Witness Testimony of Elizabeth Joyce Freeman, Veterans Affairs Palo Alto Health Care System, Veterans Health Administration, Director, U.S. Department of Veterans Affairs
Mr. Chairman and Members of the Committee, thank you for the opportunity to appear before you today to discuss the Polytrauma Rehabilitation Center (PRC) located at the Department of Veterans Affairs Palo Alto Health Care System (VAPAHCS). It is a privilege to be on Capitol Hill to speak and answer questions about this vital program and other issues that are important to veterans who have bravely served in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF).
Mr. Chairman, I would also like to thank you and your Committee for your advocacy on behalf of our Nation’s veterans. The Committee and its staff have been actively involved in many issues affecting veterans this year. Several weeks ago, I had the pleasure of hosting a visit by senior staff from the Committee, including Mr. Geoffrey Bestor and Mr. Art Wu. They toured VAPAHCS and interviewed several patients, family members and staff. I appreciated their interest, insights and suggestions.
Today, I will provide a brief overview of VAPAHCS and the PRC. I will present some of our successes, challenges and upcoming enhancements at the PRC. I will also specifically discuss areas of particular interest and recent scrutiny, including accreditation, referral process, emerging consciousness program, family support and programmatic leadership.
VA Palo Alto Health Care System (VAPAHCS)
VAPAHCS is one of the largest and most complex health care systems in the Veterans Health Administration (VHA). It provides primary, secondary and tertiary care services across a large geographic area (i.e., 10 counties over 13,500 square-miles) in the South San Francisco Bay area. VAPAHCS operates facilities at three inpatient divisions (i.e., Palo Alto, Menlo Park and Livermore) and six outpatient clinics (i.e., Capitola, Modesto, Monterey, San Jose, Sonora and Stockton). VAPAHCS offers most of the highly specialized services in VHA, including traumatic brain injury (TBI), blind rehabilitation, hospice, palliative care, spinal cord injury (SCI), post-traumatic stress disorder (PTSD), gero-psychiatric inpatient care, war-related illness and injuries, domiciliary care and organ transplantation.
In Fiscal Year (FY) 2006, VAPAHCS had enrolled more than 85,000 veterans and provided care to 53,000 unique veterans. VAPAHCS staff includes nearly 3,000 full-time equivalent employees (FTEE) and more than 1,700 volunteers. The FY 2007 operating budget for VAPAHCS is approximately $600 million. VAPAHCS has particularly strong academic programs, including the third most highly funded research program in VHA. VAPAHCS and the veterans it proudly serves benefit from a balanced relationship with Stanford University School of Medicine and affiliations with more than 100 other academic institutions.
Polytrauma Rehabilitation Center (PRC)
VA established the Polytrauma System of Care (PSC) in 2005 to address the biopsychosocial needs of the most severely injured OEF/OIF veterans. The PSC consists of PRCs, Polytrauma Network Sites (PNSs), Polytrauma Support Clinic Teams (PSCTs) and Polytrauma Points of Contact (PPOCs). PRCs serve as a regional referral center for acute medical and rehabilitative care for patients with polytrauma (defined as two or more injuries, one of which might be life threatening, resulting in significant physical, cognitive, psychological or social impairments and functional disability) and TBI. PRCs maintain a full team of dedicated rehabilitation specialists and experts from other specialties related to polytrauma. PRCs also serve as consultants to other facilities across the PSC.
The PRC at VAPAHCS is one of four PRCs in VHA (the other three are located in Minneapolis, MN; Richmond, VA; and Tampa, FL). A fifth polytrauma site was just recently announced for San Antonio, TX. The PRC offers a continuum of acute rehabilitative services in a variety of venues, including inpatient wards, outpatient clinics and residential transitional settings. Clinical care is provided by a dedicated interdisciplinary team with specific expertise in physiatry, rehabilitation nursing, neuro-psychology, psychology, speech-language pathology, occupational therapy, physical therapy, social work, therapeutic recreation therapy, prosthetics, SCI, blind rehabilitation and PTSD.
The core of the PRC at VAPAHCS is a 12-bed ward located in Building 7D on the campus of the Palo Alto Division. The PRC building also has four general rehabilitation beds that are available to polytrauma patients on a priority basis, plus two additional beds for residential rehabilitation and/or women veterans. Since its inception (i.e., from February 2005 through early September 2007), the PRC has accepted 143 patients. The average daily census (ADC) has steadily increased since FY 2005. Through the third quarter of FY 2007, the PRC ADC has been 7.9 for an occupancy rate of 65 percent.
Another important component of the PRC is the Polytrauma Residential Transitional Rehabilitation Program (PRTRP). PRTRP is designed for veterans and active duty service members who have completed their acute rehabilitation but have lingering impairments that prevent them from safely re-integrating into their community or returning to active duty. PRTRP has the goal of establishing independent living through a structured program that focuses on restoring home, community, leisure, psychological and vocational skills in a controlled, therapeutic setting. Services typically provided include individual and group therapies, case management, care coordination and vocational rehabilitation. Through the third quarter of FY 2007, the ADC in the PRTRP has been 4.7 and therefore the combined ADC for both the PRC and PRTRP is 12.6.
In part due to the ongoing war in southwest Asia and our country’s deep concern for injured veterans, the PRC at VAPAHCS has received considerable attention from domestic and international media outlets. Since the establishment of the PRC in 2005, more than 200 print and broadcast stories have been disseminated about the PRC, its patients and its staff. Stories from respected organizations such as Associated Press, New York Times, Jim Lehrer NewsHour, National Public Radio, NBC Nightly News and British Broadcasting Company, have all portrayed the quality of the care at the PRC as outstanding.
One poignant example is the story of Marine Corps Corporal (Cpl.) Jason Poole. Cpl. Poole was on his third tour in Iraq in 2004, 10 days shy of coming home, when his patrol was hit by a roadside bomb. The explosion and resulting injuries (e.g., shrapnel went into his left ear and out his left eye) left him in coma for two months. When he arrived at VAPAHCS, he was unable to walk, talk or breathe without a tube in place. Two years and seven reconstructive surgeries later, he was interviewed by the local NBC news affiliate. “I’ve been treated amazingly here,” he said. “These people [staff at the PRC at VAPAHCS] gave me my life. They are everything to me. I would not be where I am today without their help.” 1 The accomplishments of Cpl. Poole and so many other courageous men and women at the PRC are extraordinarily gratifying to me.
Challenges and improvements
While the PRC at VAPAHCS has enjoyed considerable success, it has experienced and continues to face challenges. Staffing is a major area of concern. VAPAHCS expends considerable effort to attract and retain the “best and the brightest.” The health care labor market in the greater San Francisco Bay Area is highly competitive and compounded by an exceedingly high cost of living. In part due to our affiliations with prestigious academic partners such as Stanford University School of Medicine, Washington State University and the University of California San Francisco School of Medicine; VAPAHCS generally has been successful in recruitment. However, recruitment for some positions (e.g., physiatry) has been especially problematic.
While work on the PRC is fulfilling, it is also inherently demanding. Knowledgeable and well-intended individuals can have different opinions and these differences can be exaggerated in the PRC environment. Consequently, the VHA Under Secretary for Health (USH) recently asked the VHA National Center of Organizational Development (NCOD) to visit all four PRCs to assess current structure and staff. NCOD came to VAPAHCS and met with senior leadership and front-line staff. The initial visit was beneficial and we look forward to continuing our partnership with NCOD.
Also, as noted earlier, the PRC is a highly visible endeavor. The PRC is frequently the subject of scrutiny by oversight bodies, veterans’ advocates, Department of Defense (DoD) personnel, media and elected officials. Nearly every week, VAPAHCS has the honor of hosting visits by interested parties. The vast majority of these visits are very positive and generate considerable praise and compliments for PRC staff and leadership.
However, earlier this year, the VHA Office of the Medical Inspector (OMI) received a letter from the Senate Committee on Veterans’ Affairs expressing concern about the delivery of care at the PRC at VAPAHCS. OMI was asked to look into several allegations, including delays in accreditation, inappropriate declinations of referrals and lack of effective leadership at the program level. As a result, OMI came to VAPAHCS in March 2007 and assessed the PRC. Some of the allegations were validated (e.g., delay in accreditation survey), while others were not substantiated (e.g., OMI concluded VAPAHCS did not “cherry pick” referrals). I will discuss these and other issues in the following sections.
Accreditation. One of the concerns expressed in the OMI report was the delay in the accreditation survey by the Commission on Accreditation of Rehabilitation Facilities (CARF). CARF confers up to (i.e., a maximum) three-year accreditation status to rehabilitation facilities that undergo a successful survey. VAPAHCS was due for its triennial CARF survey of rehabilitation programs (including the PRC) in February 2007. Based on internal and external assessments (e.g., a “mock survey” by a contracted private health care organization), I determined we needed additional time to prepare for the survey. Consequently, I asked CARF to delay its survey for a few months.
I am pleased to report to the Committee that the CARF survey occurred July 19-20, 2007, and resulted in full accreditation for the maximum three-years for all of the four programs surveyed (i.e., outpatient, inpatient and residential brain injury rehabilitation, as well as inpatient rehabilitation). As noted in the August 24, 2007, notification letter from CARF, “This achievement is an indication of your organization’s dedication and commitment to improving the quality of the lives of the persons served. Services, personnel, and documentation clearly indicate an established pattern of practice excellence.” I am especially pleased that areas that were previously considered weaknesses (e.g., program leadership, staff education), are now cited by CARF to be organizational strengths.
Referrals. I and my staff at VAPAHCS consider our selection as a PRC site to be a distinct privilege. We are fully committed to having an active, vibrant and highly effective rehabilitation program. We recognize that the historical level of activity at the PRC has been below capacity and we have evaluated the circumstances associated with this situation.
I would like to emphasize that we are highly motivated to receive referrals to our PRC and we make every effort to accept them. Since the PRC began operations in 2005 (through September 14, 2007), VAPAHCS has received a total of 177 referrals to its PRC and accepted 143 patients (81 percent). The PRC declined or redirected 25 patients (14 percent) and the referring site withdrew 9 referrals (5 percent). The most common reasons for the PRC not accepting referrals have been another form of treatment was needed (e.g., care for PTSD, substance abuse treatment), another venue was more appropriate (e.g., Polytrauma Network Site, different PRC for geographic reasons) or the desired service was not available at the time (e.g., coma stimulation). I would like to emphasize that the OMI reviewed this issue earlier this year and concluded that the disposition of referrals was appropriate. And, while the acceptance of some referrals was delayed due to concerns regarding medical stability (in the context of long flights from the East Coast), OMI did not substantiate the allegation that VAPAHCS was “cherry picking” referrals to achieve good outcomes.
Currently, recent changes I have initiated will make it easier for referring sites to send us patients. There is now a single point of contact for all PRC referrals at VAPAHCS who has the requisite customer service skills. This individual collects all of the relevant information and presents it to an interdisciplinary team of polytrauma experts. The team makes a recommendation to the PRC Program Director and the PRC Program Director makes a decision within two business days from the time of the referral (i.e., when the needed medical information is available). I have instructed my staff to look for every possible way to accept all patients to VAPAHCS, either at the PRC or another program (e.g., PRTRP, National Center for PTSD). The decision will be promptly communicated to the referring site. If for any reason the referring site disagrees with the decision, the referring site will be encouraged to appeal the decision to the Chief of Staff, VAPAHCS. We will fully document the disposition for each referral and will report the outcomes to the Veterans Integrated Service Network (VISN) 21 Office and VA Central Office (VACO) monthly.
Emerging consciousness program. VHA formally introduced the Emerging Consciousness (EC) following its polytrauma conference in December 2006. EC is a program developed by VHA to optimize the long-term functional outcomes of brain-injured patients by attempting to improve responsiveness, return to consciousness and advance to the next level of rehabilitation care. EC is intended for patients who range from fully comatose to minimally conscious. EC utilizes appropriate medical and nursing rehabilitation services, individualized multisensory stimulation and prevention of complications related to immobilization. EC also emphasizes support to families and caregivers. Some patients in the EC program, even with the most optimal care may not regain consciousness or advance to the next level of care.
The PRC at VAPAHCS has been providing many components of the EC program since its inception (e.g., rehabilitation services, prevention of complications and family support). However, the PRC at VAPAHCS did not initially offer the multisensory component. In the summer of 2006, VAPAHCS noted anecdotal reports of the success of multisensory stimulation and reassessed its potential value. VAPAHCS began offering this service in November 2006 and fully instituted the EC program following the polytrauma conference in December 2006. The PRC has accepted 12 patients into its EC program since November 2006, including a patient declined by private rehabilitation sites. At the time of this testimony, VAPAHCS had a census of six EC patients with five in the PRC and one in the intensive care unit.
Family support. VAPAHCS recognizes that the presence and support of family members are critical components of the successful rehabilitation of injured patients. VA has inherent constraints on its ability to provide certain services to non-veteran family members. Fortunately, since the PRC began operations, VAPAHCS has developed innovative programs to support families of PRC patients.
A wonderful example is the construction and opening of a Fisher House™ directly across from the PRC on the VAPAHCS campus. Fisher Houses™ are “comfort homes” with individual rooms for families of patients receiving medical care at major military and VA medical centers. Prior to the opening of the Fisher House™ in April 2006, many families complained of the inability to find affordable accommodations near VAPAHCS. Thanks to the generosity of donors and the Fisher House Foundation, families of OEF/OIF patients now have access to a stunning 21-suite Fisher House™. There is no charge to guests and families of OEF/OIF patients are given priority admission. The Fisher House™ is filled to capacity nearly every night.
We have also been able to provide limited monetary support from donations to our General Post Fund. The donations come from individuals and organizations such as Rotary Club. We have established a Fisher House™ Fund and an OEF/OIF Fund. These funds are used to pay for lodging, groceries, rental cars, day care for children and other incidentals.
As part of our ongoing reorganization and staffing enhancements, we are increasing the support and services to families who are with their loved ones in the PRC. We are enhancing access to the internet (e.g., to check e-mails, communicate with other family members), offering caregiver education and training, providing a “quiet room,” offering family counseling, spiritual support (e.g., chaplain services) and assistance with recreational activities. Another important benefit to families has been the placement of Department of Defense (DoD) liaisons in the PRC. The DoD liaisons are able to assist active duty patients and their families with myriad questions and services important to them.
Organization and leadership. In response to recommendations by both internal and external entities (OMI, CARF) we continue to evaluate services and shape our service delivery to meet the needs of our patient population.
In closing, Mr. Chairman, I would like to note that it is an incredible honor to host one of the four (soon to be five) PRCs in VHA. I am very proud of the talented and dedicated staff at VAPAHCS who provide outstanding and compassionate care to our Nation’s heroes. They do incredible work in challenging circumstances. I believe we have made a positive difference in the lives of so many veterans and their families. I acknowledge that we are not perfect. In VHA, when mistakes occur we “own them” and make the requisite system changes. This same philosophy holds true in the PRC at VAPAHCS and our investment of resources, service enhancements and organizational changes are evidence of that approach.
Again, Mr. Chairman, thank you for the opportunity to testify at this hearing. I and the staff who accompany me would be delighted to address any questions you might have for us.
1 NBC Channel 11: "The Bay Area at 11", KNTV-San Francisco 02/07/2007