Chairman Michaud, Ranking Member Miller, and members of the Subcommittee, Paralyzed Veterans of America (PVA) is pleased to present our views concerning H.R. 6153, the “Veterans Medical Personnel Recruitment and Retention Act of 2008,” and H.R. 3051, the “Heroes at Home Act of 2007,” which will improve the diagnosis and treatment of Traumatic Brain Injury (TBI) for members and former members of the Armed Forces.

H.R. 6153, THE “VETERANS MEDICAL PERSONNEL RECRUITMENT AND RETENTION ACT OF 2008” 

PVA’s primary concern, and the basic reason for our existence, is the health and welfare of our members and our fellow veterans. The thousands of Department of Veterans Affairs (VA) healthcare professionals and all of those individuals necessary to support their efforts are at the core of VA’s primary mission.  These individuals serve on the front line every day, caring for America’s wounded veterans from Iraq and Afghanistan and seeing to the complex medical needs of our countries older veterans from previous wars.  PVA believes that VA’s most important asset is the people it employs to care for those who have served our nation. 

Mr. Chairman, when PVA testified on May 22, 2008 concerning the human resources challenges facing the Department of Veterans Affairs’, we applauded the Subcommittee for its timely and well placed interest in the issues concerning VA health care personnel.  PVA continues to believe that Congress must assist VA efforts to recruit and retain its corps of health care professionals as the demand for health care increases both because of the ongoing Global War on Terrorism and the aging of the veteran population from previous wars.  The current serious national short fall in the supply of physicians, nurses, pharmacists, therapists and psychologists threatens VA staffing as competition for experienced medical personnel and newly licensed professionals continues to increase.  H.R. 6153 is a step in the right direction.

The United States is currently in the tenth year of a critical nursing shortage which is expected to continue through 2020.  The shortage of registered bed-side nurses and registered nurse specialists is having an impact on all aspects of acute and long-term care.  America’s nursing shortage has created nurse recruitment and retention challenges for medical-care employers nationwide and is making access to quality care difficult for consumers. 

The gap between the supply of and the demand for nurses may adversely affect the VA’s ability to meet the healthcare needs of those who have served our nation.  According to VA, it employs more than 64,000 nursing professionals, and has one of the largest nursing staffs of any health care system in the world.  Of that 64,000, VA has 43,000 registered nurses, 12,000 licensed practical nurses, and 9,000 nursing assistants.  VA also says that approximately 4,300 nurses retire or leave each year.  VA must be able to recruit the best nurses, and retain a cadre of experienced, competent nurses.  Providing high quality nursing care to the nation’s veterans is integral to the health care mission of VA. 

During PVA’s previous testimony, we asked for the Subcommittee’s consideration of specially pay for nurses providing care in VA’s specialized service programs such as: spinal cord injury/disease (SCI/D), blind rehabilitation, mental health and brain injury.  PVA is disappointed that the Subcommittee chose not to include such specific language in H.R. 6153.

Mr. Chairman, veterans who suffer spinal cord injury and disease require a cadre of specialty trained registered nurses to meet their complex initial rehabilitation and life- long sustaining medical care needs.  PVA’s data reveals a critical shortage of registered nurses who are providing care in VA’s SCI/D center system of care.  The complex medical and acuity needs of these veterans, makes care for them extremely difficult and demanding.  These difficult care conditions become barriers to quality registered nurse recruitment and retention.  Many of VA’s SCI/D nurses are often placed on light duty status because of injuries they sustain in their daily tasks.  When this happens it becomes a significant problem because it places additional patient care responsibility on those SCI/D nurses not on light duty.  PVA believes SCI/D specialty pay is absolutely necessary if nurse shortages are to be overcome in this VA critical care area.  We strongly encourage your committee to include a Title 38 specialty pay provision that will assist VA’s efforts to recruit and retain nurses in these specialized areas.

PVA is concerned about the VA’s current ability to maintain appropriate and adequate levels of physician staffing at a time when the nation faces a pending shortage of physicians.  Recent analysis by the Association of American Medical Colleges (AAMC) indicates the United States will face a serious doctor shortage in the next few decades.  The AAMC goes on to say that currently, “744,000 doctors practice medicine in the United States, but 250,000 – one in three are over the age of 55 and are likely to retire during the next 20 years.”  The subsequent increasing demand for doctors, as many enter retirement, will increase challenges to VA’s recruitment and retention efforts.  PVA believes H.R. 6153 will allow VA to be more competitive in recruiting doctors for the VA system.     

Mr. Chairman, the Veterans Health Administration has made great strides over the last decade to improve the quality of care it provides to our nation’s veterans.  Despite these gains, VA now finds itself in a precarious situation if it expects to retain its position as a vastly improved health care system.  As stated earlier, H.R. 6153 is only a first step in meeting the challenges associated with maintaining a highly qualified medical care workforce for VA.  Competition to hire medical care professionals, during a national period of low supply, is making it more-and-more difficult for VA to successfully recruit and retain qualified personnel.  This Subcommittee and VA must be vigilant in developing programs that will provide professional health care workers to care for our veterans.

H.R. 3051, “THE HEROES AT HOME ACT OF 2007” 

Traumatic Brain Injuries (TBI) have become an important topic as a result of the wars in Afghanistan and Iraq.  In fact, The Independent Budget, co-authored by PVA, AMVETS, Disabled American Veterans (DAV) and the Veterans of Foreign Wars (VFW), identified treatment for veterans with TBI as a critical issue for 2008 and beyond.  PVA welcomes the Subcommittee’s action on H.R. 3051.

TBI, Spinal Cord Injury, and other serious injuries account for almost 20 percent of the combat casualties sustained by U.S. soldiers, airman and Marines in OEF/OIF.  Explosive blast pressure waves from improvised explosive devices (IEDs) violently shake or compress the brain within the closed skull and cause devastating and often permanent damage to brain tissues.  There has been universal recognition that veterans with severe TBI will need a lifetime of intensive services to care for their injuries.  However, PVA is concerned that, at all levels, development of programs to address the needs of veterans with mild, subclinical TBI have not been fully developed or implemented.

DOD and VA experts note that TBI can also be caused without any apparent physical injuries if a person is in the vicinity of these IED detonations.  Veterans suffering from this milder form of TBI may not be readily detected; however, symptoms can include chronic headaches, irritability, disinhibition, sleep disorders, confusion, executive functioning and memory problems, and depression, among other symptoms. With tens of thousands of IED detonations now recorded in Iraq alone, it is believed that many OEF/OIF service members have suffered mild, but pathologically significant, brain injuries (including multiple concussions) that have gone undiagnosed and largely untreated thus far.  TBI and its associated symptoms may be detected later only if proper screening is conducted.

PVA is concerned about emerging literature that strongly suggests that even mildly injured TBI patients may have long-term mental and physical health consequences. According to DOD and VA mental health experts, mild TBI can produce behavioral manifestations that mimic Post Traumatic Stress Disorder (PTSD) or other conditions.  And TBI and PTSD can be coexisting conditions.  Much is still unknown about the long-term impact of these injuries and the best treatment models to address mild-to-moderate TBI.  We believe VA should conduct more research into the long-term consequences of brain injury and development of best practices in its treatment; however, we suggest that any studies undertaken include older veterans of past military conflicts who may have suffered similar injuries that thus far have gone undetected, undiagnosed or misdiagnosed, and untreated.  Their medical and social histories could be of enormous value to VA researchers interested in the likely long-term progression of these new injuries.  Likewise, such knowledge of historic experience could help both the DOD and VA better understand the policies needed to improve screening, diagnosis, and treatment of mild TBI in combat veterans of the future.  This is where PVA sees great potential for the demonstration project of Telehealth and Telemental programs proposed in H.R. 3051.  We would caution the Subcommittee, however, to ensure that this program is a supplement to regular VA programs and not used as one more way for VA to move veterans’ health care further away from VA facilities.

Individuals suffering from mild brain injury often present complex, difficult-to-assess complaints and conditions that can masquerade as other diagnoses. This complexity requires an integrated, personalized recovery plan coordinated by a cadre of specialists with expertise in TBI to diagnose and manage their medical, psychological, and psychosocial needs.

Although VA has initiated new programs and services to address the needs of severe TBI patients, gaps in services still exist.  The VA’s Office of the Inspector General (OIG) issued a report in July of 2006, titled “Health Status of and Services for Operation Enduring Freedom/ Operation Iraqi Freedom Veterans after Traumatic Brain Injury Rehabilitation.”  The report assessed health care and other services provided for veterans and active duty patients with TBI, and then examined their status approximately one year following completion of rehabilitation.

The report found that better coordination of care between DOD and VA health-care services was needed to enable veterans to make a smooth transition.  According to the report, the goal of achieving optimal function of each individual requires further interagency agreements and coordination between the DOD and VA.  PVA believes the true measure of success will be the extent to which those most severely injured veterans are eventually able to recover, reenter their communities, or at minimum, achieve stability of function at home or in the least restrictive, age-appropriate continuing care facilities provided by VA to meet their needs and preferences.

PVA strongly supports the provisions of H.R. 3051 which provide training and certification for family caregiver personal attendants at no cost to the family.  Providing the ability for family members to care for their loved ones injured in conflict will assist in keeping the families strong while properly caring for the veteran.  Though PVA remains concerned about whether VA has addressed the long-term emotional and behavioral problems that are often associated with TBI, and the devastating impact on both the veteran and his or her family, we believe this program may help address these concerns.  As noted in the July 2006 OIG report, “these problems exact a huge toll on patients, family members, and health care providers.” The following excerpt from the report is especially telling:

In the case of mild TBI, the [veteran’s] denial of problems which can accompany damage to certain areas of the brain often leads to difficulties receiving services.  With more severe injuries, the extreme family burden can lead to family disintegration and loss of this major resource for patients.

The OIG recommendations included improving case management for TBI patients to ensure lifelong coordination of care; improving collaborative policies between the DOD and VA; starting new initiatives to support families caring for TBI patients, including providing access to VA or contract caregivers; and recommending that rehabilitation for TBI patients be initiated by the DOD when clinically indicated.  We fully concur with the OIG’s recommendations and recognize that supporting these patients for a lifetime of care and service will be a continuing challenge for VA.

VA now requires a case manager be assigned to each OEF/OIF veteran enrolled in VA health care.  The case manager’s duty is to communicate and coordinate all VA benefits and services.  Also, VA has created liaison and social work positions in DOD facilities to assist injured service members with their transitions to veteran status and to provide advice and assistance to them and their families in accessing VA services.  PVA commends VA for its efforts to improve the knowledge and skills of VA clinicians through educational initiatives defining the unique experience and needs of this newest generation of combat veterans.  We also acknowledge VA’s dedication and commitment to meeting the needs of veterans with TBI through high quality services at its polytrauma-TBI lead centers, for ongoing research into this debilitating injury, and for establishing effective services with academic and military affiliates to fill gaps in service when and where they are found.  However, we are concerned about media reports from veteran patients with TBI and their family members who claim that VA TBI care is not up to par in certain locations, prompting them to seek rehabilitation services from private facilities.   VA must ensure that its TBI network provides excellent care to all veterans irrespective of their degree of impairment.  VHA’s current continuing education programs should be enhanced to ensure that all VA providers are knowledgeable about the spectrum of clinical presentation and treatment of veterans with combat-related TBI. 

We encourage VA and Congress to ensure that severely wounded TBI veterans are receiving the best treatment and rehabilitation care available and that the needs of their family caregivers be met with innovative and effective programs.

Mr. Chairman, this concludes our remarks.  PVA will be happy to respond to any questions you or members of the Subcommittee may have.