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Witness Testimony of William F. Feeley, Veterans Health Administration, Deputy Under Secretary for Health for Operations and Management, U.S. Department of Veterans Affairs

Good morning Mr. Chairman and Members of the Committee. 

Thank you for this opportunity to discuss the Veterans Health Administration’s (VHA) ongoing efforts to improve the quality of care that we provide to veterans suffering from traumatic brain injury (TBI) and complex multiple trauma.  Joining me today is Dr. Edward Huycke, Chief Officer for VA’s Office of Seamless Transition, Dr. Lucille Beck, VA’s Chief Consultant for Rehabilitation Services, and Dr. Barbara Sigford, National Program Director for Physical Medicine and Rehabilitation.

VA offers comprehensive primary and specialty health care to our veterans and active duty service members, and is an acknowledged national leader in providing specialty care in the treatment and rehabilitation of TBI and polytrauma.  Since 1992, VA has maintained four specialized TBI Centers that have served as the primary VHA receiving facilities for military treatment facilities seeking specialized care for brain injuries and complex polytrauma.  In 2005, VA established its Polytrauma System of Care, leveraging and enhancing the existing expertise at these TBI centers to meet the needs of seriously injured veterans and active duty service members from operations in , , and elsewhere.  This new era of combat and the resulting casualties have required adaptations in our approaches to care that we provide for this brave new generation of veterans.  We readily accept the challenge and opportunity to adapt VA’s existing integrated system to provide the best available continuum of care.  The focus of my testimony today will be on treatment and rehabilitation provided by VA for veterans recovering from TBI and complex multiple trauma, and the current initiatives to further enhance these services to our veterans within this system of care.

Polytrauma System of Care

The mission of the Polytrauma System of Care is to provide the highest quality of medical, rehabilitation, and support services for veterans and active duty service members injured in the service to our country.  This integrated nationwide system of care has been designed to provide access to life long rehabilitation care for veterans and active duty service members recovering from polytrauma and TBI.

Component 1 – Regional.  Currently the four Polytrauma/TBI Rehabilitation Centers (PRC) – located in Minneapolis, MN; Palo Alto, CA; Richmond, VA; and

Tampa, FL – are the flagship facilities of the Polytrauma System of Care.  A fifth polytrauma site was just recently announced for San Antonio, TX. These centers serve as hubs for acute medical and rehabilitation care, research, and education related to polytrauma and TBI.  The specialized services provided at each PRC include: comprehensive acute rehabilitation care for complex and severe polytraumatic injuries, emerging consciousness programs, outpatient programs, and residential transitional rehabilitation programs.  Clinical care is provided by a dedicated staff of rehabilitation specialists and medical consultants with expertise in the treatment of the physical, mental and psychosocial problems that accompany polytrauma and TBI.  This team includes specialists in physiatry, rehabilitation nursing, neuropsychology, psychology, speech-language pathology, occupational therapy, physical therapy, social work, therapeutic recreation, prosthetics, and blind rehabilitation. 

One of the newest programs within the PRCs is the treatment program for patients with severe disorders of consciousness.  Provision of rehabilitation services for patients who are minimally conscious or minimally responsive is currently based on expert opinion rather than scientific evidence.  Cornerstones of treatment for patients with severe disorders of consciousness include: aggressive medical care to treat potential reversible causes of impaired consciousness (infection, sedation, etc); prevention of complications (contracture, pressure sores, malnutrition); family support and education.  Additional interventions often include structured sensory stimulation, and trials with medications to increase responsiveness.  Programs providing specialized care for severe disorders of consciousness must also have a mechanism for monitoring response to treatment.  A commonly used instrument for this purpose is the Disorders of Consciousness Scale (DOCS).  VA developed its program through a process of reviewing the experience and expertise developed at those VA sites that had an established protocol, reviewing the literature, and consulting with private expert professionals providing these services.  Development of the formalized program culminated with a face-to-face working conference in December 2006, at which time the protocol was established that is currently being utilized, and the requirement was set that all Polytrauma Rehabilitation Centers would participate.  The workgroup for this new program continues to meet monthly.

In 2007, staffing for the PRC teams was increased at each center in response to increased demands of patient workload, coordination of care, and support for family caregivers.  The PRCs have affiliations and collaborative relationships with academic medical centers.  A significant number of PRC clinical providers share VA and affiliated positions in training and medical rehabilitation.  The inpatient rehabilitation programs at the PRCs maintain accreditation by the Commission on Accreditation of Rehabilitation Facilities (CARF) for both Traumatic Brain Injury and Comprehensive Rehabilitation.

Component 2 – Network.  The Polytrauma/TBI Network Sites (PNS), designated in December 2005, represent the second echelon within the Polytrauma System of Care, with one PNS located within each of VA’s 21 Veterans Integrated Service Networks (VISN).  The PNS provides key components of post-acute rehabilitation care for individuals with polytrauma/TBI, including, but not limited to inpatient and outpatient rehabilitation, and day programs.  The PNS is responsible for coordinating access to VA and non-VA services across the VISN to meet the needs of patients recovering from polytrauma and TBI, and their families.  The PNS consults, whenever necessary, with the PRC.

Components 3 and 4 – Facility.  The Polytrauma System of Care network was expanded in March, 2007, to include two new components of care: Polytrauma Support Clinic Teams (PSCT) and Polytrauma Points of Contact (PPOC).  With their geographical distribution across the VA, the seventy five (75) Polytrauma Support Clinic Teams facilitate access to specialized rehabilitation services for veterans and active duty service members at locations closer to their home communities.  These interdisciplinary teams of rehabilitation specialists are responsible for managing the care of patients with stable treatment plans, providing regular follow-up visits, and responding to new medical and psychosocial problems as they emerge.  The PSCT consults with their affiliated Polytrauma Network Site or

Polytrauma

Rehabilitation

Center when more specialized services are required.

The remaining fifty four (54) VA medical centers have an identified Polytrauma Point of Contact who is responsible for managing consultations for patients with polytrauma and TBI, and assisting with referrals of these patients to programs capable of providing the appropriate level of services.

The

Polytrauma

Rehabilitation

Centers and the Polytrauma Network Sites are linked through the Polytrauma Telehealth Network (PTN) that provides state-of-the-art multipoint videoconferencing capabilities.  This Network ensures that polytrauma and TBI expertise are available throughout the system of care, and that care is provided at a location and time that is most accessible to the patient.  This Network further provides such clinical activities that include remote consultations and evaluations of patients, and education for providers and families.

Coordination and Transition of Care

Care management across the entire continuum is a critical function in the Polytrauma System of Care to ensure lifelong coordination of services for patients recovering from polytrauma and TBI.  Consistent, comprehensive procedures and processes have been put in place to ensure transition of patients from military treatment facilities to VA care at the appropriate time, and under optimal conditions of safety and convenience for the patients and their families. 

At the direction of the Secretary, 100 Transition Patient Advocates (TPAs) have been recruited nationwide.  The TPAs contact the patient and family while in the Military Treatment Facility. One of their responsibilities is to ensure that all questions concerning VA are answered and the case is expedited through the VA benefits process.  If necessary, the TPA will travel with the family and veteran from the MTF to their home, and provide transportation to all VHA appointments.

The VA assigns a care manager to every patient admitted within the VA Polytrauma System of Care.  This care manager maintains scheduled contacts with veterans and their families to coordinate services and to address emerging needs.  As an individual moves from one level of care to another, the care manager at the referring facility is responsible for a “warm hand off” to the care manager at the receiving facility closer to the veteran’s home.  The assigned care manager functions as the point of contact for emerging medical, psychosocial, or rehabilitation coordination of care, and provides patient and family advocacy.

To facilitate continuity of medical care, the

Polytrauma

Rehabilitation

Center receives advanced notice of potential admissions to their sites.  Upon notification, the PRC team initiates a pre-transfer review and follows the clinical progress until the patient is ready for transfer.  PRC clinicians are able to complete pre-transfer review of the military treatment facility medical record, including up to date information about medications, laboratory studies, and daily progress notes.  In addition to record review, clinician-to-clinician communication occurs to allow additional transfer of information and resolution of any outstanding questions.

DoD and VA also have made significant progress sharing available electronic health information to further coordinate care of these patients.  DoD and VA are now supporting the electronic transfer of DoD inpatient data to VA clinicians at polytrauma centers.  DoD is currently transferring DOD medical digital images and electronically scanned inpatient health records to the VA polytrauma centers from

Walter

Reed

Army

Medical

Center , National Naval Medical Center Bethesda and

Brooke

Army

Medical

Center .  This effort provides VA clinicians receiving these combat veterans with immediate access to critical components of their inpatient care at DOD military treatment facilities. In the future, VA hopes to add the capability to provide this data bidirectionally to support any patients returning to DOD for further care.   Additionally, VA and DoD are supporting the secure direct connection of authorized providers at VA polytrauma centers into the health information systems at

Walter

Reed

Army

Medical

Center and

National

Naval

Medical

Center .  This direct connection provides the most timely access to much needed DoD clinical information in support of care of critically injured patients coming from combat theaters.

Psychosocial support for families of injured service members is paramount as decisions are made to transition from the acute medical, life and death, setting of a military treatment facility to a rehabilitation setting.  This encompasses psychological support, education about rehabilitation and the next setting of care, and information about benefits and military processes and procedures.  VA social worker or nurse liaisons are located at 10 military treatment facilities, including our most frequent referral sources,

Walter

Reed

Army

Medical

Center and

National

Naval

Medical

Center .  These individuals provide necessary psychosocial support to families during the transition process, advising the families through the process.  In addition, VA has a Certified Rehabilitation Registered Nurse assigned at

Walter

Reed

Army

Medical

Center to provide education to the family on TBI, the rehabilitation process, and the PRCs.  The Admission Case Manager from the PRC maintains personal contact with the family prior to transfer to provide additional support and further information about the expected care plan.  VA also has Benefit liaisons located at the commonly referring military treatment facilities to provide an early briefing on the full array of VA services and benefits to the patients and families.

Upon admission to the PRC, the senior leadership of the facility personally meets the family and service member to ensure that they feel welcome and that their needs are being met.  Additionally, a uniformed active duty service member is located at each PRC.  The Army Liaison Officers support military personnel and their families from all Service branches by addressing a broad array of issues, such as travel, non-medical attendant orders which pay for family members to stay at the bedside, housing, military pay, and movement of household goods.  They are also able to advise on Medical Boards and assist with necessary paperwork. 

The transition from the PRC to the home community is of critical importance to ensure that the treatment plan, including continued rehabilitation and medical care, psychosocial and logistical support is maintained.  Records for VA medical care are readily available through remote access across the VA system.  Follow up appointments are made prior to discharge, and the transferring practitioners are readily available for personal contact with the receiving provider to ensure full and complete communication.  Care managers at the Polytrauma Network Site and the home VA medical center provide for ongoing support and problem resolution in the home community, while continually assessing for new and emerging issues.  Finally, each PRC team carefully assesses the expected needs at discharge for transportation, equipment, home modifications, and other such needs and makes arrangements for assessed needs.

Conclusion

The VA Polytrauma System of Care is a recognized leader in healthcare for its expertise in treating combat-related injuries, and managing the overlapping effects of combat stress response.  Today, an expanded system of care is available to provide more services and to develop new, innovative approaches to these potentially debilitating conditions.  Our clinicians and researchers strive to provide the highest standard of rehabilitation care for those recovering from polytrauma and TBI, while concurrently evaluating ways to enhance services.  The VA continually assesses the unique needs of all polytrauma patients, and has responded decisively to the increased demand for services with this new generation of combat-injured veterans.  The VA is committed to providing the necessary level of resources and scope of services that ensure a continuum of world-class, lifelong care extending from acute rehabilitation to vocational and transitional community rehabilitation programs for veterans at locations closer to their home communities.

Thank you for your time and attention.  I will be glad to respond to any questions that you or other members of the committee may have.