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Witness Testimony of Mary Ramos, Ph.D., RN, U.S. Department of Veterans Affairs, Federal Recovery Coordinator, San Antonio Military Medical Center

Good morning Chairwoman Buerkle, Ranking Member Michaud, and Members of the Committee.  My name is Mary Ramos, and I work at the San Antonio Military Medical Center as a Federal Recovery Coordinator (FRC).

When asked what I do for a living, the simple answer is that I coordinate long-and short-term care for the most seriously wounded, ill, and injured for the Department of Defense (DoD) and the Department of Veterans Affairs (VA).  I say that I help clients get everything they need from DoD, VA, and the community.  People ask if that job is very difficult. I have to say that it is certainly a challenge, but also a gift. It is an honor working with Servicemembers and with Veterans and their families; every day is a learning experience in how people, health care, and systems interface to provide care and benefits to those in need.

I will begin my testimony by providing you with a general picture of who a FRC is, our roles and responsibilities.

My position as a FRC is embedded in a Military Treatment Facility (MTF), San Antonio Military Medical Center (SAMMC). We at SAMMC work hand-in-hand with military health care providers, VA and civilian providers, case managers, care coordinators, and military command as well as countless others whose roles touch the wounded, ill, and injured clients and their families. Our roles as FRCs are unique within the military and VA health care and benefits systems, and each day brings discoveries about the respective niches we fill in providing care and caring for our clients.

The FRC role is one of overarching coordination. In operational terms, that means that while others have a defined “lane,” FRCs coordinate across those “lanes” for our clients. The FRC communicates with key members of the provider team within a clinical setting and, in partnership, assesses whether there are interventions or information that might assist those providers in optimizing clinical and social outcomes.  For instance, health providers treat the various medical conditions while the clinic staffs facilitate appointments. The FRC will identify client or family issues with transportation, motivation, adherence, or information. If there are such issues, the FRC will validate those impressions with the treatment team and encourage additional personnel participation to provide what is needed, facilitating clinical and nonclinical care. This function is critical when a client is being seen in multiple clinical settings within a single facility and even more so when he or she is being seen concurrently in multiple facilities.

On any given day, an active client might be admitted to a hospital, transferred between facilities, undergo a procedure, or be seen in one of the outpatient clinics.  Tracking those events is critical to anticipating emerging needs for the clients and families as well as indicating to whom we should be communicating that day – for example, the client’s inpatient case manager, Warrior in Transition Case Manager, Recovery Care Coordinator (RCC), VA Liaison for Healthcare, VA Case Manager, or provider may be providing care that the FRC can support or facilitate. The client’s changing status may introduce questions or identify new immediate needs; an unanticipated change may introduce some instability in an already precarious client’s coping strategy.  The FRC, then, is constantly reassessing the status of each client, balancing past, emerging, and anticipated needs within the system of care and formulating flexible care coordination plans within the caregiver matrix. That reassessment may also result in a client being evaluated for a decrease in acuity within the program.

The Federal Recovery Coordination Program (FRCP) is most beneficial during periods of recovery and rehabilitation when the FRC can provide stability and support during transitions. Once a client has settled into Veteran status, is receiving benefits and has decided to return to school or work, the need for FRCP involvement is often reduced. These clients may transition to “inactive” status with FRCP.  Inactive status does not mean that FRCP support is withdrawn entirely.  Inactive clients can continue to call the FRC at any time for any reason, but regular contact and the associated Federal Individualized Recovery Plan (FIRP) work will be discontinued. Sometimes clients are made inactive if the client is unresponsive to the FRC’s outreach for at least 3 months. After that time, the FRC will send a letter to the client stating that they may become inactive or if they contact the FRC, they will remain active. Under these particular circumstances, the FRC will contact any known case manager to ensure the client is receiving appropriate services.

Referrals come to the FRCs at SAMMC in several ways.  Most of my referrals come directly to me from VA or MTF case managers, RCCs, military personnel, health care providers, or from current patients referring their friends.   I will also get referrals from VA Central Office. All referrals are always accepted and reviewed, since one of the goals of the FRCP is to provide consultative services to the facility and to respond positively to all questions.

When an FRC receives a referral, the first level of review for evaluating possible clients is to collect data from the referral source concerning the client’s medical condition, injuries, and social and family data as well as the referral source’s impression of the major issues that may be facing the possible client in the next weeks.

  • If there is a single issue or a simple question, the client may be assessed briefly and entered into the system as an “assist.” If “assists” prove to grow in complexity or if the client’s condition starts to indicate that he or she will benefit from the full FRCP, the “assist” client can be moved into active status after the FRC discusses the client with supervisory staff.
  • Comprehensive clinical review is usually accomplished with the client placed in “evaluate” status.
  • If the clinical condition or other factors do not indicate that the FRCP would be of benefit to the client or family, or if optimal services are being provided, the FRC may, after discussion with the team and with supervisory staff, “redirect” the client back to the team, offering continuing support as needed but without active involvement of the FRC.
  • If the clinical condition of the client indicates a possible long-term need for the FRCP, the referred individual’s health care records may be reviewed to validate how the FRCP might benefit the individual and family. Additionally, the individual and/or family are interviewed, the program is explained, and the individual and family are given the choice of whether to enroll in the program.  If the individual does not want the program, the choice is left open for the indeterminate future.  If they decide to enroll, the individual is placed in “evaluate” status. Further assessment follows until a discussion with supervisors may result in the client being placed in “active” status.

FRCs at SAMMC introduce clients to the FRCP very early in the initial hospitalization. While each client has a full complement of caregivers and case managers in this phase of high acuity, there are nonclinical details that can be introduced that will facilitate care and quality of life later in the recovery process. While the client is in the inpatient setting, the FRC provides additional emotional support to the client and family and, in partnership, facilitates whatever processes the case manager and clinical team suggest.  The FRC can monitor processes like application for Servicemembers Group Life Insurance Traumatic Injury Protection Program (TSGLI) and Social Security Disability Insurance (SSDI). The FRC can investigate available resources and help arrange after-school child care to enable the spouse to be with the injured Servicemember.

In providing such assistance, FRCs establish themselves as willing team members who support not only the client, but the entire care team. Willingness to serve as a team member is critical to the FRC being successful in this unique role. Another function of the FRC is to provide information about resources and benefits that are or will be available to the client and family.  Thus, emotional support, instrumental assistance and information are the products of the FRCP in the acute treatment phase.

The most important element the FRC contributes at this early treatment phase is the concept of seamless long-term clinical and non-clinical support. The FRC will be the consistent person in their journey from the most acute care through, and perhaps beyond, community reintegration. It is true that when the client is in intensive care, he or she is not thinking about whether or not they will want to leave the Service or whether they will seek funding to attend college. But, the FRC can assure the client that when they are ready for those decisions, the FRC will still be there, carrying information about what the immediate past has been for this family and supporting the decisions within the close professional relationships that have grown over time.

Because of early support during the most acute phases of care, plus a long record of supporting the family through various crises, the FRC builds the closest of professional relationships. Later care is mediated through that relationship.  The trust relationship with the client and family is the foundation for continued support through the stresses and decisions that come with the Integrated Disability Evaluation System (IDES) process and transitions into community life and new health care delivery systems. With constant interaction from early in the recovery trajectory through reintegration into the community, the FRC learns how each client and family member copes and reacts to the stress of injury, treatment, and change. That knowledge shapes FRC responses to each client for the provision of individualized care.

Extensive professional education and experience enable each FRC to make rapid, continuous assessments and formulate action plans efficiently both independently and within multiple teams. Each FRC holds at least a Master’s Degree in a health care field with basic education as either a Nurse or a Social Worker.  Many have practiced in multiple clinical settings. FRCs bring that clinical experience to the FRC cohort and to the practice setting. The variety of events, outcomes, roles and personalities in military, VA, and civilian health care settings demand an unusual level of professional adaptability in FRC practice.   Through the course of each client’s health care and recovery, the FRC role flexes to provide whatever is needed at any time. Assessment data are constantly processed and actions formulated to “fill in the blanks.”

Despite our expertise and experiences, it is expected that FRCs will be in a constant learning mode. The spheres of knowledge necessary for the position include physical and behavioral health domains, but that knowledge is utilized in a context including organizational psychology, systems theory and transitions, military command systems, military pay systems, military health care, military justice systems, military health care finance, evidence-based practice and research, VA systems of health care, VA benefits systems, community-based care and health care reimbursement, Federal, state and local tax structures, civil and criminal legal systems, real estate law, guardianships and powers of attorney, and risk communication. Additionally, the FRC must understand how to recognize their own personal knowledge deficits and to seek resources to apply to emerging situations.  Recognizing what one does not know as a FRC is as important as knowing and teaching what is known.

FRCs practice with many others who coordinate and provide care for patients. The FRC role in coordinating care, however, is unique in several aspects.   While the FRC may not possess comprehensive knowledge concerning any one aspect of a client’s life, he or she can see that aspect in the context of the client’s entire life. The FRC contributes by assimilating what is meaningful to the client’s care and by formulating an overarching care coordination plan. Service-based personnel may understand the culture of the Service much more deeply than the FRC. The FRC will defer to the Service-based representative in decisions concerning Service-related issues.  However, with broader clinical knowledge and the ability to incorporate key elements of Service-related information, the FRC can build a new care context for the client. Some explain this as “breadth versus depth.”

The care coordination role sometimes colors the character of the relationship between the FRC and the client and family. The FRC identifies processes and actions that must take place in the course of treatment and care management, and then ensures that those tasks are completed. The quasi-oversight function means that the FRC validates processes with the team members and clients and observes and assists, as needed. The FRC listens attentively to the client’s perspective and impressions of care, providing encouragement and assurance that processes will be completed. Listening and responding can accentuate the trust relationship and result in a more therapeutic-type relationship than other roles.  Maintaining professional boundaries and confidentiality is critical to sustaining an appropriate relationship, especially in light of clients’ and families’ tendencies to disclose intimate details of their lives.

Relationships with other professionals within the military treatment facility are defined by the documents that set the FRCP in place. The FRCs are provided office space and resources to support their work, and they are given access to clinical teams, patient documents, and information systems. At SAMMC, the FRCs are co-located with a large group of Warrior in Transition Unit (WTU) case managers and the WTU clinical staff. FRCs participate in clinical activities and assist providers in various care processes, establishing their roles as team members. The FRCs meet and greet incoming Commanders of WTU, the MTF Commander, and other key personnel. Interdisciplinary meetings are very productive for the FRCs, including those at the Center for the Intrepid (amputee care) and the outpatient Burn Unit meetings.  Each professional encounter serves as an outreach opportunity and to enhance an appreciation of what the FRCP can offer to teams and clients.

FRCs have open door policies, and while some clients will make appointments, some just call or e-mail to ask if they can drop in, or they just come to talk. When a client presents, the FRC checks the extant FIRP, goes over all open goals, or formulates a new plan if necessary.  If a client is hospitalized, the FRC will visit several times a week and will interact with the inpatient case manager to see if the FRC can assist with any functions. FRCs have access to client’s outpatient appointment schedules and can meet them in the clinics as desired by the clients and families. FRCs receive a copy of patients scheduled in the Center for the Intrepid for outpatient interdisciplinary clinic.  It is beneficial to meet with the client’s care team and listen to their impressions of the client’s progress, any barriers to ongoing care, and what is planned in the clinic visit.  By being quietly present, the FRC can be available to answer questions.  By observing the clinical team caring for the client, the FRC can gain insight as to how the client is interfacing with the team and whether any FRC coordination would enhance care. Every interaction with the clinical and nonclinical staff serves as outreach.  Every success ensures future referrals to the FRCP.

I would like to give you some specific examples of what I, as an FRC, do in a typical work day.

I will review my client list early in the work day using our program’s data management system to review tasks.  Much of the early activity of the day involves planning and prioritizing, processing incoming e-mails and calls.  Of course, the day will never follow the plan, and priorities evolve during the day, but reviewing issues is always beneficial.  As an example of our task management, if a new Veteran contacts me with a concern that his first benefits check is lost in the system, as a FRC, I can check on the processing of his claim and either resolve an issue or reassure the client that the system is working. Task reminders also cue the FRC to review a client’s record to check and see if benefits have been received. 

I reviewed the Veterans Health Administration (VHA) record for a client diagnosed with schizophrenia, who recently moved to another city. The client has pending examinations to support the disability rating.  VHA’s records indicated active communication between the case manager in the originating city and the receiving case manager. To ensure a seamless transition of the client’s case, I e-mailed the new case manager and Transition Patient Advocate, introducing myself and my role and offering support. I also spoke with the client to inquire if there were any other issues I could help address.

I received an e-mail from a Polytrauma Rehabilitation Center (PRC) case manager stating that a head injury patient, who was expected to be transferred back to his home VA facility, will be remaining at the PRC.  I e-mailed the Veterans Benefits Administration (VBA) representative about the planned home modifications to determine if they would continue on schedule or, given the circumstance, would be delayed or cancelled. I then spoke to the VBA representative and discussed how best to support the family in caring for the client at home following discharge from the PRC.  The family has decided to check on new construction rather than modifying the current home. I exchanged e-mails with the spouse of this client to check on the family’s well-being.

I received an e-mail from a client’s spouse, who is waiting for home modifications. Temperatures are rising with the seasonal change, and the client has very little tolerance for heat due to burn injuries.  I talked to the local VBA representative, who stated that logistics were slowing down the process but that he would speak to the client to plan for starting the project. I then directed the spouse to check the Service-Disabled Veterans Insurance Web site, and followed up as to whether the county property tax exemption paperwork had been filed.

I received a phone call from a client’s mother. The client is experiencing disturbing medication side effects.  She was very upset about several other issues as well, including some recent legal issues and a critical illness in another family member.  I provided supportive listening and encouragement. I e-mailed the VHA case manager and asked her opinion about whether the primary care provider might consider seeing the client for a possible medication change. The VHA case manager arranged the appointment.

I received a phone call from the mother of a Veteran who is worried that the Veteran is not receiving optimal care in a transitional traumatic brain injury (TBI) facility. The mother states that she is afraid that after 3 years of caring for the Veteran, her health is suffering, and she has no health insurance or income. She discussed her fear that if the Veteran is enrolled in an Independent Living Program and stays in a transitional TBI treatment facility, that she will have to sign over the Veteran’s VA benefits and she will have no income and no place to live. I called the head of the TBI program to discuss whether the Veteran meets criteria for placement and how the current family situation might have an impact on program expectations.  I also called the Veteran Outreach Specialist at a local Vet Center to see if she can assist in finding counseling resources for the mother of the Veteran.

I received a phone call from a Veteran receiving inpatient treatment at a VA Medical Center (VAMC).  The Veteran called me to clarify whether a Power of Attorney was needed now or whether it could wait until after being discharged from the VAMC. The Veteran’s spouse is working on financial issues and is worried about money. I e-mailed the VBA Regional Office to check on the client’s VA claim adjudication since the family is in financial distress and needs an income. Regional Office personnel confirmed that the client’s claim is proceeding. The Veteran also expressed anxiety about leaving the current treatment program.  I assured the Veteran that I have been planning clinical outpatient follow up so that there will be no interruption in treatment. The Veteran expressed appreciation for all of the help, and offered to help other Veterans facing similar issues. 

I met with a case manager to discuss two mutual cases. One of the cases involved an active duty Servicemember with a head injury.  Rehabilitation progress at this time is slow, and we discussed whether there is an alternative placement or if the current placement is the best. The spouse and mother of the Servicemember are discussing the best approach and are anxious about different issues. The mother would like the patient in an acute rehabilitation setting. The spouse is worried about the children, legal, and financial complications. We discussed the best physical location for the Servicemember, given the demands of multiple compensation and pension examinations in support of the Medical Board process. We also discussed the family’s applications for an auto grant and special adaptive housing, and misinformation that had been given to the spouse during the filing process.  By the end of the meeting, we had developed a single message for all family members in order to decrease family anxiety.

A Navy Safe Harbor (NSH) case manager stopped by my office to discuss a case that was troubling her.  We discussed her concerns and the scope of the issues with the individual.  I then reviewed DoD and VHA treatment records and discussed the case with the FRC located within NSH.  My review of the records indicated that the individual has significant physical and behavioral health issues, and that the current care for these conditions is fragmented. I spoke with the individual and discussed FRCP structure and function.  The individual expressed an interest in the support that the FRCP can provide, and agreed that he would work with me to develop a FIRP.  I placed the individual in evaluation status and again discussed with NSH case manager and with the FRC at NSH.  Navy personnel support the individual working with me as his FRC in partnership with NSH.

I received an email from a Veteran who had been told that he had lost his TRICARE coverage. As for many, the interface between federal programs became quite frustrating. An example is this complex relationships between Social Security Disability Income (SSDI), Medicare, and TRICARE. This wounded Service Member applied for SSDI soon after injury and started receiving SSDI within the first 6 months following his severe injury. After two years of being on SSDI, the Veteran became Medicare eligible. At that time, Medicare B premiums were deducted from his SSDI (Medicare A is without cost). The SSDI benefit continued when the (then) Veteran returned to work. SSDI payment was suspended after nine months of the Veteran’s earning more than $1000 a month. At that time, the Medicare Program billed the Veteran for Medicare premiums.  He did not understand the bills and did not pay them. Medicare is suspended.  Consequently, TRICARE eligibility ceased. My role was to explain this complicated situation, encourage him to report to the local Social Security office, and assure him that he would get any health care he needed during any transition periods.

I met with another client, who was recently discharged from the hospital. The client and spouse are interested in purchasing a home; however, they have a poor credit rating and have only saved part of their initial TSGLI to use as a down payment. We reviewed all open goals in the FIRP with the client, discussed financial counseling resources, the financial commitment of owning a home, and I provided multiple brochures and contact information. We also discussed the advantages of financial planning and strategies to raise their credit rating.

Conclusion

The examples I have provided hopefully demonstrate for you the kind of flexibility each FRC must have in providing optimal care for Veterans, Servicemembers, and their families. Each day as a FRC is an adventure in providing support that could, in all likelihood, otherwise fall through the cracks given the complexity of some of these cases.  Much of what I provide is not quantifiable, and some of what I provide would possibly not be missed by a client who did not expect a sound safety net. However, I have come to realize that an intimate understanding of a Servicemember’s or Veteran’s perspective of everyday life within overlapping, impossibly complicated, delivery systems equips me to find that (perhaps small) intervention that improves the quality of life for those who risked everything for my freedom and my grandchildren’s quality of life. I never served in battle, but I am honored to bring every minute of my personal and professional experience to bear in caring for those who bore the battle.

Thank you again for the opportunity to share my experiences and perspective with you, and I look forward to answering your questions.