we want to make sure that people get the specialized care they need. We will be doing that through these specialized teams. It is a team effort.

Mr. MICHAUD. What concerns me are the options.  If you look at a veteran, in northern Maine, they have to go to the VA Medical Center in Maine.  Then they move to Boston where they would have to travel about nine or ten hours to get there. So, the concerns I have with rural areas is making sure that veterans have access to the help that they deserve, locally and without an unnecessary travel burden.

Can you also tell us about the Department's staffing capacity to meet the range of needs of these veterans? You know, physical, rehabilitative, and mental health? And how can the VA best address these needs?

Dr. SIGFORD. Well, we actually have quite a long history of meeting the needs of traumatic brain injury and rehabilitation patients. As we began to admit individuals with polytrauma, brain injury plus other injuries, we had a good deal of experience and knowledge about what types of resources we needed to do this. We have based our staffing plans on our experience, and have been able to and are providing those appropriate staffing ratios.

Mr. MICHAUD.  Mr. Miller?

Mr. MILLER. Thank you. The DoD uses ICD-9. Does the VA use the same diagnostic code?

Dr. SIGFORD.  Yes.  They are used nationwide, civilian,  DoD, VA.

[The information from Dr. Sigford follows:]

ICD-9-CM is used for diagnostic coding in all health care settings including the VA and DoD health systems. It is used universally for morbidity statistics, reimbursement, reporting, and research. While most familiar as diagnostic codes, ICD-9 is also used for inpatient procedure coding (ICD-9-CM, Volume 3).

Mr. MILLER. Civilians, though, are moving to ICD-10, I guess, or 11, and my concern is ICD-9 has no actual TBI code. We are finding this out in DoD, in particular, where there could be four or five different diagnoses, any of which could be TBI, but they are all called organic psychiatric disorders.

My concern is why would we continue to use that code? It is obviously not an organic psychiatric disorder for TBI patients. Are we looking at what needs to be done? Somebody told me it may even be statutorily necessary to change the codes, can you explain that?

Dr. SIGFORD. To my knowledge, there is no code for TBI in the ICD-9, or the ICD-10, or the ICD-11. There are codes that reflect traumatic brain injury, such as intracerebral hemorrhage. Typically those occur—intracerebral hemorrhage due to trauma. That would be one of the codes that would tell us it is the traumatic brain injury.

[The information from Dr. Sigford follows:]

No date has been set for implementation of ICD-10-CM for disease coding by the United States.  Implementation of ICD-10-CM will be based on the process for adoption of standards under the Health Insurance Portability and Accountability Act of 1996. There will be a two year implementation window once the final notice to implement has been published in the Federal Register.

VHA has identified several problems with TBI coding in ICD-9-CM: (1) there are no actual TBI codes in ICD-9-CM, TBI is described as open or closed skull fracture or intracranial injury without skull fracture; (2) cognitive and memory disorders associated with TBI are coded as mental health problems rather than neurological disorders or symptoms of brain injury; and (3) under ICD-9-CM coding guidelines, injuries are not associated with each episode of care, making it difficult to associate symptoms with TBI and to track the costs of TBI.

ICD-10-CM offers significant improvements over ICD-9-CM. There are specific codes for TBI differentiated as diffuse or focal brain injury, cerebral edema, laceration, contusion, and hemorrhage of the brain by side of injury. ICD-10-CM makes other important changes in TBI coding such as utilizing the Glasgow Coma Scale for coding TBI and a new category for post-traumatic headache. There is a mechanism to associate symptoms (sequelae) with TBI that will allow VHA and DoD to track TBI care.

However, limitations continue to exist in ICD-10-CM Cognitive and memory problems associated with TBI are still mapped to mental health conditions (personality and behavioral disorders due to known physiological conditions).

VHA is working with the National Center for Health Statistics (NCHS), which has responsibility for the maintenance of the ICD-9-CM diagnostic codes, to correct deficiencies in TBI codes. Perhaps the most important consideration--and the one to which Mr. Miller refers--is the overlap of TBI and psychological health conditions. The VHA proposal creates two new symptoms classes: cognitive symptoms associated with TBI and emotion/behavioral symptoms associated with TBI. Common TBI symptoms such as memory disturbances, cognitive deficits, irritability, emotional lability, and impulsivity are currently coded as mental health conditions. In the VHA proposal, these symptoms will be coded as neurological conditions when they are associated with TBI.

The VHA proposal provides diagnostic alternatives to coding TBI symptoms as mental health problems. In the VHA proposal, clinicians will select the correct diagnosis and will not use a mental health code to describe a neurological condition associated with brain injury. Mental health conditions will continue to be used for some diagnoses. Clinicians will decide when appropriate condition should be classified as a neurological diagnosis or an organic psychological condition.

Statutory changes are not necessary to modify ICD-9-CM. Improvements in ICD-9-CM are made through the maintenance process outlined below. The decision to implement ICD-10-CM is made by the Secretary of the Department of Health and Human Services. Congress has been actively involved in ICD-10-CM implementation. There have been several hearings and several bills have been introduced in Congress to mandate implementation. Once ICD-10-CM is implemented, known problems such as coding some symptoms of TBI as mental health conditions can be corrected through the code maintenance process. To the extent that it is feasible, changes in ICD-9-CM are incorporated into ICD-10-CM.

Mr. MILLER. Could I ask, to interrupt you, could you get an intracerebral hemorrhage from something else?

Dr. SIGFORD. Well, part of the code is intracerebral hemorrhage due to trauma. Yes, you could have an intracerebral hemorrhage due to something else. But there are a series of codes that do reflect different mechanisms of traumatic brain injury.

One of the reasons there is no single diagnostic code for traumatic brain injury is because there are multiple mechanisms of traumatic brain injury and different severities. There are also codes for concussion and post-concussion syndrome.

And, yes, we are interested in necessary changes to reflect the appropriate code for brain injury. We are—we are very interested in pursuing that.

Mr. MILLER. How does that happen? Can you give the Committee any information? Or if you want to take it for the record and get it back to us.

Dr. SIGFORD. I would like to take that for the record. It is a very complex process.

[The information from Dr. Sigford follows:]

Many symptoms associated with TBI are caused by other diseases. For example, headaches, memory problems, cognitive impairments, and mood changes can be due to many diseases. ICD-10-CM links these symptoms to brain injury and enables TBI symptoms to be tracked during the entire course of treatment. This is not possible under current ICD-9-CM coding guidelines because injuries are not coded each time a provider treats a patient with TBI.

VHA is working with NCHS to create a mechanism in ICD-9-CM similar to the one in ICD-10-CM. The VHA proposal will allow providers to associate TBI symptoms with neurological brain injury. For example, an acute trauma-induced memory disturbance would be represented as a pair of codes: one for acute manifestation of TBI and one for the memory loss itself. This change duplicates the ICD-10-CM code process and will enable VHA to track the costs of TBI care during the entire course of treatment.

VHA is working jointly with DoD brain injury and coding experts on a code proposal that will:

  • Revise TBI codes to distinguish between conditions related TBI and mental health disorders
  • Revise concussion codes to identify TBI and severity classification
  • Add a new code for acute physical or sensory manifestations of TBI
  • Add new codes for cognitive, emotional, and behavioral manifestations of TBI
  • Revise and expand codes for persistent or residual effects of TBI

The new TBI codes will significantly improve diagnosis of TBI and operationalize the VA/DoD TBI definition within the existing structure of ICD-9-CM. Clinicians will be able to classify TBI by severity and to identify physical, cognitive, and emotional /behavioral manifestations of TBI. These improvements will allow DoD and VHA to provide better health care to service members and veterans and to identify, track, and report TBI more accurately than is possible with current ICD-9-CM diagnostic codes.

One of the most important benefits of the proposal will be the coding of cognitive and emotional/behavioral symptoms of TBI without resorting to mental health diagnoses. The code proposal addresses the concerns raised by veterans, veterans groups, and Congress that veterans with brain injuries receive mental health diagnoses that cause unintended stigma and may restrict access to necessary health care services.

Code Revision Process

  1. Disease codes are revised at least annually by the NCHS ICD-9-CM Coordination and Maintenance Committee. Responsibility for maintenance of the ICD-9-CM is divided between the NCHS and Centers for Medicare and Medicaid Services (CMS), with classification of diagnoses managed by NCHS and procedures (Volume 3) managed by CMS.
  1. Suggestions for modifications come from both the public and private sectors. Interested parties submit recommendations for modification prior to a scheduled meeting. These meetings are open to the public; comments are encouraged both at the meetings and in writing. Recommendations and comments are carefully reviewed and evaluated before any final decisions are made. No decisions are made at the meetings. The ICD-9-CM Coordination and Maintenance Committee’s role is advisory. All final decisions are made by the Director of NCHS and the Administrator of CMS. 
  1. NCHS is currently reviewing VHA’s code proposal. The proposal will be presented at the March meeting of the ICD-9-CM Coordination and Maintenance Committee and will be considered for implementation in the October 1, 2008 update. The implementation process involves posting the proposal and committee minutes for public comment, consulting with interested parties, and preparing the necessary changes in the tabular list, index, and official guidance. If the codes cannot be implemented in time for the October update, NCHS has the option to implement the codes in a mid-year (April 2009) update. To the extent feasible, changes in ICD-9-CM will be reflected in ICD-10-CM. In other words, the improvements VHA is proposing for ICD-9-CM will also improve ICD-10-CM.

NCHS web links:

http://www.cdc.gov/nchs/about/otheract/icd9/maint/maint.htm

http://www.cdc.gov/nchs/data/icd9/draft_i10guideln.pdf

ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2007/

Mr. MILLER. A 2006 report from the VA Office of Inspector General (IG), found that long-term case management needed some improvement. The question is, have you addressed the long-term case management vulnerability reported by the IG's office? If so, how? Also, I want to know is home-based care provided or made available to TBI patients after their discharge from a Polytrauma Center?

Dr. SIGFORD. Sure. Now, in terms of the IG Report, you are speaking of the report from July of 2006; is that correct?

Mr. MILLER. Correct.

Dr. SIGFORD. We have done a tremendous amount to address those concerns, which really reflect the evolution of our process of case management from the time that those individuals were initially contacted.

We do now have a very formalized system of case management in place, where we have two social work case managers and a nurse case manager assigned to 12 inpatients, a ratio of approximately two social workers for every 12 inpatient patients. We have a dedicated out-patient social work case manager and nurse case manager in each one of our Polytrauma Network Sites. And at our Polytrauma Support Clinic Teams, there will be dedicated case managers.

In addition, we have developed handbooks and training materials for our social work case managers. We are expecting proactive follow up that they don't just wait for someone to develop a problem. They make the phone call and check routinely on each of the patients who have been in our Polytrauma System of Care.

Oh, I'm sorry, the home based. Thank you. Certainly all of our patients are eligible for the same home-based care as any other veteran or active duty servicemember who is eligible for care in the system. We can put those services out into the home for them, such as homemaker home health, home-based primary care. We can send physical and occupational therapists out to the home as needed. So it is available.

Mr. MILLER. Thank you. I see the red light.

Mr. MICHAUD. Thank you, Mr. Miller. I want to thank Mr. Hare for yielding his time to Ms. Boyda of Kansas, who has to go to the floor shortly, for questions. Thank you.

STATEMENT OF THE HONORABLE NANCY BOYDA, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF KANSAS

Ms. BOYDA. Thank you so much, Mr. Hare. Thank you. And thank you for inviting me, Congressman Michaud, and thank you for your leadership as the Chairman of this Subcommittee. You are a true friend and ally to America's veterans. Thank you.

I come before you today, because our Nation's troops face a grave and growing crisis due to a startling inadequacy in our military healthcare system. The problem has simmered quietly for a decade. But now in the flames of the war of Iraq, it has disrupted into a full boil.

America's military hospitals are rightly renowned for their near miraculous ability to heal bleeding wounds and fractured limbs. Our military doctors have helped thousands of soldiers recover from injuries they endured in the service to our Nation.

But our doctors and expertise, while far reaching, is not boundless. For all their remarkable ability to repair physical wounds, they lack the background and the tools to deal with the—to heal the damaged mind.

Since the Iraq war began in 2003, almost 1,900 soldiers have suffered a traumatic brain injury or TBI. Their symptoms are pervasive and heartbreaking. Soldiers that were once outgoing, active individuals, are now introverted and without energy. Mothers and fathers no longer recognize their sons and daughters, and wives and husbands no longer recognize their spouses.

For these troops, things that you and I take for granted, our personalities, our attentiveness, our vocabulary, are ability to walk and talk and use the bathroom unassisted has vanished in the blink of an eye, lost in the crash of a Humvee or in the flash of an IED. The wave of traumatic brain injuries in Iraq flooded a military healthcare system that was sadly ill prepared to treat TBIs.

As the Department of Defense has scrambled to upgrade their capabilities, they have frequently to civilian experts on TBIs for guidance. In some instances, the DoD has even permitted soldiers to receive care at a civilian hospital where doctors have decades of experience in treating traumatic brain injuries.

But according to some very disturbing reports, the Army has rushed other brain injured soldiers into medical retirement, effectively terminating their access to civilian care. When these reports are considered in the light of the recently uncovered and deplorable conditions at Walter Reed, a picture emerges of a military healthcare system that is overburdened, under funded, and inadequate for our soldier's needs.

It breaks my heart to imagine that soldiers who gave so much to their Nation, who in the case of a TBI sufferer sacrificed the very clarity of their thoughts, would receive anything less than world-class treatment.

The hour has come for Congressional action. And the responsibility for reform begins in this Subcommittee. I ask you to approach this crisis with open minds and leave no option off the table.

Perhaps veterans and active duty soldiers could benefit from easier access to civilian care. Perhaps the Department of Defense can mount an aggressive push to develop expertise in TBIs. Or, perhaps, the best approach is something else entirely. Regardless, any plan of action must recognize that the demands placed on a soldier's family when his mind is fundamentally altered by injury.

I do not claim that even conscientious legislative action can cure every troop afflicted with TBI. But relieve every—or relieve every burden that families face as they care for a wounded soldier. But this Subcommittee can call the attention of their plight and ensure that they benefit from the very best that our national can offer. We owe nothing less to our brave soldiers and to our families.

So thank you again for speaking out. This is an issue that I hear about often in my district, as we have many veterans of both—of Vietnam and certainly now of the Iraq OEF and OIF. So thank you for your service.

I know that you are doing what you can to pull all the resources together. And this is an urgent request to do everything that we can. And you have my full support on that. Thank you so much.

Mr. MICHAUD. I want to thank the Congresswoman for your interest in this very important issue. I look forward to working with you.

Ms. BOYDA. Thank you.

Mr. MICHAUD. And your Subcommittee on Military Personnel as well.

Ms. BOYDA. Thank you so much.

Mr. MICHAUD. Now, I am pleased to recognize Mr. Kline who is also on the Military Personnel Subcommittee.

STATEMENT OF HON. JOHN KLINE, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MINNESOTA

Mr. KLINE. Thank you. My microphone doesn't work. I'll move. Let me scoot over here. Technology whips us again.

Thank you very much, Mr. Chairman, for allowing me to join you today, add my remarks to the gentle lady's. It is nice to look at problems from a different perspective sometimes.

We, of course, have been spending a lot of time and energy in the HASC Military Personnel Subcommittee. But it is clear there is an overlap.

Let me ask unanimous consent to just enter some prepared remarks in the record, if I could.

Mr. MICHAUD. Without objection, so ordered.

Mr. KLINE. Thank you, Mr. Chairman.

And then say how delighted—this is so complicated up here.

Mr. MICHAUD. That is quite all right.

Mr. KLINE. How delighted I am that you are here. As you know, we have a Polytrauma Center in Minneapolis that we are actually very proud of. I think they are doing some innovative work and some very good work. And I know that you are very familiar with that.

I would like to, though, address my concerns and questions to an issue, which you discussed in your remarks as I was entering the room. And that is this break in care. This lapse in care, if you will, that is occurring way too often. We struggle with it on the Armed Services side. The gentle lady, Ms. Boyda, was talking about defense medical care. You are here as part of the Veterans Administration. It is veterans' care.

But to our men and women who have been injured, whether traumatic brain injury or any other injury, it really ought to be much more seamless than it is.

I visited that VA hospital in Minneapolis, that Polytrauma Center, a couple of years ago with the former Chairman of this whole committee, Mr. Buyer, and talked to Steven Kleinglass who heads that hospital.

And while we were—while we were discussing this sometimes breakdown in coverage, Mr. Buyer and I stepped aside to talk to a wounded soldier and his wife. And it was very clear in this conversation that they didn't understand what was going to happen next and who was responsible for it. There were questions like, "Well, we are supposed to go back to Walter Reed, but where do we get the orders?" And, "Who is going to pay for it?"

And it seemed—it occurred to me and to Mr. Buyer that that is the kind of question that should never be asked, should not have to be asked by any wounded soldier, or their spouse, or family member. It should be a seamless issue for them. It ought to be taken care of.

You mentioned there was an active duty officer now, which is an important step towards fixing that. But even with that step, we have soldiers who are falling through the cracks.

We had a terrible tragedy in Minnesota with a Marine Reservist who had been back from combat and committed suicide. Had been identified to the VA hospital and to the system. And it seems to me that that just shouldn't happen. There is a breakdown in there.

I wondered if you could take—I don't know how much time is left in the green and red light system, but could you talk a little bit more? You mentioned you had some teams and so forth. We really have got to do better to fix that. And it may be a coming together of this Committee and the Armed Services Committee to well this together. But I would be interested if you would just expand a little bit on what you see the Veterans Administration—what you are doing to fix that gap so we don't have any more soldiers, sailors, airmen or Marine fall through that crack and drop out of our care.

Dr. SIGFORD. Well, what we are doing from the VA side, as I mentioned in the opening remarks, is we are putting together a system of care, so that as soon as we are aware of an individual needing polytrauma or traumatic brain injury care, they are assigned a case manager who tracks them through the system.

Mr. KLINE. Let me interrupt just a minute. How are you first made aware of this? What makes you aware of this, the patient arriving, communication from the Department of Defense? How does that happen?

Dr. SIGFORD. It happens in multiple ways. First of all, from notification from—for our various—and it happens differently depending on the severity of the injury. For someone who is very severely injured, we receive direct contact from the medical treatment facility at which they are being cared for.

They contact our VA and assign social workers who then contact our social workers in our Polytrauma System of Care. And we then make all of the appropriate and necessary arrangements for that transfer.

For those patients who are not—who don't enter the system directly from a military treatment facility, they may enter on a referral from a CBHOC, or a Community Based Health Care Organization (CBHCO), or their medical command, their Guard command, their Reserve command, a friend, a buddy. We are willing to accept referrals from wherever they come.

And we are doing a tremendous—we have actually assigned all of our polytrauma network sites, the assignment of reaching out to their local communities, their Guard, their Reserve, the bases, the military commands, to let them know that we would like to care for these individuals.

Mr. KLINE. Thank you very much. And I see the inevitable red light has popped up. So thank you, Mr. Chairman. I do yield back.

[The prepared statement of Congressman Kline appears in the Appendix.]

Mr. MICHAUD. Thank you very much, Mr. Kline.

Mr. Hare?

Mr. HARE. Mr. Kline, if you would like to take some of my time, because I am interested in the seamless transition too. And I know you had some additional questions. I have one question. And then I would refer the balance of my time to you.

In terms of the shortage of healthcare professionals. From your perspective, one of the issues faced by all neurobehavioral and the community-integrated rehabilitation programs, involves the national shortage of key providers such as occupational therapists, physical therapists, speech language pathologists, and other professionals. What steps is the VA taking to recruit and retain key providers in these areas?

Dr. SIGFORD. Well, we have—we have a number of mechanisms for recruiting providers. The majority of our facilities in the polytrauma system have academic affiliates. We serve as training grounds for PTs, OTs, speech therapists, physicians. And that is an incredible recruitment tool, because individuals come and they work with these patients at the VAs. And they want to continue that work.

This is—as a matter of fact, in Minneapolis, the VA is the prime spot right now for training PTs in training. And so once they are there and they see the care we provide and the opportunities, they love to come and work for us. We also are able to touch the professional societies, to bring in skilled professionals, which has also been very useful. In terms of retention, we provide—I think—first of all, we—well, we provide really challenging and interesting work opportunities for individuals, as well as the opportunity for ongoing education, which is important to professionals that they not just stagnate in, you know, doing one type of care. We really do provide them a wonderful opportunity in which to work. And we have great retention in this particular area.

Mr. HARE. Thank you, Doctor. I would like to yield the balance of my time to Mr. Kline.

Mr. KLINE. I thank the gentleman. And I realize that I have got way too big an elephant here to chew in these little bites.

But continuing on the theme of this continuous coverage, could you just take one piece of that? You mentioned the active duty officer that is assigned. Could you talk about the role of that person? And what that is doing to fill some of these gaps? Help us understand that role a little bit better. I had high hopes for it. I am not sure it is doing what I thought it was going to do so.

Dr. SIGFORD. Right. We do have active duty Army officers right now assigned to each one of the four Polytrauma Rehabilitation Centers. They are the experts in military policy and procedure. And they are there to meet with the families on a day-by-day, hour-by-hour basis to solve any—to help them fill out the paperwork, understand the paperwork, understand the medical boarding process, get through the medical boarding process, provide them advice on the system. They are there.

Mr. KLINE. Is this a workload that they can handle? I mean, one officer at Minneapolis, I have no idea if that is enough in order to do that. But it is obviously addressing the problem that I described earlier of the family who was supposed to go back to Walter Reed, and they don't know where the orders are going to come from, and who is going to pay for it.

This officer trained or perhaps MOS in personnel and administrative policies could help with that. Is the officer enough, or do we need to do something about that? Do we need statute, or money, or is that—is one officer—is it working fine, and one officer is able to take care of those things?

Dr. SIGFORD. Currently our—currently given the current workload, one officer is fine. And this officer is part of the VA team. And really our VA teams are also very knowledgeable about many of the military. And they have really learned about many of the military processes and procedures. But at this time, and we constantly monitor and assess, one officer is sufficient.

Mr. KLINE. Okay. Thank you. I just have one last comment. I have been very excited about a concept that the Marine Corps has taken up with the will—recently called the Wounded Warrior Regiment with a Wounded Warrior Battalion on each coast. And dedicated Marine Corps personnel to help follow through and see that people don't fall through the cracks.

And I just think that we ought to be exploring all of these avenues, the activity duty officer assigned to the trauma center, our efforts on the part of the active duty military, the services, the efforts that are underway by the National Guard. We have a wonderful example in Minnesota.

We here in Congress, and this Committee, and in the Armed Services Committee, we really do need to be open to these ideas and supporting them in every way we can with probably legislation and resources.

Thank you. I yield back.

Mr. MICHAUD. I thank the gentleman. And I agree. This is an important issue, one that everyone in this room, and in your Committee, and our Committee as well, feel strongly about.

And if we are going to get to the bottom of it and do the best that we can to make sure our men and women in uniform and those veterans are taken care of, we have to do it in a comprehensive, bipartisan manner. And I look forward to working with the gentleman as we move forward this Congress.

I would now like to recognize Congresswoman Herseth.

Ms. HERSETH. Well, thank you, Mr. Chairman. I want to thank you and the Ranking Member for holding this hearing. And for the testimony provided today. I know that there were hearings in the prior Congress as well to explore the care that our men and women who are receiving traumatic brain injuries are receiving.

I appreciate the line of questioning and the focus of this Subcommittee hearing today on the seamless transition. I have a few question that I think are related to that. But also go to the issue of a certain category of servicemember who, I think, is falling through the cracks.

And so if you could just answer these questions, if you have the information with you today. And if not, if you could take them for the record and provide the information.

What is the average length of stay at any of the four Polytrauma Regional Centers by a servicemember receiving care for traumatic brain injury?

Dr. SIGFORD. I would have to take that for the record.

[The information from Dr. Sigford follows:]

The average length of stay at our 4 Polytrauma rehabilitation Centers for inpatient service members injured at a foreign theater with a brain injury from March 2003 through September 30, 2007 is 43 days.

Ms. HERSETH. And does certain progress have to be made within 90 days for a servicemember to continue getting the full regiment of therapies?

Dr. SIGFORD. That is not part of our policy. No.

Ms. HERSETH. Are you aware that—well, it may not be part of the policies. Is it a practice, if certain progress has not been made by a servicemember within 90 days, to—that the case management has tried to move an individual to a long-term care department within a medical center or to another long-term care facility within the VA?

Dr. SIGFORD. Let me have you rephrase that question.

Ms. HERSETH.  Your response to my first question is that it is not a policy—

Dr. SIGFORD. Right.

Ms. HERSETH. —of the system of care to move anyone to a long-term care department or other facility if certain progress isn't made in 90 days. And so I will just rephrase the question simply. I understand your response is that it is not a policy. Are you aware of whether or not it has been a practice in any of the four regional facilities?

Dr. SIGFORD. Our clinicians provide services based on what an individual can tolerate and what they seem to be responding to. And I—these are individual decisions made by the individual clinicians and practitioners.

I am not aware that there is an automatic rule for staying at a certain number of days or that people are operating under those — you know, a certain number of days and you must go to long-term care.

But they are using their clinical judgment, you know, day in and day out to provide the appropriate or the right types of care for the individual.

Ms. HERSETH. And are you aware of—what is the percentage of individuals transferred to long-term care facilities of those that have received care at the Polytrauma Centers for traumatic brain injuries since Operation Enduring Freedom and Operation Iraqi Freedom?

Dr. SIGFORD. I would like to take that for the record as well.

[The information from Dr. Sigford follows:]

According to the VA's national database for inpatient rehabilitation, ten (10), or 2.2%, active duty service members have been discharged from a Polytrauma Rehabilitation Center (PRC) to a Long Term Care (LTC) Facility between March 2003 and September 2007.  This data does not account for patients who may have subsequently transferred to a LTC facility following initial discharge to an interim setting from a PRC, or for those who later transferred to LTC from a less restrictive care setting.

Ms. HERSETH. And do you know the number that have been transferred to private facilities ultimately?

Dr. SIGFORD. I will take that for the record and see.

[The information from Dr. Sigford follows:]

The 4 Polytrauma Rehabilitation Centers report that between March 2003 and September 2007, 24 active-duty service members have been discharged to a private treatment facility.

Ms. HERSETH. The reason I pose these questions is I do think it relates to an issue of seamless transition. I have a constituent who now is receiving care at a private facility. And the sense from his family is that the Polytrauma Center in Minneapolis had given up on him, because certain progress had not been made by a certain period of time.

There was an effort by the case manager to—and they had to go through a couple of different case workers to feel comfortable that that person was actually serving as an advocate for them rather than an advocate for the facility, or for the DoD, or for the VA. It was very confusing to the family.

And we intervened to stop the medical retirement process, because for the full regiment of therapies to continue, they can't be medically retired for TRICARE to cover the cognitive therapy.

So he was transferred to Casa Colina in Pomona, California. You may be familiar with that facility. And he has made tremendous progress since.

And could you, perhaps, explain if you have tracked any of the individuals that have been transferred to private facilities, how you might explain their progress at these private facilities that they were not experiencing within the Polytrauma System of Care at the VA?

Dr. SIGFORD. Yes. I can't, obviously, comment on specific patients or patient care. But I think that really a critical point for people to understand is that when these patients are transferred to Polytrauma Rehabilitation Centers, they still have multiple medical problems, they are still recovering, and this period take a—this takes a significant period of time.

What we know physiologically from brain recovery, is that there is—there is this lengthy period, particularly for the severely injured, for the brain to recover sufficiently to really get, you know, the most benefit out of rehabilitation. And that may not be in the first two weeks, or the first month, or maybe even sometimes the first six months before, you know, people can remain so medically fragile that rehabilitation is beyond them.

So there is a period, and oftentimes it happens in the Polytrauma Rehabilitation Centers, where we are maximizing the recovery of the brain to allow that progress to take place later.

Ms. HERSETH. I know my time is up. May I follow up with one more question? If you could take this for the record, I would appreciate your explanation.

My concern is that if there has been an effort, whether because there are funding battles going on between DoD and VA and there is a problem with this seamless transition, that certain individuals who have been transferred to long-term care departments or facilities within the VA never get the aggressive therapy again after they reach the point in time that you just described, where the brain is more fully recovered and that they would actually be responding to a greater degree to that regiment of therapy. Because they are not getting it at a long-term care facility.

If Cory had been transferred to a different floor at the medical center, he would have gotten up to an hour, one hour, of physical therapy a day. No occupational therapy, no cognitive therapy, and I am just concerned that there is something going on in practice, perhaps not in policy, that we have a subset of individuals who have fallen through the cracks who have far greater potential. But they are not getting it, if they were medically retired too early and for whatever reason aren't at the point in time that they would respond more positively getting that type of therapy.