Mr. Chairman and Members of the Subcommittee:

Thank you for inviting Wounded Warrior Project to share its perspective on issues of “Seamless Transition” between the Departments of Defense and Veterans Affairs. 

I was an Army captain who in 2003 became one of the first IED casualties of Operation Iraqi Freedom, and have made that transition myself.  Now, after 20 operations at 7 different hospitals including amputation of my right leg, I am an Area Outreach Coordinator with WWP, working with hundreds of wounded warriors and covering Florida, Georgia, South Carolina and Alabama.

Over the past 6 years DoD and VA have made significant progress in care coordination and information sharing.  I have seen firsthand real dedication to wounded warriors and their families.  Certainly this subcommittee’s steady focus on these issues has helped achieve greater “seamlessness” for wounded warriors in making a transition from the military to VA care and to receipt of VA benefits. 

The Goal: That Warrior’s Thrive

Even the most well coordinated, “seamless” handoff to a welcoming VA will not change the fact, however, that?for many wounded warriors?this transition feels like having been thrown off a cliff.  In short, more work needs to be done?by the departments and by the Congress?to achieve not only “seamlessness” but to ensure that our new veterans have a successful transition and reintegration into the community. 

Certainly much progress has been made in coordinating the clinical care of the severely injured servicemember.  The DoD-VA Disability Evaluation System pilot program has also had success in expediting VA disability ratings.  But while the departments can take pride in certain areas of real progress, wounded warriors leaving the service continue to face programmatic, cultural, and structural barriers at VA.   It is critical, in our view, that those barriers be toppled and that key VA programs and service-delivery mechanisms be re-engineered, as necessary, to help wounded warriors not simply to recover from their injuries but to thrive?physically, psychologically and economically.

Meeting Warrior’s “Co-occurring” Needs

More specifically, critical VA programs, benefits, and service-delivery models fall short in many instances of providing the array of 21st century services wounded warriors need.  We work with men and women who are not only combating co-occurring PTSD and substance-use problems, but “co-occurring” traumatic brain injury, burns and amputations.  Often, they’re also dealing with pain, anger, depression, unemployment and lack of employment opportunity, lack of permanent housing, and more.  In some cases, behavioral health problems have resulted in difficulties with the law. 

VA has an array of programs targeted at specific problems, but little in the way of a holistic coordinated approach to turn these lives around.  The goal of “One VA”?a department that provides “wraparound” services that seamlessly and effectively integrate Veterans Health Administration (VHA) services and Veterans Benefits Administration (VBA) benefits seems sadly remote.  Yet, as a panel of the National Academy of Public Administration has observed, care and benefits to veterans could be improved if VA management, organization, coordination, and business practices were transformed with the aim of improving outcomes for veterans, rather than simply aiming to improve operational processes.[1]  Most importantly, that National Academy panel has provided VA detailed recommendations constituting a comprehensive blueprint for that needed transformation.[2]  At its core is its emphasis on the importance of leadership commitment to creating and maintaining veteran-centered systems, including a “no wrong door” policy to ensure receipt of appropriate guidance regardless of point of contact.  The Academy has provided VA a vision, strategy and detailed recommendations for organizing and delivering veteran-centered services.  We urge the Committee to press VA to implement these important recommendations.

Bridging Programmatic Gaps

The Academy report aptly cites the need to strengthen VA’s system of care, including its care-management tools.[3]  The need for better coordination between VHA programs serving wounded warriors is aptly illustrated by reference to the separate development and separate administration of its specialized PTSD programs and its polytrauma system of care.  As VA researchers observed in a recently published paper[4], the Department has not developed a systemwide program or set of guidelines for treating the many OEF/OIF veterans who may have both combat-related stress disorders and mild explosive-induced concussive injury.  Researchers pursuing this important subject initiated interviews with VA clinicians who provide specialized PTSD or TBI services with the aim of helping to identify systemwide approaches to improve services offered to OIF/OEF veterans with mild TBI and PTSD.  Highlighting just some of the findings, the interview data reportedly suggested considerable variation in the degree and type of collaboration between PTSD and polytrauma teams, and indicated that coordinating assessment and treatment depend on individual clinician initiative and can take considerable time, as well as entail potential problems in managing medications across teams and care-settings.[5]  Of particular note, many providers emphasized that TBI/PTSD can co-occur with other clinical problems, and expressed particular concern about the lack of adequate treatment availability for pain and sleep-related problems.[6]  To their credit, providers also cited a need for vocational services for these veterans, noting that employment difficulties are a significant problem for them.[7]

While it is encouraging that VA researchers are searching for best practices for treating these two, often co-occurring “signature wounds” of this war, what does this knowledge-gap say about care-coordination for wounded warriors with even more complex co-occurring problems?  

In that regard, we applaud the Department for having initiated the Federal Recovery Coordination (FRC) program, which plays an important coordinating role for those it serves.   But with only about 15 Federal Recovery Coordinators already carrying full workloads, many severely injured warriors, who are still struggling years after their injuries, are unable to benefit from such efforts.   We see a real need to augment the number of FRC’s assigned to help wounded warriors, but more profound system changes are also needed.  To illustrate, the most able FRC or other case-manager cannot solve such problems as a systemwide lack of treatment capacity, whether in the area of treatment of pain or sleep-disorder, or of co-occurring PTSD and substance-use disorder.  Individual case-management assistance afforded by an FRC is surely no substitute for the kind of delivery-system changes needed to most effectively help individuals who, for example, may be struggling with “co-occurring” polytraumatic injury, behavioral health problems, and unemployment.

The importance of VA’s developing more holistic, integrated systems’ approaches to help wounded warriors thrive should not, however, detract from improving targeted programs.

Mental Health: An Example of Need for Programmatic Change

Much more must be done, for example, to make VA mental health care more “veteran-centric,” a yet-to-be realized VA policy goal.  VA mental health policy (articulated in a recent VHA publication establishing uniform mental health services requirements for VA facilities) is clear: “Mental health services must be recovery-oriented.” [8] The policy explains that “recovery-oriented care” is individualized, person-centered care; care that empowers the individual and builds on his or her strengths; and is aimed at enabling the person to live a meaningful life in the community.[9]   But too many veterans under VA care for PTSD or other mental health problems are still simply being given pills to manage their symptoms.  That has to change.

One concrete step VA can take toward realizing a recovery-orientation for returning veterans who need mental health care is to employ a cohort of OIF/OEF veterans to provide peer-outreach and peer-support.   VA policy recognizes that peer-support is one of the fundamental components of recovery,[10] but only requires that that service be provided to veterans with “serious mental illness.”[11]  Peer-support and peer-mentoring, however, are as beneficial to veterans struggling with PTSD as to veterans with so-called “serious mental illnesses,” and should be a widely available, integral component of VA mental health care afforded OEF/OIF veterans.

To offer another example of a need for change, our own work with wounded warriors has highlighted the difficulties facing those who have severe PTSD (and often co-occurring substance use problems) and need residential treatment.  Too often, those veterans’ circumstances do not “fit” VA placement criteria for specialized PTSD care.  In essence, OEF/OIF veterans in the greatest need of mental health care too often confront barriers that effectively deny them access to the very care they need.   In short, they seem to be experiencing “barrier-centric care” rather than “veteran-centered care.”   Let me illustrate my point.  VA inpatient PTSD programs lack systemwide uniformity in admissions policy; they appear instead to be governed by an array of differing rules that have barred warriors from needed specialized inpatient care based on such diverse requirements as that the veteran?

• have had success in outpatient group therapy for 3 to 6 months to qualify for admission;
• must have no suicidal attempts or ideations in the past 6 months;
• not be on benzodiazepines (a drug some physicians use for treating the anxiety that accompanies PTSD);
• must first complete outpatient anger management treatment;
• must be substance-free for a certain amount of time; and
• must first be interviewed and, if accepted, will be admitted at a later date.

Tragically, many OEF/OIF veterans have suffered with severe PTSD for some time before VA encounters them.  In such instances, an individual may be barely hanging on, and cannot wait for a residential PTSD program admission date which is anywhere from a few weeks to several months away.  In such instances, the individual is generally too acutely ill to benefit from outpatient treatment, and due to unavailability of services are generally seen once every two to six weeks for ongoing therapy.  During that time they often relapse, and may be readmitted to the psychiatric unit, become involved with the justice system or experience severe deterioration of their condition.

Wounded Warrior Project field staff has considerable experience in helping OEF/OIF veterans get needed mental health care from VA facilities, but we have encountered great difficulty in attempting to facilitate needed placements under circumstances where a veteran’s condition poses a relatively urgent need for specialized inpatient treatment for PTSD (or co-occurring PTSD and substance-use problems).

The most pronounced of these cases have involved veterans who have been jailed because of behaviors linked to PTSD and substance use, and whose cases have come before a judge who is open to having the veteran undergo treatment rather than incarceration.  In several such cases, however, VA medical center personnel who have attempted to help facilitate such placements have been stymied by long waiting lists at specialized inpatient facilities in their network (VISN).   On numerous occasions, our field staff have inquired on behalf of our warriors about placement options for specialized inpatient PTSD care beyond the confines of the particular VISN, only to learn that VA staff have no national data base or centralized information source to which to turn to identify other potential VA placement sources.  Yet I’m aware of an instance in which a VA facility’s inpatient PTSD/substance-use treatment program had 125 veterans on its waiting list while a similar program 180 miles away in a neighboring VISN had open beds. 

In light of this troubling information-gap, we have urged the Department to establish a regularly updated “clearinghouse” on all specialized VA PTSD programs to provide relatively real-time placement information, to include nature of the program (such as whether the program provides treatment for dual-diagnosis patients; program requirements; length-of-stay limits; etc.); capacity; bed availability; length of any waiting list; OEF/OIF veteran census; and contact-personnel.  Such a resource should be available and accessible to VA personnel as well as to veterans’ advocates.  To date, however, our recommendation has elicited no response.

Employment: Programmatic Gaps

We have highlighted some of the programmatic gaps relating to VA mental health, not because these programs are uniquely flawed, but because mental health is so important to overall health and to whether wounded warriors are thriving.  To cite another area that cries out for programmatic improvement, employment is certainly key to successful reintegration.  Yet even in programs targeted at helping disabled veterans gain federal employment, wounded warriors encounter obstacles in gaining employment.  It is particularly painful to find that warriors encounter problems in seeking employment with VA, the one federal department one would expect to go the extra mile.  VA certainly appears to have the needed legislative authority to be a leader in employing wounded warriors.   As you know, Mr. Chairman, service-connected disabled veterans (and those retired from service on disability) are entitled to a ten-point preference in federal hiring (in a system using 100 as the top score), and are entitled to hiring preference over other applicants with the same or lower scores.   But those extra points seem to give veterans little or no practical help.  Instead, the complex hurdles associated with demonstrating one’s qualifications for a particular federal job (in particular, demonstrating that one has the requisite “KSAO’s,” namely the Knowledge, Skills, Abilities, and Other Characteristics) often knock otherwise qualified wounded warrior applicants out of contention, even in VA.   Surely the Department could establish mechanisms to help overcome such hurdles.  But wounded warriors encounter frustration with VA even when they get jobs through a Veterans Recruitment Appointment (VRA), a special authority by which a federal department or agency can employ a disabled veteran without competition.    While the VRA authority has occasionally provided warriors jobs, such VA appointments seldom tap the leadership and other skills wounded warriors developed in service.

In short, Mr. Chairman, to achieve its ultimate goals, “seamless transition” will not only require more work to close the remaining gaps between DoD and VA, but substantial transformation within VA?in the area of mental health programming, vocational rehabilitation and employment, and many other areas?to make warriors’ transition an easier journey to successful community reintegration.

That concludes my testimony; I would be happy to answer any questions you may have.

[1] National Academy of Public Administration, “After Yellow Ribbons: Providing Veteran-Centered Services,” October 2008, p. ix.

[2] Ibid.

[3] Ibid, p. 51 et seq.

[4] Nina Sayer, Nancy Rettmann, Kathleen Carlson, Nancy Bernardy, Barbara Sigford, Jessica Hamblen, Matthew Friedman, “Veterans with History of mild traumatic brain injury and posttraumatic stress disorder: Challenges from provider perspective,” Journal of Rehabilitation Research & Development 46 (Nov. 6, 2009).

[5] Ibid., 710.

[6] Ibid., 711.

[7] Ibid.

[8] Department of Veterans Affairs, Veterans Health Administration, Uniform Mental Health Services in VA Medical Centers and Clinics, VHA Handbook 1160.01, September 11, 2008, 5.

[9] Ibid.

[10] Ibid.

[11] Ibid., 30.