Witness Testimony of Mahdulika Agarwal, M.D., MPH, Veterans Health Administration, Chief Officer, Patient Care Services, U.S. Department of Veterans Affairs
Good morning, Mr. Chairman and members of the Subcommittee. Thank you for the opportunity to discuss the Department of Veterans Affairs’ (VA’s) care for seriously wounded veterans after they complete their inpatient care. I am accompanied by Dr. Lucille Beck, Chief Consultant for Rehabilitation Services and Ms. Kristin Day, Chief Consultant Care Management & Social Work Service, Veterans Health Administration (VHA).
VHA has long emphasized the importance of a personalized continuum of care for service members. Our commitment extends beyond the initial transition across systems of care to ensure services continue to be provided to these individuals as veterans, and to their family members, who are essential to the recovery and rehabilitation of these injured warriors.
It is important to emphasize, however, that neither the transfer between health care systems, nor the transfer to veterans’ status is a linear path. To ensure every veteran or service member receives the care and benefits they deserve, VA has created a Case Management Program for Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans. The VA/DoD Federal Recovery Coordination Program (FRCP) further provides needed assistance and support for veterans and service members with serious injuries or illnesses. VA’s provision of both inpatient and outpatient rehabilitation services in locations across the country is designed to meet the short- and long-term needs of veterans with serious injuries, including Polytrauma, Traumatic Brain Injury (TBI), Spinal Cord Injury (SCI), and mental health needs. These overlapping strategies of case management and coordination of rehabilitative care allow me to state with confidence that VA is adapting to the needs of our returning veterans and operating a system capable of providing lifelong care to them. These programs provide little net value if veterans are unaware of the services available to them; consequently, VA has pursued outreach on multiple levels to see that our veterans, particularly those with severe injuries or illnesses, can access our system and receive the care they have so bravely earned.
OEF/OIF Case Management Program & Federal Recovery Coordination Program
We deeply appreciate the recommendations of The President’s Commission on Care for America’s Returning Wounded Warriors, chaired by Senator Dole and Former Secretary Shalala. Specifically, we echo their description of the importance of integrated care management, which they describe as providing, “…patients with the right care and benefits at the right time in the right place by leveraging all resources appropriate to their needs. For injured service members – particularly the severely injured – integrated care management would build bridges across health care services in a single facility and across health care services and benefits provided by DoD and VA.”
VHA and VBA published a joint handbook (VHA Handbook 1010.01) in May 2007 establishing procedures for the transition of care, coordination of services and case management of OEF/OIF veterans. This joint Case Management Program represents a fully integrated team approach, and includes a Program Manager, Clinical Case Managers, a VBA Veterans Service Representative, and a Transition Patient Advocate. These teams are active at every VA Medical Center (VAMC). The Program Manager, who is either a nurse or social worker, has overall administrative and clinical responsibility for the team, and must ensure all OEF/OIF veterans are screened for case management needs. OEF/OIF veterans with severe injuries are automatically provided a case manager; all other OEF/OIF veterans are assigned a case manager upon request. Clinical Case managers, who are either nurses or social workers, coordinate patient care activities and ensure all VHA clinicians are providing care to the patient in a cohesive, integrated manner. VBA team members assist veterans by educating them on VA benefits and assisting them with the benefit application process.
The Transition Patient Advocates (TPAs) serve as liaisons between the VAMC, the Veterans Integrated Service Network (VISN), VBA, and the patient. The TPA acts as a communicator, facilitator and problem solver. The team documents their activities in the Veterans Tracking Application (VTA), a web-based tool designed to track injured and ill service members and veterans as they transition to VA. VHA is also using the Primary Care Management Module (PCMM), an application within VHA’s VistA Health Information system, to track patients assigned to an OEF/OIF Case Management team.
VA has developed a rigorous training schedule for this new program to ensure it is operating fully and effectively for all veterans requesting assistance. TPAs and VISN Points of Contact attended a training conference in Washington, D.C. in June 2007, and Program Managers received training in September 2007. VA held a week-long training conference in San Diego in January 2008 for Case Managers, and two regional training conferences for the entire OEF/OIF Case Management Team are planned for May and June 2008.
As a part of this effort, VHA and VBA are jointly developing a comprehensive list of severely injured OEF/OIF veterans. The two administrations are defining the requirements and definitions for this list, and will establish a single record to track VHA or VBA contact each month with severely injured veterans and service members.
VA and DoD are working on jointly developing and implementing a comprehensive policy on improvements to the care, management, and transition of recovering service members, pursuant to the National Defense Authorization Act of 2008.
In October 2007, VA partnered with DoD to establish the Joint VA/DoD Federal Recovery Coordination Program (FRCP). The FRCP will identify and integrate care and services for the seriously wounded, ill, and injured service member, veteran, and their families through recovery, rehabilitation, and community reintegration. VA hired an FRCP Director, an FRCP Supervisor, and eight Federal Recovery Coordinators (FRCs) in December 2007. The FRCs are currently deployed to Walter Reed and Brooke Army Medical Centers, as well as National Naval Medical Center at Bethesda. Two additional FRCs are currently being recruited and will be stationed at Brooke Army Medical Center and Balboa Naval Medical Center in San Diego. The FRCP is intended to serve all seriously injured service members and veterans, regardless of where they receive their care. The central tenet of this program is close coordination of clinical and non-clinical care management for severely injured service members, veterans, and their families across the lifetime continuum of care.
The Caregiver Pilot Task Force was formed in response to a provision of the "Veterans Benefits, Health Care, and Information Technology Act of 2006". Eight Caregiver Assistance Pilot Programs were awarded grants beginning in October 2007, at a total cost of approximately $5 million. The goal is to explore options for providing support services for caregivers in areas across the country where such services are needed for families of disabled or aging veterans, and where there are few other options available. These programs will also increase the caregiver support services available to OEF/OIF veterans in the immediate future and the long term. Examples of these pilots include:
Home Based Primary Care programs, in Memphis and Palo Alto, are implementing interventions from the evidence-based REACH II National Institutes of Health Initiative to train and support caregivers in managing patient behaviors and their own stress.
Caregivers in Gainesville, Florida will participate in a Transition Assistance Program using videophone technology to provide skills training, education and supportive problem solving.
In Ohio, Caregiver Advocates will be available via telephone 24 hours a day to coordinate between VA and community services.
VA will work with a community coalition to provide education, skills, training, and support for caregivers of veterans with TBI in California, using telehealth technology.
The VA Pacific Islands Healthcare System will develop a Medical Foster Home program to provide overnight respite care for veterans.
In Miami and Tampa, funding will be used to expand respite care, train home companions, and develop an emergency response system.
Atlanta will use a model telehealth program to provide instrumental help and emotions support to caregivers who live in remote areas.
VA is committed to providing key services to assist caregivers with case management, service coordination, and support for the veteran, as well as education on how to obtain community resources such as legal assistance, financial support, housing assistance, and spiritual support.
Medical Foster Homes & Volunteer Respite Services
In February 2008, VA’s Under Secretary for Health approved funding for programs to facilitate the transition and support of seriously injured veterans with Polytrauma, TBI, and/or SCI by providing specialized support and care in their homes and communities. This program will aid both veterans living in their homes and those who are no longer able to live independently but prefer an in-home alternative within their community. The Volunteer Respite program will create access to needed home respite services for family caregivers, while giving members of the community an opportunity to volunteer with VA closer to home, regardless of distance from a VA facility. VA Voluntary Service would recruit, train, and coordinate community volunteers to provide respite care in the homes of OEF/OIF veterans. The Medical Foster Home component provides an in-home alternative to nursing home care, merging personal care in a private home with medical and rehabilitation support from specialized VA home care programs.
Through these programs and others, VA will expand the availability of Medical Foster Homes (MFH) to seriously injured OEF/OIF veterans near specialized facilities within the communities in which they live. We will also expand the number of MFH sites and modify them to meet the needs of younger, seriously injured veterans with Polytrauma, TBI, and/or SCI, and strengthen the rehabilitation expertise of the VA home care teams who will serve them. Veterans with disabling injuries or conditions may need the support of a non-familial caregiver as they work toward independent living in the community, or may have long term care needs that initially, or eventually, exceed the capabilities their family can sustain. MFH may be a favorable alternative to nursing homes for these veterans as we facilitate their return to homes and communities.
VA provides clinical rehabilitative services in several specialized areas that employ the latest technology and procedures to provide our veterans with the best available care and access to rehabilitation for polytrauma and traumatic brain injury, spinal cord injury, visual impairment, and other areas. VA’s Under Secretary for Health directed our facilities to seek a second opinion from civilian physicians upon request. Whenever an OEF/OIF veteran requires specialized rehabilitative services, the assigned OEF/OIF case manager engages with the clinical case manager that is appropriate for that area of rehabilitation; e.g., polytrauma, spinal cord injury, blindness. Throughout the rehabilitative process, the OEF/OIF case manager coordinates with the appropriate clinical case manager regarding the veteran’s progress and rehabilitation.
Polytrauma System of Care
Over the past two years, VA has implemented an integrated system of specialized care for veterans sustaining traumatic brain injury (TBI) and other polytraumatic injuries. The Polytrauma System of Care consists of four regional TBI/Polytrauma Rehabilitation Centers (PRC) located in Richmond, VA; Tampa, FL; Minneapolis, MN; and Palo Alto, CA. A fifth PRC is currently under design for construction in San Antonio, TX, and is expected to open in 2011. The four regional PRCs provide the most intensive specialized care and comprehensive rehabilitation for combat injured patients transferred from military treatment facilities. As veterans recover and transition closer to their homes, the Polytrauma System of Care provides a continuum of integrated care through 21 Polytrauma Network Sites, 76 Polytrauma Support Clinic Teams and 54 Polytrauma Points of Contact, located at VAMCs across the country. Throughout the Polytrauma System of Care, we have established a comprehensive process for coordinating support efforts and providing information for each patient and family member. On February 27, 2006, VA established a national Polytrauma Call Center available 24 hours a day, seven days a week, for families and patients with questions. This Center is staffed by health care professionals trained specifically in Polytrauma care and case management issues and can be reached by calling 1-888-827-4824.
The care coordination process between the referring DoD military treatment facility and the PRC begins weeks before the active duty service member is transferred to VA for health care. The PRC physician monitors the medical course of recovery and is in contact with the MTF treating physician to ensure a smooth transition of clinical care. The admissions nurse case manager maintains close communication with the referring facility, obtaining current and updated medical records. A social work case manager is in contact with the family to address their needs for psychosocial and logistical support. Prior to transfer, the PRC interdisciplinary team meets with the DoD treatment team and family by teleconference as another measure to ensure a smooth transition. The PRCs provide a continuum of rehabilitative care including a program for emerging consciousness, comprehensive acute rehabilitation, and transitional rehabilitation. Each of the PRCs is accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). Intensive case management is provided by the PRCs at a ratio of 1 case manager per 6 patients, and families have access to assistance 24 hours a day, 7 days a week. The interdisciplinary rehabilitation treatment plan of care reflects the goals and objectives of the patient and/or family.
From March 2003 through December 2007, the PRCs provided inpatient rehabilitation to 507 military service members injured in combat theaters. The transition plan from the PRCs to the next care setting evolves as the active duty service member progresses in the rehabilitation program. Families are integral to the team and are active participants in therapies, learning about any residual impairments and ongoing care needs. The team collaborates with the family to identify the next care setting, and determine what will be needed to accommodate the transition of rehabilitative care. The consultation process includes a teleconference between the PRC team, the consulting team, the family, and the patient. These conferences allow for a coordinated transfer of the plan of care, and an opportunity to address specific questions.
Prior to discharge, each family and patient is trained in medical and nursing care appropriate for the patient. Once a discharge plan is coordinated with the family, VA initiates contact with necessary resources near the veteran’s home community. Based upon location, an agreement is reached with one of the 21 VA Polytrauma Network Sites or an appropriate local provider within the patient’s community. As veterans and service members transition to their home communities, ongoing clinical and psychosocial case management is provided by a rehabilitation nurse and social worker from one of 76 Polytrauma Support Clinic Teams. VA social work case managers follow each patient within the Polytrauma System of Care at prescribed intervals contingent upon need. For example, there are four levels of case management: intensive case management, where contact is made daily or weekly; progressive case management, where VA contacts the patient monthly; supportive case management, quarterly; and lifetime case management, annually. For the many patients who are still active duty service members, the military case managers are responsible for obtaining authorizations from DoD regarding orders and follow-up care based upon VA medical team recommendations.
VA is committed to ongoing review and improvement of our provision of care for these wounded or injured warriors. In this spirit, VA assembled a national research task force last summer to review and evaluate the long term care needs of our most seriously wounded or injured returning OEF/OIF veterans. This taskforce recently completed its work and identified several recommendations, which are being submitted to the Secretary for his review. Moreover, in compliance with the 2008 National Defense Authorization Act, VA is collaborating with the Defense and Veterans Brain Injury Center to design and execute a five-year pilot program to assess the effectiveness of providing assisted living services to eligible veterans to enhance their rehabilitation, quality of life, and community integration.
Spinal Cord Injury and Disorders
For Spinal Cord Injury and Disorders (SCI/D), VA has the largest single network of care in the nation. VA facilities nationwide provided a full range of services to 26,191 veterans with SCI/D in 2007; 12,789 of these veterans received specialized care within the Spinal Cord Injury Centers and Spinal Cord Injury Support Clinics. For veterans with SCI/D, VA provides health care, maintains their medical equipment, and provides supplies, education and preventive health services. Since 2003, 364 active duty service members have been treated in VA SCI units; of these, 116 acquired spinal cord injury in an OEF/OIF theater of operations. Each of these patients received care from a VA facility accredited by CARF. A national, multi-site vocational improvement research project identifies evidence-based vocational rehabilitation programs for veterans with SCI/D.
VA is improving and expanding our SCI/D nationally, with plans for a ribbon-cutting ceremony for a new facility in Minneapolis in February 2009. Our Denver, CO facility’s design was funded in 2004 and land was acquired in 2006, while our Jackson, MS facility’s funding is still being determined. Tampa’s LTC facility (30 beds) is under construction and planning is underway for the VISN 3 SCI LTC facility. Each VA Spinal Cord Injury Center will be provided with state-of-the-art technology and equipment to better support home-based therapies, provide closer management and monitoring of function and complications in the home, and offer closer attention to health promotion and prevention.
For veterans and active duty personnel with visual impairment, VA provides comprehensive Blind Rehabilitation services that have demonstrated significantly greater success in increasing independent functioning than any other blind rehabilitation program. Currently, 164 Visual Impairment Service Team (VIST) Coordinators provide lifetime case management for all legally blind veterans, and all OEF/OIF patients with visual impairments. Additionally, 38 Blind Rehabilitation Outpatient Specialists (BROS) provide blind rehabilitation training to patients who are unable to travel to a blind center.
The VA Blind Rehabilitation Continuum of Care, announced January 2007, further extends a comprehensive, national rehabilitation system for all veterans and active duty personnel with visual impairments. Program expansion during 2008 will add 55 outpatient vision rehabilitation clinics, 35 additional BROS at VAMCs currently lacking those services, and 11 new VIST positions. The continuum of care will provide the full scope of vision services – from basic, low vision services to blind rehabilitation training – across all Veteran Integrated Service Networks (VISNs).
VA has always been committed to outreach, and all the more so during periods of armed conflict. Given the importance of outreach to service members and veterans of OEF/OIF, VA promotes and conducts activities at both national and local levels. VA has developed an array of training materials, directives, publications, and established points of contact at each VA facility. VA also partners with federal agencies, Veterans Service Organization (VSOs), and state, county, and local agencies and governments. Our outreach to OEF/OIF participants begins when the service member returns home and continues through the transition period from service member to veteran and beyond.
Outreach to active duty personnel is a major part of VA’s Outreach program and is generally accomplished through the Transition Assistance Program (TAP) sponsored in cooperation with the Departments of Defense and Labor. All VA benefits and services are included in TAP briefings. All returning OEF/OIF service members are given a copy of VA Pamphlet 80-06-01, Federal Benefits for Veterans and Dependents.
Special outreach to Reserve/Guard members is an integral part of VA’s outreach efforts. VA provides briefings on benefits and health care services at town hall meetings, family readiness groups, and during unit drills near the homes of returning Reserve/Guard members.
Since 2003, VA’s outreach to those severely injured in OEF/OIF includes placing VA/DoD Social Work and Registered Nurse Liaisons and Benefits Counselors at Walter Reed Army Medical Center, the National Naval Medical Center and nine other military treatment facilities across the country.
In November 2005, VA began partnering with DoD in implementing the Post-Deployment Health Reassessment (PDHRA) among National Guard and Reserve Component (RC). The PDHRA is a DoD global health-screening tool that includes specific questions covering PTSD, alcohol misuse and Traumatic Brain Injury (TBI). VA’s role in this partnership is fourfold: provide information on VA benefits among Reserve and Guard personnel; enroll eligible veteran in VA health care; provide assistance in scheduling follow-up appointments at VAMCs and Vet Centers; and develop on-going referral and training relationships with Reserve and Guard Commanders. As of January 31, 2008, VA has supported PDHRA referrals from DoD’s 24/7 Call Center, 283 Unit Call Center PDHRA events and 888 Unit On-Site PDHRA events. The RC PDHRA initiative has generated over 75,000 referrals, including 36,199 referrals to VAMCs and 17,214 referrals to Vet Centers representing 71% of total referrals.
Vet Center staff regularly participates in DoD-sponsored PDHRA events. Vet Centers provide information on VA benefits and care to service members as they transition from military to civilian life at National Guard and Reserve demobilization sites, active duty transition briefings, and community events involving returning combat veterans such as homecoming events. Outreach is also performed with local VSOs and community agencies. Vet Center outreach is designed to provide information, minimize stigma, and help veterans obtain needed services as early as possible. More than 200,000 service members have been provided outreach services, primarily at military demobilization sites, including National Guard and Reserve units. Vet Centers initiate outreach efforts to area military installations and closely coordinate their efforts with military family support services at various military bases.
In October 2005, DoD Health Affairs began providing VA with a list of service members entering the Physical Evaluation Board (PEB) process. These service members sustained an injury or developed an illness that may preclude them from continuing on active duty and result in medical separation or retirement. This list will enable VHA to send outreach letters encouraging them to contact the nearest VA medical facility for future assistance in enrolling in VA health care and addressing their health care needs as they transition from active duty to veteran status. As of January 31, 2008, the VA has mailed 16,905 PEB outreach letters to service members.
The Veterans Assistance at Discharge System process mails a “Welcome Home Package,” including a letter from the Secretary, “A Summary of VA Benefits” (VA Pamphlet 21-00-1), and “Veterans Benefits Timetable” (VA Form 21-0501), to veterans recently separated or retired from active duty (including Guard/Reserve members). We re-send this information six-months later to these veterans.
The Secretary of Veterans Affairs sends a letter to newly separated OEF/OIF veterans. The letters thank veterans for their service, welcome them home, and provide basic information about health care and other benefits provided by VA. To date, VA has mailed over 766,000 initial letters and 150,000 follow-up letters to veterans.
VA Regional Offices assist and support seriously injured OEF/OlF service members and veterans by conducting case management activities, including outreach, coordinating services, and streamlining claims processing procedures.
In collaboration with DoD, VA published and distributed one million copies of a new brochure called, “A Summary of VA Benefits for National Guard and Reservists Personnel.” The new brochure summarizes health care and other benefits available to this special population of combat veterans upon their return to civilian life.
As part of VA’s “Coming Home to Work” program, participants work with a Vocational Rehabilitation and Employment Counselor (VRC) to obtain unpaid work experiences at government facilities. This represents an early outreach effort with special emphasis on OEF/OlF service members pending medical separation from active duty at military treatment facilities.
VA also continues its Benefits Delivery at Discharge program, where service members can apply for service-connected compensation, vocational rehabilitation, and employment services before discharge. Normally, prior to discharge, required physical examinations are conducted, service medical records are reviewed, and rating decisions are made.
Access to Care
VA has identified access to outpatient care as a priority in our effort to provide care for seriously wounded veterans after inpatient care is complete. VHA’s strategic direction is to enhance non-institutional care with less dependence on large institutions. Our comprehensive care management plans offer guidance for providing care to veterans in their homes and communities. For those veterans who prefer to visit in person, VA issued a directive last June instructing our medical centers to explore offering extended hours for veterans unable to schedule appointments during the day. Similarly, our Vet Centers are available to veterans on nights and weekends for readjustment counseling needs.
Community Based Outpatient Clinics (CBOCs) have been the anchor for VA’s efforts to expand access for veterans. CBOCs are complemented through partnerships, such as contracts in the community for physician specialty services or referrals to local VA medical centers, depending on the location of the CBOC and the availability of specialists in the area. In addition, we provide rural outreach clinics that are operated by a parent CBOC to meet the needs of rural veterans.
Telehealth provides veterans with access to care in their homes and local communities where possible and appropriate. It is a new modality of care requiring robust clinical practices, technology infrastructure and business processes to maintain and sustain the modality. Telehealth capabilities in VA have expanded in all clinical areas since FY 2004. There are telehealth programs within all VISNs and many programs have grown from point-to-point connections to inter-hospital and VISN-based networks. VA continues to evaluate the effectiveness of telehealth and to work with clinical leadership in the VISNs and VA facilities to introduce new clinical processes based on information technologies to assist clinicians in meeting the health care needs of older veterans. This reduces the barriers of distance and time that may restrict the availability of care. Currently, VA is piloting applications to create national tele-consultation networks to expand the provision of specialty care to rural and remote areas.
We are honored to provide care and service to America’s veterans. For those who return from combat with serious injuries or illness, we work closely with DoD to ensure a swift and seamless transition to VA, but we also work with those who do not need immediate care to make it as accessible as possible. Thank you again for you the opportunity to meet with you today. I would be happy to address any questions that you have at this time.
 President’s Commission on Care for America’s Returning Wounded Warriors. “Serve, Support, and Simplify: Subcommittee Reports and Findings.” p. 20-21. Available online: http://www.pccww.gov/docs/TOC%20Subcommittee%20Reports.pdf.