INTRODUCTION

Chairman Michaud, Ranking member Congressman Brown, and members of the House Veterans Affairs Subcommittee on Health, on behalf of the Blinded Veterans Association (BVA), thank you for this opportunity to present our testimony today on “Healing the Physical Injuries of War.” BVA is the only congressionally chartered Veterans Service Organization (VSO) exclusively dedicated to serving the needs of our Nation’s blinded veterans and their families for over 65 years. Today, as U.S. forces remain engaged in two wars and with the surge into Afghanistan resulting in more wounded returning from the battlefields, this hearing is important in reviewing the current systems specialized services and what works and does not work well. While the media often covers the signature injury of the wars, “Traumatic Brain Injuries” and the mental health problems like Post Traumatic Stress Disorders (PTSD) it is important to note that most wounded return with several injuries “poly trauma” and they should all be considered in planning for VA specialized care and benefits they require.

SEAMLESS TRANSITION ISSUES

During the past couple years, BVA has worked extensively with the members of the Committee and tried to get the House Armed Services Committee (HASC) to hold DoD more accountable for the many organizational problems associated with the Seamless Transition process involving the battle eye-injured and those with visual complications associated with Traumatic Brain Injury (TBI). Many severely eye-injured OIF and OEF wounded service members are not centrally tracked, making the implementation of the Eye Trauma Registry vital. This tracking failure negatively affects some in their access to the full continuum of VA Eye Care Service, Blind Rehabilitation Service (BRS), and Low-Vision outpatient programs that these committees helped establish. BVA again stresses that, according to DoD data compiled between March 2003 and December 2009, DoD reported 10 percent of all combat-injured casualties evacuated from OIF and OEF had associated mild, moderate, or severe eye injuries, considering that 38,497 U.S. service members have been evacuated from being wounded or injured this is obviously a significant number. Fortunately, due to advanced combat surgery teams, and the rapid evacuation military aero-medical system, the severely eye injured in these wars have had their vision sometimes fully or partially restored, but approximately 124 blinded have required treatment at one of the ten VA Blind Rehabilitation Centers (BRCs) and there are large numbers with TBI low vision problems. There has been insufficient governance or oversight of the Vision Center Excellence (VCE) by the Joint Executive Council (JEC) and some failure of both agencies to provide detailed budgets, necessary for VCE joint staffing, implementing the Eye Trauma Registry has been delayed, and the planned construction renovation for 3,870 square feet of office space for the VCE at the National Naval Medical Center in Bethesda is not expected to be completed until April FY 2011. BVA requests that no further delays for the immediate operational implementation plans for the VCE in FY 2010 are acceptable and they should not be tolerated.

BVA points to the frustrating fact that despite the MILCON/VA Appropriations including $6.8 million for FY 2009 for VA implementation of its portion of the VCE initiative, it was April 2010 before VA had a total of four staff appointed to the VCE. Members found that the funding had been reprogrammed over five years instead of utilizing the funds to urgently start the VCE operations. BVA requests that Congress include $9,350,000 in the Defense Appropriations FY 2011 and require that VHA and DoD Assistant Secretary Defense for Health Affairs (ASDHA) report quarterly on VCE joint staffing plans, the status of the Eye Trauma Registry, and expenditures of the MILCON/VA appropriations provided to HVAC  and HASC.  

BVA believes that the VCE and its Eye Trauma Registry are where improved coordination to ensure availability of eye care and vision rehabilitation services, best outcome practices, and evidence-based clinical research measures can be developed and refined for the TBI-wounded who face vision dysfunction and those suffering penetrating eye wounds. Research coordinated with the Defense Veterans Brain Injury Centers (DVBIC) and the Defense Intrepid Center of Excellence (NICOE) for TBI, along with VA Polytrauma sites, can be facilitated, data-analyzed, and published to improve both acute injury care and long-term vision rehabilitation. We predict that the number of TBI-injured will continue to rise as a result of the troop surge into Afghanistan this year. 

VA’s Full Continuum of Care

A very positive note is that VA continues to build on a now 62-year history of successful blind rehabilitation programs, which include 10 residential Blind Rehabilitative Centers (BRC’s) throughout the United States and construction on two new BRC’s is occurring now. At present, the implementation of a sweeping $40 million, three-year Full Continuum of Care plan has been completed that this committee supported. While the plan was originally initiated to serve the projected aging population of veterans with degenerative eye diseases requiring specialized services, the new 55 intermediate and advanced low vision blind rehabilitation outpatient programs also have specialized staffing in place to provide the full range of basic, intermediate, and advanced vision services essential to the new generation of eye injured veterans from OIF and OEF. In addition, VA continues to emphasize medical vision research and the latest advances in prosthetic adaptive equipment, with access to new vision technology through a coordinated team approach that is designed to benefit both low vision and blinded veterans of all eras.

VA Blind Rehabilitative Centers  

BRCs are especially important for the returning OIF and OEF service personnel because they often suffer from multiple traumas that include TBI, amputations, other neurosensory losses, and limb injuries. One VA research study found PTSD in 44 percent of TBI patients, 22 percent suffer depression, 40 percent had acute and chronic pain management issues. Mild TBI was found in 44 percent of these 433 patients, with 56 percent diagnosed with moderate to severe TBI with 12 percent of those had penetrating brain trauma. The Defense Veterans Brain Injury Center (DVBIC) reports that an analysis of the first 433 TBI wounded found 19 percent had concomitant amputation of an extremity.  The VA BRC can deliver the entire array of highly specialized care needed for them to optimize their rehabilitation outcomes and successfully reintegrate within their families and communities. Mr. Chairman, we wish to strongly emphasize that private agencies may lack all of the highly specialized consultant services, and prosthetics expertise, that our residential blind centers have now developed, and they all have Commission on Accreditation of Rehabilitation Facilities (CARF) approval. Only the inpatient VA Blind Centers have all the various specialized consultant services needed such as prosthetics, orthopedics, neurology, rehabilitative medicine, surgery, ophthalmology and low vision optometry, and psychiatry to treat these polytrauma service members.

There is no environment of which we are aware that better facilitates the initial emotional adjustment to the severe problems associated with the traumatic loss of vision than full, comprehensive VA blind rehabilitation. One BVA recommendation though is that VHA BRS should have more central control over VA blind center staffing resources and the funding levels because BRS will be better able to track demand for workload across all centers, monitor waiting times, and improve the overall allocation of critical resources in meeting new staffing demands. 

VISUAL IMPAIRMENT SERVICES TEAMS AND BLIND REHABILITATION OUTPATIENT SPECIALISTS

The mission of each Visual Impairment Service Team (VIST) program is to provide blinded veterans with the highest quality of adjustment to vision loss services and blind rehabilitation training. To accomplish this mission, VIST has established mechanisms to maximize the identification of blinded veterans and to offer a review of benefits and services for which they are eligible. The VIST concept was created in order to coordinate the delivery of comprehensive medical and rehabilitation services for blinded veterans. VIST Coordinators are in a unique position to provide comprehensive case management and Seamless Transition services to returning OIF/OEF service personnel for the remainder of their lives. They can assist not only the newly blinded veteran but can also provide his/her family with timely and vital information that facilitates psychosocial adjustment.

The VIST system now employs 114 full-time Coordinators and 43 who work part-time. The average caseload is 375 blinded veterans. VIST Coordinators nationwide serve as the critical key case managers for some 49,269 blinded veterans, a number that is projected to increase to 52,000 within a couple of years. The VIST teams are able to coordinate local services when a veteran requires them and follow blinded veterans who attend a BRC and later require any additional training due to improvements in adaptive equipment or technology.

BLIND REHABILITATIVE OUTPATIENT SPECIALISTS  (BROS)

VA BRS established several new Blind Rehabilitative Outpatient Specialists positions during FY 2009 in facilities throughout the system, bringing the total of BROS to 73 working full-time, triple the number from 2004 largely due to the efforts of this committee and Chairman Michaud. The creation of the positions placed VA in a better position to deliver accessible, cost-effective, top-quality outpatient blind rehabilitation services.

While the BROS is a highly qualified professional who, often is dually certified; that is, he/she has a dual masters science degree both in Orientation and Mobility (living skills and manual skills) and Rehabilitation Teaching and is credentialed and privileged in VA medical centers there is problem within DoD medical treatment facilities (MTF). The defense health care system has never before credentialed BROS professionals because for sixty years blinded service members were sent to VA BRC’s. While DoD credentials other occupations with similar master’s degrees for example, occupational and physical therapists, DoD has no policy for credentialing of VA BROS. We credit VHA and VCE director, COL Gagliano, for trying over the past year for DoD MTF’s to credential these VA BROS into selected MTF’s to begin early blind rehabilitative training skills for the severely wounded that may be pending  being transferred to VA BRC.Walter Reed Med Center and Navy Medical Center currently have been unable to credential the local VA BROS so they can provide this training.  Such training prepares these individuals to provide the full range of mobility, living, and adaptive manual skills that are essential early skills in recovery and return to the veteran's home environment and BROs provide reassurance to family members that the training will lead to independence. Today in several DoD and VA medical centers there are wide number of clinical providers, social workers, and other staff working together within each department’s facilities to improve transition and clinical care. BVA would strongly recommend that the VA Committee working with HASC provide “NDAA report language” that VA credentialed and privileged BROS shall be granted MTF clinical privileges as VA clinical consultants representing VA Blind Rehabilitative Service and that DoD and VHA report back to the committees on the implementation of this privileging process.

ADVANCED BLIND REHABILITATION PROGRAMS 

Pre-admission home assessments, individualized evaluations, and outpatient training, all of which are complemented by a post-completion home follow-up, are part of the new three year expansion of VA’s Advanced Outpatient Blind programs. These programs have been referred to historically as VISOR (Visual Impairment Services Outpatient Rehabilitation Program). They consist of a nine-day rehabilitation experience, offering Living Skills Training, Orientation and Mobility, and Low-Vision Adaptive Devices Therapy with appropriate prosthetics while staying in Hoptel bed at a medical center with nursing care as necessary during the stay. A VIST Coordinator with low-vision credentials manages the program with other key staff members consisting of certified BROS, Orientation and Mobility Specialists, Rehabilitation Teachers, Low-Vision Therapists, and Low-Vision Ophthalmologists. These new programs considerably improve access, provide new rehabilitation services of the highest quality, reduce waiting times, and decrease veteran travel across networks.

INTERMEDIATE LOW-VISION OPTOMETRY PROGRAMS: VICTORS

Another important model of service delivery that does not fall under VA BRS is the Visual Impairment Center to Optimize Remaining Sight (VICTORS), an innovative program operated by VA Optometry Service. It consists of special services to low-vision veterans who, although not legally blind, suffer from severe visual impairments. Veterans must usually have a visual acuity of 20/70 through 20/200 to be considered for this service. The program, entirely outpatient, typically lasts three days. Veterans undergo a comprehensive, low-vision optometric evaluation and then appropriate low-vision prosthetics devices are then prescribed. The Low-Vision Optometrists employed in Intermediate programs are ideal for the highly specialized skills necessary for the assessment, diagnosis, treatment, and coordination of services for returnees from Iraq or Afghanistan with TBI visual dysfunction and who also require low-vision services. These new low-vision programs assist veterans with some residual vision from conditions such as macular degeneration, diabetic retinopathy, glaucoma and other degenerative eye diseases in maintaining independence and functional status at home or work. 

PRIVATE AGENCIES and POLY TRAUMA REHABILITATION SERVICES

BVA objects to finding that private agencies for blind are asking for members to earmark various ‘centers of excellence’ and private agencies trying to initiate new independent programs to “manage these new OIF and OEF combat wounded,” adding to the confusion and negatively impacting transition between DoD and VA. Recent combat blinded service members often suffer from multiple traumas that include TBI, amputations, neuro-sensory losses, PTSD, pain management, and depression. The New England Journal of Medicine’s January 31, 2008 article on the experience of mild TBI wounded found even mild cases were significantly more likely within three to four months after injury to develop altered mental status, depression, headaches, emotional distress in up to 30 percent of cases, again evidence that without neurology, neuro-psychology or psychiatry staff, the specialized treatment necessary for recovery will be missed. Only VA Blind Rehabilitation Centers (BRC’s) can deliver the entire full array of these inpatient medical-surgical and psychiatric specialized care often needed for veterans to fully optimize their rehabilitation outcomes and successfully reintegrate into their families and communities. They need the specialized VA mental health services with coordinated multidisciplinary health care teams that the VA medical centers are capable of providing.

We caution that residential private agencies for the blind do not have the full specialized nursing, physical therapy, pain management, speech pathology, pharmacy services, and lab or radiology support services, along with subspecialty surgery specialists, to provide the clinical care necessary for the wounded. The lack of electronic health care records in the private agencies would make things worse when veterans returned into DoD or VA medical services. BVA requests that any private agencies should demonstrate peer reviewed quality outcome measurements that are a standard part of VHA BRS and they also must be accredited by either the National Accreditation Council for Agencies Serving the Blind and Visually Handicapped (NAC) or the Commission on Accreditation of Rehabilitation Facilities (CARF) and blind rehabilitation instructors must be certified by the Academy for Certification of Vision Rehabilitation and Education Professionals (ACVREP). They should also have the specialized medical staffing necessary for complex wounds.

BVA believes that the DoD-VA Seamless Transition process for eye trauma cases must include the sharing of outcome studies, clinical guidelines, and joint peer reviewed research projects on vision care and vision loss prevention through the exchange of electronic medical records and clinical specialized consultation. These components are not present in private agencies for the blind.

RECOMMENDATIONS

• Congress must ensure the full establishment and budget of the Vision Center of Excellence VCE and Eye Trauma Registry must become operational. Joint DoD/VA staffing resources available now is critical for successful Seamless Transition of eye injured. Request DoD appropriations include $9,350,000 for FY 2011 for operations and staffing for the VCE. Section 1624 of NDAA FY 2008 must be modified and specific organizational governance alignment for the VCE Director and VA Deputy Director shall report directly to the Assistant Secretary of Defense for Health Affairs and to the Under Secretary of Health (USH) in VHA. 
• BVA would strongly recommend that the VA Committee with HASC provide “NDAA report language” that VA credentialed and privileged Blind Rehabilitative Outpatient Specialists (BROS) ‘shall be granted MTF clinical privileges as VA clinical staff’ for VA Blind Rehabilitative Service (BRS) and that DoD and VHA shall report back to the committees on the implementation of this privileging process for BROS.
• The new, specialized VA programs for blinded and low-vision veterans Continuum of Care must be utilized by DoD and to ensure that continuing education of DoD staff about this must occur along with the various VA Case Managers, the Federal Recovery Coordinators (FRCs) and the Vision Center of Excellence (VCE). Veterans and their families must know where these resources are located so that they continue to receive the high quality VA vision health care.
• BVA supports the National Alliance for Eye Vision Research’s (NAEVR) position that extramural defense vision research funding through the dedicated Peer Reviewed Medical Research-Vision line item in the DOD’s Congressionally Directed Medical Research Program (PRMRP) is essential. BVA urges that PRMR-Vision be funded at $10 million in FY2011 defense appropriations and BVA also appreciates the dear colleague letter of Congressman Walz dated July 15, 2010 requesting members support this level of funding. 

 CONCLUSION:

Once again, Mr. Chairman, and Members of the subcommittee, BVA appreciates this opportunity to present our testimony on Specialized VA Health Care services confronting the newly injured returning from OIF and OEF. I will answer any questions you have.